ALASKA STATE LEGISLATURE  HOUSE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE  May 3, 2022 3:09 p.m. MEMBERS PRESENT Representative Tiffany Zulkosky, Co-Chair Representative Ivy Spohnholz Representative Zack Fields Representative Ken McCarty Representative Mike Prax MEMBERS ABSENT  Representative Liz Snyder, Co-Chair Representative Christopher Kurka COMMITTEE CALENDAR  CS FOR SENATE BILL NO. 98(FIN) "An Act relating to adult adoption; relating to medical assistance for recipients of adult home care services; establishing an adult home care home license and procedures; providing for the transition of individuals from foster care to adult home care settings; and providing for an effective date." - HEARD & HELD SENATE BILL NO. 132 "An Act exempting veterinarians from the requirements of the controlled substance prescription database." - HEARD & HELD PREVIOUS COMMITTEE ACTION  BILL: SB 98 SHORT TITLE: ADULT HOME CARE; ADULT ADOPTION SPONSOR(s): RULES BY REQUEST OF THE GOVERNOR 03/03/21 (S) READ THE FIRST TIME - REFERRALS 03/03/21 (S) HSS, FIN 03/18/21 (S) HSS AT 1:30 PM BUTROVICH 205 03/18/21 (S) Heard & Held 03/18/21 (S) MINUTE(HSS) 03/30/21 (S) HSS AT 1:30 PM BUTROVICH 205 03/30/21 (S) Moved SB 98 Out of Committee 03/30/21 (S) MINUTE(HSS) 03/31/21 (S) HSS RPT 4DP 1NR 03/31/21 (S) DP: WILSON, BEGICH, COSTELLO, HUGHES 03/31/21 (S) NR: REINBOLD 04/07/21 (S) FIN AT 9:00 AM SENATE FINANCE 532 04/07/21 (S) Heard & Held 04/07/21 (S) MINUTE(FIN) 03/31/22 (S) FIN AT 9:00 AM SENATE FINANCE 532 03/31/22 (S) 04/05/22 (S) FIN AT 9:00 AM SENATE FINANCE 532 04/05/22 (S) Heard & Held 04/05/22 (S) MINUTE(FIN) 04/12/22 (S) FIN AT 1:00 PM SENATE FINANCE 532 04/12/22 (S) Moved CSSB 98(FIN) Out of Committee 04/12/22 (S) MINUTE(FIN) 04/15/22 (S) FIN RPT CS 4DP NEW TITLE 04/15/22 (S) DP: STEDMAN, BISHOP, HOFFMAN, WIELECHOWSKI 04/27/22 (S) TRANSMITTED TO (H) 04/27/22 (S) VERSION: CSSB 98(FIN) 04/29/22 (H) READ THE FIRST TIME - REFERRALS 04/29/22 (H) HSS, FIN 05/03/22 (H) HSS AT 3:00 PM DAVIS 106 BILL: SB 132 SHORT TITLE: CONTROLLED SUB. DATA: EXEMPT VETERINARIAN SPONSOR(s): HOLLAND 04/28/21 (S) READ THE FIRST TIME - REFERRALS 04/28/21 (S) HSS, L&C 02/03/22 (S) HSS AT 1:30 PM BUTROVICH 205 02/03/22 (S) Heard & Held 02/03/22 (S) MINUTE(HSS) 02/08/22 (S) HSS AT 1:30 PM BUTROVICH 205 02/08/22 (S) Moved SB 132 Out of Committee 02/08/22 (S) MINUTE(HSS) 02/09/22 (S) HSS RPT 4DP 02/09/22 (S) DP: WILSON, REINBOLD, BEGICH, HUGHES 02/23/22 (S) L&C AT 1:30 PM BELTZ 105 (TSBldg) 02/23/22 (S) Heard & Held 02/23/22 (S) MINUTE(L&C) 03/02/22 (S) L&C AT 1:30 PM BELTZ 105 (TSBldg) 03/02/22 (S) Moved SB 132 Out of Committee 03/02/22 (S) MINUTE(L&C) 03/04/22 (S) L&C RPT 2NR 1DP 03/04/22 (S) NR: COSTELLO, REVAK 03/04/22 (S) DP: GRAY-JACKSON 03/04/22 (S) FIN REFERRAL ADDED AFTER L&C 03/17/22 (S) FIN AT 9:00 AM SENATE FINANCE 532 03/17/22 (S) Heard & Held 03/17/22 (S) MINUTE(FIN) 03/22/22 (S) FIN AT 9:00 AM SENATE FINANCE 532 03/22/22 (S) Moved SB 132 Out of Committee 03/22/22 (S) MINUTE(FIN) 03/23/22 (S) FIN RPT 7DP 03/23/22 (S) DP: STEDMAN, BISHOP, HOFFMAN, WILSON, WIELECHOWSKI, OLSON, VON IMHOF 03/28/22 (S) TRANSMITTED TO (H) 03/28/22 (S) VERSION: SB 132 04/04/22 (H) READ THE FIRST TIME - REFERRALS 04/04/22 (H) HSS, L&C 04/14/22 (H) HSS AT 3:00 PM DAVIS 106 04/14/22 (H) Scheduled but Not Heard 04/19/22 (H) HSS AT 3:00 PM DAVIS 106 04/19/22 (H) -- MEETING CANCELED -- 04/26/22 (H) HSS AT 3:00 PM DAVIS 106 04/26/22 (H) Heard & Held 04/26/22 (H) MINUTE(HSS) 04/28/22 (H) HSS AT 3:00 PM DAVIS 106 04/28/22 (H) Heard & Held 04/28/22 (H) MINUTE(HSS) 05/03/22 (H) HSS AT 3:00 PM DAVIS 106 WITNESS REGISTER JOHN LEE, Director Division of Senior and Disabilities Services Department of Health and Social Services Juneau, Alaska POSITION STATEMENT: Explained the changes in CSSB 98(FIN), on behalf of the bill sponsor, Senate Rules by request of the governor and answered questions. TONY NEWMAN, Deputy Director Division of Senior and Disability Services Department of Health and Social Services Juneau, Alaska POSITION STATEMENT: Gave the sectional analysis for CSSB 98(FIN), on behalf of the bill sponsor, Senate rules by request of the governor and answered questions. CRAIG BAXTER, Program Manager Residential Life Division of Health Care Services Department of Health and Social Services Anchorage, Alaska POSITION STATEMENT: Responded to questions during the hearing on CSSB 98(FIN). STEPHANIE WHEELER, Long Term Care Ombudsman Department of Revenue Anchorage, Alaska POSITION STATEMENT: Testified in support of SB 98. MICHELE GIRAULT, Executive Director Hope Community Resources Anchorage, Alaska POSITION STATEMENT: Testified in favor of the concept of SB 98. LIZETTE STIEHR, Executive Director Alaska Association on Developmental Disabilities Chugiak, Alaska POSITION STATEMENT: Testified during the hearing on SB 98. JIM DELKER, DVM, Legislative Liaison Alaska Veterinary Medical Association Soldotna, Alaska POSITION STATEMENT: Gave invited testimony during the hearing on SB 132. TRACY WARD, DVM, President Alaska Veterinary Medical Association Juneau, Alaska POSITION STATEMENT: Gave invited testimony during the hearing on SB 132. LAURA CARRILLO, MPH, Executive Administrator Alaska Board of Pharmacy Prescription and Drug Monitoring Program Division of Corporations, Business and Professional Licensing Department of Commerce, Community & Economic Development Juneau, Alaska POSITION STATEMENT: Answered questions during the hearing on SB 132. MCKAYLA DICK, DVM, Past President Alaska Veterinary Medical Association North Pole, Alaska POSITION STATEMENT: Answered questions during the hearing on SB 132. HAL GEIGER, PhD, Member Board of Veterinary Examiners Juneau, Alaska POSITION STATEMENT: Provided information during the hearing on SB 132. SARA CHAMBERS, Director Division of Corporations, Business and Professional Licensing Department of Commerce, Community and Economic Development Juneau, Alaska POSITION STATEMENT: Provided information during the hearing on SB 132. NICHOLAS PAPACOSTAS, MD, FACEP Alaska Chapter American College of Emergency Physicians Anchorage, Alaska POSITION STATEMENT: Answered questions during the hearing on SB 132. ACTION NARRATIVE  3:09:12 PM CO-CHAIR ZULKOSKY called the House Health and Social Services Standing Committee meeting to order at 3:09 p.m. Representatives Spohnholz, Fields, McCarty, and Zulkosky were present at the call to order. Representative Prax arrived as the meeting was in progress. SB 98-ADULT HOME CARE; ADULT ADOPTION  3:10:32 PM CO-CHAIR ZULKOSKY announced that the first order of business would be SENATE BILL NO. 98, "An Act relating to medical assistance for recipients of adult foster care services; establishing an adult foster care home license and procedures; and providing for the transition of individuals from foster care to adult foster care homes." [Before the committee was CSSB 98(FIN), reported out of the Senate Finance Committee on April 12, 2022.] 