HOUSE FINANCE COMMITTEE April 25, 2022 2:06 p.m. 2:06:59 PM CALL TO ORDER Co-Chair Merrick called the House Finance Committee meeting to order at 2:06 p.m. MEMBERS PRESENT Representative Neal Foster, Co-Chair Representative Kelly Merrick, Co-Chair Representative Dan Ortiz, Vice-Chair Representative Ben Carpenter Representative Bryce Edgmon Representative DeLena Johnson Representative Andy Josephson Representative Bart LeBon Representative Sara Rasmussen Representative Steve Thompson Representative Adam Wool MEMBERS ABSENT None ALSO PRESENT Representative Liz Snyder, Sponsor; Sorcha Hazelton, Staff, Representative Kelly Merrick; Senator Elvi Gray-Jackson, Sponsor. PRESENT VIA TELECONFERENCE Justin Ruffridge, Chairman, Board of Pharmacy, Soldotna; Dr. Tom Wadsworth, Assistant Dean of University of Alaska Anchorage and Idaho State University Pharmacy Program, Wasilla; Barry Christiansen, Legislative Chair, Alaska Pharmacists Association; Daniel Nelson, Director of Pharmacy, Tanana Chief's Conference, Fairbanks; Talethia Bogart, Self, Anchorage; Glenn Hoskinson, Deputy Director, Division of Corporations, Businesses and Professional Licensing, Department of Commerce, Community and Economic Development. SUMMARY HB 145 EXPAND PHARMACIST AUTHORITY CSHB 145(HSS) was REPORTED out of committee with nine "do pass" recommendations and two "no recommendation" recommendations and with one new zero impact note by the Department of Commerce, Community and Economic Development. CSSB 80(HSS) PUBLIC SCHOOLS: MENTAL HEALTH EDUCATION HCSCSSB 80(FIN) was REPORTED out of committee with five "do pass" recommendations, two "do not pass" recommendations, one "no recommendation" recommendation, and three "amend" recommendations and with one new fiscal impact note by the Department of Education and Early Development. Co-Chair Merrick reviewed the meeting agenda. HOUSE BILL NO. 145 "An Act relating to the Board of Pharmacy; relating to health care services provided by pharmacists and pharmacy technicians; and relating to the practice of pharmacy." 2:07:35 PM REPRESENTATIVE LIZ SNYDER, SPONSOR, thanked the committee for hearing the bill. She relayed that the bill allowed pharmacists to practice within the full scope of their practice. The statute needed to be updated to reflect the ongoing evolution of the field. The bill defined the patient care services that pharmacists and pharmacy support staff could independently provide, it allowed pharmacy technicians to administer vaccines and emergency medication, and it empowered the Board of Pharmacy to regulate pharmacists of all types to provide pharmacy services. Lastly, the bill updated the current provider anti-discrimination statute to support insurance coverage of patient care services when provided by a pharmacist. She noted that the bill did not expand pharmacists' prescriptive authority or allow them to practice outside of their scope, training, or knowledge. The bill was a result of collaboration between pharmacists and medical groups. 2:10:08 PM Representative Wool wondered if pharmacists would be able to bill individual patients for services rendered, or if billing independently was what pharmacists wanted to do. He asked for clarification regarding the process for insurance payments. Representative Snyder replied that when pharmacists were providing care within the scope of their practice, it would allow for those services to be billable to insurance even if those services were normally provided by a physician. She noted that testifiers would be speaking to their experience in this realm later in the meeting. Representative Rasmussen was aware pharmacists could administer vaccines, but there were other services she was surprised to learn about that could be provided by pharmacists. She wanted to hear more examples of the different services pharmacists could provide. 2:13:01 PM Representative Johnson asked about how standards were applied for pharmacists. She wondered if pharmacists had the same standards for patient care as physicians. Representative Snyder deferred to the chairman of the Board of Pharmacy. 2:13:28 PM JUSTIN RUFFRIDGE, CHAIRMAN, BOARD OF PHARMACY, SOLDOTNA (via teleconference), responded that pharmacists held two forms of liability. As an independent pharmacy owner, he held liability to cover the facility itself, and each of the pharmacists who worked for him held their own individual liability. He indicated that was the standard of practice. Most insurance plans would refuse to credential or contract with a provider without proof of liability insurance coverage. The policies would usually run from $1 million to $3 million. Representative Johnson thought the amount seemed surprisingly low. Dr. Ruffridge replied that the amount was the minimum requirement for most insurance companies. Many pharmacists carried greater amounts for their own personal wellbeing. 