HOUSE HEALTH, EDUCATION AND SOCIAL SERVICES STANDING COMMITTEE April 11, 1996 2:07 p.m. MEMBERS PRESENT Representative Cynthia Toohey, Co-Chair Representative Con Bunde, Co-Chair Representative Gary Davis Representative Norman Rokeberg Representative Caren Robinson Representative Tom Brice Representative Al Vezey MEMBERS ABSENT None COMMITTEE CALENDAR CS FOR SENATE BILL NO. 193(L&C) "An Act requiring insurance coverage for certain costs of birth; and providing for an effective date." - PASSED HCS CSSB 193(HES) OUT OF COMMITTEE CS FOR SENATE BILL NO. 158(L&C) am "An Act relating to pharmacists and pharmacies." - PASSED HCS CSSB 158(HES) OUT OF COMMITTEE CS FOR SENATE BILL NO. 259(HES) "An Act extending the termination date of the Alaska Commission on Aging; and providing for an effective date." - PASSED OUT OF COMMITTEE CS FOR SENATE BILL NO. 165(L&C) "An Act relating to psychologists and psychological associates." - PASSED HCS CSSB 165(HES) OUT OF COMMITTEE PREVIOUS ACTION  BILL: SB 193 SHORT TITLE: MANDATORY INSURANCE FOR COSTS OF BIRTH SPONSOR(S): SENATOR(S) SALO, Donley, Ellis, Duncan, Kelly, Pearce, Zharoff; REPRESENTATIVE(S) Robinson, B.Davis, Finkelstein, G.Davis, Navarre JRN-DATE JRN-PG ACTION 12/29/95 2056 (S) PREFILE RELEASED - 12/29/95 01/08/96 2056 (S) READ THE FIRST TIME - REFERRAL(S) 01/08/96 2057 (S) LABOR & COMMERCE 01/16/96 2143 (S) COSPONSOR(S): DUNCAN 02/15/96 (S) L&C AT 1:30 PM BELTZ ROOM 211 02/15/96 (S) MINUTE(L&C) 02/21/96 2487 (S) L&C RPT CS 2DP 1NR SAME TITLE 02/21/96 2487 (S) ZERO FNS TO SB & CS (DCED,ADM,DHSS) 02/21/96 2487 (S) FIN REFERRAL ADDED 02/21/96 2498 (S) COSPONSOR: KELLY 02/27/96 (S) FIN AT 9:00 AM SENATE FINANCE 532 03/07/96 (S) FIN AT 9:00 AM SENATE FINANCE 532 03/12/96 (S) FIN AT 9:00 AM SENATE FINANCE 532 03/12/96 2707 (S) FIN RPT 5DP 2NR (L&C)CS 03/12/96 2707 (S) PREVIOUS ZERO FNS (DHSS, ADM) 03/12/96 2707 (S) ZERO FN (DCED) 03/12/96 2718 (S) COSPONSOR(S): PEARCE, ZHAROFF 03/13/96 (S) RLS AT 11:00 AM FAHRENKAMP RM 203 03/13/96 (S) MINUTE(RLS) 03/22/96 2834 (S) RULES TO CALENDAR 3/22/96 03/22/96 2840 (S) READ THE SECOND TIME 03/22/96 2840 (S) L&C CS ADOPTED UNAN CONSENT 03/22/96 2841 (S) ADVANCE TO THIRD RDG FLD Y8 N11 E1 03/22/96 2841 (S) THIRD READING 3/25 CALENDAR 03/25/96 2868 (S) READ THE THIRD TIME CSSB 193(L&C) 03/25/96 2868 (S) PASSED Y17 N3 03/25/96 2868 (S) EFFECTIVE DATE(S) SAME AS PASSAGE 03/25/96 2869 (S) Sharp NOTICE OF RECONSIDERATION 03/26/96 2911 (S) RECONSIDERATION NOT TAKEN UP 03/26/96 2912 (S) TRANSMITTED TO (H) 03/27/96 3386 (H) READ THE FIRST TIME - REFERRAL(S) 03/27/96 3386 (H) HES, L&C 03/28/96 3465 (H) CROSS SPONSOR(S): B.DAVIS 03/29/96 3495 (H) FIRST CROSS SPONSOR(S): ROBINSON 03/29/96 3495 (H) CROSS SPONSOR(S): FINKELSTEIN, G.DAVIS 04/01/96 3552 (H) CROSS SPONSOR(S): NAVARRE 04/11/96 (H) HES AT 2:00 PM CAPITOL 106 BILL: SB 158 SHORT TITLE: PHARMACISTS AND PHARMACIES SPONSOR(S): SENATOR(S) MILLER JRN-DATE JRN-PG ACTION 04/13/95 1025 (S) READ THE FIRST TIME - REFERRAL(S) 04/13/95 1026 (S) LABOR & COMMERCE 04/25/95 (S) L&C AT 1:30 PM FAHRENKAMP RM 203 04/25/95 (S) MINUTE(L&C) 05/02/95 (S) L&C AT 1:30 PM FAHRENKAMP RM 203 05/02/95 (S) MINUTE(L&C) 05/05/95 1524 (S) L&C RPT CS 3DP 2NR SAME TITLE 05/05/95 1524 (S) FISCAL NOTE TO SB (DCED) 05/05/95 1524 (S) ZERO FISCAL NOTE TO CS (DCED) 05/07/95 (S) RLS AT 1:00 PM FAHRENKAMP ROOM 203 05/07/95 (S) MINUTE(RLS) 02/21/96 2489 (S) RULES TO CALENDAR 2/21/96 02/21/96 2489 (S) ZERO FISCAL NOTE TO CS (FY97)(DCED) 02/21/96 2491 (S) READ THE SECOND TIME 02/21/96 2491 (S) L&C CS ADOPTED UNAN CONSENT 02/21/96 2492 (S) AM NO 1 ADOPTED UNAN CONSENT 02/21/96 2492 (S) AM NO 2 ADOPTED UNAN CONSENT 02/21/96 2492 (S) ADVANCED TO THIRD READING UNAN CONSENT 02/21/96 2492 (S) READ THE THIRD TIME CSSB 158(L&C) AM 02/21/96 2493 (S) PASSED Y19 N- E1 02/21/96 2498 (S) TRANSMITTED TO (H) 02/22/96 2852 (H) READ THE FIRST TIME - REFERRAL(S) 02/22/96 2852 (H) HEALTH, EDUCATION & SOCIAL SERVICES 04/09/96 (H) HES AT 3:00 PM CAPITOL 106 04/11/96 (H) MINUTE(HES) 04/11/96 (H) HES AT 2:00 PM CAPITOL 106 BILL: SB 259 SHORT TITLE: COMMISSION ON AGING SPONSOR(S): RULES BY REQUEST OF THE GOVERNOR JRN-DATE JRN-PG ACTION 02/02/96 2282 (S) READ THE FIRST TIME - REFERRAL(S) 02/02/96 2282 (S) HES, FIN 02/02/96 2282 (S) FISCAL NOTE (ADM) 02/02/96 2283 (S) GOVERNOR'S TRANSMITTAL LETTER 03/08/96 (S) HES AT 9:00 AM BUTROVICH ROOM 205 03/08/96 (S) MINUTE(HES) 03/11/96 2685 (S) HES RPT CS 2DP 1NR NEW TITLE 03/11/96 2686 (S) PREVIOUS FN (ADM) 03/27/96 (S) FIN AT 9:00 AM SENATE FINANCE 532 03/28/96 (S) FIN AT 8:30 AM SENATE FINANCE 532 03/28/96 2941 (S) FIN RPT CS 5DP 2NR NEW TITLE 03/28/96 2942 (S) ZERO FN TO CS (ADM) 03/29/96 (S) RLS AT 12:05 PM FAHRENKAMP RM 203 04/03/96 3045 (S) RULES TO CALENDAR 4/3/96 04/03/96 3046 (S) READ THE SECOND TIME 04/03/96 3047 (S) FAILED TO ADOPT FIN CS Y9 N10 E1 04/03/96 3047 (S) HES CS ADOPTED Y12 N7 E1 04/03/96 3048 (S) ADVANCED TO THIRD READING UNAN CONSENT 04/03/96 3048 (S) READ THE THIRD TIME CSSB 259(HES) 04/03/96 3048 (S) PASSED Y19 N- E1 04/03/96 3048 (S) EFFECTIVE DATE(S) SAME AS PASSAGE 04/03/96 3053 (S) TRANSMITTED TO (H) 04/04/96 3634 (H) READ THE FIRST TIME - REFERRAL(S) 04/04/96 3635 (H) HES, FINANCE 04/09/96 (H) HES AT 3:00 PM CAPITOL 106 04/09/96 (H) MINUTE(HES) 04/11/96 (H) HES AT 2:00 PM CAPITOL 106 BILL: SB 165 SHORT TITLE: PSYCHOLOGISTS & PSYCHOLOGICAL ASSOCIATES SPONSOR(S): HEALTH, EDUCATION & SOCIAL SERVICES BY REQUEST JRN-DATE JRN-PG ACTION 04/25/95 1230 (S) READ THE FIRST TIME - REFERRAL(S) 04/25/95 1230 (S) HES, L&C 01/17/96 (S) HES AT 9:00 AM BUTROVICH ROOM 205 01/17/96 (S) MINUTE(HES) 01/18/96 2166 (S) HES RPT CS 4DP SAME TITLE 01/18/96 2166 (S) ZERO FISCAL NOTE TO SB & CS (DCED) 01/30/96 (S) L&C AT 1:30 PM FAHRENKAMP RM 203 01/30/96 (S) MINUTE(L&C) 01/31/96 2262 (S) L&C RPT CS 2DP 2NR SAME TITLE 01/31/96 2262 (S) PREVIOUS ZERO FISCAL NOTE (DCED) 02/02/96 (S) RLS AT 10:15 AM FAHRENKAMP RM 203 02/02/96 (S) MINUTE(RLS) 02/07/96 2324 (S) RULES TO CALENDAR 2/9/96 02/09/96 2359 (S) READ THE SECOND TIME 02/09/96 2359 (S) L&C CS ADOPTED UNAN CONSENT 02/09/96 2359 (S) ADVANCED TO THIRD READING UNAN CONSENT 02/09/96 2359 (S) READ THE THIRD TIME CSSB 165(L&C) 02/09/96 2360 (S) PASSED Y19 N0 E1 02/09/96 2363 (S) TRANSMITTED TO (H) 02/12/96 2718 (H) READ THE FIRST TIME - REFERRAL(S) 02/12/96 2718 (H) HEALTH,EDUCATION AND SOCIAL SERVICES 04/02/96 (H) HES AT 3:00 PM CAPITOL 106 04/02/96 (H) MINUTE(HES) 04/04/96 (H) HES AT 3:00 PM CAPITOL 106 04/04/96 (H) MINUTE(HES) 04/09/96 (H) HES AT 3:00 PM CAPITOL 106 04/09/96 (H) MINUTE(HES) 04/10/96 3682 (H) ECD AND L&C REFERRAL ADDED WITNESS REGISTER BRUCE RICHARDS, Legislative Administrative Assistant to Senator Judy Salo Alaska State Legislature Capitol Building, Room 504 Juneau, Alaska 99801-1182 Telephone: (907) 465-4940 POSITION STATEMENT: Presented Sponsor Statement for SB 193 JANET PARKER, Deputy Director Division of Retirement & Benefits Department of Administration P.O. Box 110203 Juneau, Alaska 99811-0203 Telephone: (907) 465-4470 POSITION STATEMENT: Testified on CSSB 193(L&C) STEVE LeBRUN, Senior Account Manager Aetna Health Plan Aetna Life Insurance Company P.O. Box 91032 Seattle, Washington 98111-9132 Telephone: (206) 467-2803 POSITION STATEMENT: Testified on CSSB 193(L&C) GAIL McGILL, Registered Nurse and Director of Quality and Utilization Management Columbia Alaska Regional Hospital Anchorage, Alaska 99501 Telephone: (907) 264-1754 POSITION STATEMENT: Testified in support of CSSB 193(L&C) JANET OATES, Representative Providence Health System P.O. Box 196604 Anchorage, Alaska 99519 Telephone: (907) 261-4946 POSITION STATEMENT: Testified on CSSB 193(L&C) DR. RICHARD NIST, Obstetrician/Gynecologist 4120 Laurel Anchorage, Alaska 99508 Telephone: (907) 563-6515 POSITION STATEMENT: Testified on CSSB 193(L&C) GORDON EVANS, Lobbyist Health Insurance Association of America 318 4th Street Juneau, Alaska 99801 Telephone: (907) 586-3210 POSITION STATEMENT: Testified in opposition to CSSB 193(L&C) NANCY WELLER Division of Medical Assistance Department of Health & Social Services P.O. Box 110660 Juneau, Alaska 99811-0660 Telephone: (907) 465-3355 POSITION STATEMENT: Answered questions on CSSB 193(L&C) JANET THURSTON 436 Valley View Drive Fairbanks, Alaska 99701 Telephone: (907) 457-1164 POSITION STATEMENT: Testified on CSSB 193(L&C) PAT SENNER, Executive Director Alaska Nurses Association P.O. Box 102264 Anchorage, Alaska 99510 Telephone: (907) 243-8044 POSITION STATEMENT: Testified in support of CSSB 193(L&C) SCOTT CALDER P.O. Box 75011 Fairbanks, Alaska 99707 Telephone: (907) 474-0174 POSITION STATEMENT: Testified on CSSB 193(L&C) SENATOR JUDY SALO Alaska State Legislature Capitol Building, Room 504 Juneau, Alaska 99801-1182 Telephone: (907) 465-4940 POSITION STATEMENT: Prime sponsor of SB 193 ALISON ELGEE, Deputy Commissioner Department of Administration P.O. Box 110200 Juneau, Alaska 99811-0200 Telephone: (907) 465-2200 POSITION STATEMENT: Testified on CSSB 