Legislature(2015 - 2016)HOUSE FINANCE 519

03/30/2016 01:30 PM House FINANCE

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Audio Topic
01:32:04 PM Start
01:33:07 PM SB74
06:20:27 PM Adjourn
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
Heard & Held
- Telemedicine
- Prescription Drug Database
- Sponsor/Department Wrap-up
+ Bills Previously Heard/Scheduled TELECONFERENCED
CS FOR SENATE BILL NO. 74(FIN) am                                                                                             
     "An   Act  relating   to   diagnosis,  treatment,   and                                                                    
     prescription  of drugs  without a  physical examination                                                                    
     by a  physician; relating to  the delivery  of services                                                                    
     by  a  licensed  professional counselor,  marriage  and                                                                    
     family    therapist,     psychologist,    psychological                                                                    
     associate, and  social worker by audio,  video, or data                                                                    
     communications;  relating to  the duties  of the  State                                                                    
     Medical  Board;  relating  to limitations  of  actions;                                                                    
     establishing the Alaska  Medical Assistance False Claim                                                                    
     and  Reporting  Act;  relating  to  medical  assistance                                                                    
     programs administered  by the Department of  Health and                                                                    
     Social Services;  relating to the  controlled substance                                                                    
     prescription database;  relating to  the duties  of the                                                                    
     Board  of  Pharmacy;  relating to  the  duties  of  the                                                                    
     Department   of  Commerce,   Community,  and   Economic                                                                    
     Development;   relating  to   accounting  for   program                                                                    
     receipts; relating  to public record status  of records                                                                    
     related to  the Alaska  Medical Assistance  False Claim                                                                    
     and   Reporting   Act;  establishing   a   telemedicine                                                                    
     business registry; relating  to competitive bidding for                                                                    
     medical assistance  products and services;  relating to                                                                    
     verification  of  eligibility   for  public  assistance                                                                    
     programs administered  by the Department of  Health and                                                                    
     Social  Services; relating  to annual  audits of  state                                                                    
     medical  assistance  providers; relating  to  reporting                                                                    
     overpayments    of    medical   assistance    payments;                                                                    
     establishing  authority to  assess civil  penalties for                                                                    
     violations of medical  assistance program requirements;                                                                    
     relating  to seizure  and  forfeiture  of property  for                                                                    
     medical  assistance fraud;  relating to  the duties  of                                                                    
     the   Department  of   Health   and  Social   Services;                                                                    
     establishing    medical     assistance    demonstration                                                                    
     projects;  relating  to   Alaska  Pioneers'  Homes  and                                                                    
     Alaska Veterans'  Homes; relating to the  duties of the                                                                    
     Department  of Administration;  relating to  the Alaska                                                                    
     Mental Health Trust  Authority; relating to feasibility                                                                    
     studies for the provision  of specified state services;                                                                    
     amending Rules  4, 5, 7,  12, 24,  26, 27, 41,  77, 79,                                                                    
     82, and 89,  Alaska Rules of Civil  Procedure, and Rule                                                                    
     37, Alaska  Rules of Criminal Procedure;  and providing                                                                    
     for an effective date."                                                                                                    
1:33:07 PM                                                                                                                    
Co-Chair  Thompson relayed  that the  committee would  begin                                                                    
with the telemedicine portion of the legislation.                                                                               
STEWART  FERGUSON, CHIEF  TECHNOLOGY OFFICER,  ALASKA NATIVE                                                                    
TRIBAL  HEALTH CONSORTIUM  (ANTHC),  addressed a  PowerPoint                                                                    
presentation titled  "Better Care. Lower Costs.  Impacts and                                                                    
Outcomes  of  Telehealth  in  Alaska"  (copy  on  file).  He                                                                    
communicated  that ANTHC  had  been  operating a  telehealth                                                                    
system  in Alaska  for  almost two  decades.  He planned  to                                                                    
speak to  outcomes from about  250,000 telehealth  cases. He                                                                    
clarified  that   ANTHC  used   the  terms   telehealth  and                                                                    
telemedicine   interchangeably  (slide   2).  The   American                                                                    
Telemedicine  Association (the  largest  body  in the  world                                                                    
dedicated to telemedicine) treated  the words as synonymous;                                                                    
the  terms  referred to  the  use  of telecommunications  to                                                                    
exchange  information that  could  be  done through  medical                                                                    
records, audio, video, or a  combination of the two in order                                                                    
to care for patients.                                                                                                           
Mr.   Ferguson   highlighted    the   different   types   of                                                                    
telemedicine. The  most common  type of telemedicine  in the                                                                    
Lower   48   was   video-teleconferencing   or   synchronous                                                                    
telemedicine  where  the  patient  and  provider  were  both                                                                    
participating  at the  same time  from different  locations.                                                                    
When ANTHC began building telemedicine  in the late 1990s it                                                                    
did    not   have    the   bandwidth    to   support    live                                                                    
videoconferencing so it had begun  building its system based                                                                    
on  store-and-forward technology,  which involved  capturing                                                                    
data and sending  it. The system captured  images, heart and                                                                    
lung sounds, pressure-wave  forms of the ear,  and other. He                                                                    
believed  ANTHC was  currently one  of  the world's  leading                                                                    
authorities on  the specific technology; it  used the system                                                                    
for about 40,000  to 50,000 cases per  year. Home telehealth                                                                    
was  the third  type  of telemedicine.  The  system was  not                                                                    
commonly  used  in Alaska,  but  he  believed it  should  be                                                                    
considered.  The system  tried to  care for  chronically ill                                                                    
patients  in  their  home   setting  by  monitoring  weight,                                                                    
glucose, blood  pressure, and  other. He  turned to  slide 4                                                                    
and  discussed  that  telemedicine was  extremely  prevalent                                                                    
throughout  the  U.S. and  worldwide.  The  side included  a                                                                    
chart showing that in 2011  there had been over 200 networks                                                                    
throughout the  U.S. -  of which  the Alaska  Federal Health                                                                    
Care Access  Network (AFHCAN)  was one  - with  almost 4,000                                                                    
service sites;  at that  time over  half the  U.S. hospitals                                                                    
used telemedicine,  which was currently  a standard  of care                                                                    
delivery throughout North America.                                                                                              
1:36:00 PM                                                                                                                    
Mr.  Ferguson relayed  that his  presentation would  address                                                                    
the evidence  gained, primarily in the  Alaska Tribal Health                                                                    
System (slide 5). He shared  that he worked for ANTHC, which                                                                    
co-managed  the Alaska  Native Medical  Center (the  largest                                                                    
Native hospital  in the  U.S.) with  Southcentral Foundation                                                                    
to provide  primary care services. The  tribal health system                                                                    
also had  six regional hospitals (including  Mount Edgecumbe                                                                    
Hospital  in Sitka);  multi-physician  health centers;  sub-                                                                    
regional  centers staffed  by nurses,  physician assistants,                                                                    
and in  some cases  doctors; and the  "bread and  butter" of                                                                    
providing  care  was the  use  of  village clinics  in  very                                                                    
remote  settings  where  community  health  aides  delivered                                                                    
care.  Alaska's tribal  health system  had been  designed to                                                                    
serve all  of the  facilities, to  work in  remote settings,                                                                    
and to  meet primary care  needs. He  turned to slide  6 and                                                                    
shared  that in  FY 15  the system  had about  43,000 cases,                                                                    
1,500 providers,  and 26,000  patients. He  highlighted that                                                                    
26,000 patients  represented about 18 percent  of the Alaska                                                                    
Native  population.  He  did   not  believe  another  system                                                                    
existed  anywhere  in the  world  where  18 percent  of  its                                                                    
patients  were involved  in telehealth  on an  annual basis.                                                                    
The  43,000  cases  represented   about  3  percent  of  all                                                                    
outpatient  encounters  in  the  tribal  health  system.  He                                                                    
believed a  person would be  hard pressed to find  any other                                                                    
healthcare  system  with  that   level  of  penetration.  He                                                                    
relayed that  growth could  increase significantly,  but the                                                                    
current  system  was  well utilized  throughout  the  entire                                                                    
tribal health  system. Slide 6 included  the system's store-                                                                    
and-forward data representing how  often the system captured                                                                    
and sent data.                                                                                                                  
Mr.  Ferguson  turned to  slide  7  and spoke  to  specialty                                                                    
healthcare  clinics available  by  video teleconference.  He                                                                    
shared  that  the  system  had   a  growing  use  of  video-                                                                    
teleconferencing,   primarily  because   it   now  had   the                                                                    
necessary bandwidth out to most  village clinics through the                                                                    
expansion   efforts  of   a   number  of   telecommunication                                                                    
carriers.  The slide  provided a  list of  various specialty                                                                    
clinics  offered by  the Alaska  Native  Medical Center.  He                                                                    
pointed out that telemedicine offered  by the center was not                                                                    
strictly  contained  within  Alaska's borders.  He  detailed                                                                    
there were  many areas where specialists  were not available                                                                    
in  Alaska.   For  example,  in  adolescent   medicine  many                                                                    
pediatric specialists were located in  the Lower 48 (some at                                                                    
Seattle  Children's Hospital).  The center  tried to  screen                                                                    
women  at  a  high  risk of  developing  breast  cancer  and                                                                    
conducted  regular  telehealth   consultations  between  the                                                                    
patients and  the Mayo Clinic  in Rochester,  Minnesota. One                                                                    
of  the beauties  of  telehealth was  the  ability to  bring                                                                    
providers and patients together independent of distance.                                                                        
1:38:54 PM                                                                                                                    
Mr.  Ferguson shared  that  one of  the  benefits of  having                                                                    
developed  the system  in Alaska  was a  built-in evaluation                                                                    
component.  He  detailed  that  every  time  someone  did  a                                                                    
telemedicine  case in  Alaska,  the  center asked  questions                                                                    
about  whether the  service improved  the  quality of  care,                                                                    
educated  the patient,  made the  provider's  job more  fun,                                                                    
etcetera. Slide  8 included  two questions  community health                                                                    
aides  were  asked  in  the  village:  whether  telemedicine                                                                    
improved  the  quality  of  care  and  whether  it  improved                                                                    
patient satisfaction. He relayed  that three-quarters of the                                                                    
almost  12,000   responses  showed  that   telemedicine  had                                                                    
improved the  quality of  care and  about two-thirds  of the                                                                    
time  they believed  it  improved  patient satisfaction.  He                                                                    
drew the committee's  attention to two images  on the slide:                                                                    
the  lower   left  image  showed  a   cochlear  implant.  He                                                                    
specified that a higher percentage  of babies were born deaf                                                                    
in  the  tribal  health  system   compared  to  the  general                                                                    
population.  He elaborated  that traditionally  the patients                                                                    
could either  remain deaf or  travel to  the Lower 48  for a                                                                    
cochlear implant  and remain  in the Lower  48 for  about 12                                                                    
months of intensive speech  therapy. However, telehealth had                                                                    
enabled the cochlear  implants to be done  in Anchorage, the                                                                    
patient could  return to their  home, and all of  the speech                                                                    
therapy was  conducted by telehealth.  He stressed  that the                                                                    
system  could now  do things  that had  never been  possible                                                                    
Mr.  Ferguson pointed  to  the image  of  a diabetic  retina                                                                    
shown  on the  lower  right  of slide  8.  He detailed  that                                                                    
diabetic  patients could  start  to have  problems with  the                                                                    
microvasculature of  the blood vessels  in the  retina; when                                                                    
those vessels started to bleed  or clog it caused blindness.                                                                    
However, the  affliction was easily treatable  if diagnosed.                                                                    
Several years back  the center had done a  pilot study where                                                                    
it sent the  equipment out to the villages  and screened all                                                                    
the  diabetics it  could find.  The  three-month effort  had                                                                    
reversed a seven-year  decline in the percent  of annual eye                                                                    
exams for  diabetics. Additionally, 100 of  the 300 patients                                                                    
screened had needed follow up and  care - they had been on a                                                                    
path  to blindness.  Telehealth allowed  ANTHC to  take care                                                                    
out to the patients and  enabled patients to remain in their                                                                    
homes. He  addressed that telehealth saved  money, primarily                                                                    
in patient  travel (slide  9). They  estimated that  most of                                                                    
the  time if  travel  was saved  it was  only  saved to  the                                                                    
nearest  regional hospital  (not  necessarily to  Anchorage)                                                                    
and  that not  all  cases prevented  travel; however,  ANTHC                                                                    
estimated  that annually  about  $10 million  was saved  per                                                                    
year in patient travel. He  underscored that for every $1.00                                                                    
reimbursed  for  Medicaid about  $10  to  $11 was  saved  in                                                                    
patient travel.                                                                                                                 
1:41:43 PM                                                                                                                    
Mr. Ferguson  addressed improving patient access  to care on                                                                    
slide  10.  He  explained  that it  was  very  difficult  to                                                                    
measure access  and improvements  to access in  a healthcare                                                                    
system. He  relayed that  Dr. Phil  Hofstetter based  out of                                                                    
Nome  had  looked   at  the  number  of   new  referrals  to                                                                    
specialists between  1991 and 2007;  he had  discovered that                                                                    
prior  to telemedicine  for a  span  of about  11 years,  47                                                                    
percent of  the patients waited  5 months  or more to  see a                                                                    
doctor in person. Once telemedicine  began to be utilized to                                                                    
screen  the patients  to decide  who needed  to be  flown to                                                                    
Anchorage and  who could wait,  the number had dropped  to 8                                                                    
percent  and 3  years later  it  dropped to  3 percent.  The                                                                    
takeaways were  that telemedicine enabled  patient screening                                                                    
to make decisions  and get patients to care  faster and that                                                                    
the  impact of  telehealth  did not  happen immediately.  He                                                                    
elaborated that it had taken 3  years for the number to drop                                                                    
from 8  percent to  3 percent; some  of the  things required                                                                    
process  change.   He  moved  to   slide  11   titled  "ANMC                                                                    
Turnaround  Time" and  shared  that  telehealth also  helped                                                                    
improve how  long it took for  a patient to get  a specialty                                                                    
consult.  He  detailed  that the  medical  center  currently                                                                    
turned  around  25 percent  of  the  health consults  in  60                                                                    
minutes or  less. He explained  a parent living in  a remote                                                                    
village there  was a  1 in  4 chance  of having  a specialty                                                                    
consult  and  treatment  plan  before  leaving  the  village                                                                    
clinic.  He explained  it was  a  better level  of care  and                                                                    
higher turnaround than  a person could get if  they lived in                                                                    
Anchorage   and   went   to  their   family   physician   or                                                                    
pediatrician.  Additionally, about  two-thirds of  the cases                                                                    
were turned around in one day.                                                                                                  
Mr. Ferguson addressed the bigger  picture of telehealth and                                                                    
how it  related to the  changing world of  healthcare (slide                                                                    
12). The  healthcare world was  moving away from  fees based                                                                    
on  procedures to  a performance  and quality  based payment                                                                    
structure; therefore,  it was necessary  to think  about how                                                                    
to change  the delivery of  care. He detailed that  the vast                                                                    
majority of the center's patients  were low risk (care could                                                                    
be provided  when a person was  sick and then they  left the                                                                    
system). High  risk patients  were at the  other end  of the                                                                    
pyramid (patients  with complex diseases  and comorbidities)                                                                    
and  constituted 5  percent of  the  center's patients;  the                                                                    
group  accounted  for  a  low  percentage  of  the  center's                                                                    
patients,  but  consumed  a significant  percentage  of  its                                                                    
costs.  He continued  that the  center had  known for  years                                                                    
that one of  the ways to treat the patients  was to shift to                                                                    
care  management  models  to   care  for  the  patients.  He                                                                    
guaranteed increased  care management  was necessary  if the                                                                    
desire was  to manage  the expense of  patients and  to keep                                                                    
them healthier.                                                                                                                 
Mr. Ferguson detailed that the  center had conducted a pilot                                                                    
study several  months back  where it tried  to bring  all of                                                                    
the people  involved in  caring for its  patients in  two of                                                                    
the most remote  villages into a video  session to determine                                                                    
whether good  care management could be  done over telehealth                                                                    
(slide  13).  He  elaborated that  the  center  worked  with                                                                    
patients  in  Gambell  and  Savoonga  out  on  St.  Lawrence                                                                    
Island;  the  locations  had been  selected  because  Norton                                                                    
Sound  Health  Corporation based  out  of  Nome was  heavily                                                                    
focused on  a patient-centered  medical home model  with the                                                                    
goal of  keeping patients  in the  village. The  trouble was                                                                    
the  case managers  were typically  in Nome  and not  in the                                                                    
villages and the  case managers for the  specialists were in                                                                    
Anchorage. The only  way to implement the  model was through                                                                    
the use of telecommunications.  He expounded that the center                                                                    
had conducted a  three-way virtual field clinic  with a case                                                                    
manager in  Nome and Anchorage,  a specialist  in Anchorage,                                                                    
and  the  patients  in  Gambell  and  Savoonga.  The  center                                                                    
believed it was one of the  ways it could help to manage the                                                                    
more expensive patients.                                                                                                        
1:45:31 PM                                                                                                                    
Mr.   Ferguson  stated   the  bottom   line  was   the  fact                                                                    
telemedicine  enabled  the center  to  deliver  care to  the                                                                    
patients  in their  homes.  Additionally,  the center  could                                                                    
start trying to  predict the trajectory of  its patients and                                                                    
to  use telehealth  to manage  them before  they necessarily                                                                    
enter the system. The center  had done a study several years                                                                    