3:11:09 PM JOHN LEE, Director, Division of Senior and Disabilities Services, Department of Health and Social Services (DHSS), on behalf of the bill sponsor, Senate Rules by request of the governor, explained the changes to CSSB 98(FIN) made by the Senate Finance Committee. He stated that the bill was amended to widen its reach and strengthen the home- and community-based support for Alaska's vulnerable populations. He said that the changes were inspired by one central idea - whether adult foster care services could be extended to more people than just those aging out of the foster care system. When this question was asked to stakeholders, he reported, the response was "an enthusiastic 'yes.'" He explained that the change would mean more opportunities for community-based care, create options less expensive than group homes, have less demanding staffing requirements, and allow care to be provided in a home-like setting. He added that the intention would be to have the regulations mirror child foster parent and home expectations. He stated that these changes would allow more seniors to receive care within their communities instead of having to move to urban areas where senior living facilities were more available. He posited that there could also be an economic benefit. He said that there would be some additional staff required for monitoring this new type of care setting, but otherwise providing the service would be cost neutral to the state. CO-CHAIR ZULKOSKY asked for a review of the sectional analysis. 3:14:32 PM TONY NEWMAN, Deputy Director, Division of Senior and Disability Services, Department of Health and Social Services, on behalf of the bill sponsor, Senate Rules by request of the governor, gave the sectional analysis for CSSB 98(FIN) [included in the committee packet], which read as follows [original punctuation provided]: Section 1: Amends AS 25.23, Who May Adopt, to allow for the adoption of an adult by only one member of a married couple as long as the spouse consents to the adoption. Section 2: Adds a new section to AS 47.07, Medicaid Assistance for Needy Persons, to create a new program- adult home care services for individuals. Adult home care services will be available for individuals at least 18 years of age or older who are enrolled in a home and community-base[d] waiver. The Department of Health will develop regulations establishing the standards and rates of the program and providing an efficient process to allow existing foster homes to transition into the new adult home care license. Section 3: Amends AS 47.32.010(b) to add a new setting, "adult home care homes," that shall be subject to the centralized licensing functions of the Department of Health. Section 4: Adds a new section to AS 47.32 that defines the conditions under which the department may license an adult home care home. A person may be licensed to operate such a home for up to two persons age[d] 18 or older who are enrolled in home and community-based waiver services. This section requires the department to streamline the application process necessary for the person to be approved as an adult home care home provider and requires that the department approve variances of building code requirements to the extent permitted by state, local, or federal law. Section 5: Amends uncodified law by adding a new section that requires the Department of Health to submit for approval by the United States Department of Health and Human Services an amendment to the state medical assistance plan, waivers, or an 1115 demonstration waiver as necessary to allow eligible individuals to receive adult come care services and other long-term care services that are not duplicative. Section 6: Amends uncodified law adding a new section related to the conditional effect of section 4 and the required state plan amendments submitted to the United States Department of Health and Social Services. Requires the department to notify the revisor of statutes of the approval of state plan amendments. Section 7: Effective date related to the requirement for the department to provide notification of the revisor of statutes of approval of state plan amendments. Section 8: Provides for a July 1, 2022 effective date to align with the effective date of Executive Order 121 and the change of the applicable department to the Department of Health. 3:17:33 PM REPRESENTATIVE FIELDS referred to language on page 4 of the bill which would require DHSS to give instruction to adult foster- care applicants on acquiring a variance for their application if their home does not meet building code requirements. He posited that the new setting envisioned in CSSB 98(FIN) would include family homes and asked why the department would advise a variance rather than requiring the applicant to improve the home to meet safety standards. 