259(FIN) ACTION NARRATIVE TAPE 96-39, SIDE A Number 001 The House Health, Education and Social Services Standing Committee was called to order by CO-CHAIR CYNTHIA TOOHEY at 2:07 p.m. Members present at the call to order were Representatives Toohey, Davis, Rokeberg and Brice. A quorum was present to conduct business. CO-CHAIR TOOHEY announced the calendar for the meeting was CSSB 193 (L&C), "An Act requiring insurance coverage for certain costs of birth; and providing for an effective date"; CSSB 158(L&C) am "An Act relating to pharmacists and pharmacies"; CSSB 259(FIN), "An Act extending the termination date of the Alaska Commission on Aging; and providing for an effective date"; and if time allows, CSSB 165(L&C) "An Act relating to psychologists and psychological associates." CO-CHAIR CON BUNDE arrived at 2:09 p.m. CSSB 193(L&C) - MANDATORY INSURANCE FOR COSTS OF BIRTH Number 199 BRUCE RICHARDS, Legislative Administrative Assistant to Senator Judy Salo, said Senator Salo introduced this legislation basically to set some guide limits for the coverage on the cost of hospitalization and medical care after birth. Senator Salo had been contacted during the interim by a constituent who had been told that her insurance would not cover an additional day beyond the 24 hours following the birth of her child and she didn't feel she was ready to go home. Senator Salo started doing some checking and found this is not a huge problem in Alaska, but she has been getting more and more calls since she introduced the legislation. It is quite a large problem in the Lower 48 which is where all Senator Salo's information came from. She had the legislation drafted and basically what it does is require mandatory coverage of hospitalization or medical care for 48 hours after a vaginal birth and 96 hours after a caesarean section. It does not mandate the patient to stay in the hospital if the patient wishes to go home; it is purely a cost question of who is paying. CO-CHAIR TOOHEY asked if the insurance companies charge for the 24 hours or for the actual time in the hospital? MR. RICHARDS asked if she was referring to the time right after birth. CO-CHAIR TOOHEY said this legislation would allow for 48 hours after a vaginal birth, but if the patient decided to stay only 24 hours, which is the patient's option, is that what the insurance company charges for or do they charge for all 48 hours? MR. RICHARDS said if a patient is in the hospital for only 24 hours after the birth, that's what the insurance company charges for. CO-CHAIR TOOHEY asked if there were any additional questions of Mr. Richards. Hearing none, she asked Janet Parker to come forward to testify. REPRESENTATIVE CAREN ROBINSON arrived at 2:12 p.m. and REPRESENTATIVE AL VEZEY arrived at 2:13 p.m. Number 394 JANET PARKER, Deputy Director, Division of Retirement & Benefits, Department of Administration, said she was available to answer questions the committee might have regarding the fiscal note or how this bill applied to the state health plan. CO-CHAIR BUNDE noted there were three zero fiscal notes, yet this bill would increase coverage and wondered who was going to pay for that increased coverage? MS. PARKER responded the division doesn't believe there will be much increase at all for the state's plan; definitely not enough to impact the premium. The state's plans are based on experience and 1.7 days is the average hospital stay for an uncomplicated vaginal delivery. Based on that, currently more mothers are staying for two days, but there are a lot of them going home after one day. She commented it hasn't been a problem with the state's plan. In her discussions with nurses at Aetna, they don't recall there being a conflict with a doctor saying his/her patient needs another day in the hospital. The division does not believe this legislation will have an impact. CO-CHAIR TOOHEY asked Ms. Parker if the division had received any complaints? MS. PARKER recalled having a complaint for someone who wanted to be certified in advance for two days, but the state's plan only certifies for one day. The nurses at Aetna will advise that an individual can be certified for one day and to simply call if an additional day is needed. CO-CHAIR TOOHEY said she understood there is a difference in delivery versus entry time. For example, some hospitals don't start counting the time until the delivery takes place while others start counting from the time a patient enters the hospital. MS. PARKER commented that Bartlett Memorial Hospital in Juneau actually does a delivery charge time and then starts the patient in the hospital upon birth as far as staying as a patient. She noted that hospitals bill from midnight to midnight on any hospital stay. CO-CHAIR TOOHEY asked her to explain. MS. PARKER said she walked into the hospital at ten minutes past midnight and delivered her baby at 12:55 a.m. so her day didn't start until the following day because the hospital counts from midnight to midnight. On the other hand, if she had gone into the hospital at 11:00 p.m., the hospital would have started the day and charged for the full day if she had left at 10:00 the next morning. CO-CHAIR TOOHEY asked if a mother delivers her child at 1:00 a.m., 24 hours would be 1:00 a.m. the next day, so is that when the mother would leave? MS. PARKER replied no, she actually left about 36 hours later and was charged one day by the hospital which was paid by the insurance. CO-CHAIR TOOHEY inquired who absorbs the rest of it? MS. PARKER said the hospital bills from midnight to midnight, so the hospital is absorbing it. The hospital doesn't charge for the day of discharge. CO-CHAIR TOOHEY asked if that was okay with the hospital? MS. PARKER deferred the question to a hospital representative. Number 678 REPRESENTATIVE GARY DAVIS said it appears there's a patient day - midnight to midnight - but the legislation speaks specifically to the period of time after child birth. He asked if that would be in conflict with any hospital policies? MS. PARKER said she didn't think so. She believed that Aetna uses the guidelines of starting from the point of birth. CO-CHAIR BUNDE observed that if a patient delivers her child at 1:00 a.m., conceivably a hospital could ask the patient to leave at 1:00 a.m. the following day. MS. PARKER said she didn't think that would happen. CO-CHAIR BUNDE said conceivably it could happen if they enforced the 24 hours. Number 765 REPRESENTATIVE ROBINSON said it was her understanding that this legislation eliminates some of the red tape that occurs if a patient needs to stay an additional day. MS. PARKER didn't know if Aetna, with regard to the state's plan, would change its procedure to check up and see if the patient needs to be there. She views it more in the line that if managed care came into Alaska and tried to do a 6-hour discharge after delivery, it would be more of a protection. She reiterated she doesn't believe there is a problem now. In her particular case, Aetna certified an additional day for her and her baby because the doctor thought the baby needed to stay in the hospital a while longer. REPRESENTATIVE ROBINSON noted it was the local hospital board who actually requested this legislation because of problems at Bartlett Memorial Hospital. Number 835 CO-CHAIR TOOHEY asked if the division had a specific criteria for caesarean births? MS. PARKER said the state does not, but Aetna does. She believed that Aetna would certify three days at the start, and a person could call for anything beyond that. CO-CHAIR TOOHEY asked if the division intervenes when a problem arises between a patient and the insurance company? If so, do they win? MS. PARKER said the division does intervene a lot and they don't lose them all. CO-CHAIR TOOHEY commented they do lose a certain amount of them, however. MS. PARKER said that was true and added they are not doctors. CO-CHAIR TOOHEY said that was the statement she wanted to hear; they aren't doctors and neither are the insurance companies. Doctors are doctors and they make the final judgment. Number 894 CO-CHAIR BUNDE said the fiscal note represents the state's policy with Aetna and based on Ms. Parker's experience, it's not a problem with Aetna if a doctor requests certification for a patient to stay for an additional length of time. Therefore, this bill isn't really needed and doesn't have an impact on the state employers who are covered by the state program through Aetna. It may however, have an impact on other businesses and other insurance programs. MS. PARKER said she could not speak to what other companies are doing. CO-CHAIR BUNDE said the point he was getting at is that while there will be no fiscal impact at this point to the state, there may well be fiscal impact for private industry. MS. PARKER said potentially yes. CO-CHAIR TOOHEY asked if there were additional questions of Ms. Parker. Hearing none, she asked Steve LeBrun to present his testimony. Number 973 STEVE