2:15:14 PM Representative Wool wondered about the process for billable services by pharmacists. He asked if people made appointments with pharmacists in a similar way that people made appointments with physicians. If so, he wondered whether these appointments were billable. Dr. Ruffridge responded in the affirmative. There had been a recent pattern where pharmacists were prescribing medications for "self-limiting diagnoses." It was helpful for pharmacists to be empowered to prescribe medications to remove some of the burden off of overwhelmed physicians. However, there were statutory limitations that did not allow pharmacists to fully perform the duties they had been trained to do. The statutory language simply did not match what had been in practice. The bill was representative of what pharmacists were able to do and were already doing. Representative Wool had been unaware that people could make appointments with pharmacists. He noted that naturopaths wanted to be able to prescribe antibiotics, but medical doctors did not want to relinquish control. He wondered whether this was as contentious with pharmacists if pharmacists were already prescribing antibiotics. Dr. Ruffridge responded that pharmacists had been prescribing antibiotics for quite some time by working with physicians through collaborative practice agreements. The service was not done unilaterally nor without oversight. The bill established the few things that pharmacists would be permitted to do independently of the collaborative practice agreement. The independent duties were also things pharmacists had been doing for quite some time. Representative Wool was not aware of collaborative practice agreements. He wondered if other states had this option. He understood pharmacists were overburdened just as medical doctors were and asked how the redistribution of work would help. He asked if there was a shortage of licensed pharmacists. Dr. Ruffridge would be happy to talk about the topics at hand for hours and suggested that they talk outside of the committee. He responded that many other states had similar language that allowed for similar practice agreements. He relayed that Alaska actually had an abundance of pharmacists. One of the issues was that retail pharmacies were often chaotic which he thought related to pharmacists' inability to reimburse themselves for medications. This resulted in diminished personnel hired in pharmacies due to things like direct and indirect remuneration fees, which could sometimes amount to hundreds of thousands of dollars. If some of the issues were resolved, pharmacists would be able to employ more people and the environment would be less chaotic. 2:22:51 PM Representative Rasmussen asked for more detailed information on the training completed by pharmacists. It was her understanding that some pharmacists were more experienced than some medical doctors. Dr. Ruffridge responded pharmacists were highly trained professionals. For the past twenty years, a student could not graduate from pharmacy school with anything less than a doctorate. Pharmacists also were trained in diagnostic tools, which included things like COVID-19 testing and flu testing. Pharmacists were a highly motivated, highly educated workforce. He suggested that Dr. Tom Wadsworth could provide more detailed information. Representative Rasmussen asked how much leeway a pharmacy had in dispensing medication prescribed by a doctor. Dr. Ruffridge responded that pharmacists had a small amount of leeway, but there were a few things they could not change. Pharmacists could not change the patient, the drug itself, or the ultimate dosage form without speaking to the prescribing doctor. Some of the language in HB 145 suggested allowing pharmacists to have the authority to change dosage form. For example, if a parent did not want their child to take prescribed medication in a pill form, the pharmacist could change it to a liquid form. 2:26:13 PM DR. TOM WADSWORTH, ASSISTANT DEAN OF UNIVERSITY OF ALASKA ANCHORAGE AND IDAHO STATE UNIVERSITY PHARMACY PROGRAM, WASILLA (via teleconference), spoke in support of the bill. He indicated that the bill was a collaboration between the Alaska Pharmacist Association, the University Pharmacy Program, and the Board of Pharmacy. It was a "housekeeping" bill because all the activities expanded by the bill were tasks that pharmacists were already performing. He reported that for over 30 years, pharmacists had been providing non- dispensing healthcare services and prescribing medicines. He relayed that 60 percent of pharmacists practiced in the healthcare industry rather than in retail stores such as Walgreens. Many pharmacists were in disease management and post-diagnostic disease management and prescribed medication along with physicians through collaborative practice agreements. It might seem as though there were not many pharmacists, but most pharmacists were not public facing. There was a tendency to lump all pharmacists into the field of community pharmacy, but it was not an accurate representation of the entire field. Dr. Wadsworth emphasized that the bill would update regulation to ensure that all pharmacists were represented in statute. The bill would also help the board to regulate practices outside of the community setting. Many pharmacists were imbedded with primary care physicians and provided non-dispensing healthcare services in collaboration with practitioners. The pharmacists helped improve the patient experience and worked to lower drug costs. He reemphasized there were many tasks done by pharmacists of which the general public was not aware. He urged the passage of the bill so the Board of Pharmacy could properly regulate the profession. 