3:18:19 PM CRAIG BAXTER, Program Manager, Residential Life, Division of Health Care Services, Department of Health and Social Services, explained that meeting many of the building codes for traditional care facilities would require changes which could be cost prohibitive for families providing the care, such as installing a sprinkler system. He stated that the new setting would be residential homes and voiced the understanding that there are no codes currently in effect for residential care in these new facilities. However, if building codes change in the future, he explained that this provision of the bill would allow DHSS to direct adult foster-care applicants to obtain a variance; this is included to showcase the department's willingness to help applicants go through the process if needed. He reiterated that current residential-care building codes require more updates only if the household is caring for three or more people; therefore, most of the people targeted by this bill would not be asked to comply. REPRESENTATIVE FIELDS asked how many people per home the bill would address. MR. BAXTER explained that CSSB 98(FIN) would create a new license for homes providing care for two or fewer individuals, in comparison to facilities which care for three or more. He explained that current building codes effect only home care settings serving three or more people. REPRESENTATIVE FIELDS expressed the understanding that fire codes would not be an issue for the new applicants. 3:21:44 PM REPRESENTATIVE MCCARTY noted that the proposed bill would limit each home providing adult home care services to two or fewer individuals. He questioned the inclusion of language which would allow this number to be increased at the discretion of DHSS. MR. LEE replied that the intent is for two or fewer and explained that there are possible scenarios where the state would want to grant an exception. He stated that being able to keep families together is the intent behind this language. REPRESENTATIVE MCCARTY questioned the frequency of multiple family members with adult foster care needs who would request waivers. MR. LEE explained that it is not common but does occur, and he referred to a current case where three family members are being served on waivers. REPRESENTATIVE MCCARTY expressed the belief that the language which would address this is "wide open" and questioned whether it should be fine-tuned to be more specific to family-based exceptions. MR. LEE explained that the regulations would be made to manage exceptions. 3:24:45 PM REPRESENTATIVE SPOHNHOLZ shared her experience with having her own home licensed for foster care and explained the coding requirements. She expressed concern that treating adult foster care homes as a subset of assisted living homes could introduce a building code work-around for assisted living homes. She asked why the adult foster-care licensing process is not being conducted the same way as child foster care licensing. 3:26:18 PM MR. BAXTER explained that for adult care facilities, local and state fire codes would not differentiate between the type of residence, rather the consideration would be the number of adults being served. He stated that municipalities enforce these codes based on the thresholds within the code and not on how the service is labeled. He restated that the intent is for DHSS to assist applicants who exceed the code thresholds, as there are currently no fire codes within Alaska which require the installation of a sprinkler system for homes serving two or fewer adults. REPRESENTATIVE SPOHNHOLZ noted that the proposed bill would allow the licensing of adult foster care homes as foster care, but they would be treated as assisted living homes. She asked whether a new standard could be created for adult foster homes to differentiate them from assisted living homes. She explained that if the bill is truly "creating a whole new category" of licensing for adult foster care, then the license should not be subject to standards for a different type of care. She suggested that the language of the bill be "tidied up" to prevent the mixing of regulations. 3:29:47 PM MR. NEWMAN explained that the intent of the bill is to "thread the needle" to create a setting between foster care and assisted living, and this aligns with the needs of stakeholders. He explained that the language would be a safety net to allow variances if needed later. REPRESENTATIVE SPOHNHOLZ suggested that she may draft an amendment to specify when variances could be made to increase the limit of adults. 3:30:44 PM REPRESENTATIVE FIELDS expressed opposition to including variances, citing the possibility of a single caregiver being unable to manage three adults with disabilities in the event of an emergency like a fire. He argued that the department should not be encouraging variances, and the language should be stricken from the bill entirely. He continued that, if the proposed legislation does not pass, those affected may not receive appropriate care. He pointed out the difference between staying at home or moving into an assisted living facility. MR. LEE confirmed that most of the individuals affected would be served with in-home support or with assisted living, and the intent of the bill is to create a new option. He clarified that the intent is not to divert clients from other options, but instead to lower the barriers of providing care to create more options across the state and increase access to care in places where it would not otherwise exist. He shared that stakeholder feedback supported creating another choice, as this would be valuable for those wanting to remain in their communities or not wanting to live in a group home. REPRESENTATIVE FIELDS pointed to the higher cost associated with the proposed setting as compared to receiving services through a personal care attendant (PCA) and inquired about the differences in workload between the two options. MR. LEE explained that there are many ways in which people can receive care and services from the state; however, this depends on the individual's condition, and CSSB 98(FIN) would open "certain avenues of support" for individuals to receive these services. He deferred to Mr. Newman for further detail. 