ALASKA STATE LEGISLATURE  HOUSE HEALTH, EDUCATION AND SOCIAL SERVICES  STANDING COMMITTEE  March 20, 2001 3:03 p.m. MEMBERS PRESENT Representative Fred Dyson, Chair Representative Peggy Wilson, Vice Chair Representative John Coghill Representative Gary Stevens Representative Vic Kohring Representative Sharon Cissna MEMBERS ABSENT  Representative Reggie Joule COMMITTEE CALENDAR  HOUSE BILL NO. 115 "An Act allowing a physician assistant or advanced nurse practitioner to certify the need for emergency treatment as a result of intoxication." - HEARD AND HELD HOUSE BILL NO. 113 "An Act relating to health care insurance payments for hospital or medical services; and providing for an effective date." - MOVED CSHB 113(HES) OUT OF COMMITTEE HOUSE BILL NO. 124 "An Act prohibiting nursing facilities and assisted living homes from employing or allowing access by persons with certain criminal backgrounds, with exceptions." - BILL HEARING CANCELED   PREVIOUS ACTION  BILL: HB 115 SHORT TITLE:EMERGENCY COMMITMENT ORDERS SPONSOR(S): REPRESENTATIVE(S)KAPSNER Jrn-Date Jrn-Page Action 02/07/01 0263 (H) READ THE FIRST TIME - REFERRALS 02/07/01 0263 (H) HES 02/07/01 0263 (H) REFERRED TO HES 03/07/01 0501 (H) COSPONSOR(S): DYSON 03/20/01 (H) HES AT 3:00 PM CAPITOL 106 BILL: HB 113 SHORT TITLE:HEALTH CARE INSURANCE PAYMENTS SPONSOR(S): REPRESENTATIVE(S)GREEN Jrn-Date Jrn-Page Action 02/05/01 0241 (H) READ THE FIRST TIME - REFERRALS 02/05/01 0241 (H) L&C, HES 02/26/01 (H) L&C AT 3:15 PM CAPITOL 17 02/26/01 (H) Heard & Held MINUTE(L&C) 02/28/01 (H) L&C AT 3:15 PM CAPITOL 17 02/28/01 (H) Moved CSHB 113(L&C) Out of Committee MINUTE(L&C) 03/07/01 0496 (H) L&C RPT CS(L&C) 3DP 2NR 1AM 03/07/01 0496 (H) DP: CRAWFORD, HAYES, MEYER; 03/07/01 0496 (H) NR: HALCRO, MURKOWSKI; AM: ROKEBERG 03/07/01 0496 (H) FN1: ZERO(CED) 03/07/01 0496 (H) FN2: INDETERMINATE(ADM) 03/13/01 0579 (H) COSPONSOR(S): DYSON 03/20/01 (H) HES AT 3:00 PM CAPITOL 106 WITNESS REGISTER REPRESENTATIVE MARY KAPSNER Alaska State Legislature Capitol Building, Room 424 Juneau, Alaska 99801 POSITION STATEMENT: Sponsor of HB 115. SENATOR DONALD OLSON Alaska State Legislature Capitol Building, Room 510 Juneau, Alaska 99801 POSITION STATEMENT: Cross-sponsor of HB 115. PAM WATTS, Director Governor's Advisory Board on Alcoholism & Drug Abuse Office of the Commissioner Department of Health & Social Services PO Box 110608 Juneau, Alaska 99801 POSITION STATEMENT: Testified on HB 115.   BARBARA CRAVER, Attorney 506 West 9th Street Juneau, Alaska 99801 POSITION STATEMENT: Answered questions on HB 115 on behalf of herself and Pam Watts. ANNE HENRY, Special Projects Coordinator Division of Mental Health & Developmental Disabilities Department of Health & Social Services PO Box 110620 Juneau, Alaska 99811 POSITION STATEMENT: Testified on HB 115. REPRESENTATIVE JOE GREEN Alaska State Legislature Capitol Building, Room 403 Juneau, Alaska 99801 POSITION STATEMENT: Sponsor of HB 113. KEVIN JARDELL, Staff to Representative Joe Green Alaska State Legislature Capitol Building, Room 403 Juneau, Alaska 99801 POSITION STATEMENT: Testified on HB 113 on behalf of the sponsor. JIM JORDAN, Executive Director Alaska State Medical Association 4107 Laurel Street Anchorage, Alaska 99508 POSITION STATEMENT: Testified on HB 113. KATIE CAMPBELL, Actuary Life/Health Division of Insurance Department of Community & Economic Development PO Box 11805 Juneau, Alaska 99811 POSITION STATEMENT: Testified on HB 113. NICOLE BAGBY, Account Executive Aetna 601 Union Street Seattle, Washington 98101 POSITION STATEMENT: Testified on HB 113. ACTION NARRATIVE TAPE 01-30, SIDE A Number 0001 CHAIR FRED DYSON called the House Health, Education and Social Services Standing Committee meeting to order at 3:03 p.m. Members present at the call to order were Representatives Dyson, Wilson, Coghill, Stevens, and Kohring. Representative Cissna joined the meeting as it was in progress. HB 115-EMERGENCY COMMITMENT ORDERS CHAIR DYSON announced that the first order of business would be HOUSE BILL NO. 115, "An Act allowing a physician assistant or advanced nurse practitioner to certify the need for emergency treatment as a result of intoxication." Number 0160 REPRESENTATIVE MARY KAPSNER, Alaska State Legislature, came forth as sponsor of HB 115. She stated that this bill proposes to change the involuntary commitment statute, Title 47, to allow midlevel practitioners such as physician assistants and advanced nurse practitioners to sign medical certificates of necessity for treatment for individuals with alcohol and drug dependency. Number 0216 REPRESENTATIVE COGHILL made a motion to adopt the proposed committee substitute (CS) for HB 115, version 22-LS0059\F, Ford, 2/15/01, as a work draft. There being no objection, proposed