2:31:00 PM Representative Wool asked whether the Chief Andrew Isaac Health Center (CIHC) and Fairbanks Memorial Hospital (FMH) operated in the same manner because of the difference between federal and state regulations. Dr. Wadsworth responded that pharmacists often had difficulty engaging with commercial or private insurances due to difficulty getting enrolled in credentials. In Alaska, pharmacists had been designated as rendering and billing providers by statute. He had been involved in some consultation with health centers to try to establish practices in the facilities to employ pharmacists. The bill would help to provide better access to pharmacists of all types. Representative Wool indicated his child had a history of strep throat. He wondered how the process of getting antibiotics would change if a pharmacist was imbedded in a clinic. He wondered if he could take his daughter to a pharmacist in a retail store like Fred Meyer for a test for strep throat and be prescribed antibiotics immediately. Dr. Wadsworth responded that it was nuanced. Currently, there were lab tests that anyone could perform, including pharmacists, which would diagnose things like strep throat. Under a collaborative practice agreement, the patient could then receive proper treatment or a referral. Many pharmacists were doing such tests already, yet some did not because they had barriers with payments from insurance. The bill would increase options for patients. 2:34:54 PM BARRY CHRISTIANSEN, LEGISLATIVE CHAIR, ALASKA PHARMACISTS ASSOCIATION (via teleconference), was a practicing pharmacist in Ketchikan. He had two daughters also training to become pharmacists. He spoke in support of HB 145. He believed that pharmacists were in a unique position to help patients reach their pharmaceutical needs. The statutory updates in the bill were vital to ensure that pharmacists could continue to meet patient needs as well as encourage the recruitment of new pharmacists. The legislation ensured that pharmacists could continue to practice in the manner they had already been practicing and would not expand prescriptive authority. 2:36:31 PM DANIEL NELSON, DIRECTOR OF PHARMACY, TANANA CHIEF'S CONFERENCE, FAIRBANKS (via teleconference), supported the bill and echoed the comments of Dr. Ruffridge and Dr. Wadsworth. The bill updated the statutes and also allowed the Board of Pharmacy to regulate pharmacy support staff. It was important to ensure that pharmacists could continue to provide vaccines, which was allowed in a majority of other states. Currently, the only way Alaska pharmacists were able to provide vaccines was through a federal exception waiver. The reason why pharmacies were so busy was because of the remuneration of the pharmacy benefit managers. Insurance companies would not reimburse pharmacists for services because pharmacists were not listed in the anti-discrimination statute. 2:39:10 PM Co-Chair Merrick OPENED public testimony. TALETHIA BOGART, SELF, ANCHORAGE (via teleconference), was a student pharmacist at the University of Alaska Anchorage. She supported HB 145. Patient care was her top priority and she wanted to make a difference in the lives of her patients. She thought the bill would improve patient access to care and improve the overall health and wellbeing of patients. She thought the bill needed to pass in order to allow her to practice what she had learned in school. 2:40:24 PM Co-Chair Merrick CLOSED public testimony. Co-Chair Merrick invited Ms. Glenn Hoskinson to review the fiscal note with control code diCXR by the Department of Commerce, Community and Economic Development. 2:40:49 PM GLENN HOSKINSON, DEPUTY DIRECTOR, DIVISION OF CORPORATIONS, BUSINESSES AND PROFESSIONAL LICENSING, JUNEAU (via teleconference), was looking for the correct fiscal note. 2:41:35 PM AT EASE 2:42:07 PM RECONVENED Co-Chair Merrick referred to the control code and asked Ms. Hoskinson if she had the correct fiscal note. Ms. Hoskinson responded that she had been referring to the wrong fiscal note. The fiscal note with control code diCXR was a zero fiscal note. She relayed that the department would absorb the costs of the bill. 2:42:58 PM Representative Johnson asked what type of birth control pills pharmacists could prescribe under the bill. Representative Snyder deferred to Dr. Ruffridge. 