3:35:04 PM MR. NEWMAN confirmed that the department's vision for the new adult home care license is to target the needs of patients, specifically the elderly, who are just starting to need at-home assistance a few hours a week. He explained that, under current practice, those people can receive services only within an assisted living setting, and he posited that the proposed bill would allow these people to continue living in a family home setting and receive services, even as the services increase over time. He described the proposed setting as a place one could "stop at during the journey of your life." REPRESENTATIVE FIELDS questioned the stakeholder input and whether the money allocated through the new setting would be enough to provide proper care. MR. LEE explained that the reimbursement rate for adult home care would need to be established and, because each person requires a different level of service, the plans are "person- centered," with the cost depending on the individual. He noted that the costs spoken about during the presentation were all example figures; the actual costs would vary based on each person's needs. 3:37:16 PM REPRESENTATIVE SPOHNHOLZ posited that the creation of the adult home care setting could function as a workaround to assisted living care by allowing compensation for similar care at a lower rate. MR. LEE reiterated that the goal is to create a care option which is less restrictive and easier to procure licensure. He pointed out that other states with similar policies have proven to have valuable and viable care settings. He explained that a new setting type must be established for the new license type to be created. MR. NEWMAN added that the main difference between the proposed setting type and an assisted living home is the habilitation requirements associated with the medical plan model of assisted living facilities. He reported that many stakeholders have expressed the desire to have a care option without habilitation goals. He explained that the new setting for an adult home care license would allow for service delivery without the habilitation goals. 3:39:55 PM REPRESENTATIVE MCCARTY reiterated the understanding that some minors in foster care "age out" but still require care for a mental or physical disability, and the proposed legislation would allow them to stay with the foster family, with whom they have a relationship, and continue to receive services. After listening to testimony, he expressed the understanding that the bill would be focused on allowing elderly people to move into a home care situation without a prior relationship with their caregiver, and this would allow other licensed facilities to be bypassed. He questioned the situation the bill would be addressing. MR. LEE explained that the bill started with a focus on those aging out of foster care; however, after hearing from stakeholders and community members, it was rewritten to be inclusive of other care recipients. REPRESENTATIVE MCCARTY asked whether the new category in this bill would allow for an elderly person to move in with an extended family member [who gets the new license type] and have the state pay for the services. MR. LEE replied that the intent of the bill is to allow people to choose a setting which best fits their needs. He explained that people who have the space within their home and the desire to provide services would be allowed to apply for the license, and this would become an option for people receiving care. He provided the scenario where an elderly person wished to remain in his/her current home with a family member, who already resided in the home. This family member would need the required license to give the needed care. He pointed out that this scenario would need to be addressed through regulation, as it was not the original intention of the bill. REPRESENTATIVE MCCARTY referenced the service waivers for people with developmental disabilities and shared his concern that the pool of eligible recipients would be widened too much by the proposed legislation. He sought clarification on who would be eligible to receive services. MR. LEE explained that in order to receive services in the proposed setting, an individual would have to already be on a waiver. 3:45:25 PM REPRESENTATIVE SPOHNHOLZ recollected that, for individuals who need care past the age of 18, the House companion bill of CSSB 98(FIN) would only allow for the continuation of foster-care services with the same family. She voiced support for the House's version of the legislation. She shared her appreciation of the intent to move away from the medical model of care for people with intrinsic disabilities or needs which will never "go away;" however, she voiced concern that the senior and disabilities services waiver qualification would be mixing two disparate groups. She suggested that expanding a bill intended for extending foster care to also include senior care within a new setting could lead to the creation of substandard assisted living homes. She expressed discomfort in mixing foster care and assisted living policy because they are two different levels of service which are treated differently in eligibility determination and licensing standards. She opined that the new setting and licensure pathway the bill proposes is not the same as a continuation of a family-like living model. She expressed opposition to mixing the two. MR. LEE referenced other states' plans which have created more options for the aging population. These plans, along with listening to feedback from stakeholders, informed the decision to create a new service type for the benefit of older Alaskans. He reiterated that the proposed setting would allow for more care opportunities in rural areas where establishing assisted living facilities would be much harder. REPRESENTATIVE SPOHNHOLZ asked how eligibility and access would be determined for the new setting and how this would be different from the existing waiver system. She expressed the opinion that there is more demand for [waiver] services than the state can meet. She questioned whether the proposed legislation would increase the demand for services and whether the criteria for waiver eligibility would be changed. MR. LEE explained that new regulations would need to be put into place, but that the eligibility criteria would not change. He stated that, once a person has been determined eligible, the new setting would be an additional option for receiving services. 