CSHB 115 was before the committee. REPRESENTATIVE KAPSNER continued, stating that this bill also expands the definition of mental health professional to include licensed clinical social workers, licensed marital and family therapists, and licensed professional counselors. She explained to the committee the reason she decided to sponsor this bill. She said: The requirement that a physician involuntarily commit patients is quite burdensome, especially in remote and rural areas of Alaska where physicians aren't readily accessible in many instances. This results in reduced access to treatment for those vulnerable Alaskans, many of whom move through both the criminal justice system and emergency medical facilities. The proposed change will allow communities where physicians may not be present to utilize physician's assistants and advanced nurse practitioners who staff local clinics to complete the required certificates of necessity for treatment. REPRESENTATIVE KAPSNER remarked that she hasn't met anyone opposed to this legislation. Number 0350 SENATOR DONALD OLSON, Alaska State Legislature, came forth as cross-sponsor of HB 115. He remarked that he is privileged to be a part of this bill, having gone to medical school and return to practice health care amongst the people that he was raised and grew up with in the Nome area. He said the reason he came back was because there was a significant physician shortage in Western Alaska and all of the Bush hospitals. Number 0464 SENATOR OLSON remarked that Nome recognized [the shortage] early on and fairly aggressively recruited physicians. He shared that [once] during the shortage he had a lady in the delivery room, a gunshot victim in the emergency room, a knifing going on in the village, and he was by himself. He said that the last thing he wanted to be doing was giving the nod to an evaluation by a midlevel person saying that he or she wanted to commit a person. Number 0555 CHAIR DYSON asked Senator Olson if he sees any chances of abuse [under this bill]. SENATOR OLSON replied that with any type of bill there is possible abuse. He said he feels that the portion of times that it has happened has been very minimal. He stated that right now, especially in rural Alaska, there are midlevel practitioners who are doing almost the same things that fully licensed physicians are doing, and they take that responsibility with a fair amount of weight. He remarked that he had never seen it abused. CHAIR DYSON asked if someone in power commits a person, what rights a person has to appeal. Number 0685 REPRESENTATIVE STEVENS asked Senator Olson what the process is when somebody certifies an individual as needing emergency treatment. SENATOR OLSON answered that if somebody comes to the emergency room in the middle of the night while the physician on call is there and a midlevel practitioner admits the person, there is usually a protocol for him or her to have emergency treatment. Mainly, someone from mental health or substance abuse gets involved. He stated that if a patient is seen out in a rural setting by somebody who thinks he or she needs to be admitted or committed, it is the obligation of the physician in charge to send a "Medivac" with adequate personnel to make sure that the health and welfare of [the patient] is taken care of. The person would then go to a hospital, where the same thing would occur as if he or she had gone to the emergency room. Number 0830 PAM WATTS, Director, Governor's Advisory Board on Alcoholism & Drug Abuse (ABADA), Office of the Commissioner, Department of Health & Social Services, came forth and stated that the [ABADA] supports HB 115. She said the involuntary commitment statute in the state requires that a licensed physician in Alaska be able to sign a certificate of necessity for treatment that must accompany a petition for commitment. She stated that the problem is that in rural communities there often are not physicians available. Although the physician is not generally the person who is actually applying for the commitment, the physical examination has to be conducted by a licensed physician. She remarked that the end result is that many rural residents who are eligible for involuntary alcohol commitments keep rotating through the correctional system and don't get the help they need because there is no one available to sign the certificates. She added that physicians are understandably reluctant to sign [following a telephone call], without physically examining the individual. CHAIR DYSON asked what civil rights protections the patients have. Number 0990 BARBARA CRAVER, Attorney, [speaking on behalf of herself and Pam Watts] responded that there are actually three different procedures being dealt with by HB 115. She stated