LeBRUN, Senior Account Manager, Aetna Health Plan, Aetna Life Insurance Company, said that SB 193 relates to the (indisc.) topic given that (indisc.) delivery is the most frequent cause of hospital admission in the United States. He said it's also true that the trend for hospital length of stay for mothers and newborns has been decreasing for many years. He said the committee had already heard that not all mothers want to stay in the hospital and that many would prefer to be at home with their families as soon as they can. Nevertheless, Aetna understands this trend has raised concerns, often based on anecdotal stories bubbling up from the Lower 48. He believes everyone shares the goal of seeing that the care and coverage needs of each individual mother and newborn are recognized. Admittedly, coverage policies on payment criteria from one health insurer to another may vary. In that regard, Aetna would not be opposed to taking steps to avoid or weed out blatant abuses as to where they exist or develop. MR. LeBRUN said that Aetna Health Plan doesn't itself have a policy which requires routine discharge of maternity patients from the hospital after a one day stay. In pre-certifying hospital stays for maternity, this is usually a process done months in advance of the delivery date. Aetna does, in fact, generally pre-certify for one day of hospitalization on the assumption of a routine, uncomplicated delivery. However, after the birth has taken place they will discuss with the attending obstetrician and pediatrician and work with them if additional time in the hospital appears appropriate and warranted, given the condition of the mother and the newborn. In answer to a question, it is Aetna's standard up- front certification for a caesarean section to allow for three days essentially without question and then as with any confinement, whether maternity related or otherwise, to then work with the patient's physician to certify additional days as medically needed. Aetna also agrees that medical decisions should be made by the attending medical professional after consultation with their patients and after an assessment of their medical condition. Likewise, just for clarification, all of Aetna's benefit payment decisions concerning maternity and maternity length of stay are also made by medical professionals, either registered nurses or physician (indisc.) reviewers; they don't use clerks or bureaucrats or have any sort of blanket rule making. MR. LeBRUN said Aetna doesn't want mothers and newborns discharged from the hospital unless they meet appropriate guidelines. They, in fact, use the guidelines that have been developed over time by the American Academy of Pediatrics and the American College of Obstetrics and Gynecology. Aetna has implemented those guidelines in full, using the standards established by these groups. The criteria included in these guidelines are fairly extensive and include among other things, consideration that the mother has had a full term, uncomplicated pregnancy, that infant growth is appropriate, that development is normal, that lab screen tests have been performed and there's been an assessment that the mother and infant have been observed for sufficient time to ensure that both are stable, the mother has received instruction in child care and the social environment has been assessment, so from that perspective it is appropriate and timely for her to go home or not go home, and that the specific physical condition and status of both mother and child has been attained prior to release. CO-CHAIR TOOHEY commented that Mr. LeBrun had sent her the guidelines for a 24-hour discharge following an uncomplicated vaginal delivery and asked if she had his permission to distribute that document to the committee. MR. LeBRUN responded he had no problem with that. He noted the guidelines are not Aetna developed guidelines; Aetna uses what he thinks are the guidelines established by the medical review body. CO-CHAIR TOOHEY referred to Mr. LeBrun's comment that decisions are made by medical personnel and said she believes the only medical personnel that should be consulted is the doctor who is caring for the mother and the baby. She asked if Aetna gives paramount consideration to them? MR. LeBRUN said certainly, the attending physicians are in the best position to assess the health status; therefore, they would be looked to for advice and consultation. CO-CHAIR TOOHEY asked how often does Aetna disagree and not allow the physician's advice to carry any weight? Also, if a patient signs out of a hospital AMA, meaning away without medical advice, that carries a lot of weight; however, if Aetna determines a patient needs to leave the hospital and will not pay for the additional service, shouldn't there be a legal document which states that Aetna is taking on the responsibility for that patient? MR. LeBRUN said in answer to the first question, he didn't have firm data with him on weights of acceptance or denial, other than to say it would be the rare circumstance where there would be a difference of opinion. Also, his involvement with the state employees' plan as well as other plans, is that in this area in working with Alaska facilities and providers, maternity lengths of stay is not in any way a chronic ongoing issue. Regarding the second question, he agreed there are some difficulties with the concept, but Aetna's role is as a fiduciary of the health insurance plan and it's in that role as administer of a health plan of benefits, not as a care giver, that they are making a benefit decision. Certainly, it is their hope and he thinks it's almost always the case that Aetna's review for benefit coverage purposes coincides with the physician's intent in that manner and that Aetna is in agreement that items are medically needed and not just convenient. Obviously, if a patient wants to stay and it's primarily for convenience and not for a medical reason, it is possible they may end up at odds with each other. Aetna does work directly with attending physicians to fully understand the patient's medical circumstances, but they can make an individualized decision, when necessary. CO-CHAIR BUNDE referenced a memorandum which indicated that if a mother and newborn baby leaves the hospital within 24 hours, they are eligible for a home care visit. However, if they stay in the hospital longer than 24 hours, they lose the option for the home care visit. He asked how this legislation would affect that policy? MR. LeBRUN said he wasn't aware that is Aetna's policy. He didn't know of any hard and fast rule that would make home care visit contingent on length of stay. Generally, he thinks there are many cases where a home visit may not be necessary the next day, but he wasn't aware of any blanket rule in that regard. He added that Aetna has consistently promoted home health care visits as a good quality cost effective alternative. CO-CHAIR BUNDE said the conversation regarding the home care visits had originated with Janet Keough of Aetna in Seattle and said he would share the information with Mr. LeBrun, if he desired. MR. LeBRUN reiterated that if it is the policy, he wasn't aware of it. He said he would be happy to discuss the issue in his office and confirm or clarify that issue for the committee. CO-CHAIR BUNDE said he would appreciate that because to quote her, "A mother and an infant discharged together within 24 hours of birth qualify for a follow-up home visit. If the mother and child are in the hospital longer than 24 hours after the birth, then a home follow-up is not covered as a necessary medical expense." MR. LeBRUN said he would follow up and provide comments back to the committee. CO-CHAIR TOOHEY asked if there were any questions of Mr. LeBrun. Hearing none, she asked Gail McGill to testify. Number 1464 GAIL McGILL, Registered Nurse and Director of Quality and Utilization Management, Columbia Alaska Regional Hospital, testified in support of CSSB 193(L&C). She said as a hospital with an active maternal child unit, they strive to work with their patients, physicians, nurse midwives and the payers in providing the most cost effective quality care. If there is medical necessity for the patient to stay, the insurance reviewers often will extend the stay, but will provide a disclaimer that the bill may not be paid by the insurer. Columbia Alaska Regional Hospital supports the legislation as it provides the option for a 48-hour or 96-hour stay when it is determined to be in the patient's best interest. As the length of stay for postpartum parents and infants has dropped, they have seen an increase in the number of infants brought into the emergency room and in the number of questions phoned into the hospital about care of infants and mothers recovering from the birth process. The shortened stay does not provide the time for the physical and emotional recovery of the mother and the adaptation of the newborn to the (indisc.) uterine