3:51:24 PM REPRESENTATIVE PRAX referred to a list of levels of available care examples in the summary of CSSB 98(FIN) provided to the committee, which read as follows [original punctuation provided]: • Live at home and receive personal care services and waiver services. Daily Cost - $284 • Live in an Assisted Living Home and receive Group Home Services and other waiver services. Daily Cost - $416 Live in a Nursing Home and receive no waiver services. Daily Cost - $771 REPRESENTATIVE PRAX asked whether the level of care for the proposed setting would be between the levels detailed in the first and second bullets. MR. LEE responded in the affirmative. 3:52:11 PM CO-CHAIR ZULKOSKY opened public testimony on SB 98. 3:52:38 PM STEPHANIE WHEELER, Long-Term Care Ombudsman, Department of Revenue, expressed support for SB 98. She explained that the proposed legislation would give seniors alternatives to the existing services and living environments. As part of her work ensuring quality care for Alaska's seniors, she explained that she conducts unannounced visits to assisted living facilities. She reported that many elders within these facilities express the desire to receive care closer to their communities and families. She opined that SB 98 would help elders meet their care needs in the community of their preference. 3:54:05 PM MICHELE GIRAULT, Executive Director, Hope Community Resources, testified in favor of the concept of SB 98, citing a need for greater flexibility for providers of youth with intellectual and developmental disabilities. She reported that many families currently providing foster care to children with disabilities have resisted transitioning to an adult assisted living license because of the complexities and additional facility needs associated with this licensure. This has caused individuals with disabilities to be removed from the care of families, with whom they have formed relationships. The individuals are then placed in assisted living facilities, even though they often need youth transition support well into their twenties. She acknowledged some of the complications of the new service setting but opined that the proposed legislation would simplify the transition process for young adults with disabilities, allowing them a continued sense of normalcy and sense of family, and she reiterated support for SB 98. 3:56:11 PM LIZETTE STIEHR, Executive Director, Alaska Association on Developmental Disabilities (AADD), testifying on SB 98, explained that the AADD is the trade association for care providers who work with individuals with intellectual and developmental disabilities and expressed that AADD is "thrilled" by the proposed addition of a new service setting. She expressed the opinion that adding more options for service settings would allow recipients to live "meaningful" lives with more choices. She spoke about the complexity of the regulations concerning assisted living homes and stated that this has been a barrier to families providing care. She continued that the adult foster care license would be beneficial to many people within the system. She explained that the bill would provide broader options and lower costs for care. She posited that many of the questions brought up by the committee would be answered through regulation. 3:58:26 PM CO-CHAIR ZULKOSKY, after ascertaining that there was no one else who wished to testify, closed public testimony on SB 98. 3:58:34 PM CO-CHAIR ZULKOSKY announced that SB 98 was held over. SB 132-CONTROLLED SUB. DATA: EXEMPT VETERINARIAN  3:58:45 PM CO-CHAIR ZULKOSKY announced that the final order of business would be SENATE BILL NO. 132, "An Act exempting veterinarians from the requirements of the controlled substance prescription database." 3:58:55 PM The committee took a brief at-ease. 3:59:58 PM CO-CHAIR ZULKOSKY announced the committee would hear invited testimony. 4:00:33 PM JIM DELKER, DVM, Legislative Liaison, Alaska Veterinary Medical Association (AKVMA), shared a conversation he had had with an Alaska State Trooper. He stated that the trooper, with over 20 years of experience working on a drug task force as an undercover agent, had not witnessed any cases of drug abuse involving humans with veterinary prescriptions. Also, he referenced numerous physicians, including emergency care and drug treatment specialists, who sent in letters to attest they had never treated a person with a drug overdose, where the person had obtained the drugs through a veterinarian. DR. DELKER reported that at the request of the legislature, AKVMA met with the Alaska College of Emergency Physicians (ACEP) and the Board of Emergency Physicians to discuss some of the concerns. He described the dialogue between the boards as positive, and despite concerns from the physicians, there were no concrete examples of drug abuse of this type brought forward. He stated that the boards had also discussed the two studies the physicians had referred to in their letters of concern. He shared that one was an unrandomized survey conducted of a small portion of veterinarians in Colorado; these veterinarians had influenced Colorado to keep veterinarians out of the Prescription Drug Monitoring Program (PDMP). DR. DELKER noted the other study was a properly randomized study from Pennsylvania; however, it only took data from a single large referral hospital. He stated that only 6 percent of veterinarians in the country work in a similarly specialized setting and opined that it was unfair to say the study was indicative of the prescribing habits of most veterinarians. He shared that, in their discussion, members from the boards had expressed disagreement with letters of support from former ACEP members, while current members unanimously support the ACEP's letter of concern; however, he stated that this is in direct conflict with the conversations he had with current members, who stated that they had never heard of SB 132, or the letter of concern. He stated that some of these members had submitted their own letters of support for SB 132. DR. DELKER related that veterinarians are frustrated with the task of repeatedly entering data, which "disappears" and cannot be accessed by other physicians or veterinarians. He expressed disagreement with the idea that veterinarians are "out of touch" with the opioid epidemic. He shared a personal experience concerning loss because of opioid addiction, and he suggested that other veterinarians have similar stories. He acknowledged that the opioid crisis is serious and opined that veterinarians want to do their part to help. He asked that their efforts not be wasted but instead result in measurable benefits. 