back  where it  had  looked  at infants  who  were the  most                                                                    
expensive and vulnerable Medicaid  population (slide 14). He                                                                    
elaborated that they were typically  infants who had entered                                                                    
a  neonatal intensive  care  unit (NICU).  He  pointed to  a                                                                    
chart on  slide 14 and  relayed that most of  these children                                                                    
would cost between $40,000 and  $80,000 in the first year of                                                                    
their  lives.  He  continued  that   the  infants  would  be                                                                    
returned to  a village clinic with  no specialists, doctors,                                                                    
and potentially  no nurses. He  furthered that if  an infant                                                                    
went into  a NICU with  a diagnosis of  respiratory disease,                                                                    
congenital anomalies,  or both, they were  almost guaranteed                                                                    
to be  an expensive patient  for several years to  come. The                                                                    
center  proposed wrapping  a "whole  umbrella of  telehealth                                                                    
services  around these  children."  The  minute the  infants                                                                    
were  discharged   from  the   NICU  there   were  pediatric                                                                    
specialists  willing to  be involved  and  case managers  to                                                                    
support them. He explained that  parents suddenly had access                                                                    
to resources throughout Alaska and  the Lower 48. The center                                                                    
estimated  the model  could  save about  37  percent of  the                                                                    
overall  patient  cost  through fewer  emergency  department                                                                    
visits,  fewer  hospitalizations,  and other.  He  explained                                                                    
that  telehealth  could  provide  day-to-day  care  for  the                                                                    
center's  patients and  it  could  be part  of  a much  more                                                                    
complex,  solution  focused way  to  take  care of  patients                                                                    
through proper analytics.                                                                                                       
1:47:26 PM                                                                                                                    
Vice-Chair  Saddler asked  for  the terminology  for an  in-                                                                    
person consultation.  Mr. Ferguson  replied that it  was "in                                                                    
Vice-Chair  Saddler  had  heard from  providers  that  while                                                                    
telemedicine allowed improved  access, there were challenges                                                                    
with  the  non-standard  charting.  He  explained  providers                                                                    
received chart notes and could  not interpret them. He asked                                                                    
if there were chart note standards.                                                                                             
Mr.  Ferguson   replied  that  one  of   the  challenges  in                                                                    
telehealth had always  been to make sure to  have a complete                                                                    
patient record in  front of the remote site.  The center was                                                                    
addressing the issue in a  couple of ways. He explained that                                                                    
the tribal health  system was moving to  a shared electronic                                                                    
health record, which  did help. He elaborated  that when the                                                                    
center  utilized  telehealth, especially  store-and-forward,                                                                    
it  trained the  providers to  put the  relevant information                                                                    
into the  telehealth consult  to send  to the  provider. The                                                                    
center  was   currently  in   the  process   of  integrating                                                                    
telehealth  back  into  the  electronic  health  records  so                                                                    
things  were appropriately  logged  and  charted within  the                                                                    
patient's chart.                                                                                                                
Vice-Chair  Saddler   asked  if   the  level  of   care  was                                                                    
qualitatively the same for telehealth  versus in person. Mr.                                                                    
Ferguson believed  center clinicians would say  the level of                                                                    
care was as  good or better [via telehealth].  The trick was                                                                    
to  avoid  doing  things  that  were  not  possible  through                                                                    
telehealth. He  elaborated that the center's  providers were                                                                    
trained to immediately  suggest a patient be  seen in person                                                                    
if the provider could not  treat the patient, recognize what                                                                    
they were looking at, or could not care for the patient.                                                                        
Vice-Chair  Saddler   asked  what  could  not   be  done  by                                                                    
Mr. Ferguson answered that  services provided via telehealth                                                                    
were broad.  He explained  that procedures  requiring skills                                                                    
to touch a  patient could not be done  via telehealth. There                                                                    
were  certain  things  where perhaps  the  appropriate  data                                                                    
could  not  be captured.  For  example,  if a  provider  was                                                                    
testing heart  and lung  sounds and  could not  hear exactly                                                                    
what they  needed, it would  require an in person  visit. He                                                                    
relayed that  ANTHC had done  a study for the  Indian Health                                                                    
Service  (IHS)  about  five  years   earlier  where  it  had                                                                    
addressed the  percentage of healthcare  that could  be done                                                                    
through telehealth  and what percentage  could not.  As part                                                                    
of  the  study  ANTHC  had interviewed  about  10  different                                                                    
specialists including dermatologists  and cardiologists. The                                                                    
general answer had  been that it varied from about  10 to 80                                                                    
percent  depending on  the specialty.  He elaborated  that a                                                                    
high  percentage  of  dermatology   could  be  done  through                                                                    
imagery, whereas  things like  behavioral and  mental health                                                                    
required live video.                                                                                                            
Vice-Chair  Saddler asked  if the  practice of  telemedicine                                                                    
had been  hindered by  technological limitations  (i.e. end-                                                                    
user equipment or broadband access  between the provider and                                                                    
telehealth consult) in Alaska.                                                                                                  
Mr.  Ferguson  answered  that  about  12  to  15  years  ago                                                                    
bandwidth had  not been sufficient,  but it was no  longer a                                                                    
challenge. He  detailed that although  about half  the sites                                                                    
were  on satellite,  which introduced  a delay,  it was  not                                                                    
really a hindrance to telehealth at present.                                                                                    
1:51:02 PM                                                                                                                    
Representative Guttenberg quoted from  a speech given by the                                                                    
Federal   Communications   Commission   (FCC)   Commissioner                                                                    
Jessica  Rosenworcel to  the American  Telephone Association                                                                    
several years  earlier "In Alaska,  under the  leadership of                                                                    
Dr. Stewart Ferguson, I saw  how village clinics well beyond                                                                    
the  last  road  mile,  so  remote that  they  can  only  be                                                                    
assessed by telephone,  can nevertheless provide first-class                                                                    
care   using  a   mix  of   broadband   and  store   forward                                                                    
technology." He  thanked Dr.  Ferguson for  his work  at the                                                                    
forefront   of  delivering   telehealth  services.   He  was                                                                    
involved in  broadband issues because he  lived in Fairbanks                                                                    
and did  not have the  service; everything was  buffered. He                                                                    
referred  to  healthcare pilot  program  charts  done a  few                                                                    
years earlier by the FCC  and a presentation provided by FCC                                                                    
Chairman   Kevin  Martin.   He   referenced   dots  on   the                                                                    
presentation  representing villages  across  Alaska. He  was                                                                    
astounded  all of  the places  across  Alaska had  broadband                                                                    
capabilities  for   telemedicine.  He  added  that   he  was                                                                    
delighted, but astounded. He had  been in villages where all                                                                    
of the kids and the  village council were huddled around the                                                                    
library  taking  broadband  off   the  routers  because  the                                                                    
service  was   not  available  elsewhere  or   it  was  very                                                                    
expensive. He  asked if the clinics  had dedicated broadband                                                                    
accessibilities  that was  only  available  to rural  health                                                                    
clinics as part  of the pilot program. He  asked about costs                                                                    
that were  exorbitant many places  in Alaska. He  noted that                                                                    
costs were driven  down by e-rate in some  places. He stated                                                                    
that  for   medicine,  regardless  of  the   costs,  may  be                                                                    
efficiencies. He asked  if they were factors  or whether the                                                                    
program  was  so  far  along they  were  integrated  into  a                                                                    
Mr. Ferguson  answered that the clinics  depended heavily on                                                                    
the Universal  Services Fund (USF) for  access to bandwidth.                                                                    
He  explained  that  the fund  was  a  federally  subsidized                                                                    
program (paid for with funds  brought in from telephone bill                                                                    
tax),  which enabled  rural  healthcare facilities  (village                                                                    
clinics  and  sub-regional  hospitals   in  Alaska)  to  buy                                                                    
bandwidth  at  no   more  than  the  cost   in  the  nearest                                                                    
municipality  or  city  of   50,000  (i.e.  Anchorage).  For                                                                    
example,  connectivity could  be bought  from Savoonga  into                                                                    
Anchorage or Nome for the  same cost he would personally pay                                                                    
to get from his hospital  across to Providence in Anchorage.                                                                    
He  relayed that  a T1  satellite link  of 1.5  megabits per                                                                    
second ran  about $8,000  per month;  in Anchorage  the cost                                                                    
was $180  per month. He  explained that it meant  the clinic                                                                    
in Savoonga  would pay  $180 per month  and USF  would cover                                                                    
the  remaining  cost  of  the  $8,000.  He  elaborated  that                                                                    
because of the  high cost of satellite in  Alaska, the state                                                                    
consumed  about 60  percent of  the entire  national subsidy                                                                    
for USF.  Most of  the tribal  system's village  clinics had                                                                    
between two and  four T1s, which gave  them enough bandwidth                                                                    
to  do   multiple  videoconferencing   sessions,  electronic                                                                    
health  records,  store-and-forward,   phone  and  fax,  and                                                                    
other. He  continued that the electronic  capability was due                                                                    
to USF. He  added that he met with the  FCC whenever it came                                                                    
to Alaska due  to the critical importance  of continuing the                                                                    
program; without the program the  tribal health system could                                                                    
not afford the connectivity.                                                                                                    
1:56:16 PM                                                                                                                    
Representative Guttenberg believed he had  part of a plan in                                                                    
place [related to bandwidth], but  he noted it was a subject                                                                    
for a different time. He  stated that the bill included very                                                                    
little   dialogue   about   doing   reports   on   broadband                                                                    
availability.  He  asked  if  the  bill  needed  to  include                                                                    
language   specifying   that  telemedicine   programs   were                                                                    
eligible for  USF. Alternatively,  he asked if  the programs                                                                    
were  already  eligible  for  the   funds  under  the  rural                                                                    
healthcare programs.                                                                                                            
Mr.  Ferguson  answered  that almost  all  rural  healthcare                                                                    
facilities (e.g.  doctor offices, public health,  and other)                                                                    
were eligible  to apply for USF.  He did not believe  it was                                                                    
necessary for the state to take any action.                                                                                     
Representative  Edgmon remarked  that SB  74 was  an omnibus                                                                    
reform  bill  for  healthcare, which  devoted  a  number  of                                                                    
sections   to  telehealth   and   attempted  to   facilitate                                                                    
increased   telehealth   opportunities  in   primary   care,                                                                    
behavioral health, and urgent care.  He asked whether one of                                                                    
the  areas   may  be  a   priority  in  terms   of  expanded                                                                    
Mr.  Ferguson  replied  that he  could  not  prioritize  the                                                                    
areas, which were all huge for  Alaska. The state did not do                                                                    
anywhere  near the  amount of  behavioral and  mental health                                                                    
services it  could be  providing to  patients in  Alaska. He                                                                    
stressed the  tremendous need and relayed  that the services                                                                    
were  one  of the  easiest  to  provide via  telehealth.  He                                                                    
detailed  that  most telehealth  programs  in  the Lower  48                                                                    
started with tele-mental  health and tele-behavioral health;                                                                    
therefore  it  was  easily done  -  the  infrastructure  and                                                                    
bandwidth   were   available.   He  believed   looking   for                                                                    
opportunities  to expand  the area  was great.  He specified                                                                    
that the death by trauma rate  had been 5 times the national                                                                    
average  in   Alaska.  He  continued  that   the  state  had                                                                    
incredible emergent  emergency department  needs throughout;                                                                    
therefore,  the   ability  to   connect  with   someone  via                                                                    
telehealth  to  determine whether  a  patient  needed to  be                                                                    
flown to a  hospital or stabilized was  potentially huge for                                                                    
the  state.  He noted  that  ANTHC  had started  some  pilot                                                                    
programs, which  had been very successful.  He remarked that                                                                    
the  system  did  a  significant   amount  of  primary  care                                                                    
telehealth, but  he did not  believe it was utilized  at the                                                                    
level   it  could   be.  Additionally,   he  believed   care                                                                    
management  was the  secret to  helping  manage costs  going                                                                    
forward and telehealth was a substantial part of that.                                                                          
Representative  Edgmon  relayed  that  he  had  spoken  with                                                                    
Robert  Clark at  the Bristol  Bay  Area Health  Corporation                                                                    
(BBAHC) who  had communicated that the  Bristol Bay Hospital                                                                    
did a significant amount of  behavioral health services [via                                                                    
telehealth].  He asked  if Mr.  Ferguson  believed the  bill                                                                    
went  far  enough  to  aid what  ANTHC  and  other  regional                                                                    
providers were attempting to do with telehealth.                                                                                
Mr.  Ferguson believed  from  a  telehealth perspective  the                                                                    
bill was  pretty much  right on. One  of the  challenges was                                                                    
determining what  the system wanted  to do  with telehealth;                                                                    
the service  did not merely  happen on its own.  He believed                                                                    
the  state  and tribal  health  system  needed to  determine                                                                    
where to put the focus and  how to do it. He understood that                                                                    
part  of  the legislation  was  to  work  on that  level  of                                                                    
planning. He believed the bill  focused on the areas of need                                                                    
and the  obvious areas  of opportunity.  He did  not believe                                                                    
ANTHC  or he  personally, would  be asking  for anything  in                                                                    
addition to the current bill language.                                                                                          
2:01:44 PM                                                                                                                    
Representative  Edgmon  asked  if  the bill  would  open  up                                                                    
opportunities  for  accessing   providers  residing  out  of                                                                    
state.  He wondered  if the  opportunities  would be  hugely                                                                    
significant  or  a  good   compliment  to  current  services                                                                    
offered to  patients. He referred to  Mr. Ferguson's earlier                                                                    
testimony that  the majority of  the tribal  health system's                                                                    
patients fell into the lower risk category.                                                                                     
Mr.  Ferguson replied  that there  were  different kinds  of                                                                    
telehealth. Telehealth provided by  some other companies was                                                                    
a direct to  consumer service, which he  believed had value.                                                                    
He  believed  the  committee would  hear  from  the  company                                                                    
Teladoc later in the meeting.  He elaborated that there were                                                                    
plenty of  consumers who would  like to have the  ability to                                                                    
talk to  a doctor  at night. The  telehealth offered  by the                                                                    
tribal health  system was primarily provider  to provider or                                                                    
care management and often times  involved complex cases. The                                                                    
system made every  effort to ensure it  was fully integrated                                                                    
into the  electronic health record,  which was  an important                                                                    
piece of what the system did.  There was room for all of the                                                                    
various  types of  telehealth services,  which were  not all                                                                    
the same. He relayed that  no matter what kind of telehealth                                                                    
an entity  used, there was  a growing need to  reach outside                                                                    
the  state's  borders.  He   detailed  that  many  pediatric                                                                    
specialists simply did not exist  in Alaska - many had moved                                                                    
out of Alaska  based on changes that  occurred at Providence                                                                    
Hospital and  other places. Efforts were  always underway to                                                                    
make it  work; therefore, anything  to help with  the effort                                                                    
was beneficial.                                                                                                                 
2:03:35 PM                                                                                                                    
Representative  Gara expressed  appreciation Mr.  Ferguson's                                                                    
work. He understood what the bill  did in terms of making it                                                                    
more  permissive  to  do telehealth  for  behavioral  health                                                                    
treatment,  but he  was  unsure how  the  bill expanded  the                                                                    
ability for  more telehealth services. He  observed that the                                                                    
tribal  health system  was  already  offering a  substantial                                                                    
amount of  services. Apart from the  behavioral health area,                                                                    
he  wondered  what  else  the   bill  was  doing  to  expand                                                                    
telehealth outside of the behavioral health services.                                                                           
Mr.   Ferguson  answered   that  the   bill  included   some                                                                    
provisions to  support new models working  directly with IHS                                                                    
and  tribal  facilities to  expand  telehealth.  One of  the                                                                    
challenges was in  aligning the payment model  with the cost                                                                    
of   providing  telehealth.   He  detailed   that  sometimes                                                                    
telehealth  cost more  than traditional  healthcare, but  it                                                                    
became beneficial  when factoring  in money saved  on travel                                                                    
and  identifying  disease earlier.  Part  of  what the  bill                                                                    
offered  was the  conversation with  the  state to  consider                                                                    
what  else could  be done  and how  to model  the associated                                                                    
Vice-Chair  Saddler  asked  if  other states  had  the  same                                                                    
requirement  as Alaska  that  telehealth  providers must  be                                                                    
licensed in the same state as the patients resided.                                                                             
Mr.  Ferguson replied  that it  varied across  the U.S.  For                                                                    
example, Minnesota  specified that a licensed  provider with                                                                    
good   standing  in   any  state   could  provide   care  to                                                                    
Minnesotans,  whereas New  Mexico  required  a $10  separate                                                                    
license to provide telehealth,  which was easily attainable.                                                                    
The American  Telemedicine Association identified  the issue                                                                    
as one of  the greatest barriers to  telemedicine because it                                                                    
made  it hard  for physicians  to know  what they  needed in                                                                    
different states.                                                                                                               
Vice-Chair   Saddler   asked   if  there   was   any   place                                                                    
telemedicine had expanded too far  and it had been necessary                                                                    