environment. The process of nursing a newborn is often not established with the early discharge and new mothers may encounter feeding problems without resources for solving them. It does provide a difficult situation when a physician's assessment indicates the best course of treatment is to provide continued hospitalization for the mother, but the insurance policy is limited and does not cover the additional stay. She said they recognize the need for cost containment in health care, however they see the need for safe relevant care in the most appropriate setting. The attending physician or nurse midwife is the most appropriate provider to determine when the mother and newborn are medically stable enough to be discharged. They support the mother and infant staying hospitalized on the order of a physician to be sure there are no complications and that the recovery process is successfully underway. They have begun a new program for home follow-up with new mothers and infants through their home health agency, using their experienced maternal child registered nurses. They will be assessing the infants and providing any additional teaching which may be necessary to ensure the safety and health of the newborn. This is being provided as a continuation of the hospital visit. They know that home visits are not the answer for all postpartum patients, but will provide for early intervention of those newborn or others who develop problems in the very early postpartum period. She commented they would support amendments to this bill with regard to home health services as well. She thanked the committee for the opportunity to testify. Number 1579 CO-CHAIR TOOHEY asked if Ms. McGill had found there was a reluctance to accept a doctor's recommendation for a longer hospital stay? MS. McGILL said the staff had indicated sometimes there is but often times if they can justify with the information, then the insurance reviewers, who are usually registered nurses, state the additional stay will be covered if there is medical indications. CO-CHAIR BUNDE asked Ms. McGill if the maternity unit pays for itself? MS. McGill said she didn't know. CO-CHAIR BUNDE said he had heard that maternity units were expensive to operate and other services, such as a tonsillectomy, are often padded to pay for maternity units. He felt this could lead to patients being encouraged to stay longer. CO-CHAIR TOOHEY asked if there were other questions of Ms. McGill. Hearing none, she asked Janet Oates to testify. Number 1645 JANET OATES, Representative, Providence Health System, said that she agreed with Ms. McGill in that there is a bit of a problem. They are aware of situations such as the one brought to Senator Salo's attention that prompted the introduction of this legislation. As Mr. LeBrun had mentioned, they can't say this is the rule for a particular hospital; rather there are a variety of plans and choices. In most cases, the employer is making a choice among several different options offered by an insurance company, so one insurance company could have a variety of ways and approaches to providing maternity benefits and may include the length of stay. Obviously, an employer in looking at an overall health plan, is trying to stretch the dollars to provide the most coverage to all employees. She added there are various ways the insurance companies can (indisc.) take a hospital depending on the particular plan that's being used; some are straight fee for service, some are discounts, some are per diem rate, and they can all be from the same insurance company. In the same way, the timing of when a patient is charged can depend not on the hospital, but on the particular plan - is it from the time of delivery or from the time the person walks into the hospital. MS. OATES said on the medical side, their doctors and nurses have been concerned, and as Ms. McGill said 12 to 24 hours rarely allows the physical and mental adjustment as well as the education needed for mothers and newborns, especially in the area of breast-feeding. In fact, when there has been a reluctance by an insurer to pay for an additional stay, many times the hospital as a convenience to the family, will allow them to stay longer. They do absorb the cost and it does get cost shifted. Providence Health System likes the language under Section 21.42.347(c) because it does allow some flexibility. She believes there is a movement away from the very rigid and expensively short stays in insurance plans even in the Lower 48, because they've seen it hasn't worked. She thinks there has been negative feedback from employees who complain to the employer, who then change the benefit package. She is aware there has been debate on whether this is something that needs to be addressed by the legislature, but she believes they are comfortable with this bill because there is flexibility in it and they support the intent of it. Number 1806 REPRESENTATIVE ROKEBERG said it was his understanding that Providence has adopted what could be described as a miniature or mini-managed care plan for their own employees. He asked Ms. Oates what the maternity benefits of that plan were with regard to this topic? MS. OATES responded that it was so new - it began January 1, and because she is so far removed from it, she hasn't looked at that particular benefit. She suspected they would move more toward the 48 hours, but she couldn't confirm that. She offered to look into that and provide information back to the committee. CO-CHAIR TOOHEY called Dr. Richard Nist to testify from Anchorage. Number 1853 DR. RICHARD NIST, Obstetrician/Gynecologist, testified from Anchorage via teleconference. He is on the staff at both hospitals, but he does almost all his work at the Providence Hospital. He said there can be problems with short stays in the hospital particularly with very young mothers who need extra time just to guide them in the right direction of caring for newborn babies. Alternatively, a mother who has gone through a prolonged labor may be exhausted and may not be physically up to going home at that point in time. He said it's difficult to place a standard of 24 hours for discharge for normal vaginal deliveries and it appears to him that it is important to be able to use some judgment and have some flexibility with regard to mothers and newborns. He has seen patients who have had tremendous hassles and problems with their insurance company. CO-CHAIR TOOHEY inquired if Dr. Nist, in his practice, feels this legislation is warranted? DR. NIST said he felt a lot of patients could go home after 24 hours and he didn't believe that mandating 48 hours is necessary. He simply thinks it should be a medical judgment, but also with some flexibility regarding the discharge. In other words, a physician can't always find some medical reason that a patient should not be discharged. For example, if a new mother is exhausted, he wasn't sure that would fit into an insurance company's standard. He affirmed that some flexibility is needed. Number 2008 REPRESENTATIVE ROBINSON commented this bill does not mandate, it just allows the option. REPRESENTATIVE ROKEBERG asked Dr. Nist to comment "on the position of the physician who would tend, particularly in OB/GYN, who happened to be the most involuntary litigious portion of the medical profession, wouldn't the tendency be to practice more defensive medicine by tending to allow a patient who might otherwise be discharged in 24 hours to stay an extra day?" DR. NIST said on the litigious side of it, he thinks much more involves the labor and delivery. He said he could certainly see that a doctor could run into a patient that is somewhat abusive about staying for 24 hours and the threat of potential litigation would motivate a physician to allow the patient to stay longer. Hopefully, that wouldn't happen and he thought it would be a rare occasion. He feels quite strongly that physicians would not keep patients hospitalized longer because of their fear of litigation. CO-CHAIR BUNDE said he had heard a couple of comments in discussion regarding babies who have gone home relatively quickly after delivery, become jaundiced and had to go back to the hospital. He asked if that happens to babies who stay in the hospital more than 24 or 48 hours? Also, is the going home early a factor in the jaundice or is it just more likely to be caught? DR. NIST said he didn't believe the fact that a baby goes home early influences jaundice. He thinks the pediatricians can follow up in the office. In his opinion keeping a mother longer than 48 hours would not prevent any of those problems and would simply add to the cost. CO-CHAIR TOOHEY announced that concluded the teleconference testimony. She asked Gordon Evans to present his testimony. Number 2142 GORDON EVANS, Lobbyist, Health Insurance Association of America, said the Health Insurance Association of America (HIA) is a trade association of commercial health insurance