2:44:01 PM Dr. Ruffridge asked Representative Johnson to clarify her question. Representative Johnson referred to the document "Alaska's Pharmacists: Improving People's Health" (copy on file). The document indicated that Oregon pharmacists wrote 10 percent of all birth control prescriptions since a landmark law was passed and suggested that Alaska pharmacists could follow suit. She asked what type of drugs pharmacists would be dispensing and wondered if the morning after pill would be included. Dr. Ruffridge indicated pharmacists would need to have a collaborative practice agreement with a physician in order to prescribe birth control. The bill would not allow pharmacists to prescribe birth control unilaterally or independently. He explained that the morning after pill was already available over the counter and did not require a prescription. The decision to allow this was made at the federal level through the Food and Drug Administration (FDA). Representative Johnson asked the sponsor if the administration or the chief medical officer of the state had any opinion on the bill. Representative Snyder replied that there was a letter from the Board of Pharmacy (copy on file) supporting the bill. Representative Johnson wondered what medical doctors thought about the bill. She thought it seemed like an industry bill as most testifiers were in the industry. She wondered whether pharmacists would be able to prevent prescribed medication from being dispensed. Representative Snyder indicated there was also a letter of support from the Alaska State Medical Association (copy on file) in member packets as well. There had not been any opposition to the bill from physician groups. Her primary motivation with the bill was to increase access to care. Pharmacists were already providing important services and the bill would simply reflect that activity in statute. There was a shortage of primary care providers in the state and there was other legislation in process that aimed to address the shortage. Allowing pharmacists to provide some of the primary care services that fell within the scope of their training was part of the legislation. She asked Representative Johnson to repeat her second question. Representative Johnson wondered about the line between a doctor and a pharmacist. She asked to what extent a pharmacist could second-guess a doctor and decide against filling a prescription. She did not want to allow for the expansion of a pharmacist's authority. She wanted to put her faith in her doctor's decisions. Representative Snyder noted that others had expressed the same concern. She thought that the bill had an unfortunate and misleading title. It would not expand authority, but instead updated statute to reflect what pharmacists already did. She reached out to the Division of Corporations, Business, and Professional Licensing to ensure that nothing in the bill would expand the authority of pharmacists beyond their scope of practice. She was told that the bill was prescriptive and would not allow for inappropriately expanded authority. There was a document in the bill packet that confirmed that information. 2:51:38 PM Representative Johnson thought the ability for pharmacists to prescribe birth control would be expanded. Representative Snyder responded that a collaborative practice agreement would be required in that situation. However, certain types of birth control such as the morning after pill were already available over the counter. They were not overlapping issues. Representative Johnson clarified for the record that the bill did not expand the ability of pharmacists to prescribe contraception. Representative Snyder responded that was her understanding and suggested that Dr. Ruffridge provide his perspective for added certainty. Dr. Ruffridge responded that Representative Johnson was correct. Pharmacists could not prescribe contraceptive medications without a collaborative practice agreement with a doctor. Representative Johnson asked if Dr. Ruffridge could provide more detail on situations that would allow pharmacists to choose to not dispense prescriptions. Dr. Ruffridge responded that there had been much discussion on the topic. The situations in which pharmacists could choose to not dispense prescriptions were related to birth control prescriptions, the opioid epidemic, and COVID-19. In each instance, pharmacists were left with a dilemma and had to determine where to draw the line. For example, should a pharmacist cease dispensing prescriptions to a person who had been addicted to opiates for many years. The Board of Pharmacy had attempted to answer such questions. The board thought that pharmacists had to have the patient's best interest in mind, and this language was included in statute and regulations. If a pharmacist had a moral barrier to dispensing birth control, the board ensured that there was another pharmacy location where the patient could have the medication dispensed. With opiates, pharmacists had to do a complete assessment of patients' mental states and there were laws in place to prevent patients from receiving high dosages. The Board of Pharmacy encouraged pharmacists to talk to the patient and determine the appropriateness of the medication. The law had been very clear that the pharmacist and prescriber had an equal obligation to the patient. If something were to happen as a result of a prescription, the blame would fall equally on both the prescriber and the pharmacist. Ultimately, the patient's best interests should be the most important factor. 