to pull back from something  not working as anticipated. Mr.                                                                    
Ferguson  was  not aware  of  any.  He  stated that  in  his                                                                    
experience  of running  and building  a couple  of different                                                                    
programs,  he   had  observed   the  opposite   problem.  He                                                                    
elaborated  that it  took significant  effort  to build  the                                                                    
programs and  many times it  was necessary to  continue work                                                                    
on the  program to  keep it  going; therefore,  programs did                                                                    
not typically get  to a point where they ran  amok. He added                                                                    
that he was not aware of any other programs that had.                                                                           
2:07:17 PM                                                                                                                    
Representative  Guttenberg  highlighted that  several  years                                                                    
earlier a  broadband taskforce  had determined  the standard                                                                    
for the state should be  100 megabits, which was clearly not                                                                    
the case.  He noted the  standard speed had been  lowered to                                                                    
10 megabits.  He was concerned about  chasing the technology                                                                    
and reasoned it would not be  possible to run a program on a                                                                    
10-year-old   computer.  He   asked   if  the   telemedicine                                                                    
community was planning for  future capabilities. He reasoned                                                                    
that a  program in the  development phase  may not run  on a                                                                    
computer in  a rural area.  He detailed that  programs would                                                                    
be  pushing technology  due to  increasing capabilities.  He                                                                    
wondered  if  there  was  a  planning  group  observing  the                                                                    
situation. He  asked how  the interconnectivity  worked with                                                                    
someone in  a rural community  interacting with a  doctor in                                                                    
Anchorage  who  needed a  specialist  in  another state.  He                                                                    
asked if the capability existed.                                                                                                
Mr. Ferguson  agreed that the  technology was changing  at a                                                                    
rapid  rate,  which impacted  telemedicine  in  a number  of                                                                    
ways. There  were a  number of  lower cost,  high performing                                                                    
devices,  which  made it  necessary  for  the tribal  health                                                                    
system to do  the appropriate level of  testing to determine                                                                    
whether they  were good enough  for clinicians to  use. Some                                                                    
of the devices  available were not diagnostic  quality - the                                                                    
items  may  be  sufficient  for   a  quick  image,  but  not                                                                    
something  a specialist  could use.  He relayed  that Alaska                                                                    
had   the  world's   only  National   Telehealth  Technology                                                                    
Assessment Center,  which had been  federally funded  and in                                                                    
operation  for  about  six years.  He  elaborated  that  the                                                                    
center  assessed  about  six different  technologies  on  an                                                                    
annual   basis  (e.g.   stethoscopes,   other  scopes,   and                                                                    
etcetera). The challenge was to  locate funding or work with                                                                    
organizations to  pay to put  the technologies out  into the                                                                    
field, but  it was  done with  the ANTHC's  tribal partners.                                                                    
Additionally,  they  were  looking at  some  mobile  devices                                                                    
available.   He  detailed   that  the   system's  telehealth                                                                    
platform had  gone from computer-based to  IPad, IPhone, and                                                                    
Android - providers  used the tools when  doing consults. He                                                                    
elaborated that the system  did videoconferencing on IPhones                                                                    
out to village sites. He shared  that in the past the system                                                                    
had used  an otoscope to  take a  still image, but  it could                                                                    
now  beam the  image live  to the  doctor. The  system mixed                                                                    
store-and-forward  and  live   telehealth  capabilities.  He                                                                    
spoke  to involving  other providers  and  relayed that  the                                                                    
system  had gone  to  a  desktop videoconferencing  solution                                                                    
called  Vidyo.  He  detailed  that   the  system  liked  the                                                                    
service, which enabled  people to join a  secure room; other                                                                    
clinicians could  be invited and  it enabled the  sharing of                                                                    
images and live feeds from medical devices.                                                                                     
2:11:08 PM                                                                                                                    
Representative  Edgmon asked  about  fiber  optic cable.  He                                                                    
referred  to  an  article   about  the  company  Quintillion                                                                    
breaking  ground  in  Nome. He  believed  there  was  future                                                                    
prospect of  fiber optic cable  paralleling the  outer coast                                                                    
of Alaska  to get services  out to the Aleutians,  the North                                                                    
Slope, and  higher services  to Kodiak.  He remarked  on the                                                                    
significant  difference between  fiber  optic cable  service                                                                    
and  the traditional  TERRA  Southwest  service provided  in                                                                    
Southwest  Alaska.  He  noted   Southwest  Alaska  was  very                                                                    
grateful for  the TERRA  Southwest service  provided through                                                                    
GCI.  He asked  about  ways the  services  could be  further                                                                    
expanded  once  the fiber  optic  cable  was more  fully  in                                                                    
Mr. Ferguson  answered that fiber allowed  a transition from                                                                    
satellite  to  terrestrial,  which  significantly  decreased                                                                    
delays.  Additionally  it  provided much  bigger  bandwidth,                                                                    
which was the biggest issue.  The most significant impact of                                                                    
the  Quintillion   fiber  would  be  to   bring  terrestrial                                                                    
connectivity  to   the  villages   along  the   North  Slope                                                                    
(especially to Barrow  where the tribal health  center had a                                                                    
regional  hospital). Once  Barrow was  off of  satellite the                                                                    
hospital  would have  the ability  to  access an  electronic                                                                    
health record shared in Kansas  City, which was not possible                                                                    
over satellite  (he noted it  was possible at a  clinic, but                                                                    
not at a  hospital). The increased service  would enable the                                                                    
tribal health  facilities to  all be  on one  medical record                                                                    
and  higher bandwidth  videoconferencing would  be possible.                                                                    
He  remarked that  the upgrade  would change  everything for                                                                    
the remote  villages. He believed  once TERRA  reached Nome,                                                                    
Dillingham, and Kotzebue it huge  impact on healthcare. When                                                                    
TERRA had reached the villages  the tribal health system had                                                                    
put  Nome  on the  same  electronic  health record  and  the                                                                    
system had increased tribal health in the areas.                                                                                
2:13:23 PM                                                                                                                    
Co-Chair Neuman  believed the most recent  cost estimates of                                                                    
expanding  fiber optics  statewide was  over $2  billion. He                                                                    
asked  if the  amount  was accurate.  Mr. Ferguson  answered                                                                    
that he did not know the cost, but it would be huge.                                                                            
Co-Chair Neuman  remarked on Mr. Ferguson's  testimony about                                                                    
many of  the wonderful capabilities of  telemedicine. He had                                                                    
not received information  specifying opportunities available                                                                    
for Southwestern  Alaska with specific internet  services or                                                                    
the  connectivity   that  could   be  used   regionally.  He                                                                    
understood  that technology  changed daily.  He wondered  if                                                                    
there was a way  to get a better idea of  what could be used                                                                    
and what  could not be  used throughout the state.  He asked                                                                    
about technology available in Alaska.                                                                                           
Mr. Ferguson  replied that the tribal  health system tracked                                                                    
what the current connectivity was  to its 200-plus sites. As                                                                    
a  general rule,  the system  did not  find that  the delays                                                                    
introduced  by  satellite  prohibited it  sufficiently  from                                                                    
utilizing  telemedicine.  The  largest issue  was  how  much                                                                    
bandwidth  the villages  had (even  over a  satellite link).                                                                    
Most  of the  system's sites  had sufficient  bandwidth; the                                                                    
system was not  limited to providing the  services it wanted                                                                    
to    provide    related    to    store-and-forward,    live                                                                    
videoconferencing,    electronic    health   records,    and                                                                    
integrating the  villages into its other  services provided.                                                                    
He added that  the tribal health system  even utilized tele-                                                                    
pharmacy  to  dispense  medications  at  remote  sites.  The                                                                    
tribal  health system  was almost  past the  point of  being                                                                    
limited  by   bandwidth  or   satellite.  He   relayed  that                                                                    
terrestrial connectivity did help  for large facilities like                                                                    
hospitals.  He concluded  that at  present there  was not  a                                                                    
kind of telehealth  the system could not do  because a place                                                                    
was on satellite or lower bandwidth.                                                                                            
2:16:08 PM                                                                                                                    
Co-Chair Thompson  thanked Mr.  Ferguson for  the tremendous                                                                    
work  he  did. He  remarked  how  surprising the  technology                                                                    
capabilities were at present.                                                                                                   
REBECCA   MADISON,  EXECUTIVE   DIRECTOR,  ALASKA   E-HEALTH                                                                    
NETWORK   AND  BOARD   MEMBER,  NORTHWEST   TELEHEALTH  (via                                                                    
teleconference), spoke from prepared remarks:                                                                                   
     Thank you for inviting me to address your committee.                                                                       
     My name is Rebecca Madison. I am the Executive                                                                             
     Director of  the Alaska eHealth  Network and am  on the                                                                    
     Executive   board  of   the  Alaska   Telemedicine  and                                                                    
     Telehealth    Collaborative.   Both    are   non-profit                                                                    
     organizations dedicated to  decreasing healthcare costs                                                                    
     through effective  use of  technologies. I  also served                                                                    
     as  chairman of  the Alaska  Federal Healthcare  Access                                                                    
     Network   for  9   years   as   that  group   developed                                                                    
     telemedicine  technology for  the Alaska  Native health                                                                    
     I  would  like   to  speak  to  the   strong  need  for                                                                    
     telemedicine, prescription drug  monitoring, and health                                                                    
     information exchange  as they apply to  Medicaid Reform                                                                    
     starting  with  some  real world  examples  from  other                                                                    
        · Mississippi implemented a home based telemedicine                                                                     
          program  directed at  diabetes  and other  chronic                                                                    
          conditions.   The    program   saved   Mississippi                                                                    
          Medicaid $189  million in its  first year  and was                                                                    
          so successful that  Texas has begun implementation                                                                    
          of the same program in Austin.                                                                                        
        · Maine showed a cost savings of $2 million dollars                                                                     
          in one  60 day  period for  162 patients  by using                                                                    
          telemedicine for patient  follow up, thus reducing                                                                    
          hospital re-admissions.                                                                                               
        · New Mexico implemented a hospital-level care                                                                          
          program   in   patient  homes.   Patients   showed                                                                    
          comparable  or better  clinical  outcomes and  the                                                                    
          program achieved savings of  19 percent over costs                                                                    
          for   similar  in-patients.   Cost  savings   came                                                                    
          through less time in the  hospital and fewer tests                                                                    
        · A study in Michigan showed a 59 percent and 67                                                                        
          percent  reduction in  CT scans  and chest  x-rays                                                                    
          respectively,    when   providers    used   health                                                                    
          information exchange services  to review radiology                                                                    
2:18:38 PM                                                                                                                    
Ms. Madison continued to read from prepared remarks:                                                                            
     And  savings aren't  just to  Medicaid. Departments  of                                                                    
     Justice  and Corrections  also  have shown  significant                                                                    
        · The University of Texas Medical Branch conducted                                                                      
          over 250,000 telemedicine consultations with                                                                          
          prison inmates at a net savings to taxpayers of                                                                       
          $780 million dollars.                                                                                                 
        · The Colorado Department of Corrections reported                                                                       
          savings of $450 per telemedicine intervention,                                                                        
          about $100,000 per year through transportation                                                                        
          and security cost reductions.                                                                                         
     In  our  own state  of  Alaska,  Providence Health  and                                                                    
     Services  provides  eICU  services to  Critical  Access                                                                    
     Hospitals  statewide keeping  patients and  families in                                                                    
     their communities.                                                                                                         
     You  also heard  from  Stewart Ferguson  on the  Tribal                                                                    
     Health  system travel  savings and  the impact  on wait                                                                    
     SCL  Health, a  private  corporation  with services  in                                                                    
     Montana,  Colorado and  Kansas saw  a combined  savings                                                                    
     across  all payors  of $226.7  million by  implementing                                                                    
     clinician  to clinician  specialty consults,  clinician                                                                    
     to  patient virtual  visits and  consumer mobile  self-                                                                    
     tracking services.                                                                                                         
     Telemedicine, opioid monitoring  and health information                                                                    
     exchange  without  a   doubt  are  definitely  becoming                                                                    
     mainstream  and  are  no longer  specialized  projects.                                                                    
     One major issue  is that much of this  data was siloe'd                                                                    
     in the  past and required  providers to sign  into many                                                                    
     different systems  to get the information  they needed.                                                                    
     This  silo'ing   of  data   systems  means   that  many                                                                    
     providers  don't use  the  systems  because they  don't                                                                    
     have  time  or  knowledge to  search  through  multiple                                                                    
     databases for all the patient data they need.                                                                              
     In Alaska,  we can now leverage  the health information                                                                    
     exchange infrastructure  to provide  a single  point of                                                                    
     entry  into  health  data  from  many  systems  -  from                                                                    
     electronic health records,  to telemedicine systems, to                                                                    
     drug  databases  and a  host  of  other services.  This                                                                    
     single  point  of  entry  can  further  streamline  and                                                                    
     produce   savings  to   both  Medicaid   and  providers                                                                    
2:20:58 PM                                                                                                                    
Ms. Madison continued to address a written statement:                                                                           
     Cost   savings  are   accomplished  through   healthier                                                                    
     patients.  By putting  data in  the hands  of providers                                                                    
     and, yes, also in the  hands of patients, we can ensure                                                                    
     a  healthier population.  It takes  a  team of  payers,                                                                    
     providers and patients to lower healthcare costs.                                                                          
     Of  course,  there  is also  a  significant  impact  on                                                                    
     patients and patient  care, particularly those patients                                                                    
     with chronic  conditions, which  we could  also discuss                                                                    
     at  length.   But  in  light  of   our  current  fiscal                                                                    
     situation, I felt  it is important today  to stress the                                                                    
     financial   impact   which    coordinated   access   to                                                                    
     telehealth  and  other  healthcare   data  has  on  the                                                                    
     healthcare   system  in   general   and  Medicaid,   in                                                                    
     particular.   We  must   stem   the   rising  cost   of                                                                    
     healthcare. We have the systems  and the will to do so.                                                                    
     Medicaid reform  can leverage  these systems,  in place                                                                    
     today, to  give all Alaskans an  opportunity to receive                                                                    
     better care at a lower cost.                                                                                               
2:22:12 PM                                                                                                                    
Co-Chair Neuman  referred to  Ms. Madison's  testimony about                                                                    
the abilities of  other states to use  telemedicine, much of                                                                    
which he  believed sounded wonderful.  He asked how  much of                                                                    
the technology was available in Alaska.                                                                                         
Ms.  Madison replied  that all  of the  technology could  be                                                                    
made available,  there was  no reason  Alaska could  not use                                                                    
the  same technologies  as other  states. Some  may be  cost                                                                    
prohibitive because of the size  and number of patients, but                                                                    
a business case could be done for those things.                                                                                 
Co-Chair  Neuman asked  if Ms.  Madison believed  Alaska was                                                                    
doing everything  possible in  the telemedicine  industry to                                                                    
support  and  utilize  its  current  programs.  Ms.  Madison                                                                    
replied that she  believed the state was doing  all it could                                                                    
to use  its current programs.  However, she did  not believe                                                                    
everything possible  was being  done to reach  the patients.                                                                    
She believed  it was  important to  include the  patients in                                                                    
the healthcare through their care managers.                                                                                     
Co-Chair  Neuman believed  Ms.  Madison  had testified  that                                                                    
Alaska  had  the  ability  to  purchase  the  technology  to                                                                    
acquire  some of  the  things other  states  were doing.  He                                                                    
asked for  verification that Alaska  currently did  not have                                                                    
the necessary  technology. Ms.  Madison answered  that there                                                                    
was sufficient technology in Alaska  to do much of the work,                                                                    
but there were some things that  could not be done (e.g. the                                                                    
state  was  not  currently  set  up for  some  of  the  home                                                                    
telehealth  programs).  She  concluded that  the  state  had                                                                    
significant  technology to  provide many  of the  telehealth                                                                    
Co-Chair Neuman  requested an update from  the Department of                                                                    
Health and  Social Services (DHSS) on  telemedicine services                                                                    
currently  provided.  Additionally,  he  was  interested  in                                                                    
services the  state did not  provide and whether  they could                                                                    
be offered.                                                                                                                     
Co-Chair  Thompson noted  his office  would try  to get  the                                                                    
information from DHSS.                                                                                                          
2:24:52 PM                                                                                                                    
Vice-Chair  Saddler referred  to  page 20  of Ms.  Madison's                                                                    
presentation  on Live  Health Online  (LHO), which  made the                                                                    
notation that  the patient's copay  was the same for  an LHO                                                                    
visit  as it  would be  for an  in person  visit [note:  the                                                                    