4:06:15 PM TRACY WARD, DVM, President, Alaska Veterinary Medical Association, reviewed the current regulations on PDMP use in the veterinarian field. She explained that all veterinarians who prescribe, administer, or dispense Schedule II or III drugs must query PDMP before doing so. She further explained the "zero reporting" regulations, stating that veterinarians who dispense any Schedule II, III, and IV substances must report to PDMP daily, including on days they do not dispense. She listed the dispense reporting exemptions, which included substances dispensed in an emergency department for a supply lasting less than 24 hours, controlled substances administered to an inpatient of a hospital, controlled substances used at the scene of an emergency, controlled substances used during or within 48 hours before or after a surgery, and writing a non-refillable prescription which lasts no more than three days. 4:08:42 PM The committee took a brief at-ease. 4:09:11 PM CO-CHAIR ZULKOSKY asked Laura Carrillo or Sara Chambers from the Department of Commerce, Community & Economic Development (DCCED) what recommendations and accommodations have been made by DCCED to make the utilization of PDMP more streamlined for veterinarians. 4:11:16 PM LAURA CARRILLO, MPH, Executive Administrator, Alaska Board of Pharmacy, Prescription and Drug Monitoring Program, Division of Corporations, Business and Professional Licensing, Department of Commerce, Community and Economic Development, explained that when the original bill passed in 2017, the Board of Veterinary Examiners (BOVE) had several questions for DCCED, including who to query when prescribing controlled substances for nonhuman patients. She stated that the department advised the board to query the human client and have this posted with the licensure. She shared the board's other concern about animal and human data comingling. She stated that DCCED worked with the Department of Law and the database vendor on ways to clarify the data entry process. In response to this, she stated, DCCED posted guidelines on its website about how to properly input species codes and prevent comingling of data, and the vendor added an animal graphic to help practitioners visually differentiate between human and animal prescriptions. She added that the department continued talks with various boards to adjust issues and instated a biweekly PDMP meeting of chairs to continue the conversation. 4:15:22 PM CO-CHAIR ZULKOSKY asked how DCCED's improvements made the process more user friendly for veterinarians. 4:16:27 PM MCKAYLA DICK, DVM, Past President, Alaska Veterinary Medical Association, explained that as a small animal veterinarian she had seen no changes in PDMP and very little guidance on how to use it in a clinic setting. She stated that "the system just doesn't work" for veterinarians because of the fundamental differences in human and animal data. These differences have led veterinarians to be investigated for clerical issues rather than deliberate misuse of the system. She opined that the changes put into place by DCCED have not been properly conveyed to practitioners and often did not work to solve the issues. 4:17:46 PM HAL GEIGER, PhD, Member, Board of Veterinary Examiners, shared that the private conversations with veterinarians were consistent with their public testimony, which expressed that changes made by DCCED were not helpful, and training had been insufficient. He reported that veterinarians are confused and frustrated with a system which they find to be "completely unworkable." CO-CHAIR ZULKOSKY asked about other efforts the department had made in response to the feedback that the changes were not enough. SARA CHAMBERS, Director, Division of Corporations, Business and Professional Licensing, Department of Commerce, Community and Economic Development, expressed the belief that the department had made all the changes brought to its attention and had provided all information about the changes to the board. She expressed the understanding that it was BOVE's responsibility to disseminate that information. She opined that the board's efforts to do so had "fallen by the wayside," and BOVE had not posted the guidelines on its website or circulated them to veterinarians. She posited that much of the frustration with the system comes from the existential question of whether PDMP is relevant to veterinarians and opined that, because veterinarians believe their participation in PDMP to be [useless], there is less motivation to implement the fixes provided by the department. She expressed the belief that all parties should buy in to PDMP and utilize the tools provided, or statutory changes should be made. 4:22:39 PM The committee took an at-ease from 4:22 p.m. to 4:26 p.m. 4:26:39 PM REPRESENTATIVE SPOHNHOLZ referred to a report from DCCED on the 14 best practices for veterinary use of PDMP and asked Ms. Carrillo to explain how the report was communicated to BOVE. MS. CARRILLO explained that the Bureau of Justice Assistance (BJA) compiled the report, and it was presented at the PDMP training center in January 2022. She stated that the report used studies conducted in other states to derive the best practices. She shared that, to her knowledge, the report was given to BOVE members during a board meeting, and it was included in their meeting packet. In response to a follow-up question, she said the report was presented to BOVE in February of the same year. REPRESENTATIVE SPOHNHOLZ opined that the best practices provided by BJA were very detailed. She referenced a letter sent by Dr. Papacostas to the Senate Finance Committee where he stated that veterinarians now surpass dentists in the prescription of morphine. She requested that Dr. Papacostas explain this information and ACEP's stance on excluding veterinarians from PDMP. 4:32:47 PM NICHOLAS PAPACOSTAS, MD, FACEP, Alaska