companies, but Aetna or Blue Cross is not included in their membership. He said HIA is opposed to Senate Bill 193 for a couple of reasons. First, because it mandates coverage by the use of the language "shall provide." State mandated benefits will ultimately result in increasing health care costs and limit access to health care or quality care, and this legislature just recently has gone on a mandated benefit binge. In addition to this bill, there is mandated coverage for cancer detection tests in the form of prostate testing for men and pap smears for women, as well as the coverage for victims of domestic violence. Because all of these benefits will be mandated if they pass, the insurers will have to include that factor into their underwriting considerations, which can only result in higher premiums, especially for individual premiums. As was noted earlier, with group insurance that coverage is usually negotiated and will be included, so the increase would not be noticed that much, but it would certainly reflect in an individual's policy. MR. EVANS said that HIA believes that mothers and their doctors in partnership with the health plan, can best determine when the mother and her newborn are ready to leave the hospital safely. They believe the legislature should not be making medical decisions or embodying such decisions in law, especially since the decision quite often varies according to individual circumstances. In a way, their opposition to CSSB 193(L&C) would be just adding another law on the books to cure what presently is a nonexistent problem in this state. They realize there are some anecdotal problems, but it is not prevalent. It has become obvious that the health care industry is not getting across some key points they've been making on this mostly emotional issue. First, this is not a debate about covering medically necessary care; insurers will cover that. If it is care that should be performed in the hospital and the doctor confirms that, the insurance company will cover it for as many hours as are needed. During the last decade, the health care industry has made great strides in providing and delivering quality health care at a reduced cost. One of the most noticeable ways in which this has been achieved is by lowering the number of in- patient hospital stays for a variety of illnesses, including maternity length of stay. In fact the average length of stay for maternity is not the result of a change in policy by insurance companies, but rather as a result of the long trend of stated declines. For example, the average length of stay for a vaginal delivery was 4 days in 1970, 2.2 days in 1988 and 2 days or less in 1993. This decline is consistent with the decline for other services which are also due to increasing medical knowledge and advances in the patient care process. The real issue is how insurers should cover care that is not medically necessary or is given in an unduly expensive setting such as in the hospital versus the home. Critics of early discharge programs fail to understand that not paying for unnecessary care or in an unnecessary setting is precisely what enables these insurers to offer the numerous other services that managed care programs provide, such as well- baby, dental and vision programs, all of which most people would want up to a thousand dollar a day extra day's stay in the hospital. No one wants a discharge program that jeopardizes the health of the mother or the child. As he noted earlier, insurance companies would not use early discharge programs if they were not medically safe and if they were not used only when discharge is safe. As a matter of fact, there is a lack of data to indicate that discharge before 48 hours after a vaginal delivery and before 96 hours after a caesarean section delivery is harmful or unsafe to the mother or baby. Other than isolated anecdotes of early discharge problems here in Alaska, the advocates of these new mandates such as proposed in SB 193 have provided no evidence that insurance companies doing business in Alaska are systematically, as a matter of practice, requiring mothers and newborns to be discharged before they are medically ready to be discharged. In fact, there is no evidence to suggest how long a hospital maternity stay should be. No where in medical textbooks or guides will a person find a magic number, such as 48 hours or 96 hours, mentioned. MR. EVANS said in summary, HIA believes that the services and length of hospital stays for mothers and their newborns should be determined on a case-by-case basis and on the medical necessity of both mother and child as determined jointly by the mother and her doctor and not by a legislative decision. He added that everyone knows that maternity visits or hospital stays are one of the more expensive stays. On a personal note, his daughter had a caesarean section nearly three years ago. TAPE 96-39, SIDE B Number 001 MR. EVANS continued that the hospital bill was a little over $8,800 and she and her husband were uninsured at the time. He added that Bartlett Memorial Hospital has been very good understanding and they are still paying on it. CO-CHAIR TOOHEY asked how long his daughter stayed in the hospital? MR. EVANS responded she was there six days. CO-CHAIR TOOHEY, speaking philosophically, said no one wants to pass a mandate; this is very poor legislation in that it's a very poor process for the state to have to go through. However, there is a necessity for this; it wouldn't be done if this issue wasn't coming to the forefront and needed. She noted that she had a personal experience with the delivery of a newborn baby where the parents were given such a hassle for staying one extra day and they were denied by the insurance company. MR. EVANS asked if the doctor had deemed it necessary. CO-CHAIR TOOHEY responded affirmatively. MR. EVANS said he couldn't speak to that situation. CO-CHAIR TOOHEY said if it takes this kind of legislation to save one baby and one mother, then it is important. Number 057 CO-CHAIR BUNDE said he couldn't speak to Co-Chair Toohey's experience, but he couldn't imagine a hospital throwing a patient out. He supposed that if a person said they chose to stay or the doctor requested they stay, the person may have to sign a promissory note, like he did before he could take his daughter home. CO-CHAIR TOOHEY commented that when it comes to young parents who don't have the money for an extended stay, generally the mother and newborn infant will leave the hospital. MR. EVANS commented that his daughter was 18 at the time and the hospital didn't force her to leave. Number 086 REPRESENTATIVE ROBINSON said this legislation does not mandate that everyone stay in the hospital for 48 or 96 hours; it merely states that it would be approved if the doctor and the patient believed it was necessary. MR. EVANS said that's why HIA believes it is unnecessary, because their insurance companies have indicated they already do that. REPRESENTATIVE ROBINSON questioned if that is true, why then did the hospital board of the Bartlett Memorial Hospital come to her and state that it is clearly a problem at Bartlett Memorial. MR. EVANS said frankly, the hospital has a lot of empty beds and a thousand dollars a day helps pay their bills. REPRESENTATIVE ROKEBERG inquired how many insurance companies were in the association represented by Mr. Evans. MR. EVANS said about 95 companies and added the top five companies such as Aetna, Principal and others are out of the group, but most of the others are in. REPRESENTATIVE ROKEBERG asked Mr. Evans if he was a member of the Alaska Bar Association? MR. EVANS responded yes. REPRESENTATIVE ROKEBERG said, "Can I ask the same question I asked before about the decision of a doctor where he felt there was a potential for litigation arising out of this set of circumstances, where he may be practicing preventive medicine as a result of this particular law being enacted and choose to allow the patient to stay over another day." MR. EVANS stated he did not do personal injury type work, but he knows of people that do and believes that is a correct answer. He believes that if a patient advised her doctor that she was not ready to go home, most doctors would give her that extra day. He realized that insurance companies have to agree, but the insurance companies have told him that it is usually extended if the doctor says it is necessary. REPRESENTATIVE ROKEBERG asked if Mr. Evans was aware of the vacancy rate in hospital beds in the top five hospitals in the state of Alaska. MR. EVANS said he didn't have that information readily available. CO-CHAIR TOOHEY said that wasn't the point. The point is - will the insurance company pay for it. The hospital will absorb that cost one way or another. MR. EVANS interjected, "or pass it on." Number 206 CO-CHAIR BUNDE said it had been acknowledged this legislation would probably not impact the rates for the state of Alaska with Aetna, but