presentation referred  to was provided by  a presenter later                                                                    
in the  meeting]. He understood  that the access  was easier                                                                    
timewise.  He asked  if there  was a  disincentive to  using                                                                    
telemedicine if  the cost  was the same.  He asked  if there                                                                    
was any advantage to the patient if the cost was the same.                                                                      
Ms.   Madison  replied   that  she   had  provided   several                                                                    
references  and  was  uncertain  which  document  Vice-Chair                                                                    
Saddler was  referring to.  She stated  that the  bill began                                                                    
the  process to  use  the  items to  determine  how to  best                                                                    
contain  costs; it  started the  discussion for  things like                                                                    
parity and what  the cost of a telemedicine  visit should be                                                                    
versus the cost  of an office visit. She  believed the topic                                                                    
was  another  discussion that  needed  to  be looked  at  by                                                                    
Medicaid and the current administration.                                                                                        
Representative   Guttenberg   referred  to   Ms.   Madison's                                                                    
testimony that Alaska  was not doing enough to  reach out to                                                                    
the patients.  He asked if she  differentiated between rural                                                                    
and urban on  the issue. He believed the state  had taken on                                                                    
rural  healthcare  first  because it  included  the  largest                                                                    
savings. He  remarked that in other  communities the savings                                                                    
may not  be much,  but they  may be  considerable relatively                                                                    
speaking.  He  asked   her  to  be  more   specific  on  her                                                                    
Ms. Madison clarified  that she had not meant  the state did                                                                    
not reach  out. She  explained that  as providers  there was                                                                    
still not  the direct patient in-the-home  connectivity that                                                                    
would  benefit the  patients. For  example, Mississippi  had                                                                    
done  a home-based  telemedicine program  that had  involved                                                                    
screening  every patient  discharged  from  the hospital  to                                                                    
determine  whether the  patient should  use telehealth  from                                                                    
home.  Subsequently, the  patients  on  telehealth had  been                                                                    
monitored in their  homes (e.g. if a person were  at risk of                                                                    
falling they  would be monitored  by video and if  a patient                                                                    
was  diabetic   they  would  be  monitored   with  equipment                                                                    
measuring  glucose and  other various  tests). She  detailed                                                                    
that monitoring  the individuals at home  had eliminated the                                                                    
need for  readmission and  had brought  many of  the chronic                                                                    
conditions  under  control  because  the  patients  had  not                                                                    
previously  had sufficient  interaction with  providers. She                                                                    
elaborated that  much medical follow  up could be  done with                                                                    
nurses at a much lower cost.                                                                                                    
Co-Chair Thompson clarified  that the presentation currently                                                                    
shown on a projector screen in  the committee room was for a                                                                    
later presenter.                                                                                                                
2:29:09 PM                                                                                                                    
DOCTOR  HENRY DEPHILLIPS,  CHIEF  MEDICAL OFFICER,  TELADOC,                                                                    
NASHVILLE,  TENNESSEE (via  teleconference), relayed  he had                                                                    
been  pleased to  hear Dr.  Ferguson's testimony.  He lauded                                                                    
Dr. Ferguson  for doing a  phenomenal job with  a phenomenal                                                                    
program.  He remarked  that legislation  the prior  year (HB
281) had moved the State  of Alaska forward significantly in                                                                    
the  world of  telemedicine. He  discussed that  Teladoc had                                                                    
worked with  the Alaska State Medical  Association (ASMA) on                                                                    
HB  281  and  in  deference   to  ASMA,  bill  sponsors  had                                                                    
incorporated  a provision  requiring  a physician  rendering                                                                    
telemedicine  care  be  licensed  in Alaska  and  an  Alaska                                                                    
resident. He referred Dr. Ferguson's  response to an earlier                                                                    
question that  licensing requirements varied in  the U.S. He                                                                    
did not want to speak for  Dr. Ferguson, but he believed the                                                                    
doctor   had   probably   been   referencing   the   federal                                                                    
telemedicine programs,  which he believed the  tribal health                                                                    
system  was a  part of  (the Veterans  Administration system                                                                    
and many others were also a  part of the federal system). At                                                                    
the  state level  (i.e. private  companies and  people under                                                                    
state government  programs) where the state  legislation and                                                                    
regulations   apply    there   was    actually   substantial                                                                    
uniformity. To  do a telemedicine consultation  in any state                                                                    
a provider was required to have  a license in that state. He                                                                    
elaborated  that  only  Alaska-licensed  physicians  in  the                                                                    
private  sector  and state  government  were  allowed to  do                                                                    
telemedicine consultations for the citizens of Alaska.                                                                          
2:31:41 PM                                                                                                                    
Mr.  DePhillips  returned to  discussing  HB  281 (from  the                                                                    
prior year)  and the  ASMA. He relayed  that after  the bill                                                                    
had passed  and Teladoc went  to recruit positions  to offer                                                                    
telemedicine services  in Alaska, it had  quickly discovered                                                                    
that the  supply and  demand challenge  was much  more acute                                                                    
than it had  thought. He continued it was  very difficult to                                                                    
ask doctors in  Alaska to do additional  work via telehealth                                                                    
or other  because they  were already  stressed to  or beyond                                                                    
capacity.  Subsequently,  a  group (including  Teladoc)  had                                                                    
come together  in the current  year to discuss  removing the                                                                    
residency  requirement. He  detailed  that  for decades  the                                                                    
Alaska  State Medical  Board  responsible for  credentialing                                                                    
and licensing physicians to render  services to Alaskans had                                                                    
been issuing  licenses to physicians  resident in  Alaska as                                                                    
well  as  physicians outside  the  state  (primarily in  the                                                                    
State of  Washington, but  other states  as well)  to render                                                                    
services to Alaskans. He highlighted  his intent to speak to                                                                    
the provision in  SB 74 that removed  the in-state residency                                                                    
requirement to  allow Alaska licensed  physicians (certified                                                                    
by  the state's  medical board)  to render  telemedicine and                                                                    
other services to Alaskans. He  communicated that Alaska was                                                                    
the only state with  a residency requirement encapsulated in                                                                    
2:33:12 PM                                                                                                                    
Mr. DePhillips  relayed that telemedicine had  existed for a                                                                    
bit and  Teladoc had built  its program around  primary care                                                                    
telemedicine  for   common  uncomplicated   medical  issues.                                                                    
Teladoc had  been established in  2002 and was coming  up on                                                                    
1.5 million  e-visits across all  50 states. From  a patient                                                                    
safety  standpoint, across  the country  for in  person care                                                                    
for  about every  1  million visits  there  were 17  medical                                                                    
malpractice cases  filed and  carried through  to completion                                                                    
where an  award was made  (the average award  was $248,000).                                                                    
Teladoc  was approaching  1.5 million  visits and  had never                                                                    
had  a  medical malpractice  go  through  to completion  and                                                                    
awarded, filed  with its carrier, or  litigated. He believed                                                                    
the record was a reasonably  good marker for patient safety.                                                                    
From  an oversight  perspective, a  comprehensive electronic                                                                    
health  record embedded  in a  technology platform  provided                                                                    
the ability to do very  intense quality oversight, which was                                                                    
not  available  in  a  private  practice  brick  and  mortar                                                                    
setting. Teladoc  looked at  the data  including prescribing                                                                    
patterns,  appropriate prescribing,  and  other. He  relayed                                                                    
that the company  did not allow any  Drug Enforcement Agency                                                                    
(DEA)  controlled  substances  or  lifestyle  drugs  in  the                                                                    
program.   The  company's   overall  prescribing   rate  was                                                                    
currently  running at  77 percent  of all  consult requests;                                                                    
the brick and  mortar average as reported on  the Center for                                                                    
Disease Control  (CDC) website was currently  82 percent. He                                                                    
detailed  that based  on the  company's volume,  its overall                                                                    
prescribing  was   statistically  significantly   below  the                                                                    
national average.                                                                                                               
Mr.  DePhillips   discussed  the   comprehensive  electronic                                                                    
health  record  shared  between the  patient  and  physician                                                                    
prior to the  visit, completed during the  visit, and shared                                                                    
with the  patient's primary care physician  after the visit.                                                                    
He referred  to a  committee member's earlier  comment about                                                                    
concern  related  to  the quality  of  medical  records.  He                                                                    
believed that  because of the platform  approach and quality                                                                    
oversight that the quality of  the clinical record was quite                                                                    
strong compared  to charts  in the  in person  setting where                                                                    
there  was less  oversight. The  company wanted  care to  be                                                                    
local; Teladoc  had built a  five minute lead time  into the                                                                    
platform  that gave  a licensed  and resident  physician the                                                                    
opportunity to respond to the  consult before a non-resident                                                                    
physician could respond. The  company actually preferred for                                                                    
care to be  given by licensed and  resident physicians (they                                                                    
had  to  be licensed  by  law),  but  the capacity  was  not                                                                    
sufficient to service the clients.                                                                                              
2:36:41 PM                                                                                                                    
Mr. DePhillips  addressed cost savings and  referenced well-                                                                    
done third-party  studies. He shared that  a Harvard Medical                                                                    
School researcher had studied claims  in the population of a                                                                    
national home  improvement retailer  - He noted  the company                                                                    
did not want  its name used in the study,  but he added that                                                                    
its logo was  orange. He shared that for  every consult done                                                                    
by one  of the company's 150,000  employees (including those                                                                    
in Alaska),  for the  self-insured employer  responsible for                                                                    
the cost  of medical  care across  the individuals  who used                                                                    
the  service and  their  independents who  did  not use  the                                                                    
service  there  was a  savings  per  consult of  $1,157.  He                                                                    
stressed  that  the savings  was  much  higher than  he  had                                                                    
expected.  He  believed it  indicated  the  shortage of  the                                                                    
provision of  primary care services. Before  the individuals                                                                    
in the study had the  telemedicine benefit they had used the                                                                    
emergency  room  for   non-emergency  common,  uncomplicated                                                                    
medical  issues. He  relayed that  Teladoc  had worked  with                                                                    
ASMA on  SB 74  and he believed  the entity's  concerns were                                                                    
understandable.  He  referred  to  the  credible  nature  of                                                                    
Teladoc's  program. The  association  had vocalized  concern                                                                    
about  other  companies that  may  come  up if  things  were                                                                    
legislated.  The company  recommended that  the standard  of                                                                    
care for  any medical issue  needed to be met  regardless of                                                                    
the  modality  of  treatment  (i.e.  whether  in  person  or                                                                    
remote)  and the  standard must  be the  same. Additionally,                                                                    
Teladoc  recommended  a   technology  neutral  approach.  He                                                                    
referred  to  the two  prior  testifiers  who had  specified                                                                    
technology was moving extremely  quickly. He did not believe                                                                    
any legislature in the country  should be in the business of                                                                    
assessing  and determining  what technology  was appropriate                                                                    
in healthcare.  He believed the  issue should be left  up to                                                                    
practicing   physicians   to   decide   how   they   collect                                                                    
information  and  what information  they  need  to meet  the                                                                    
standard of care.                                                                                                               
Mr.  DePhillips   addressed  three  modalities   offered  by                                                                    
Teladoc  including   audio-videoconferencing;  uploading  of                                                                    
high  definition photographs,  which were  probably superior                                                                    
to video (smart phone still  cameras had about seven to nine                                                                    
times the  resolution of the  video camera) for  things like                                                                    
skin lesions, pink  eye, and other; and a  subset of medical                                                                    
issues  could be  handled by  telephone. He  elaborated that                                                                    
the ability to diagnose  issues (e.g. bronchitis, sinusitis,                                                                    
urinary tract  infections, and other) over  the phone helped                                                                    
with the bandwidth  issue and the diagnosis  could be safely                                                                    
done  after the  medical  record was  shared via  store-and-                                                                    
forward.  He  relayed that  no  data  indicated any  of  the                                                                    
modalities were  either superior or  inferior to any  of the                                                                    
others, which was the reason  Teladoc continued to offer all                                                                    
three options. He added that  if data emerged showing one of                                                                    
the modalities was superior, the  company would go with that                                                                    
option.   He  communicated   that   Teladoc  was   currently                                                                    
servicing  GCI,  Alaska  Airlines, Fred  Meyer,  and  Aetna,                                                                    
Premera,  Lowes,  Costco, BP,  Shell,  and  other. He  noted                                                                    
Aetna would  love to bring  the program to  state employees.                                                                    
The company would  love to have the ability  to allow Alaska                                                                    
licensed  physicians  residing  in other  states  to  render                                                                    
services in Alaska  to the employees of the  entities he had                                                                    
2:40:47 PM                                                                                                                    
Representative Munoz  asked if Teladoc's fees  were the same                                                                    
across  state   lines.  Mr.   DePhillips  answered   in  the                                                                    
affirmative. For  example, for  a company doing  business in                                                                    
all 50  states, Teladoc charged  the company the  same price                                                                    
to  offer  the service  in  each  state.  There was  also  a                                                                    
uniform  fee schedule  for reimbursement  going  out to  the                                                                    
board  certified physicians  rendering  care.  There were  a                                                                    
couple of  minor, few  and far  between exceptions,  but the                                                                    
company tried hard to have a uniform fee schedule.                                                                              
Representative Munoz  asked if  the fees were  published and                                                                    
whether the  patient knew the  fees prior to  services being                                                                    
rendered.  Mr.  DePhillips answered  that  the  cost of  the                                                                    
visit was  $45.00. He  detailed that  the sponsor  (i.e. the                                                                    
employer  or health  plan) would  pick up  a portion  of the                                                                    
amount  (some  sponsors  covered   the  entire  amount).  He                                                                    
referred to an earlier question  by a committee member about                                                                    
why  the service  would be  utilized if  an in  person visit                                                                    
cost the same.  The data was clear that  unlike most medical                                                                    
benefits it  was a benefit  a company should  want employees                                                                    
to use more  and not less because it provided  a safe access                                                                    
to care option  for patients to use rather  than being faced                                                                    
with  going   to  the  emergency  room   or  utilizing  more                                                                    
expensive options.  The companies paying the  entire $45 had                                                                    
four  times the  utilization  of the  companies pitching  in                                                                    
nothing. He  furthered that the  ROI [return  on investment]                                                                    
for the company  responsible for the cost of  care went from                                                                    
5 to  1 on  the $45  patient copay to  20 to  1 on  the zero                                                                    
patient copay.                                                                                                                  
2:42:51 PM                                                                                                                    
Vice-Chair  Saddler   asked  if   there  was  any   area  of                                                                    
telehealth that  was not providing  the results he  hoped to                                                                    
see. He  asked if there  were areas in which  Mr. DePhillips                                                                    
would advise against using telehealth.                                                                                          
Mr.  DePhillips  answered  that  behavioral  health  was  an                                                                    
"absolute  slam dunk"  for telehealth.  He pointed  to short                                                                    
supply  of behavioral  health  services,  especially in  the                                                                    
pediatric  population. He  mentioned dermatology  as another                                                                    
area where telemedicine provided  a good option. He stressed                                                                    
the  conservative nature  of the  industry and  relayed that                                                                    
when  interviewed  for  his  position   at  Teladoc  he  had                                                                    
interviewed all board members and  senior management and had                                                                    
asked what they  would choose if they had  to decide between                                                                    
patient safety and  profit. He would not have  taken the job                                                                    
if the answer had not been  patient safety every step of the                                                                    
way.  The bottom  line  was  no one  in  the industry  could                                                                    
afford  an article  on the  front  page of  the Wall  Street                                                                    
Journal saying  that the  industry had  done too  much, gone                                                                    
too far,  and had a bad  result; the situation would  be bad                                                                    
for the  specific company and  for the industry as  a whole.                                                                    
He reiterated  that the industry had  been very conservative                                                                    
and  had  good  clinical  guardrails  in  place  around  the                                                                    
programs.  He believed  all of  its direct  competitors also                                                                    
had a clean medical liability  history. He stressed that the                                                                    
industry  had  not   gone  too  far.  He   believed  it  had                                                                    
intentionally  been  very  conservative in  the  rollout  of                                                                    
services because they all wanted  to ensure clinical quality                                                                    
was the first priority.                                                                                                         
Vice-Chair   Saddler  referred   to   testimony  about   the                                                                    
malpractice  rate.   He  asked   about  the   liability  and                                                                    
insurance  implications for  a  physician offering  services                                                                    
via telemedicine.                                                                                                               
Mr. DePhillips replied  that the problem had  been solved by                                                                    
using  an   insurance  carrier  that  insured   all  of  the                                                                    
physicians  who worked  in the  Teladoc and  other programs.                                                                    
Teladoc provided  the medical malpractice insurance  for all                                                                    
of  the  doctors.  Second,  Teladoc's  agreements  with  the                                                                    
physicians included a hold harmless  clause specifying if an                                                                    
issue occurred, Teladoc would  take responsibility on behalf                                                                    
of the physician.                                                                                                               