2:59:07 PM Representative Carpenter referred to Section 8 of the bill which added language to the statute enabling collaborative practice agreements. He asked what defined, controlled, or limited the boundaries of what could be included in the collaborative practice agreement. He asked for more details about the structure of the agreement. Dr. Ruffridge replied that the writers of the agreement determined the limits of the collaborative practice agreement. The agreement then had to be reviewed by the State Medical Board. If the agreement was approved, it would then go to the Board of Pharmacy for additional review. He relayed that the review process was extensive and rigorous. Representative Carpenter thought there might be a conflict between independent prescription authority for vaccines and an established collaborative practice agreement. Dr. Ruffridge responded that pharmacists were limited to independent prescribing and dispensing of medication and required vaccines related to emergencies. Anything outside of the two areas would require a collaborative practice agreement. Vaccines and related emergency medications were being supplied by pharmacists in the state already. The bill simply described in clear language the process of pharmacists giving vaccines. The current language in statute stated "independently administer" but did not say how the administration of the vaccines would come about. The first step in the process would be to determine that a person needed a vaccine, which would essentially involve prescribing it. The bill provided clear distinctive language. 3:03:21 PM Representative Carpenter referred to Section 3 regarding the emergency permit. He wondered what the impact of changing the language would be. Dr. Ruffridge indicated pharmacists had to issue many emergency permits during the pandemic. The referenced section allowed the board to not only issue emergency permits to practice pharmacy, but also to practice the other license types that pharmacies were required to have, such as interns and pharmacy technicians. The other issue that arose was that other emergency permits were granted due to the governor's emergency declaration. The language would provide clarity as to what pharmacists could and could not do. 3:04:51 PM Representative Wool commented that naturopathic doctors had to study pharmacy as part of their education, and many states allowed them to prescribe medication. He wondered how many hours student pharmacists spent helping patients in a clinical setting. Dr. Wadsworth replied that pharmacy students accumulated thousands of hours of direct patient care during their training, and it was required for licensing. Many student pharmacists would choose to undergo additional training after they became licensed in order to become specialized in a field like infectious disease or psychiatry. By the time pharmacists were practicing independently, they had accumulated thousands of hours of direct patient care. Pharmacists also sat for a board exam to become board certified. Additionally, pharmacists were required to take continuing education to maintain their license. Representative Wool commented that the legislature had not heard from any medical doctors on the bill, but perhaps doctors were simply too busy to testify. He understood that there had been no opposition received, which seemed similar to receiving support. He wondered if pharmacists took the Hippocratic Oath like medical doctors. Dr. Wadsworth replied that there was a similar code of ethics to which pharmacists were required to adhere. Every healthcare discipline had an ethical standard or code, and pharmacists were no different. 3:09:53 PM Representative Wool asked for more information about the decision making power the corporations that owned pharmacies had over pharmacists. He understood that corporations could influence the type of prescription a patient would receive. Dr. Wadsworth added that in any medical or healthcare discipline, medical professionals might encounter moral quandaries that put them at odds with their employer. Entities such as the health system, managed care organizations, and preferred provider organizations had significant decision-making power over medical professionals. He agreed that pharmacists were no different and found themselves in similar situations. Co-Chair Foster MOVED to report CSHB 145(HSS) out of committee with individual recommendations and the accompanying fiscal note. There being NO OBJECTION, it was so ordered. CSHB 145(HSS) was REPORTED out of committee with nine "do pass" recommendations and two "no recommendation" recommendations and with one new zero impact note by the Department of Commerce, Community and Economic Development. 