he questioned how it might impact rates for other insurers in the state. MR. EVANS said if it is a group policy, generally it is figured in and negotiated over the entire price. If it is an individual policy, the individual will pay for each little thing that is in the policy. If something is mandated, it has to be there rather than make it a mandated offering. The difference is that if it is mandated, an insurance company has to provide that coverage. On the other hand, if it is a mandated offering, the purchaser of the policy has the right to select it if they so desire or turn it down if they don't want it, depending on the cost. CO-CHAIR BUNDE said in the case of a group policy in which this is mandated, in his opinion 24 hours will become the norm because as Representative Rokeberg had mentioned, there is some liability involved if a patient is sent home earlier and as long as the insurance company is paying for it, the patient will stay. He noted however, that insurance companies aren't paying for it - the people who buy the insurance are paying for it and that's why he is curious about the impact on a company that isn't a huge insurer like the state of Alaska. MR. EVANS mentioned that most policies pay 80 percent, so people will pick up 20 percent of the bill anyway, even with the state of Alaska policy. He said it would have some impact on it but he just couldn't say how much. REPRESENTATIVE ROKEBERG asked if there was anyone available from the Department of Health & Social Services to explain the fiscal note. Number 322 NANCY WELLER, Division of Medical Assistance, Department of Health & Social Services, said the division operates the Medicaid program which pays for 38 percent of the births in the state of Alaska. She said this bill does not affect the Medicaid program because they are not an insurance company. REPRESENTATIVE ROKEBERG asked Ms. Weller to comment on the notation in the fiscal note regarding the potential future impact of this particular legislation if the division entered into managed care type programs. MS. WELLER said there could be some anticipated impact if they entered into a capitated arrangement at some time in the future. REPRESENTATIVE ROKEBERG asked if she had had the opportunity to look at a managed care system to see what the impacts of this type of legislation would be on in-patient hospital stays. MS. WELLER said she had not. She added that the Medicaid program currently covers 24 hours for a vaginal birth and 72 hours for a caesarean birth. There is no pre-certification or authorization, but if the patient needs to stay longer, they call the professional review organization on contract with the division and the attending physician explains the circumstances to the reviewer. An extended stay is generally tied to medical necessity or often times transportation problems because the Medicaid program covers so many people from rural Alaska who have to fly in and the discharge time is tied as much as possible with their plane time. Number 410 CO-CHAIR BUNDE commented that a thousand dollars a day was an expensive motel while waiting for an airplane. He inquired as to how long a patient normally has to wait to catch the plane. MS. WELLER said they usually don't keep people for days, but they may need to stay for an additional half day because there is no transportation to their community until the following day. CO-CHAIR BUNDE asked Ms. Weller to confirm that 38 percent of the births in Alaska are covered by Medicaid. MS. WELLER said that was correct. She added the Medicaid program covers pregnant women to 133 percent of the poverty level. CO-CHAIR TOOHEY interjected it was federally mandated. REPRESENTATIVE ROKEBERG assumed that dealing with such a large number of births and if this legislation were to pass, the division would have to change the guidelines to their utilization reviewer. He questioned if that wouldn't have a fiscal impact on the state in terms of Medicaid? MS. WELLER replied no. She said the division feels they already meet the requirement of this bill because it requires hospitalization or other medical care. She added they cover all pregnant women for 60 days following birth. CO-CHAIR BUNDE pointed out that Ms. Weller had said that Medicaid covers a 72-hour stay for a caesarean section, but this legislation calls for 96. MS. WELLER explained that it requires hospitalization or other medical care; it doesn't require in-patient hospital care. CO-CHAIR TOOHEY believed that office visits were covered under that. MS. WELLER interjected it would cover office visits or home health care, whatever the doctor orders. CO-CHAIR TOOHEY asked if there were other questions for Ms. Weller. She noted there were two individuals wishing to testify via teleconference from Fairbanks. Number 482 JANET THURSTON testified via teleconference from Fairbanks that based on the testimony given, newspaper articles and discussions with people, she has come to three conclusions. First, the problems associated with early discharge are related to poor management, follow-up and access to health care. Secondly, this legislation will not reduce infant mortality significantly in Alaska and finally, this bill as worded will not change discharge criteria. She said the initial case that prompted similar legislation in Washington was a case in New Jersey in which a woman had her baby, went home and the baby developed a rash and began throwing up formula. She called the doctor several times and was reassured that everything was okay. A nurse was supposed to come to the home, but didn't and within hours her baby died from strep B infection. Two significant problems with her management were that she was not screened pre-natalist and was not informed to return to the clinic and the visiting nurse program was poorly coordinated. She said it is important for parents and people to know this information so they understand it was not the time of discharge that created the problem; it was the fact that she didn't know she should return to the hospital or clinic. Strep B infection can occur much later than 48 hours after birth. In fact so can jaundice. She noted that most babies in Alaska who die do so after 28 days of age. Alaska infant mortality problem is associated with the high post-neonatal infant mortality rate that exceeds national levels by 30 percent. Another issue to consider is the significant problem of (indisc.) drug use. In 1989, a study at the Fairbanks Memorial Hospital revealed 14 percent of women had illicit drugs in their systems at the time of delivery. This study when repeated in Anchorage, revealed a 16 percent rate of infants exposed to drugs at birth. She asked what does that tell you about the needs of mothers and babies in Alaska? To her, it says the needs are not only in the hospitals, but in the communities as well. Taxpayers are funding health care for mothers and babies. A majority of care in the Interior is provided by government sponsored health care - Medicaid funds 50 percent of obstetric patients at Fairbanks Memorial Hospital and Champus funds beds at (indisc.) community hospital and there are many other government employed programs, so the question is "How can these dollars best be spent?" There are many examples, at (indisc.) hospital, certified nurse and midwives dropped the caesarean rate from 19 percent to 11 percent. Similarly, birth centers throughout the country were developed as alternatives to home birth and developed the early discharge system we see today, but unfortunately the process was poorly understood by most people. This early discharge program was never meant for all women. It emphasizes pre-natal education, risk identification, referral and extensive home care. She questioned why we are willing to pay $1,000 for a day in the hospital, but not $5 on programs such as coordinated home care and pre-natal education. Hospitals will not develop these programs until they are reimbursed. She had several recommendations that would be sent to the committee via facsimile. She concluded that a 24-hour stay in the hospital won't do much good as mothers do not receive the education and support they deserve. Education should be given pre-natally and continue into home and into the community. CO-CHAIR BUNDE said he shared Ms. Thurston's concerns about education. Unfortunately, if it really worked, there would never be a second FAS (fetal alcohol syndrome) birth. CO-CHAIR TOOHEY asked if there were questions of Ms. Thurston. Hearing none, she asked Pat Senner of Anchorage to testify. PAT SENNER, Executive Director, Alaska Nurses Association, testified from Anchorage that at the annual convention of the Alaska Nurses Association in October 1995, the issue of postpartum length of stay was raised and they decided to do some research to see if it really was a problem in Alaska. They did identify some problems and a lot of them related to education for mothers. They found