2:45:20 PM                                                                                                                    
WALLACE  ADAMSON, VICE  PRESIDENT,  ANTHEM, INC.,  COLUMBUS,                                                                    
OHIO (via  teleconference), spoke  in support  of SB  74. He                                                                    
shared  that he  was a  family physician  and had  worked in                                                                    
various  business  capacities over  the  past  16 years  for                                                                    
Anthem.  Anthem   was  a   health  insurance   company  with                                                                    
approximately 36  million members  operating Blue  Cross and                                                                    
Blue  Shield plans  in 14  states and  Medicaid plans  in 20                                                                    
states through  its Amerigroup subsidiary. He  currently led                                                                    
the  physician  strategy  for Anthem's  telehealth  solution                                                                    
LiveHealth  Online. He  addressed a  PowerPoint presentation                                                                    
titled "Introducing  LiveHealth Online"  (copy on  file). He                                                                    
explained that  LiveHealth Online allowed consumers  to have                                                                    
live  face-to-face real  time visits  with the  physician of                                                                    
their  choice.  In  addition to  the  consumer  option,  the                                                                    
system also offered LiveHealth Online  to physicians for use                                                                    
in their  practices, which enabled them  to offer telehealth                                                                    
opportunities to  their own patient populations.  He relayed                                                                    
that  the  wait  time  for  a  visit  on  LiveHealth  Online                                                                    
averaged  10 minutes  or less.  The  program targeted  minor                                                                    
health  problems of  a somewhat  urgent  nature (i.e.  sinus                                                                    
infections, ear aches, and other).  Visits were available 24                                                                    
hours per day, 7 days a week, and 365 days per year.                                                                            
Mr. Adamson  moved to  slide 3  that included  a map  of the                                                                    
United States.  He detailed that  the program  was currently                                                                    
offered to  16 million Anthem  members in 47 states  and the                                                                    
District of Columbia  (shown in green). The  company did not                                                                    
operate  in Alaska,  Texas, and  Arkansas due  to the  local                                                                    
regulatory  and legislative  environments  (shown in  gray).                                                                    
California was shown  in a darker green  because its program                                                                    
included a  Spanish language  offering of  LiveHealth Online                                                                    
called Cuidado Medico.  Indiana was shown in  light green to                                                                    
indicate that the  state recently had a  statute change that                                                                    
would  allow prescribing  via  telehealth  effective July  1                                                                    
Mr. Adamson  relayed that Anthem  offered a real  time video                                                                    
visit  giving   patients  access  to  the   board  certified                                                                    
physician of their  choice. The company had  also rolled out                                                                    
a  LiveHealth Online  psychology. He  noted that  behavioral                                                                    
health  was a  natural fit  for telehealth  and worked  very                                                                    
well.  He spoke  to the  importance of  telehealth from  the                                                                    
employer prospective.  He detailed the company  had national                                                                    
employers  including   Wells  Fargo,  FedEx,   Safeway  that                                                                    
offered  LiveHealth  Online  to their  employees  (excluding                                                                    
2:49:39 PM                                                                                                                    
Mr.  Adamson  relayed  that   Anthem's  primary  reason  for                                                                    
providing  the service  was related  to access  and cost  of                                                                    
care.  The company  preferred for  individuals to  see their                                                                    
own physician  and believed patients  could get  the highest                                                                    
quality care  from the ongoing relationship  with the doctor                                                                    
they  had chosen.  Unfortunately, many  individuals did  not                                                                    
have the benefit of that  type of relationship; the majority                                                                    
of Anthem members did not  have an ongoing relationship with                                                                    
a primary  care physician.  He addressed the  busy schedules                                                                    
doctors  held and  referred to  earlier testimony  about the                                                                    
demands on  Alaska physicians. He detailed  that the company                                                                    
liked to be  available as the backup (e.g. at  10:00 p.m. on                                                                    
a Friday  night or Sunday  morning at 7:00 a.m.)  if someone                                                                    
was  in  need   of  care.  He  turned  to   slide  5  titled                                                                    
"HealthCore study results are  promising" and spoke to cost-                                                                    
savings.  The company  had conducted  an extensive  study of                                                                    
Anthem  results from  its claims  data on  people using  the                                                                    
program.  The study  had  compared  LiveHealth Online  users                                                                    
living in the  same state with the same  health problem. For                                                                    
example,  the  study  had  looked  compared  Anthem  members                                                                    
living in Ohio who received  treatment for a sinus infection                                                                    
through  LiveHealth  Online,  urgent  care,  a  clinic,  the                                                                    
emergency  room, and  a primary  care visit.  The study  had                                                                    
looked  at a  three-week  period, which  included costs  for                                                                    
follow up,  imaging, pharmacy, and  other; it  had concluded                                                                    
there was a savings of  approximately $201 to $202 per visit                                                                    
with LiveHealth  Online. The study had  also determined that                                                                    
the  patterns of  care  were very  comparable  to the  other                                                                    
locations.  For example,  follow up  visits and  prescribing                                                                    
were very  closely aligned  between the  different treatment                                                                    
settings.  He communicated  that the  program was  valued by                                                                    
consumers; 90  percent of individuals  who used  the program                                                                    
specified they  would use it  again and 85  percent reported                                                                    
that their medical problem was completely resolved.                                                                             
Mr.  Adamson   addressed  an  earlier  question   about  the                                                                    
benefits of  telemedicine even if the  cost differential was                                                                    
the same.  Anthem had  heard loud  and clear  from consumers                                                                    
about the  time savings  telemedicine provided.  He believed                                                                    
the time  savings would  only be  amplified in  Alaska given                                                                    
its landscape  and geography. He  detailed that  most people                                                                    
in the  Lower 48 reported they  saved two to three  hours of                                                                    
time using  telemedicine versus an  in person  doctor visit.                                                                    
He noted the value to employers  when they were able to keep                                                                    
people in the workplace.                                                                                                        
2:53:29 PM                                                                                                                    
Vice-Chair Saddler referred  to language on slide  20 of the                                                                    
presentation   specifying   that    the   copay   for   each                                                                    
consultation  was  a flat  $49,  which  was  the same  as  a                                                                    
doctor's visit.  He asked  if it was  a disincentive  to use                                                                    
telehealth if the cost was the same as an in person visit.                                                                      
Mr.  Adamson answered  that the  total cost  of a  visit was                                                                    
$49, which  included the health plan's  contribution and the                                                                    
individual's  copay (some  people had  copay and  others had                                                                    
coinsurance).  When Anthem  had implemented  the program  in                                                                    
2013 there  had been a  "spirited" discussion on what  to do                                                                    
with  copays  compared  to primary  care.  The  company  had                                                                    
decided the least disruptive strategy  at the time was to be                                                                    
equal with  the primary  care component. The  company wanted                                                                    
the  program to  be neutral  and did  not want  to stimulate                                                                    
excess demand or  create a disincentive for its  use. With a                                                                    
couple  of years  under  its belt,  the  company heard  from                                                                    
consumers  that  the price  was  very  fair, especially  for                                                                    
individuals  with  a  health  savings  account  and  a  high                                                                    
deductible plan  ($49 for a  visit was much better  than the                                                                    
rate at  a local urgent  care or an emergency  room). Anthem                                                                    
spoke to many different companies  that set the benefits and                                                                    
different companies  did different things. He  detailed that                                                                    
some companies wanted to offer  low copays to individuals to                                                                    
encourage them  to use the service,  whereas other companies                                                                    
had higher  copays because they  believed the  service would                                                                    
be over-utilized.                                                                                                               
Vice-Chair Saddler  asked if Anthem experienced  any problem                                                                    
with the  over-prescription of  opioids via  telehealth. Mr.                                                                    
Adamson  answered  that  opioids and  lifestyle  drugs  were                                                                    
blocked  on  LiveHealth  Online;  therefore, it  was  not  a                                                                    
problem for the  company. He believed the same  was true for                                                                    
most of the major telehealth companies.                                                                                         
2:56:34 PM                                                                                                                    
Representative Gattis  relayed that  she had offered  a bill                                                                    
related to telehealth  in the past; she was  a big proponent                                                                    
of technology  and telehealth. She spoke  to the significant                                                                    
amount of time  it took parents to take a  sick child to the                                                                    
doctor, which included driving  and wait time. Additionally,                                                                    
she  believed waiting  in  a waiting  room  with other  sick                                                                    
children  had to  factor  in to  the  convenience factor  of                                                                    
using  telemedicine.   She  remarked  on  the   advances  of                                                                    
technology  over time.  She believed  telemedicine added  to                                                                    
convenience, cost-savings,  and provided another  option for                                                                    
Co-Chair Thompson thanked Mr.  Adamson for his testimony. He                                                                    
spoke   to  advances   in   technology   and  reasoned   the                                                                    
legislature  would eventually  have teleconferencing  to see                                                                    
the testifiers.                                                                                                                 
2:58:21 PM                                                                                                                    
HEATHER SHADDUCK,  STAFF, SENATOR  PETE KELLY,  relayed that                                                                    
Sections 13  through 19  of the  legislation dealt  with the                                                                    
Prescription  Drug Monitoring  Program (PDMP),  beginning on                                                                    
page 15, line  23. Section 13 was amended  by only requiring                                                                    
data collection  for the database or  dispensing for federal                                                                    
Schedule II,  III or IV  controlled substances.  Section 14,                                                                    
page 16,  line 1  amends by  only requiring  data collection                                                                    
for  prescribing,   administering,  or   dispensing  federal                                                                    
Schedule  II, III,  or IV  drugs. The  section updated  data                                                                    
collection to a minimum of  once a week (line 11). Currently                                                                    
the PDMP was updated on a monthly basis.                                                                                        
Ms. Shadduck  addressed changes in  Section 15,  which added                                                                    
additional access to the database  (page 16, line 27 through                                                                    
page 18, line 16). The first  change was in number 3 on page                                                                    
17,  line  9 where  the  bill  amended  law to  authorize  a                                                                    
licensed  practitioner  to  delegate database  access  to  a                                                                    
supervised  employee or  clinical staff.  The second  change                                                                    
started  on  line  14  and   would  authorize  a  registered                                                                    
pharmacist  to   delegate  database  access   to  supervised                                                                    
employees or clinical staff. The  third change was in number                                                                    
7 on line 29; a new  section was added to authorize database                                                                    
access  to the  State of  Alaska Medicaid  pharmacy program.                                                                    
The fourth change  appeared in number 8 on page  18, line 3;                                                                    
a new section was added  to authorize database access to the                                                                    
State of  Alaska Medicaid Drug Utilization  Review Committee                                                                    
for  utilization review  of prescription  drugs provided  to                                                                    
Medicaid recipients. Number 9 on  line 8 added a new section                                                                    
to authorize database access to  the State of Alaska medical                                                                    
examiner. Number  10 added a  new section to  authorized de-                                                                    
identified data access to the  State of Alaska DHSS Division                                                                    
of  Public Health.  The division  would not  need access  to                                                                    
identifiable  data  to   fulfill  public  health  objectives                                                                    
regarding controlled substances.                                                                                                
Ms. Shadduck  addressed the change  in Section  16 beginning                                                                    
on page  18, line  17. The change  removed optional  use and                                                                    
maintained immunity  for individuals using PDMP.  Section 18                                                                    
on page 19 related to  board regulations and review of PDMP.                                                                    
Number 3  was added to  the section  to set a  procedure and                                                                    
timeframe for  registration for the PDMP.  Number 4 required                                                                    
prescribers  and   pharmacists  to  review   the  controlled                                                                    
substance   prescription    database   before   prescribing,                                                                    
administering, or dispensing a  federal Schedule II, III, or                                                                    
IV controlled  substance to a  patient. Some  exemptions had                                                                    
been added in  based on some public testimony  in the Senate                                                                    
including: a) for  those in an inpatient setting;  b) at the                                                                    
scene  of  an  emergency  or  in  an  ambulance;  c)  in  an                                                                    
emergency  room; d)  immediately before,  during, or  within                                                                    
the first  24 hours after  surgery. Section 19  included new                                                                    
subsections:  o)  required  prescribers and  pharmacists  to                                                                    
review the  PDMP database when  prescribing or  dispensing a                                                                    
federal Schedule  II, III, or  IV controlled substance  to a                                                                    
patient;  p)   required  notifications  to  boards   when  a                                                                    
practitioner  registered with  the  database; q)  authorized                                                                    
the Board  of Pharmacy to forward  unsolicited notifications                                                                    
to prescribers and dispensers  of database information about                                                                    
patients   who  may   be  obtaining   controlled  substances                                                                    
inconsistent  with generally  recognized standards  of care;                                                                    
and r) collect dispensing data  and update the PDMP database                                                                    
on at  least a weekly  basis. She  relayed that most  of the                                                                    
items  were conforming  to  clean up  changes  in the  other                                                                    
sections.    She   reminded    the   committee    that   the                                                                    
recommendations  had  come  from  the  Controlled  Substance                                                                    
Advisory Committee, which had  been reported to the governor                                                                    
prior to the start of the current session.                                                                                      
3:03:59 PM                                                                                                                    
Representative Guttenberg stated that  the pharmacists had a                                                                    
concern about  the redundancy  of the  requirement mandating                                                                    
them  to check  the database  before filling  a prescription                                                                    
because a  doctor was  also required  to check  the database                                                                    
when  writing a  prescription. He  asked for  Ms. Shadduck's                                                                    
feedback on the issue.                                                                                                          
Ms.  Shadduck  replied  that the  sponsor  had  worked  with                                                                    
others  in  the Senate  and  with  DHSS  on the  issue.  She                                                                    
explained   that  the   pharmacists  were   responsible  for                                                                    
populating the database.  She believed it made  sense not to                                                                    
require   pharmacists   to   check   the   database   before                                                                    
dispensing,  but they  had to  populate it.  The requirement                                                                    
for  physicians to  check the  database prior  to writing  a                                                                    
prescription would  remain. She  explained the  change would                                                                    
alleviate some  of the problems  where the  pharmacists feel                                                                    
they had to enforce the issue,  when it should really be the                                                                    
doctor's  responsibility  to know  whether  it  was wise  to                                                                    
prescribe  a   controlled  substance.  She   furthered  that                                                                    
doctors would  be the most  equipped to consider  whether an                                                                    
addiction problem was present.                                                                                                  
Representative Guttenberg  remarked that the  discussion was                                                                    
only  about individuals  the system  had  problems with.  He                                                                    
surmised  that most  of the  population was  fine. He  spoke                                                                    
about   individuals   shopping   for  doctors   to   receive                                                                    
prescriptions. He asked for  verification that doctors would                                                                    
have the  ability to see  what other doctors  had prescribed                                                                    
to a patient.                                                                                                                   
Ms. Shadduck  replied that it  was what the  sponsor wanted.                                                                    
Part of  the information came  from the white paper  she had                                                                    
provided from  the Controlled Substances  Advisory Committee                                                                    
[State  of Alaska  Controlled Substances  Advisory Committee                                                                    
"White  Paper:  Increasing  the  Effectiveness  of  Alaska's                                                                    
Prescription Drug Monitoring  Program (Alaska's PDMP)" dated                                                                    
January  29,  2016  (copy on  file)];  currently  only  13.5                                                                    
percent  of prescribers  and 40  percent of  dispensers were                                                                    
using the  database as an  optional database.  She furthered                                                                    
that  by making  use of  the database  mandatory would  give                                                                    
doctors access to the information.  She knew DHSS had worked                                                                    
hard  to  improve  the database;  the  intent  of  requiring                                                                    
database  updates at  least once  a  week that  it would  be                                                                    
updated   more  frequently.   The   goal   was  to   provide                                                                    
flexibility  for pharmacies  that were  ready to  update the                                                                    
database on  a daily basis  (some small pharmacies  were not                                                                    
ready  for that).  The intent  was for  doctors to  have the                                                                    
ability to  see if a  person was doctor shopping.  She noted                                                                    
that  Doctors  Inc.  had given  great  testimony  about  the                                                                    
emergency room project  - once they had the  data they could                                                                    
identify individuals who were doctor shopping.                                                                                  
3:07:58 PM                                                                                                                    
Co-Chair  Thompson   noted  that  Senator  Pete   Kelly  and                                                                    
Representative Liz Vasquez were present in the room.                                                                            
MELINDA   RATHKOPF,   PRESIDENT,    ALASKA   STATE   MEDICAL                                                                    
ASSOCIATION, WASILLA  (via teleconference), spoke  to ASMA's                                                                    
position on  the PDMP. The  association's goal was  care for                                                                    
patients in Alaska  and determining the best  way to provide                                                                    
the care.  The association  was supportive  of the  PDMP (it                                                                    
had  been working  with the  legislature and  administration                                                                    
and recognized  the national and global  problem with opioid                                                                    
abuse)  and of  looking at  ways to  improve the  problem of                                                                    
opioid abuse in Alaska.  The association appreciated some of                                                                    
the language included in the  bill about ways to utilize the                                                                    
database  to  its  fullest potential  without  being  overly                                                                    
burdensome  to  the  provider. She  relayed  that  ASMA  had                                                                    
requested  that Schedule  IV be  dropped from  the mandatory                                                                    