that according to the title [of the bill], the first part of the Act, Section 1, talks about a mental health commitment. This is a special kind of commitment for people who may harm themselves or others due to a mental health disability or condition. She stated that she believes that the ex parte commitment is an initial 72-hour hold. If it is decided that the person is suitable for a longer commitment of 30 days, he or she will have an attorney appointed and a judge must issue the commitment order. Number 1042 REPRESENTATIVE WILSON asked who would [issue the commitment order] in areas such as Wrangell, where there isn't a judge. MS. CRAVER answered that an ex parte commitment is a 72-hour hold and she doesn't believe that a judge has to be present in granting that. REPRESENTATIVE WILSON remarked that she was involved in something similar to this in Wrangell and a magistrate was involved. MS. CRAVER remarked that there may be some kind of a preliminary judicial involvement in the beginning of the mental health procedures, but for a short-term situation the judicial involvement is fairly minimal. She continued, stating that Sections 2 and 3 deal with an emergency commitment for alcohol and drug abuse to public treatment facilities, which is a fairly select group of facilities. She stated that Sections 4 and 5 apply to a long-term commitment for alcohol or drug abuse. People who are issued an alcohol commitment are entitled to an attorney and a court-appointed attorney if they are indigent. They are encouraged within the 48-hour period, in Sections 2 and 3, to have access to legal counsel. She stated that if a 30-day commitment is sought under [Sections 4 and 5], a person is entitled to an attorney and a trial before a judge. She added that there are two opportunities for the petitioner to go back for 180-day recommitments. She noted that [people who are involuntarily committed] basically have the same rights as if in a criminal trial. Number 1197 REPRESENTATIVE COGHILL asked Ms. Craver to clarify what she said about Section 1. MS. CRAVER replied that she has never dealt with a mental health commitment, but she believes that when a longer hold is issued an attorney must be appointed to the person. REPRESENTATIVE STEVENS remarked that the title [of the bill] speaks just to intoxication, yet the body talks about mental health and long-term care. He asked if this is the proper format and if the title should reflect all of the changes being requested in the bill. CHAIR DYSON replied that a [semi] colon on line 2 of the title makes mental health proceedings separate, in parallel construction to civil proceedings on line 3. MS. WATTS stated that the section pertaining to mental health professionals doesn't change who can commit people for a mental health commitment. The issue is that a number of mental health professionals currently do the examinations that are then reviewed by a psychiatrist prior to a commitment. She stated that this would amend the statute to broaden the definition of mental health professional. Number 1469 ANNE HENRY, Special Projects Coordinator, Division of Mental Health & Developmental Disabilities, Department of Health & Social Services, came forth to testify on HB 115. She stated: The Division of Mental Health & Developmental Disabilities supports the efforts to expand the pool of mental health professional available to do mental health civil commitments as an issue of increasing consumer health and safety. When a person with a mental health problem seeks an evaluation for possible admittance to a mental health hospital facility, a mental health professional (MHP) is called upon to conduct the evaluation. The goal of the evaluation is to determine whether or not the individual has a mental health illness and, as a result, is gravely disabled or likely to cause serious harm to self or others. The goal of that mental health professional at the time that [he or she is] doing that evaluation is actually to do the least restrictive thing for that patient. If the MHP determines that the individual fits the criteria for civil commitment, and the individual refuses voluntary hospitalization, a call is placed to a consulting psychiatrist or physician. And if that psychiatrist or physician concurs with the evaluation of the MHP, then they contact a judge. ... The judge hearing the results of the evaluation and the concurrence of the psychiatrist and physician then makes the decision whether or not to involuntarily commit that person. There is currently very limited choice of who is eligible to do these commitments. According to the current statutes a mental health professional is defined as a psychiatrist or physician who is licensed to practice in this state or employed by the