that mothers were not able to get babies to breast feed properly, so they switched to formulas; mothers did not understand the teaching that is given in the hospitals because it occurs too soon after the child is born; and infants developing problems postpartum that were not identified quickly. A hospital stay should be viewed as a chance to educate people that may be lost in the system later on. She felt that nurses have a different definition than that of a physician of what may be medically necessary. They believe that patients should have the option of either a 48-hour length of stay or home visits by a maternal child or lactation nurse postpartum. The early home health programs started at the turn of the century actually had nurses visit every mother in the home, not just particular ones. She concluded that the Alaska Nurses Association supports CSSB 193(L&C). CO-CHAIR TOOHEY thanked Ms. Senner for her testimony and asked Scott Calder of Fairbanks to testify. Number 765 SCOTT CALDER said this legislation may not be construed to require hospitalization or medical care if the mother and the health care provider agree that it is not necessary, which should address some of the concerns raised about that issue. He thought it was fairly well known that nurses, midwives and parents are often some of the most important experts in the area of health and well-being of children. He noted that in 1994 there was a Senate bill that was drafted to put the services of a midwife at the top of the list of services to be cut from Medicaid payments. It seemed to him that placed a parent in the difficult position of not having the right as a parent to choose to save the state or government money by having Medicaid payments go to what is well known to be a more economical and probably a better quality of service for some cases. He thought this was an adequate piece of legislation, but he doesn't feel it addresses the other important issues relating to cost of birth. Number 864 CO-CHAIR TOOHEY asked if there was anyone else wishing to testify either via teleconference or in person. Hearing none, she closed public testimony. She asked what the wishes were of the committee. CO-CHAIR BUNDE distributed an amendment which would mandate the offering of this coverage rather than mandating the coverage. The amendment would delete "requiring" and insert "relating to" on page 1, line 1; delete "provide" and insert "offer" on page 1, line 6; and delete "provide" and insert "offer" on page 1, line 10. He made a motion to adopt Amendment 1. REPRESENTATIVE ROBINSON objected for discussion purposes. CO-CHAIR BUNDE explained that mandating the offering of the coverage would allow people who are of child bearing age to buy this coverage and people who are celibate wouldn't have to buy the coverage. It would simply give people the option to purchase this coverage. REPRESENTATIVE ROKEBERG appreciated the intent of the amendment, but wondered if a mere "offering" versus "provide" the coverage, would allow the insurance company to make the differential within their policy construction to make that an elective? CO-CHAIR BUNDE said perhaps the insurance representative could speak to that question, but it was his understanding that it would allow the offering of the insurance and if a person wished to take advantage of the offering, the person would then pay premiums. Number 977 SENATOR JUDY SALO, Prime Sponsor, said at first glance she didn't have any problem with the amendment, but she may after further review or discussing it with the Department of Law. As she understands the amendment, if maternity coverage is offered under a policy, whether it be an individual or a group policy, then the 48 hours and the 96 hours "shall" be provided. CO-CHAIR BUNDE reiterated he would like to hear Mr. Evans' comments on the amendment. MR. EVANS said this amendment would make it a mandated offering, and as he stated earlier, the insurance companies do not oppose a mandated offering because what that means is, for example, if a male buys an insurance policy, he is covered for a mammogram whether he wants it or not. Number 1066 REPRESENTATIVE ROBINSON withdrew her objection. CO-CHAIR TOOHEY asked if there was further objection. Hearing none, Amendment 1 was adopted. Number 1072 CO-CHAIR BUNDE made a motion to pass HCS CSSB 193(HES) out of committee with attached fiscal notes and individual recommendations. REPRESENTATIVE ROKEBERG objected for the purpose of comment. He expressed his concern regarding the zero fiscal note from the Department of Health & Social Services. His concern relates to the impact on the Medicaid payments from the state and the potential impact on everyday practice of medicine in the state. Although he appreciated the testimony from the department that we are paying for it already, but the point in fact is, they have some guidelines that Representative Rokeberg believed would have to be adjusted if this bill were to pass. CO-CHAIR TOOHEY asked if there were other comments. REPRESENTATIVE ROKEBERG withdrew his objection. CO-CHAIR TOOHEY asked if there were further objections. Hearing none, HCS CSSB 193(HES) passed from the House HESS Committee. CO-CHAIR TOOHEY turned the gavel over to CO-CHAIR BUNDE. CSSB 158(L&C) AM - PHARMACISTS AND PHARMACIES Number 1198 CO-CHAIR BUNDE announced the next order of business to come before the House HESS Committee was CSSB 158(L&C) am. He asked Dave Knight, staff to Senator Mike Miller to present the bill. DAVE KNIGHT, Researcher for Senator Mike Miller, read the following sponsor statement: "The passage of this legislation is necessary to keep the practice of pharmacy in Alaska in step with national standards and to afford the public the safety and protection it deserves. "Current statutes are antiquated and obsolete. For example, investigative personnel within the Division of Occupational Licensing have continually experienced difficulty in investigating and processing complaints against licensed personnel and facilities because of vague, inadequate or nonexistent language regarding unprofessional conduct and disciplinary sanctions. Many of the statutes are dated from the l970s and do not reflect the current practice of pharmacy or changing nature of the profession. "Using the Model State Pharmacy Act of the National Association of Boards of Pharmacy as a template, this legislation reflects over four years of work by the pharmacy community and is supported by the Alaska Pharmaceutical Association and the Alaska Board of Pharmacy." MR. KNIGHT noted that Chris Corsey, member of the State Pharmacy Association and Barbara Gabier from the Division of Occupational Licensing were available to answer any questions. REPRESENTATIVE ROKEBERG asked if there was a companion bill in the House? MR. KNIGHT responded no. Number 1290 CHRIS CORSEY, President, Alaska Board of Pharmacy, said he was also representing the Alaska Pharmaceutical Association and was one of the original authors of the Model State Pharmacy Act. He echoed Mr. Knight's comments in that the existing statutes and regulations that govern the practice of pharmacy are antiquated. For example, we require pharmacies to have reference texts which are no longer published, we do not have a definition of the practice of pharmacy in the Pharmacy Practice Act, we do not have a definition of unprofessional conduct and we don't address the use of pharmacy or recognize the use of pharmacy technicians which is an important trend in the development of pharmacy practice, especially with the effort to contain health care costs. The current statutes and regulations are a compilation of small pieces of legislation, mostly dating back to the (indisc.). He felt this legislation was good for the public and the pharmacists themselves want a higher standard and guideline by which to practice. This legislation would move the practice of pharmacy into the 1990s and he urged the committee to pass it. He noted the Division of Occupational Licensing has recommended some minor changes and as President of the Board of Pharmacy, he supports those changes. CO-CHAIR BUNDE asked if there was someone available to speak to the changes and pointed out the changes were reflected in the committee substitute before the committee. Number 1422 BARBARA GABIER, Program Coordinator, Division of Occupational Licensing, Department of Commerce & Economic Development, said the changes were minor concerns the division had with the existing wording and the committee substitute before the committee would clarify the wording. The division fully supports this legislation. She commented she would be happy to go through each of the changes if the committee so desired. CO-CHAIR BUNDE asked if the changes were substantive in nature? MS. GABIER responded no. REPRESENTATIVE ROKEBERG inquired if this legislation had another committee referral. CO-CHAIR BUNDE responded it does not have another committee referral. Number 1495 