pre-lookup. She detailed  that ASMA saw the  need to include                                                                    
Schedule II and  III (opioids and drugs more  likely to have                                                                    
a  higher abuse  potential), but  it felt  that Schedule  IV                                                                    
(that   by  nature   had  a   lower  abuse   potential)  was                                                                    
potentially  very burdensome  on providers  on a  day-to-day                                                                    
basis.  She referred  to the  exception  made for  instances                                                                    
within the  first 24  hours after  surgery and  requested to                                                                    
add  "or procedure"  to the  exemption.  She explained  that                                                                    
often  it was  not necessarily  a surgery,  but a  procedure                                                                    
where  a doctor  may be  prescribing a  short-term substance                                                                    
pre-procedure.  She relayed  that ASMA  wanted to  work with                                                                    
the  legislature  and strongly  supported  the  idea of  the                                                                    
database,  but wanted  to look  at ways  to make  the system                                                                    
more usable for  the provider and to determine  the best way                                                                    
to deal with the overall problem.                                                                                               
3:11:20 PM                                                                                                                    
Representative  Gara asked  about  the current  prescription                                                                    
drugs  doctors  were  required  to  look  up.  Dr.  Rathkopf                                                                    
answered that there was currently  no requirement for a pre-                                                                    
lookup. At  present providers were  using the  database when                                                                    
they had concerns about over-prescribing  or about a patient                                                                    
who  may  be  doctor   shopping  and  getting  prescriptions                                                                    
Vice-Chair   Saddler  asked   if   Dr.   Rathkopf  had   any                                                                    
information about  breeches of privacy in  the current PDMP.                                                                    
Dr. Rathkopf  answered that  she had not  heard of  any. She                                                                    
elaborated that  the ASMA had  not discussed or had  as many                                                                    
issues  with the  privacy concerns.  She  explained that  as                                                                    
providers  they  were  looking at  the  utilization  of  the                                                                    
database  on  a  patient  level;  at  that  level  providers                                                                    
already assumed  patients were sharing  personal information                                                                    
and  providing  access  to   their  prior  medications.  She                                                                    
believed the  biggest concern  was giving  doctors a  way to                                                                    
look  up  patients'  prescriptions  in case  they  were  not                                                                    
forthcoming   about  medications   they  were   taking.  She                                                                    
detailed  that when  patients saw  doctors  on a  one-on-one                                                                    
basis  they had  already  waived their  rights  for some  of                                                                    
those issues. She  concluded that the privacy  issue had not                                                                    
come out  of the provider side  and it had not  been brought                                                                    
up by physicians that she was aware of.                                                                                         
Vice-Chair  Saddler asked  how  long it  took  to check  the                                                                    
database.  Dr. Rathkopf  answered that  she was  a pediatric                                                                    
allergist/immunologist  and prescribed  very little  opioids                                                                    
and narcotics;  therefore, she did not  utilize the database                                                                    
in her own  day-to-day patient care. Other  providers in the                                                                    
emergency room and  pain specialists had told  her the check                                                                    
could  take up  to 10  minutes. She  had registered  for the                                                                    
database to see how difficult the registration process was.                                                                     
Representative Gara  looked at the emergency  room treatment                                                                    
exception in the  bill where pre-lookup in  the database was                                                                    
not  required.  He  did not  want  to  provide  prescription                                                                    
access to a person seeking  extra narcotics. He assumed that                                                                    
unless a person  was suffering a real injury  a person would                                                                    
not  have the  ability to  walk into  the emergency  room to                                                                    
obtain  a prescription.  He asked  whether Dr.  Rathkopf saw                                                                    
any room for abuse in the area.                                                                                                 
Dr. Rathkopf replied  that the purpose of  the exemption was                                                                    
that ASMA  did not  want to  delay response  to a  person in                                                                    
critical condition.  She believed the database  was utilized                                                                    
most  frequently  by  pain specialists  and  emergency  room                                                                    
doctors; they already  saw the utility of  the database. She                                                                    
was  not saying  that  an emergency  room  doctor would  not                                                                    
consult  the database  if someone  was  being discharged  in                                                                    
stable condition with a prescription  for Schedule II or III                                                                    
drugs. The primary concern was  about having to halt patient                                                                    
care until the mandatory pre-lookup was done.                                                                                   
3:15:50 PM                                                                                                                    
Representative   Gara   understood   the  reason   for   the                                                                    
exception. He  could not envision  a circumstance  where the                                                                    
emergency  room  exemption  would  make it  possible  for  a                                                                    
person  to get  extra prescriptions  they did  not need.  He                                                                    
asked if there was any danger he was missing.                                                                                   
Dr.  Rathkopf answered  that  she did  not  believe so.  She                                                                    
expounded that the idea was  to ensure that patient care was                                                                    
not  hindered. The  emergency  room  providers were  already                                                                    
using the database  and individuals who were seen  as a high                                                                    
risk of  seeking multiple prescriptions  would be  looked up                                                                    
in the system.                                                                                                                  
Co-Chair Neuman asked what it took  to get on and enter into                                                                    
the database. Dr. Rathkopf answered  that she had registered                                                                    
the  prior  day.  She  detailed  that  the  database  was  a                                                                    
separate site  not tied to  licensing or anything  else. The                                                                    
initial registration  took about  five minutes, but  then it                                                                    
required  the  registrant to  download  a  form requiring  a                                                                    
notary. She  relayed that  fortunately she  had a  notary in                                                                    
her  office,  but  most  providers   did  not.  The  process                                                                    
included   finding   a   notary,  scanning   the   document,                                                                    
resubmitting it. Once all of  the information was submitted,                                                                    
it took overnight to get approval.                                                                                              
Co-Chair Neuman relayed that he  had spoken to other doctors                                                                    
about the  topic. He  had asked  DHSS for  information about                                                                    
the  topic,  but had  not  yet  received  it. He  asked  for                                                                    
verification that  the registrant  was required to  read and                                                                    
sign 7 pages of regulations.                                                                                                    
Ms.  Rathkopf answered  that there  were some  documents she                                                                    
had  read, which  required the  registrant to  agree to  the                                                                    
terms. Subsequently, the registrant  was sent the additional                                                                    
paperwork.  The  registrant  was  required  to  have  a  DEA                                                                    
number,  provider  number,  and state  license  number.  The                                                                    
reason  for the  notary requirement  was to  show proof  the                                                                    
person registering for the database  was who they claimed to                                                                    
be. She had not  found the initial registration particularly                                                                    
cumbersome   other   than   the  notary   requirement.   She                                                                    
reiterated  that after  completing the  registration it  had                                                                    
taken overnight  to get  the approval. She  had not  had the                                                                    
need to  look up  a patient  for an  opioid narcotic  so she                                                                    
could not personally attest to  how long that part took. She                                                                    
had heard  reports that  the process took  an average  of 10                                                                    
Co-Chair Neuman  had heard concerns from  other doctors that                                                                    
they  were hesitant  to sign  that they  had read  and fully                                                                    
understood  all  of  the regulations.  He  referred  to  the                                                                    
confusing  nature of  federal  documents.  The doctors  were                                                                    
concerned they could  lose their DEA license  because it was                                                                    
essentially  perjury if  a doctor  did not  fully understand                                                                    
what  they read.  He asked  Dr. Rathkopf  if she  would feel                                                                    
comfortable signing the documents.                                                                                              
3:19:46 PM                                                                                                                    
Ms.  Rathkopf  answered  that  she  had  read  many  of  the                                                                    
documents in her role on  ASMA and surmised that perhaps she                                                                    
was more comfortable reading through  the documents. She was                                                                    
much more familiar with the system  than she had been a year                                                                    
ago   before  she   had  become   president  of   ASMA.  The                                                                    
requirements did not stand out  as bothersome or concerning,                                                                    
but it  may be because she  was more prepared going  into it                                                                    
based on her experience on ASMA.                                                                                                
Co-Chair   Neuman  asked   Dr.  Rathkopf   believed  general                                                                    
practitioners  (the  bulk  of the  state's  family  doctors)                                                                    
would  feel   comfortable  signing   each  of   the  federal                                                                    
documents.  He  remarked  that individuals  who  signed  the                                                                    
agreement, but did not understand  it could potentially lose                                                                    
their DEA license.                                                                                                              
Ms. Rathkopf  responded that it was  difficult to generalize                                                                    
across  a spectrum  of providers.  She  specified that  some                                                                    
individuals could be more concerned  and read things in more                                                                    
detail  and there  were others  who  did not  and were  more                                                                    
Co-Chair Neuman had  spoken to several doctors,  one of whom                                                                    
was  from  a  pain  clinic,  who had  refused  to  sign  the                                                                    
documents because of the concern.  He remarked that the bill                                                                    
also allowed  assistants or people  who worked for  a doctor                                                                    
to  access the  database.  He asked  if  Dr. Rathkopf  would                                                                    
allow her employees to access the database.                                                                                     
Ms. Rathkopf replied that she  believed the provision, which                                                                    
enabled a  doctor to  have a  designee, was  very favorable.                                                                    
She  could  see there  could  be  concerns about  giving  an                                                                    
unlicensed  person  the  ability  to  do  something  on  the                                                                    
doctor's behalf, however, doctors  would be selective in who                                                                    
they chose. She furthered that  most likely the doctor would                                                                    
select a  medical assistant  or nurse  who had  some medical                                                                    
training. The  board supported the addition  of the delegate                                                                    
account. She relayed that it  had been identified nationally                                                                    
as  a   best  practice   of  prescription   drug  management                                                                    
3:22:55 PM                                                                                                                    
Co-Chair  Neuman  stated  he had  spoken  with  doctors  who                                                                    
relayed  that  doctors  tended   to  know,  particularly  in                                                                    
smaller communities  like Juneau  and Mat-Su,  which doctors                                                                    
tended  to   over-write  prescriptions.  He  asked   if  Dr.                                                                    
Rathkopf felt the same.                                                                                                         
Ms.  Rathkopf believed  it  was one  of  the things  doctors                                                                    
thought they  knew. She  stated it  was like  the proverbial                                                                    
"you think your  neighbor has a problem, but  you don't have                                                                    
a problem."  She furthered that  it was hard to  say because                                                                    
it was not possible to be  in the other person's shoes or to                                                                    
know their patients. She elaborated  that a person may see a                                                                    
lot of  prescriptions were coming  from a  certain provider,                                                                    
but she  did not know  of any doctors over  prescribing. She                                                                    
knew both  pain specialists and emergency  room doctors, who                                                                    
by  volume  probably prescribed  more  than  doctors not  in                                                                    
those specific  fields. She concluded it  was very difficult                                                                    
to make that  generalization without being in  the room with                                                                    
the individual patients, knew the  indications, and how many                                                                    
prescriptions the  doctor was  prescribing. She  believed it                                                                    
was a hard generalization to make.                                                                                              
Co-Chair  Neuman  referred  to Dr.  Rathkopf's  remarks.  He                                                                    
surmised  doctors and  pharmacists  had a  moral or  ethical                                                                    
oath to notify the state  medical or doctor's boards if they                                                                    
felt  one  of their  peers  was  possibly writing  too  many                                                                    
Dr. Rathkopf believed if a  provider witnessed provider care                                                                    
that was harmful  to a patient they  had some responsibility                                                                    
to address  the provider personally or  through other means.                                                                    
She had  not had  to take  that action  at a  provider level                                                                    
[note: due  to a  poor phone  connection some  testimony was                                                                    
inaudible], but at a pharmacy  level she had reported to the                                                                    
pharmacy  board  when  she thought  inappropriate  care  was                                                                    
given. She  replied that  if she  witnessed an  instance [of                                                                    
inappropriate care] she would put  it under the same type of                                                                    
moral obligation or ethical category.                                                                                           
3:26:29 PM                                                                                                                    
Co-Chair Neuman  asked Dr. Rathkopf  if she or  a pharmacist                                                                    
suspected a person of over  writing prescriptions that there                                                                    
was a moral obligation to report the person.                                                                                    
Ms. Rathkopf replied that her  answer reflected her personal                                                                    
belief, but she could not  answer for every provider because                                                                    
the question pertained  to what a person  believed was moral                                                                    
and  ethical.  She explained  what  was  normal for  a  pain                                                                    
specialist  to prescribe  was a  much higher  threshold than                                                                    
what was normal for her to prescribe.                                                                                           
Co-Chair  Neuman  believed  there were  already  systems  in                                                                    
place. He  surmised that if  there was more than  one doctor                                                                    
in  a  community they  generally  knew  who tended  to  over                                                                    
prescribe. He opined they would  have a moral duty to report                                                                    
the issue  to the Alaska  State Medical Board.  He continued                                                                    
that  the  board would  question  why  the reporting  doctor                                                                    
believed another doctor  was over-prescribing. Subsequently,                                                                    
the board would take action  if they believed the doctor was                                                                    
over-prescribing. He believed there  were already systems in                                                                    
place to stop  the over prescribing of  opioids. He believed                                                                    
the system  was already managed  by doctors and  the medical                                                                    
board.  He asked  if the  state needed  more intrusive  laws                                                                    
into people's lives.                                                                                                            
Ms. Rathkopf  answered that the  country was still  facing a                                                                    
national problem [with opioid  use]. She detailed that other                                                                    
states with  prescription drug  database programs  had shown                                                                    
decreases in opioid prescriptions.  There were best practice                                                                    
models  in  certain states,  which  had  shown decreases  in                                                                    
prescriptions  for  opioid  narcotics  with  the  use  of  a                                                                    
prescription database.                                                                                                          
3:29:02 PM                                                                                                                    
Representative Gara asked Ms.  Shadduck if the bill included                                                                    
a requirement for a physician to  submit a list of the drugs                                                                    
they prescribed to the board and the database.                                                                                  
Ms.  Shadduck answered  in the  negative. The  bill required                                                                    
the prescriber to  check the database prior  to dispensing a                                                                    
prescription.  The population  of the  database was  done by                                                                    
the pharmacist.                                                                                                                 
Representative   Gara  asked   for  verification   the  bill                                                                    
required a  weekly report  to be sent  to the  state medical                                                                    
board. Ms. Shadduck replied in  the affirmative. She pointed                                                                    
to  Section  14,  page  16,  line  11,  which  required  the                                                                    
database to be updated a minimum of once a week.                                                                                
Representative  Gara  referenced  Ms.  Shadduck's  statement                                                                    
that only  pharmacists would  enter data  into the  PDMP. He                                                                    
provided  a  personal  example   where  he  had  received  a                                                                    
prescription   medication  at   the  emergency   room  after                                                                    
breaking some ribs the previous  year. He assumed his doctor                                                                    
had  prescribed the  medication, which  was provided  at the                                                                    
hospital. He  wondered if  emergency room  prescriptions did                                                                    
not get entered into the database.                                                                                              
Ms. Shadduck  answered in the  negative. She  clarified that                                                                    
the   pharmacist  filling   the  prescription   entered  the                                                                    
information into the PDMP. She  explained that every written                                                                    
prescription should  not be entered  into the  database. For                                                                    
example, a doctor  could prescribe a narcotic  to a patient,                                                                    
but the  patient could  decide not  to get  the prescription                                                                    
filled. The point was to  prevent including prescriptions in                                                                    
the  PDMP that  had  never been  filled.  Under the  current                                                                    
system, if  the pharmacist who filled  Representative Gara's                                                                    
prescription  was  one  of  the  40  percent  who  used  the                                                                    
database, they  would have entered the  information into the                                                                    
Representative  Gara  asked  if  pharmacists  always  filled                                                                    
prescriptions.  He  wondered  if  a  prescription  could  be                                                                    
filled in  an emergency  room by  a physician.  Ms. Shadduck                                                                    
deferred the question to DHSS.                                                                                                  
3:32:42 PM                                                                                                                    
AT EASE                                                                                                                         
3:43:35 PM                                                                                                                    
Co-Chair  Thompson introduced  the following  testifiers who                                                                    
would continue to address the PDMP.                                                                                             
DOCTOR  JAY BUTLER,  CHIEF  MEDICAL  OFFICER, DEPARTMENT  OF                                                                    
HEALTH AND SOCIAL SERVICES, expressed  his intent to provide                                                                    
context on the  PDMP portion of the bill. He  shared that in                                                                    
2015  more than  80 Alaskans  had died  following an  opioid                                                                    
overdose. He  remarked that while  heroin use  had dominated                                                                    
the  news  headlines,  it was  important  to  remember  that                                                                    
almost  twice as  many deaths  occurred due  to overdose  of                                                                    
prescription opioids. Of the 36  individuals who had died of                                                                    
a  heroin overdose,  more  than half  had  also been  taking                                                                    
prescription  opioids at  the time  of death.  He considered                                                                    