3:12:28 PM AT EASE 3:14:23 PM RECONVENED CS FOR SENATE BILL NO. 80(HSS) "An Act relating to mental health education." 3:14:38 PM Co-Chair Merrick indicated SB 80 was the companion bill to HB 60. 3:14:50 PM Co-Chair Foster MOVED to ADOPT proposed committee substitute for CSSB 80(HSS), Work Draft 32-LS0514\W (Marx, 04/22/22). Co-Chair Merrick OBJECTED for discussion. 3:15:21 PM SORCHA SORCHA HAZELTON, STAFF, REPRESENTATIVE KELLY MERRICK, indicated the CS before the committee matched the language in the amended companion bill, HB 60. Three amendments to HB 60 had been adopted and the same language was reflected in the CS. She noted that one amendment adopted by the Senate had not been adopted by the House Finance Committee; therefore, the corresponding section had been removed from the CS. Co-Chair Merrick WITHDREW the OBJECTION. There being NO further OBJECTION, HCS CSSB 80(FIN) was ADOPTED. 3:16:08 PM Representative Thompson wanted to ensure that one of the adopted amendments ensured that parents would have the choice of whether they would like their child to be put in a class that discussed mental health related topics. Co-Chair Merrick clarified that any amendment to HB 60 that was adopted by the House Finance Committee was included in the CS, and any amendment that failed to be adopted was omitted. Representative Thompson relayed that he was not present for the entire amendment process. The response did not answer his question. 3:17:15 PM Representative Wool recalled that an amendment was put forward and defeated. Representative Johnson commented that the amendment was in the Senate version of the bill. 3:17:36 PM AT EASE 3:18:28 PM RECONVENED Representative Johnson MOVED to RECIND the adoption of the House Committee Substitute. 3:18:43 PM AT EASE 3:19:42 PM RECONVENED Co-Chair Merrick asked Representative Johnson if she would like to rescind her vote on the adoption of Version W. Representative Johnson responded that she would like to object [to the adoption of the CS]. Co-Chair Foster MOVED to ADOPT proposed committee substitute for CSSB 80(HSS), Work Draft 32-LS0514\W (Marx 04/22/22). Co-Chair Merrick OBJECTED for discussion. Representative Johnson understood that the committee was adopting the changes made in the Senate version of the bill, which was not the same as the CS before the committee. She objected to Version W. 3:21:05 PM AT EASE 3:25:28 PM RECONVENED Co-Chair Merrick WITHDREW the OBJECTION. Representative Thompson OBJECTED. A roll call vote was taken on the motion. IN FAVOR: Wool, Edgmon, Josephson, Ortiz, Merrick, Foster OPPOSED: Thompson, Carpenter, Johnson, LeBon, Rasmussen The MOTION PASSED (6/5). There being NO further OBJECTION, Work Draft 32-LS0514\W (Marx, 04/22/22) was ADOPTED. 3:26:31 PM SENATOR ELVI GRAY-JACKSON, SPONSOR, thanked the committee for hearing the bill. She reiterated that the version adopted in the Senate included parental consent, but appreciated the amendments made in the House Finance Committee. Co-Chair Merrick reminded members there would still be the opportunity to amend the bill on the floor. 3:27:24 PM Co-Chair Foster MOVED to report HCS CSHB 80(FIN) out of Committee with individual recommendations and the accompanying fiscal note. Representative Carpenter OBJECTED. Representative Rasmussen commented that although she would like to see the bill amended, she would be voting to pass the bill from committee. She would be offering an amendment on the floor. Representative Wool commented that mental illness was being discussed in schools already in health classes. Teachers were not consulting parents on the topic of mental health just as they do not consult parents on many other topics. Representative Carpenter MAINTAINED the OBJECTION. A roll call vote was taken on the motion. IN FAVOR: Edgmon, Josephson, Ortiz, Rasmussen, Wool, Foster, Merrick OPPOSED: Carpenter, Johnson, LeBon, Thompson The MOTION PASSED (7/4). There being NO further OBJECTION, it was so ordered. HCS CSSB 80(FIN) was REPORTED out of committee with five "do pass" recommendations, two "do not pass" recommendations, one "no recommendation" recommendation, and three "amend" recommendations and with one new fiscal impact note by the Department of Education and Early Development. 3:29:12 PM AT EASE 3:29:28 PM RECONVENED Co-Chair Merrick reviewed the agenda for the following day. ADJOURNMENT 3:29:49 PM The meeting was adjourned at 3:29 p.m.