Chapter American College of Emergency Physicians, confirmed that the statistic was correct and clarified that both veterinarians and dentists prescribe very low rates of opioids in comparison to medical practitioners. He explained that the data was added in the report for context because there was a discussion about exempting veterinarians but not dentists from PDMP. REPRESENTATIVE SPOHNHOLZ asked Dr. Papacostas to describe the findings from the 2019 study published in the Journal of the American Medical Association, which was cited in his letter. DR. PAPACOSTAS explained that Dr. Delker was correct in his testimony; the study had come from a single large veterinary facility. He stated that the point of including this study is because many veterinarians train at referral centers, so the trend of increased opioid prescriptions at those facilities could be indicative of the prescribing habits of veterinarians in smaller, community-based practices as well. REPRESENTATIVE SPOHNHOLZ requested that Dr. Geiger comment on the information presented to BOVE during the February 2022 board meeting concerning the best practices for veterinary prescriptions. She questioned the material presented, the discussions that occurred about implementing these practices, and whether a more nuanced approach to veterinary participation in PDMP is "out of the question." 4:35:50 PM DR. GEIGER stated he was not prepared to speak about this specific meeting, as there were many meetings where suggestions were given by the department. He gave an example of a suggested regulation which would not be possible to carry out. He explained that the majority of testimony the board had heard from veterinarians was that they try to use the PDMP but it "just doesn't quite work" and has not worked since the participation requirement was put into statute. He explained that the requirement is to query the patient, but in the veterinary world, the patient is the animal. REPRESENTATIVE SPOHNHOLZ opined that, because of frustration with the system, many veterinarians have chosen to see the system as a failure rather than trying to find a solution. She cited the earlier comparison to dentists and stated that dentists prescribe fewer opioids a year than veterinarians, yet there has been no push for an exemption from dentists. She posited that this data is in direct opposition to the assertions made during testimony. She requested Dr. Geiger's opinion. DR. GEIGER replied that PDMP works for dentists and human practitioners because PDMP was designed for human patients. He shared that the board received a PDMP report which conveyed no veterinarians had queried the system during a specific timeframe, but during the discussion of the report, numerous veterinarians and their staff reported they had queried the system during the referenced timeframe. He expressed the opinion that this exemplifies the system is not working for the veterinary field. 4:39:58 PM REPRESENTATIVE PRAX expressed the understanding that veterinarians were required through regulation to query their human clients' prescription drug use. DR. GEIGER confirmed this understanding and spoke to veterinarians' frustration around lack of clarity in who to query. 4:41:01 PM DR. WARD confirmed that the query is made to the person physically in the room with the animal patient. REPRESENTATIVE PRAX stated his opinion that this practice seemed like a Health Insurance Portability and Accountability Act (HIPAA) violation and asked whether the information about the human client's prescription history was recorded. In response to a request for clarification, he described a hypothetical situation where someone goes to a veterinarian, discloses his/her own medical history in order to receive medication for the pet, and then later the person switches to a new veterinarian. He asked whether the new veterinarian would be able to see that the pet had previously been prescribed a certain drug and whether this drug would now be a part of the human client's history. DR. WARD explained that before a veterinarian makes a prescription, the human client's drug history would be questioned. She posited that this would not affect the veterinarian's decision on what to prescribe, because veterinarians are not trained in human drug dosage. However, she said, if the veterinarian decides to prescribe a scheduled substance to an animal, this information would be entered under the pet's name. She reported that a reoccurring issue is, when a veterinarian tries to query PDMP for this pet later, the information is often not visible. She added that the same issue happens for medical doctors. She described the process as not affecting public health, as veterinarians cannot interpret the data from medical doctors and [doctors] cannot access the animal data entered by the veterinarians. She confirmed that veterinarians do prescribe more opioids than dentists; however, this amount is less than one percent of all opioids prescribed and does not include the types of opioids human addicts are looking for. She stated that the focus has been on making PDMP easier for veterinarians; however, she pointed out the lack of productive data which results from this practice, which is the main concern for veterinarians. REPRESENTATIVE PRAX opined that veterinary participation in PDMP "fundamentally" accomplishes nothing and potentially violates the HIPAA rights of [the humans who bring in their pets]. DR. WARD expressed agreement with the statement. She stated that "we are accomplishing nothing" in regard to drug prevention and public health, while the process is done at a high cost [to the state]. She reemphasized that the amount of opioids prescribed by veterinarians is small in comparison to the amount prescribed by physicians. 