REPRESENTATIVE ROKEBERG moved to adopt HCS CSSB 158, Version 9- LS0525\R, Lauterbach, dated 4/9/96. Hearing no objection, the House Committee Substitute was adopted. Number 1515 REPRESENTATIVE ROBINSON made a motion to pass HCS CSSB 158(HES) with individual recommendations. Hearing no objection, it was so ordered. CO-CHAIR BUNDE called an at-ease at 3:31 p.m. The meeting was called back to order at 3:40 p.m. CSSB 259(HES) - COMMISSION ON AGING Number 1558 ALISON ELGEE, Deputy Commissioner, Department of Administration, said as a part of her job duties, she sits as the department designee on the Alaska Commission on Aging. She said the Alaska Commission on Aging went through a sunset review last summer and autumn under the normal course of business, and the legislative audit group recommended that the commission be eliminated from the sunset review process or alternatively have the commission extended to the year 2003. The Senate considered this bill and was uncomfortable with the extension of the commission and adopted a termination date of the year 2000. She offered to answer questions brought forward by the committee. REPRESENTATIVE ROKEBERG asked if this was the one commission in the state that looked after the elderly senior issues? MS. ELGEE responded yes. She explained the commission which began in 1981 was called the Older Alaskans Commission. The name was changed in 1994 and it is a separate review board from the Pioneers' Home Advisory Board. There is however, a reciprocal relationship in that the Chair of the Commission on Aging sits on the Pioneers' Home Advisory Board and likewise, the Pioneers' Home Advisory Board Chair sits on the Commission on Aging. The Commission on Aging, by statute, has no direct oversight or responsibility for either the Pioneers' homes or the longevity bonus program. The commission administers the federal programs that come in under the Older Americans Act. REPRESENTATIVE ROKEBERG asked if there was a federal mandate that Alaska have a commission like this? MS. ELGEE said there is a federal mandate that Alaska have a designated unit on aging. The commission acts underneath that state unit on aging because the entire Division of Senior Services is, in fact, the designated unit. The commission does the grants administration for the Older Americans Act funds. REPRESENTATIVE ROKEBERG inquired if the commission were to sunset, would that affect federal funds. MS. ELGEE pointed out that if the commission were to be eliminated, Alaska would continue to receive federal funds under the Division of Senior Services, but the department would have to develop a different process than the one currently being used for grant review and the other programs administered by the commission. REPRESENTATIVE ROKEBERG wondered if the Executive Director, at a range 23, was necessary because there was a flow of business activity that needed formal action. MS. ELGEE said the commission employs a number of staff; the Executive Director oversees those staff. They do the nutrition transportation support services grants, review and monitor the home and community based care grants, which include adult daycare centers, respite care, care coordination, etc. She added this is the unit that is, in essence, developing the home and community based long-term care services for the state. REPRESENTATIVE ROKEBERG asked if they were grant writers, not implementers? MS. ELGEE explained this unit does not write units; they review grant applications coming in from senior centers. REPRESENTATIVE ROKEBERG said he now understood and affirmed they are the repository for the requests for grants from throughout the state. MS. ELGEE confirmed that. Number 1800 CO-CHAIR BUNDE asked if there was any further testimony. Hearing none, he closed public testimony on CSSB 259(HES). Number 1807 REPRESENTATIVE ROKEBERG moved to pass CSSB 259(HES) out of committee with accompanying fiscal note and individual recommendations. Hearing no objection, it was so ordered. CO-CHAIR BUNDE announced the next order of business was CSSB 165. CSSB 165(L&C) - PSYCHOLOGISTS & PSYCHOLOGICAL ASSOCIATES  CO-CHAIR BUNDE announced there had been adequate public testimony at previous hearings and closed public testimony at this time. He asked Representative Rokeberg to present the amendments. Number 1860 REPRESENTATIVE ROKEBERG said the original HESS committee had appointed a subcommittee on CSSB 165(HES). The subcommittee came up with an amendment which addresses some of the questions raised in the committee hearing. He moved to adopt Amendment 1 for discussion purposes. REPRESENTATIVE BRICE objected for discussion purposes. CO-CHAIR BUNDE asked Representative Rokeberg to speak to the amendment. REPRESENTATIVE ROKEBERG said, "In the interest of moving this bill along, we did expedite the process and that's why I have permission of the subcommittee members, because of the further referral and I had some conversations with the various people involved in the bill and came up with what I would call consensus changes to the legislation before us, which is the Version G. The first part of the amendment relates to page 3, line 10, and this particular section of the amendment speaks to a concern that was raised about the definition of psychological services. Previously, in statute, the psychological associate license would specify areas or areas of activities of competency and that would be specified on the license. There was testimony that the scope of psychological services was found in statute, but a review of the statute showed that the definition was for -- to practice psychology, which was all encompassing, and the only statutory definition, which is all encompassing and really related particularly back to a psychologist which is different, as we know from the testimony, than a psychological associate." It was pointed out that existing regulations 12 AAC 60.185, subsection (b) states, "The standards to be adhered to a licensed psychologist and licensed psychological associates rendering psychological services in the state are `general guidelines for the providers of psychological services' 1987 edition of the American Psychological Association. General guidelines for providers of psychological services is incorporated by reference in this section." He explained that by adding the words, "as defined in regulation" adopts the reference in regulations which define the differential between a licensed psychologist and a licensed psychological associate. Therefore, the scope of work is more readily defined. REPRESENTATIVE ROKEBERG said the second part of the amendment is more substantive in form. CO-CHAIR TOOHEY asked if there would be any reason to add "and billed as such" following the insertion of "as defined in regulation." She said the amendment defines the difference between a psychologist and a psychological associate and it all comes down to the fee for service. REPRESENTATIVE ROKEBERG said he wasn't sure this section spoke to that. TAPE 96-40, SIDE A Number 001 REPRESENTATIVE ROKEBERG said he appreciated Co-Chair Toohey's position, but the scope of the work done by the subcommittee in the time frame, really didn't speak to that particular issue and it wasn't the intent of this amendment. The second part of the amendment page 3, line 13, which deletes "and (2)." and inserts ",(2) and (4)." has a major substantive affect on this bill. He referred to page 3, lines 1 and 2, which states, "(4) takes and passes the objective examination developed or approved by the board for psychological associates." He explained that by inserting (4) into Section 6, it mandates that a person would have take and pass an examination in order to receive a temporary license, which is substantially different than the version of the bill that came before the committee. The rationale is that, particularly given the shortening of the period of supervision to a two year period, a person has to pass an examination after graduating from an accredited university, but before going into the public sector as a psychological associate. Also, depending on what university attended, a person may not have the proper academic background to meet the requirements, so taking an examination is he feels the responsibility of the state in determining the educational background of the individual with a state license. It was his understanding that the people who support this legislation, also support this amendment. Number 198 REPRESENTATIVE BRICE withdrew his objection. CO-CHAIR BUNDE asked if there was further objection to Amendment 1. Hearing none, Amendment 1 was adopted. He asked for the wishes of the committee. Number 228 REPRESENTATIVE ROKEBERG moved CSSB 165(L&C), Version G, as amended with attached fiscal notes and individual recommendations. Hearing no objection, it was so ordered. ADJOURNMENT CO-CHAIR BUNDE adjourned the House Health, Education, and Social Service Committee meeting at 3:53 p.m.