federal government; a clinical psychologist licensed by the board; a psychological associate trained in clinical psychology and licensed by the state Board of Psychologists and Psychological Associate Examiners; or a trained nurse with a master's degree in psychiatric nursing, licensed by the State Board of Nursing; and a social worker with a master's degree in social work with substantial experience in the field of mental illness. MS. HENRY remarked that this statute was written in 1986 and since then the state has licensed social workers, marital and family therapists, and licensed professional counselors. Number 1594 MS. HENRY continued, stating: In mental health agencies across the state, there are approximately 140 mental health clinicians doing emergency service evaluations. In reality, currently, about half of these folks fit the legal definition of who's able to do this MHP evaluation. And in rural areas this is particularly difficult, to get licensed folks. MS. HENRY remarked that the state recognizes all of these different clinicians as having at least two years' worth of post-graduate experience and having passed examinations or rigorous scrutiny from the boards that license them. The Department of Health & Social Services encourages this definition change, and the Alaska Mental Health Board supports the bill. She remarked that requiring licensure and including all of the master's-level mental health clinicians enlarges the pool of MHPs who must meet the legislatively mandated standards of education, experience, and professionalism. REPRESENTATIVE STEVENS stated that he understands the logic of changing the rules of who can commit someone for alcohol [abuse] in a village or in a difficult situation in which there needs to be an emergency decision. He asked why this would also be needed for a long-term situation, since there would be more time for a physician or psychiatrist to make the decision. REPRESENTATIVE KAPSNER replied that she doesn't know how much [the bill] is directly related to just emergency situations. Midlevel practitioners do a lot of the person-to-person interaction, and there is a dearth of doctors statewide, so this would eliminate a middleman. REPRESENTATIVE STEVENS remarked that a 30-day involuntary commitment is such a serious issue he can't imagine that the rules should be changed for that. Number 1759 REPRESENTATIVE WILSON shared that when she lived in Tok and worked in a clinic the only [medical] people there were almost always advanced practitioners or PAs (physician assistants). When someone came in who needed help, there was limited [staff]. She stated that sometimes a 30-day program is available right away. If that person can go right then, when that slot is open, the [staff needs to act fast]. MS. CRAVER suggested that in Section 4, page 3, line 4, the words "physician" and "of the examination" could be deleted because if the section is passed, the bill is expanding the people who can make the examination to a licensed physician, physician assistant, or advanced nurse practitioner. She added that the language could state, "The certificate must set out the medical examiner's findings." Number 1880 CHAIR DYSON clarified that the proposed amendment on page 3, line 4, deletes "physician's" and "of the examination" and inserts the word "medical examiner's" where the word "physician's" had been. [No objection was stated, and he announced that Amendment 1 was adopted.] MS. CRAVER proposed an amendment that in Section 5, page 3, line 10, "AS 47.37.180(b) or" should be deleted because it refers to an emergency commitment under AS 47.37.180, which is a distinct and separate commitment from a 30-day commitment under AS 47.37.190 and AS 47.37.200. Number 1922 CHAIR DYSON clarified that Amendment 2 would delete on page 3, line 10, "AS 47.37.180(b) or". [No objection was stated, and he announced that Amendment 2 was adopted.] MS. CRAVER proposed an amendment in Section 5, lines 14 and 15, that "AS.47.37.180(b) or" be deleted so that it would read, "If the person has refused to be examined under AS 47.37.190(a)". Number 1962 CHAIR DYSON clarified that Amendment 3 would delete "AS 47.37.180 (b) or". [No objection was stated, and he announced that Amendment 3 was adopted.] CHAIR DYSON stated that he was going to hold this bill over in order for Representative Kapsner to assure the committee, referring to Representative Stevens' point, that during the 30- day commitment there is not a licensed physician generally available. [HB 115 was held over.] HB 113-HEALTH CARE INSURANCE PAYMENTS CHAIR DYSON announced that the committee would hear HOUSE BILL NO. 113, "An Act relating to health care insurance payments for hospital or medical services; and providing for an effective