4:45:40 PM REPRESENTATIVE MCCARTY referred to the statistic of opioid prescriptions as being "data on morphine." He questioned whether morphine is prescribed by vets more often. DR. WARD explained that the data describes morphine milligram equivalence (MME), which equates all the opioid class substances to the relative equivalency with morphine; the statistic does include all opioids prescribed. REPRESENTATIVE MCCARTY questioned the data which suggests veterinarians prescribe more opioids than dentists. He cited his knowledge of dentist-related opioid addiction. He asked Dr. Papacostas to provide the data behind the statement on prescription amounts in his letter. DR. PAPACOSTAS explained that the same data is in the white paper in graph form, and it shows that from 2016 to 2018 the amount of opioids prescribed by veterinarians had increased to surpass the amount prescribed by dentists. REPRESENTATIVE MCCARTY sought confirmation from Ms. Chambers that the administration is taking a non-stance on the issue and focusing on complying with the current statute. MS. CHAMBERS responded in the affirmative. REPRESENTATIVE MCCARTY recalled Ms. Chambers previous statement which related that veterinary participation has been a challenge for PDMP, and he remarked that there has been over a "hundred" meetings a year between the different boards on this subject. MS. CARRILLO explained that there have not been "hundreds" of meetings on this specific issue, but it has been discussed, and updates on PDMP have been a standing topic at all BOVE meetings. REPRESENTATIVE MCCARTY shared his understanding that the Division of Corporations, Business and Professional Licensing's main objective with all state boards is to assist with their professional duties to the state and ensure no harm is being done. MS. CHAMBERS confirmed his understanding. REPRESENTATIVE MCCARTY acknowledged the division's effort to follow statute and make the system workable for veterinarians; however, he pointed out that BOVE has related the participation in PDMP is "putting a square peg in a round hole." He shared his belief that testimony points towards an unsolvable issue; therefore, a change of statute is needed. 4:51:57 PM MS. CHAMBERS voiced her belief that many tools are available to the boards, and what boards do with the information directly impacts veterinarians' ability to effectively use PDMP. She expressed agreement that there is room for improvement; however, there are options other than statute change still available. She reiterated that many of the issues have been answered through the resources created by the division. She argued that many veterinarians feel frustrated by the system because they were uninformed of the resources. REPRESENTATIVE MCCARTY opined that the statute put into place in 2017 does not fit a certain group of professionals, and although the division has done its part to make the system work according to statute, PDMP does not work for veterinarians. He alluded that the legislature should follow the suit of other states which have exempted veterinarians. 4:54:09 PM CO-CHAIR ZULKOSKY requested that Ms. Chambers confirm the department had urged BOVE to adopt regulations which address the challenges faced by PDMP. MS. CHAMBERS responded in the affirmative. CO-CHAIR ZULKOSKY questioned Dr. Geiger concerning the board's response to the department, and its request to adopt regulation regarding PDMP. 4:54:51 PM DR. GEIGER explained that the board has received "high level advice" which does not address the realities facing veterinarians. He stated that there are "hundreds" of small, day-to-day problems veterinarians must deal with, such as not having internet access. He posited that getting all the information to veterinarians for each of these issues is not an easy task solved through regulation. CO-CHAIR ZULKOSKY questioned whether the board has pursued making any changes to regulations regarding PDMP, beyond the more nuanced examples which have been given. DR. GEIGER explained that the board did pass regulations trying to make PDMP work. The board took the division's advice and put the resources on the internet; however, the regulations have not been able to get veterinarians the information they need. CO-CHAIR ZULKOSKY asked Ms. Carrillo to supply the committee with screenshots of PDMP for visual clarification, as well as a list of the regulations put into place by BOVE. She questioned the amount of nationwide PDMPs and whether there has been an assessment completed on adapting PDMPs to meet the needs of veterinarians. MS. CARRILLO reported that the vendor used for PDMP has been used by 43 other states. She offered to follow up to the committee with additional information about adaptations for veterinarians. CO-CHAIR ZULKOSKY asked Dr. Papacostas about the tightening of human medical documentation concerning controlled substances, and how this could impact issues in the system. She also asked for a layman's description of the difference between 5 million and 2.9 million MME. 4:59:23 PM DR. PAPACOSTAS explained that PDMP is a tool to identify patients at risk of opioid addiction and get these patients into treatment. He pointed out that it is "disturbing" if the data veterinarians are entering is not visible to physicians. He expressed the opinion that it is individual prescriptions which expose people to opioids, and this is more of a concern than the total amount of opioids being prescribed. He explained that "catching" people misusing or diverting opioids is not the focus of emergency physicians, but rather they want to determine how patients are getting access to drugs, in hopes of intervening, if needed. He restated that the total amount of opioids being prescribed by veterinarians is not huge; however, he expressed the belief that exposure to one prescription can make a difference to a human patient. He voiced his support for removing some of the restrictions on veterinary PDMP participation and called for an investigation into why the veterinary data is not visible. He iterated ACEP's support for including veterinarians into the exemptions for very short-term prescriptions, but it would still support veterinarians entering long-term prescriptions into PDMP. He suggested that sending prescriptions to pharmacists would help veterinarians who struggle with entering prescriptions into PDMP. [SB 132 was held over.] 5:02:54 PM ADJOURNMENT  There being no further business before the committee, the House Health and Social Services Standing Committee meeting was adjourned at 5:03 p.m.