how  to stop  the situation  from continuing.  He asked  the                                                                    
committee to  think about  the opportunities  for prevention                                                                    
surrounding  an Alaskan  who  had died  of  an overdose.  He                                                                    
shared  that after  an  overdose was  taken  and a  person's                                                                    
breathing stopped, Naloxone could  have been administered to                                                                    
reverse the depressive respiratory  effects and a life could                                                                    
have been  saved. One  of the  barriers to  that opportunity                                                                    
had  been removed  with the  passage of  SB 23  [legislation                                                                    
passed in 2016 related to  the prescribing of opioids]. When                                                                    
considering the  individual's life  it would most  likely be                                                                    
discovered that  opioid dependency had led  to the overdose.                                                                    
At that  stage, prevention included screening  and diagnosis                                                                    
of dependency  as a  chronic health issue  in order  for the                                                                    
problem to  be destigmatized and treated.  Traveling further                                                                    
back in time  in the person's life may reveal  a tendency to                                                                    
self-medicate.  He  elaborated  that  self-medication  often                                                                    
started  with  an otherwise  healthy  person  living with  a                                                                    
combination  and  an  addictive substance  (the  demand  and                                                                    
supply side of the equation).                                                                                                   
Dr. Butler  continued to discuss the  scenario. He explained                                                                    
that  increasing resiliency  and wellness  early in  life by                                                                    
decreasing the  impact of adverse childhood  experiences and                                                                    
improving emotional  wellness later  in life  were important                                                                    
measures for preventing traumatic  stress and mitigating the                                                                    
impact  in  reducing demand.  To  address  the role  of  the                                                                    
addictive  substance   in  the  case  of   opioids,  it  was                                                                    
necessary to  address the  supply by  reducing the  flood of                                                                    
opioids into  the state's communities through  more rational                                                                    
pain management strategies and  prevention of diversion. The                                                                    
effort  could in  part be  addressed by  utilization of  the                                                                    
PDMP. He  stressed that the PDMP  was not a Panacea,  but it                                                                    
was  an   important  part  of  the   overall  strategy  when                                                                    
considering  the  entire  flow   of  events  leading  to  an                                                                    
overdose death. He relayed that  deaths were just the tip of                                                                    
the  iceberg; it  was estimated  that for  every person  who                                                                    
died of  an opioid overdose,  12 more were  hospitalized and                                                                    
25 were admitted in the  emergency department. The number of                                                                    
opioid  prescriptions in  the U.S.  quadrupled between  1990                                                                    
and 2010;  the number of  opioid deaths had  also quadrupled                                                                    
during the same period.                                                                                                         
Dr.  Butler   discussed  that  a   number  of   drivers  had                                                                    
contributed to  the substantial increase  in opioid  use. He                                                                    
explained there  was really no evidence  that the prevalence                                                                    
of  pain  increased  four-fold  during  1990  and  2010.  He                                                                    
emphasized  that Americans  consumed roughly  80 percent  of                                                                    
the  world's supply  of opioids.  He questioned  whether the                                                                    
U.S. really  had that much  more pain  than the rest  of the                                                                    
world. He  detailed that 19,000  Americans had died  in 2014                                                                    
of prescription opioid overdose and  10,000 more had died of                                                                    
heroin overdose.  He furthered  that the two  epidemics were                                                                    
closely  related;  80 percent  of  heroin  users started  by                                                                    
using opioid  pain killers. Additionally, many  heroin users                                                                    
also supplemented  with opioid pain killers.  Two major risk                                                                    
factors for opioid overdose are:  higher doses, which can be                                                                    
common when  opioids were used  for long periods  to control                                                                    
chronic   pain  (dosages   could  become   very  high   when                                                                    
medications were obtained from  multiple providers); and co-                                                                    
administration   with  benzodiazepines   (e.g.  Valium   and                                                                    
Xanax). The  PDMP helped providers to  monitor total dosages                                                                    
dispensed  from  all  sources and  to  identify  potentially                                                                    
dangerous  combinations. He  believed the  vast majority  of                                                                    
prescriptions were  well intentioned,  but too often  led to                                                                    
misuse,  particularly when  the  opioids  were dispensed  in                                                                    
larger-than-needed quantities.                                                                                                  
3:50:02 PM                                                                                                                    
Doctor Butler  discussed that benzodiazepines  were Schedule                                                                    
IV  drugs. Under  best practices,  often  Schedule IV  drugs                                                                    
were included  in the  required PDMP  lookup. He  had spoken                                                                    
with providers who  utilize the PDMP - one  provider who had                                                                    
seen a  patient for  the first time,  accessed the  PDMP and                                                                    
had been  surprised to find  the person had  been prescribed                                                                    
1,200 opioids  in the past  year and  1,000 benzodiazepines.                                                                    
He furthered that about half  of the prescriptions were from                                                                    
one provider.  He remarked that  the question about  what to                                                                    
do  about  that  was  very   pertinent.  He  continued  that                                                                    
Provider A had contacted Provider  B, who had responded that                                                                    
they had  no idea they  had prescribed that much.  He stated                                                                    
that the database not only  helped providers know what other                                                                    
people  were doing;  it was  also a  reminder to  individual                                                                    
providers about  what they prescribed.  The Alaska  PDMP was                                                                    
underutilized that  needed to be  used more if it  was going                                                                    
to be used.                                                                                                                     
Dr. Butler addressed  that recommendations incorporated into                                                                    
SB 74 included components  of the nine broad recommendations                                                                    
from the Controlled Substances  Advisory Committee. A number                                                                    
of  the   recommendations  were  controversial   to  various                                                                    
people.  The  two recommendations  that  had  given him  the                                                                    
greatest pause  were the  required registration  and lookup.                                                                    
He  shared that  it had  taken him  15 minutes  to register,                                                                    
which  had  involved  locating  his  DEA  number  and  other                                                                    
information. He only remembered having  to get a single page                                                                    
notarized. He  acknowledged that  finding a notary  could be                                                                    
burdensome  to  some  people.  He  would  prefer  to  remove                                                                    
barriers to make  the right choice the  easy choice, instead                                                                    
of  putting  mandates  in  place.  He  believed  there  were                                                                    
opportunities to make registration  easier. He reasoned that                                                                    
if   registration   was   tied  to   license   renewal   the                                                                    
notarization  requirement could  potentially be  eliminated.                                                                    
He  deferred to  the Department  of Commerce,  Community and                                                                    
Economic Development  (DCCED) to address the  feasibility of                                                                    
the idea. He was initially  opposed to the mandatory lookup.                                                                    
He detailed  that more than  20 states required  a mandatory                                                                    
lookup in  some form.  He elaborated  that the  bill sponsor                                                                    
had  worked to  determine how  to implement  the requirement                                                                    
while  striking the  appropriate balance  between access  to                                                                    
care,  patient  and   provider  autonomy,  patient  privacy,                                                                    
quality of care, and addressing the opioid epidemic.                                                                            
3:53:38 PM                                                                                                                    
Dr.  Butler  communicated  that  he  rarely  used  the  term                                                                    
epidemic, but he was comfortable  calling the four-fold rise                                                                    
in the  rate of death  from one  specific cause over  a less                                                                    
than  one decade  an  epidemic. He  pointed  out that  young                                                                    
people  accounted  for  many   of  the  deaths.  Thus,  when                                                                    
considering the  years of potential  life lost or  work lost                                                                    
to the state, the impact in Alaska was fairly large.                                                                            
Co-Chair Neuman remarked it had  been wonderful working with                                                                    
Dr. Butler on  reform packages over the past  four years. He                                                                    
added  he  had  first met  Valerie  Davidson,  Commissioner,                                                                    
Department  of Health  and Social  Services  during work  on                                                                    
recidivism reduction.  He asked  how many  of the  80 opioid                                                                    
overdose deaths in  Alaska [in 2015] had  been prescribed by                                                                    
a doctor.                                                                                                                       
Dr. Butler  replied that  providing access  to the  PDMP for                                                                    
the  state medical  examiner as  well as  de-identified data                                                                    
for epidemiological  analysis would help answer  those types                                                                    
of questions.  He added that  those were the  critical types                                                                    
of questions to be able to address the challenge.                                                                               
Co-Chair Neuman surmised that it  was highly likely that the                                                                    
drugs had  been over-prescribed  by the person's  doctor. He                                                                    
surmised that  a person  may have  depression issues  due to                                                                    
excess chronic pain and overdosed  because they did not want                                                                    
to live  any longer.  He asked about  the likelihood  of the                                                                    
Dr. Butler  answered that  roughly 1 in  10 deaths  had some                                                                    
evidence of  suicidal intent.  There was  some overlap  as a                                                                    
cause of death,  but it was important to  recognize that the                                                                    
vast majority  of the evidence  was that the  overdoses were                                                                    
accidental. He  addressed national  studies on  where people                                                                    
obtained  prescription opioids  without a  prescription. The                                                                    
broad  majority   obtained  the  drugs  from   a  friend  or                                                                    
relative. He  guessed that most  people at the table  had at                                                                    
some point  had opioids  in their  medicine cabinet  at home                                                                    
because the  prescription sizes had increased  over the past                                                                    
10  years.  He  explained  that there  really  was  a  ready                                                                    
available supply.  He reiterated his earlier  statement that                                                                    
the  PDMP was  not a  cure-all, but  it was  a way  to track                                                                    
prescriptions so  individual providers  could know  what was                                                                    
going   on  with   an   individual  patient.   Additionally,                                                                    
providers  would have  the ability  to look  have visibility                                                                    
into where  medications were  coming from  for a  patient or                                                                    
potentially to a  family. In terms of other  sources, it was                                                                    
interesting  that theft  and purchasing  only accounted  for                                                                    
about  5  percent.  Nationally,   about  5  percent  of  all                                                                    
prescriptions  came through  emergency departments,  whereas                                                                    
about  50 percent  came from  primary  care providers  (i.e.                                                                    
internal medicine physicians,  family practice, and advanced                                                                    
practice  nurse  practitioners).  He   noted  there  was  no                                                                    
visibility  into  the  issue  for  Alaska  on  its  own.  He                                                                    
explained  that  the statistic  did  not  mean primary  care                                                                    
providers  were   writing  a  large  percentage   of  opioid                                                                    
prescriptions;  the  number  reflected  that  the  group  of                                                                    
providers saw  a high number  of patients and did  often did                                                                    
prescribe opioids for chronic pain.                                                                                             
3:58:33 PM                                                                                                                    
Dr.  Butler continued  to answer  the  question. He  relayed                                                                    
that proposed changes  in the bill aligned with  a number of                                                                    
the national best practices and  with the recently published                                                                    
national  guideline  co-published  by the  American  Medical                                                                    
Association (AMA)  Journal and the  CDC on March  15 [2016].                                                                    
The best practices recommended a  provider to check the PDMP                                                                    
prior to  writing a  new prescription for  an opioid  and to                                                                    
recheck the  PDMP at regular  intervals if the  provider was                                                                    
prescribing opioids for chronic long-term pain management.                                                                      
Co-Chair  Neuman  discussed  that  his  family  doctor  knew                                                                    
everything about him because he  wanted to live a long life.                                                                    
He elaborated that he did  not eat right and his cholesterol                                                                    
was slightly high. He surmised  all doctors should talk with                                                                    
their  patients   about  the  cause  and   effect  prior  to                                                                    
prescribing medications. He  surmised doctors considered how                                                                    
multiple  medications worked  together  and  what the  cause                                                                    
would be of taking or not  taking them, which was the reason                                                                    
doctors  told  patients  to   take  their  prescriptions  as                                                                    
specified. He  reasoned that prescriptions were  not to give                                                                    
to a  person's friend, neighbor,  or loved one.  He followed                                                                    
the directions  of his doctor when  receiving prescriptions.                                                                    
He thought  all doctors  should have that  relationship with                                                                    
their patients.                                                                                                                 
Dr. Butler  agreed that the  scenario described  by Co-Chair                                                                    
Neuman should  happen. He shared  that he had  experienced a                                                                    
medical  issue and  a provider  had insisted  on subscribing                                                                    
some  Percocet even  though he  did not  personally feel  he                                                                    
needed  them. He  heard from  a number  of people  that they                                                                    
were  raised to  take their  medicine as  instructed -  if a                                                                    
person was prescribed 50 Percocet  they may feel the need to                                                                    
take them -  the problem was especially  prevalent for older                                                                    
people who  just added  it to the  list of  medications they                                                                    
took. What Co-Chair Neuman was  describing was the ideal and                                                                    
the  PDMP should  help to  facilitate  the relationship.  He                                                                    
stressed that the situation did  not just involve bad people                                                                    
-  people  were  all  just  human.  He  referred  to  a  new                                                                    
medication  his father  had started,  which  he noticed  was                                                                    
contradictory  to  a  medication   his  father  was  already                                                                    
taking.  His father  communicated  that the  doctor had  not                                                                    
asked about other medications.  Subsequently his father told                                                                    
the  doctor about  the other  prescriptions  and the  doctor                                                                    
immediately canceled  the new medication. He  explained that                                                                    
often the  ideal of everyone  communicating did  not happen.                                                                    
Part  of the  goal  of the  PDMP was  for  all providers  to                                                                    
understand what was being prescribed.                                                                                           
Co-Chair  Neuman  discussed  that  it was  the  job  of  the                                                                    
pharmacy to  interpret one drug's interaction  with another.                                                                    
He believed  when the pharmacy filled  the prescription they                                                                    
would have noted the new  medication was not compatible with                                                                    
others being taken by Dr.  Butler's father. He thought there                                                                    
were already things in place to catch the issue.                                                                                
Dr. Butler  answered that  it would be  great if  the person                                                                    
went to  the same pharmacy  for all of the  medications, but                                                                    
it was not what happened.                                                                                                       
Co-Chair Neuman  thought Medicaid or Medicare  billing would                                                                    
catch the issue at the end of a billing period.                                                                                 
Doctor  Butler  replied  that   Medicaid  was  an  important                                                                    
example. He detailed that  currently the Medicaid pharmacist                                                                    
did  not  have  any  visibility  on  medications  without  a                                                                    
Medicaid  claim. He  furthered that  a very  robust business                                                                    
model was to get some  opioids through the Medicaid program,                                                                    
sell them for cash, use  the cash to visit another provider,                                                                    
get more opioids, and so  on. He explained that the practice                                                                    
had  been  documented  in  other states.  He  did  not  know                                                                    
whether it was happening in Alaska,  but there was no way of                                                                    
currently knowing  because the  Medicaid pharmacist  did not                                                                    
have access to the PDMP.                                                                                                        
Co-Chair  Neuman stated  that  he had  asked the  pharmacist                                                                    
about   the   issue.   He  relayed   that   generally   when                                                                    
prescriptions were  paid for in  cash the  pharmacist called                                                                    
the prescribing  doctor to  let them  know. He  believed the                                                                    
pharmacies  were  pretty aware  of  what  was going  on.  He                                                                    
opined that pharmacies and doctors  had a tight relationship                                                                    
in Alaska.                                                                                                                      
Vice-Chair Saddler  referred to Dr. Butler's  testimony that                                                                    
the PDMP was a part of  the solution. He asked for the other                                                                    
elements of the solution.                                                                                                       
4:05:31 PM                                                                                                                    
Dr. Butler  replied that he  thought in terms  of infectious                                                                    
diseases, trains  of transmission, and the  opportunities to                                                                    
interrupt transmission.  He thought  about how a  person who                                                                    
ultimately died  of an  overdose had  started as  healthy as                                                                    
anyone in the  room at one point in time.  He specified that                                                                    
often  when people  became addicted  to  opioids it  started                                                                    
with a prescription  for an acute injury.  He continued that                                                                    
the situation  resulted in  no problem  for most  people. He                                                                    
added that most people  using opioids recreationally did not                                                                    
go  on  to  heroin,  but a  significant  portion  did.  When                                                                    
tracing   how  a   person  became   addicted,  receiving   a                                                                    
prescription for an injury was  one of the contributing risk                                                                    
factors.  He believed  that apart  from  intervening on  the                                                                    
supply of opioids in the  community through the PDMP, better                                                                    
pain  management, limiting  the number  of pills  dispensed,                                                                    
and looking for  other modalities of management  in the case                                                                    
of  chronic  pain  were   all  important.  Additionally,  he                                                                    
believed   addressing  behavioral   health  was   critically                                                                    
important  as understanding  of how  early childhood  trauma                                                                    
increased  the risk  of self-medication  later  in life.  He                                                                    
referred to a study in  England suggesting nearly 60 percent                                                                    
of heroin and crack/cocaine  use was attributable to adverse                                                                    
childhood  experiences. Also  important  was  being able  to                                                                    
recognize  addiction   and  to  intervene   with  treatment;                                                                    
treatment   opportunities   included   medication   assisted                                                                    