date." [Before the committee was CSHB 113(L&C).] Number 2038 REPRESENTATIVE COGHILL made a motion to adopt the proposed committee substitute (CS) for HB 113, version O, 22-LS0418\O, Ford, 3/19/01, as a work draft. There being no objection, proposed CSHB 113, Version O, was before the committee. Number 2050 REPRESENTATIVE JOE GREEN, Alaska State Legislature, came forth as sponsor of HB 113. He stated that HB 113 allows physicians to be reimbursed from insurance carriers in a reasonable time, which is 30 calendar days. If for some reason the insurance company finds a defect in the claim, the physician must provide a "clean claim," and then there are 15 calendar days, from that point, for the insurance company to make payment. CHAIR DYSON asked if the bill allows or requires [the insurance companies] to promptly pay. REPRESENTATIVE GREEN answered yes, [it requires the insurance companies to promptly pay]. Number 2120 KEVIN JARDELL, Staff to Representative Joe Green, Alaska State Legislature, stated that Section 1 requires the director of the Division of Insurance to place in his or her annual report the percentage of claims that are meeting the deadlines imposed by the legislation in order to see how it is having an effect on the insurance companies and providers. He stated that Section 2 ensures that if insurers receive a clean claim, they have 30 calendar days to pay that. If they do not in fact send that payment by the 30th day, interest will begin accruing on the outstanding claim. He said if the claim is not clean, the physician has 30 days to notify the provider or the insured as to what items are necessary to complete it as a clean claim and to make a judgment as to whether or not it is covered. CHAIR DYSON asked who decides what's clean. MR. JARDELL replied that there is a standard form that providers use to send claims to the insurers. Insurers will look at the claim and decide whether all the necessary information is there on that claim. If [the insurer] sees that there are items missing, [the insurer] can send a notification to the provider or the insured of what certain individual items are needed for determination. He remarked that in situations in which there is a "bad faith" action and insurers are saying that things are necessary that aren't, complaints would be expected to be filed with the Division of Insurance, which would then appropriately address them. Number 2212 REPRESENTATIVE WILSON asked what a clean claim is. MR. JARDELL answered that a clean claim is defined in subsection (k), as, "a claim that does not have a defect, impropriety, or circumstance requiring special treatment that [precludes] timely payment on the claim." He stated that definitions similar to this are used for Medicare payments. He added that he understands this is a broad definition, which is somewhat beneficial to the insurers. Number 2287 JIM JORDAN, Executive Director, Alaska State Medical Association, testified via teleconference. He clarified that the bill covers other types of medical care providers besides physicians such as hospitals, dentists, and nurses. CHAIR DYSON stated that his wife is a mental health provider; he asked if this bill would allow her to get paid quicker. MR. JARDELL responded that it is his understanding that an insurance claim made for a mental health provider would be covered. Number 2341 REPRESENTATIVE STEVENS remarked that, in Section 1, the bill asks something additional of the director of [the Division of] Insurance. He asked if there is an additional cost that would be accrued to find these figures. TAPE 01-30, SIDE B KEVIN JARDELL answered that it is his understanding that [the director has such a long report], this would not be burdensome. Number 2337 KATIE CAMPBELL, Actuary Life/Health, Division of Insurance, Department of Community & Economic Development, came forth in support of HB 113. In response to Representative Stevens' questions, she stated that it shouldn't be an additional expense. She explained that [the Division of Insurance] sends out a survey every year to the health insurers. REPRESENTATIVE COGHILL remarked that he noticed the effective date is 2002 and asked if that was to allow for more time to compile the information. MR. JARDELL responded that the extended effective date was to make sure the insurers have time to update their computers and systems in order to not "get behind the curve". Number 2259 NICOLE BAGBY, Account Executive, Aetna, testified via teleconference. She stated that Aetna is a large payer of health benefit claims in Alaska, in addition to other vendors. She stated that many customers in Alaska are self-funded, such as the State of Alaska, and [Aetna] serves as their plan administrator. Aetna does not profit from any delay in the payment of claims and, she said, the money to fund the payment of claims usually resides in the customer's bank account, not [Aetna's]. She stated that all of [Aetna's] large contracts with customers already have performance guarantees, which can financially penalize [Aetna] if it doesn't pay claims within agreed-upon timeframes. She noted that [the timeframes] are usually 30 days or less. MS. BAGBY continued, stating that [Aetna] also fully insures about 10,000 individuals in the state of Alaska, which is a small number compared to the total fully insured market segment. She concluded that with the amendments adopted by the House Labor and Commerce Standing Committee and the subsequent changes suggested by Representative Green, [Aetna] feels this requirement is in line with and similar to other states' statutes. MR. JARDELL, in response to Chair Dyson's earlier question, stated that he believes if the group insurance policy covered mental health issues it would be covered under this requirement. Number 2148 REPRESENTATIVE STEVENS asked why the [requirement] is necessary if, as Nicole Bagby said, it's in line with similar and other statutes. MR. JARDELL replied that he believes it is in line with other states' statutes, but not Alaska's. Number 2125 REPRESENTATIVE COGHILL made a motion to move the CS for HB 113, Version O, [22-LS0418\O, Ford, 3/19/01] from committee with individual recommendations and the attached zero fiscal note. REPRESENTATIVE KOHRING objected for comments. He asked what prompted the need for this legislation, MR. JARDELL responded that a number of providers had approached Representative Green's office and outlined some of the problems they were having, when dealing with the insurance companies under the current statute and regulations, with timely payments and receipts to those payments. He reported that currently the statute says an insurer may pay within 30 working days and that there is a provision that if the insured puts in writing the requirement, then [the insurer] must pay within 30 working days. Under the regulations [3] AAC 26.040, there is a ten-day notification whereby the insurance company is supposed to notify [the first-party claimant], identifying the person handling the claim including the person's name, and address, and phone number ,and file number of the claim. Under [3 AAC 26.070] there's a 15-working-day notification requirement to advise, in writing, of acceptance or denial. If further time is required, the reasons must be given and then there is a 30-working-day requirement to pay a complete claim. MR. JARDELL continued, stating that under [3 AAC 26.050] there is a 30-working-day requirement to give notification that specifically states the need and reasons for additional investigative time. After that, [3 AAC 26.070] says that within 45 working days after initial notification, reasons must be given if more investigation is needed; after that, [reasons must be given] every 45 working days until the insurance company determines whether they should be paid or not. He added that there's no finality; therefore, without some structure to hold the insurance companies accountable, it was the belief of the providers that their intake procedures were not efficient or effective. He remarked that they have never been forced to be effective because there is no requirement to pay within a certain time. Number 2001 REPRESENTATIVE KOHRING remarked that he understands that there are statutory requirements in place. He stated that he was wondering if there were any specific examples [of problems]. CHAIR DYSON responded that there certainly are to him. He remarked that a significant number of medical providers had said that they were waiting up to four months to be paid. REPRESENTATIVE KOHRING added that he sees this legislation as using the heavy hand of government to force an industry to operate a certain way. REPRESENTATIVE GREEN suggested that the heavy-handedness is actually more of a compromise. He stated that [this legislation] has brought the two factions together, and that both sides have agreed through this bill. REPRESENTATIVE KOHRING removed his objection. Number 1902 CHAIR DYSON announced that there being no objection, CSHB 113(HES) moved from the House Health, Education and Social Services Standing Committee. CHAIR DYSON called for an at-ease at 4:03 p.m. in order to hear the overviews regarding the Alaska Community Health Association and the American Institute of Full Employment. [The minutes for the overview on the Alaska Community Health Association are found in the 4:09 p.m. minutes for the same date, and the minutes for the overview on the American Institute of Full Employment are found in the 4:25 p.m. minutes for the same date.]