therapy   (e.g.  Buprenorphine).   He  believed   there  was                                                                    
currently  a   big  inequality   in  the   900,000  American                                                                    
providers  that could  write prescriptions  for Schedule  II                                                                    
opioids with  only 34,000  qualified to  write prescriptions                                                                    
for   Buprenorphine.  Methadone   was  another   option  and                                                                    
Naltrexone  was a  very promising  approach for  individuals                                                                    
who had gotten  through withdrawal and were  off opioids and                                                                    
who wanted to  take extra steps to ensure  they could remain                                                                    
4:08:11 PM                                                                                                                    
Vice-Chair  Saddler asked  if the  opioid epidemic  could be                                                                    
controlled  without increased  use of  the PDMP.  Dr. Butler                                                                    
answered that if  he was convinced it made  no difference at                                                                    
all he would not be  sitting before the committee. The seven                                                                    
states  recognized  as  doing the  largest  portion  of  the                                                                    
nationally recognized  best practices  (Tennessee, Kentucky,                                                                    
Ohio, Wisconsin,  New York, Connecticut,  and Massachusetts)                                                                    
had seen declines  in the total number  of prescriptions for                                                                    
opioids, a  decline in  the number of  high dose  opioids, a                                                                    
very significant  decline in the amount  of doctor shopping,                                                                    
and increases in the  number of Buprenorphine prescriptions.                                                                    
He submitted  it was a  sign there were more  people seeking                                                                    
treatment once they were recognized as opioid dependent.                                                                        
Vice-Chair  Saddler  asked  for  clarification.  Dr.  Butler                                                                    
replied that they  were not discussing something  like a flu                                                                    
vaccine  that he  could specify  was  60 percent  effective.                                                                    
Evidence had shown  the PDMP had helped in  other states. He                                                                    
believed  it was  more  probable the  system  would help  in                                                                    
Alaska than not.                                                                                                                
Vice-Chair  Saddler asked  for  the reason  behind the  high                                                                    
prescription of opioids.  He asked if there was  a profit to                                                                    
the pharmacist  or pharmaceutical  companies. Alternatively,                                                                    
he   asked  if   it  was   defensive  medicine   or  patient                                                                    
Dr. Butler answered  that during the early part  of the 20th                                                                    
Century as everyone responded to  the first opioid epidemics                                                                    
occurring  in  the  late  19th Century,  there  had  been  a                                                                    
tendency  to  avoid  opioids  and   there  had  not  been  a                                                                    
multitude of  other options. As  a result, he  believed pain                                                                    
had probably been under managed.  By the time he had started                                                                    
his training there  had been good progression  - he recalled                                                                    
specifically  being  told  if  he had  a  patient  dying  of                                                                    
cancer, to  make them comfortable  and not worry  about that                                                                    
patient   being  addicted   to   morphine.   In  the   1990s                                                                    
particularly  with  the  Federal Drug  Administration  (FDA)                                                                    
approval  of Oxycodone,  things  had  changed. He  specified                                                                    
that  there had  been  a perfect  storm  of an  aggressively                                                                    
marketed  opioid combined  with  a  flawed philosophy  (i.e.                                                                    
pain was  the fifth  vital sign).  The philosophy  was still                                                                    
part of  the way Center  for Medicaid and  Medicare Services                                                                    
(CMS) did  reimbursements based on patient  satisfaction. He                                                                    
was  included in  a number  of  people working  to push  the                                                                    
federal  government   to  change  the  practice,   which  he                                                                    
believed  created  an  unreasonable  impetus  to  make  sure                                                                    
people  answer  the question  that  everything  was done  to                                                                    
manage their  pain. There  had been  some very  large fines,                                                                    
particularly  against one  manufacturer, for  marketing that                                                                    
did not address the emerging  risk of addiction and overdose                                                                    
with  their product.  He believed  the  country was  finally                                                                    
beginning to  get away from  the concept of the  fifth vital                                                                    
sign. He detailed that pain  was very subjective, it was not                                                                    
like  blood  pressure,  temperature, pulse,  or  respiratory                                                                    
rate that was easy to measure.                                                                                                  
4:12:32 PM                                                                                                                    
Representative Gara  spoke from his perspective  as a spouse                                                                    
of a health professional  and believed there were physicians                                                                    
who over prescribed  opioids. He referred to  a growing pain                                                                    
medicine practice  he found troubling, which  the bill would                                                                    
not impact.  He wanted  to ensure that  all of  the required                                                                    
prescriptions were entered into  the database. He referenced                                                                    
his  earlier  question   about  whether  pharmacists  always                                                                    
filled  prescriptions in  the emergency  room. He  asked for                                                                    
verification that a pharmacist  entered the information into                                                                    
the PDMP.                                                                                                                       
Dr.  Butler  answered most  likely.  He  specified that  the                                                                    
program  was  currently  voluntary; therefore,  whether  the                                                                    
data  was entered  into  the PDMP  depended  on whether  the                                                                    
pharmacist  participated in  the program.  The participation                                                                    
was much higher among pharmacists  than by providers. In the                                                                    
ideal   situation  the   prescriber   assessed  a   person's                                                                    
controlled  substance  history  using the  PDMP,  wrote  and                                                                    
filled  a   prescription  if  there  were   no  issues;  the                                                                    
information was then recorded in  the database. He explained                                                                    
that in  terms of  the scenario described  by Representative                                                                    
Gara, it depended on where  a patient went for treatment. He                                                                    
reiterated that the program was currently voluntary.                                                                            
Representative  Gara  wanted  to  ensure  that  all  of  the                                                                    
prescriptions were  entered into  the database.  He remarked                                                                    
that  the  legislation  currently  required  pharmacists  to                                                                    
enter the data  into the PDMP. He asked if  there was always                                                                    
a  pharmacist  in  the  emergency room  or  whether  it  was                                                                    
necessary to  add specific language  to the bill  related to                                                                    
the emergency room setting.                                                                                                     
Doctor Butler answered  that it depended on  where a patient                                                                    
went.  In general  a patient  would  receive a  prescription                                                                    
from the emergency room to take  to a pharmacy, which may be                                                                    
in the hospital. He had  not experienced a situation where a                                                                    
doctor  brought  the  filled   prescription  directly  to  a                                                                    
patient in the emergency room.                                                                                                  
Representative  Gara  stated  that   he  did  not  know  the                                                                    
difference  between Schedule  II, III,  IV, or  V drugs.  He                                                                    
asked for  verification that the  bill currently  applied to                                                                    
Schedule II and III drugs.                                                                                                      
Doctor Butler answered that the  bill also included Schedule                                                                    
IV  drugs. He  explained  that Schedule  I included  illegal                                                                    
substances  the  FDA  specified had  no  recognized  medical                                                                    
value.  Schedule II  tended to  be opioids  as well  as some                                                                    
stimulants  such  as  Attention  Deficit  and  Hyperactivity                                                                    
Disorder  (ADHD) drugs.  Schedule III  included things  like                                                                    
anabolic  steroids. Schedule  IV included  benzodiazepines -                                                                    
he  remarked  it  was  a  bit of  a  conundrum  because  the                                                                    
medications were much more  frequently prescribed, but based                                                                    
on  an  analysis  of Veterans  Administration  data,  really                                                                    
potentiated  the  risk  of  death when  an  opioid  was  co-                                                                    
prescribed.  He did  not have  an  easy answer  to make  the                                                                    
requirements  easy,  while  also  reducing the  risk  of  an                                                                    
adverse event. Schedule V  drugs included Codeine containing                                                                    
cough syrups;  there was a  risk of abuse, but  probably not                                                                    
as  high. Schedule  IV also  included  drugs like  Tramadol,                                                                    
which  was  an  analgesic.  He  reported  he  was  receiving                                                                    
increased   calls  asking   about  abuse   of  Tramadol   or                                                                    
diversion. He  currently did not  know. He explained  it was                                                                    
where the de-identified access for  public health was useful                                                                    
in order to further  understand prescribing patterns. It was                                                                    
not  currently known  whether something  was coming  in from                                                                    
another country  and if it  was being prescribed  in Alaska.                                                                    
He explained  that the  office of  the medical  examiner was                                                                    
primarily to give healthcare providers  statewide a heads up                                                                    
when a substance started to be  seen more in the state (e.g.                                                                    
such as  synthetic cannabinoids the past  year). He remarked                                                                    
that a  Tramadol overdose was particularly  nasty and tended                                                                    
to include seizures and low  blood sugars. He believed being                                                                    
able to recognize the symptoms was important for providers.                                                                     
4:18:25 PM                                                                                                                    
Representative Gara  surmised there  may be an  amendment to                                                                    
remove Schedule  IV drugs from  the bill. He asked  if there                                                                    
was an easily identifiable small  group of Schedule IV drugs                                                                    
that should be left in the bill.                                                                                                
Dr.  Butler answered  that if  the list  had to  be whittled                                                                    
down he  would include drugs  that were currently  a problem                                                                    
such as  benzodiazepines and Tramadol.  The problem  was the                                                                    
situation  was always  dynamic. For  example, he  questioned                                                                    
how  to handle  a  situation  when new  drugs  arose in  the                                                                    
future - he asked if  it would be changed through regulation                                                                    
or whether it  would require a statute change.  He noted the                                                                    
State  Controlled  Substances   list  currently  required  a                                                                    
statutory  change; there  was currently  a  bill before  the                                                                    
legislature that  would add Tramadol  to the list,  which he                                                                    
believed had not been scheduled for a hearing.                                                                                  
Representative Gara  repeated drugs mentioned by  Dr. Butler                                                                    
including  benzodiazepines,  Tramadol, and  some  definition                                                                    
that would describe other drugs  by regulation the state did                                                                    
not  currently know  how to  write. He  reasoned it  was the                                                                    
legislature's job to figure out.  He had looked into writing                                                                    
a bill  to limit the  amount of  some of the  more dangerous                                                                    
opioids that could be prescribed, but  he had been told as a                                                                    
matter  of federal  law that  the  limits on  the number  of                                                                    
opioid  pills that  could be  prescribed were  stringent. He                                                                    
asked if  a person could  get addicted  to opioids on  a few                                                                    
pills   or   whether  it   took   a   multitude  of   pills.                                                                    
Additionally,  he asked  if existing  law prevented  doctors                                                                    
from prescribing an addictive amount of opioids.                                                                                
Doctor Butler  answered that  he was not  aware of  what the                                                                    
limits were. He  had heard from a number of  people over the                                                                    
past  several months  talking about  receiving 100  pills at                                                                    
one time. He  had personally received a  prescription for 50                                                                    
pills  after oral  surgery,  which he  believed  was a  high                                                                    
amount -  particularly when  the drugs  were dispensed  as a                                                                    
"just in case"  precaution. He had never run  into a problem                                                                    
with  a  patient  with  terminal  pain  requiring  continual                                                                    
refilling because  you could dispense a  fairly large amount                                                                    
if needed. He was not familiar with that being an issue.                                                                        
Representative   Gara   stated   if  there   was   something                                                                    
meaningful  that  could  be  done to  limit  the  number  of                                                                    
opioids  that   could  be  prescribed  he   would  not  mind                                                                    
considering it.                                                                                                                 
4:21:56 PM                                                                                                                    
Representative Pruitt surmised that  the database started to                                                                    
resemble  medical  reform  as opposed  to  Medicaid  reform.                                                                    
There  was some  concern  about the  privacy  of having  the                                                                    
information  exist on  a database.  He thought  there was  a                                                                    
timeframe from  which the information  was removed  from the                                                                    
database, which he  believed made sense. He asked  if it was                                                                    
the case.                                                                                                                       
Doctor Butler responded that the timeframe was two years.                                                                       
Representative  Pruitt remarked  that  the  bill focused  on                                                                    
Medicaid  reform; however,  he  believed  the database  fell                                                                    
into  the  medical  reform category.  He  referred  to  some                                                                    
concern about  the privacy  related to  people's information                                                                    
in the  database in perpetuity. He  believed the information                                                                    
was only  on the database for  a certain period of  time. He                                                                    
used  the  Division of  Motor  Vehicles  as an  example  and                                                                    
explained that at a certain  point some old offences dropped                                                                    
off a  person's record.  He believed it  made sense  for the                                                                    
information to be removed from  the database after a certain                                                                    
period of time. He reasoned that  people who had not used an                                                                    
opioid for two  or three years were not the  people the bill                                                                    
was  aiming to  address. He  asked for  verification of  the                                                                    
accuracy of  his statements.  He wanted to  put some  of the                                                                    
privacy concerns  about maintaining a database  with a long-                                                                    
term record of a person's usage of prescription drugs.                                                                          
Dr.  Butler  commented on  the  critical  importance of  the                                                                    
question. He believed the information  was maintained on the                                                                    
PDMP for two years before being deleted.                                                                                        
Representative  Pruitt saw  the  database and  conversations                                                                    
related to behavioral health as  chasing the problem in many                                                                    
cases. He opined  that the root cause had yet  to be focused                                                                    
on. He  referred to  Dr. Butler's  testimony about  the root                                                                    
cause  going back  into  the 1990s  and  making sure  cancer                                                                    
patients  did  not have  pain.  He  noted certain  committee                                                                    
members had  faced that  challenge. He  relayed that  he had                                                                    
spoken with  Dr. Rathkopf who  had highlighted that  the CDC                                                                    
had  recently  come out  with  new  recommendations that  he                                                                    
believed   may  assist   in  the   current  discussion.   He                                                                    
referenced  that the  CDC's  6th recommendation  highlighted                                                                    
that  long-term opioid  use began  with  treatment of  acute                                                                    
pain  ["CDC Guideline  for Prescribing  Opioids for  Chronic                                                                    
Pain   -  United   States,  2016"   (copy  on   file)].  The                                                                    
recommendation  noted that  in most  cases [medication  for]                                                                    
three days or  less would often be sufficient  and more than                                                                    
seven days  would rarely be  needed. He asked  whether there                                                                    
was a current opportunity  to facilitate a conversation with                                                                    
the state  medical board or other  mechanism about utilizing                                                                    
the CDC  recommendations to  put them  into regular  use. He                                                                    
spoke to beginning to address  the root cause of the problem                                                                    
in some  capacity by utilizing  the CDC  recommendations. He                                                                    
asked  if the  bill needed  to contain  language giving  the                                                                    
state  the  mechanisms  to  take   action  by  working  with                                                                    
providers  to  limit the  amount  prescribed  (to prevent  a                                                                    
person from receiving 30 to 50 days' worth of medication).                                                                      
4:26:20 PM                                                                                                                    
Dr. Butler  answered that a  number of things came  to mind.                                                                    
He relayed numerous provider surveys  and individuals he had                                                                    
spoken  to (including  medical students)  reported they  had                                                                    
not  had   significant  training   in  pain   management  or                                                                    
addiction   medicine.  He   believed   it   was  the   point                                                                    
historically where  physical health had not  been integrated                                                                    
with  behavioral  health  as   it  should  be.  He  believed                                                                    
promulgating the  guidelines would  be very  helpful because                                                                    
he heard  from providers who were  not sure what to  do. The                                                                    
common  situation   the  recommendations  did   not  address                                                                    
thoroughly was the  patient who had already  been on opioids                                                                    
for several months  and the need to get them  off the drugs.                                                                    
He concluded  that the recommendations  were not  a complete                                                                    
educational package  yet, but they  represented a  huge step                                                                    
forward.  The   recommendations  also   used  data   he  had                                                                    
referenced earlier highlighting the  risks when a person got                                                                    
above  a  certain dose  and  associating  doses often  times                                                                    
connected with more prolonged periods  of therapy as well as                                                                    
the  co-administration  with benzodiazepines.  He  specified                                                                    
that every state  had a requirement for a  certain amount of                                                                    
continuing  medical education  credits. A  number of  states                                                                    
required  the  education to  be  in  pain management  and/or                                                                    
addiction medicine. He had met  with the state medical board                                                                    
once, which had  been loath to have any  kind of requirement                                                                    
for training;  however, it  was an  option pursued  in other                                                                    
states. He  added that it  was now required for  the federal                                                                    
healthcare  workforce. He  relayed  there were  a number  of                                                                    
approaches, which could be used.                                                                                                
Representative  Pruitt remarked  on  earlier testimony  that                                                                    
doctors   sometimes  believed   other  doctors   were  over-                                                                    
prescribing  medication.  He   detailed  that  sometimes  it                                                                    
sounded like doctors were not  aware of the amount they were                                                                    
prescribing. He hoped over-prescribing  was limited in terms                                                                    
of negligence. He remarked that  training was one component.                                                                    
He  asked if  there was  still a  need for  something firmer                                                                    
than guidelines.                                                                                                                
Dr. Butler answered  that sometimes it required  "a stick as                                                                    
well  as a  carrot" to  make  that happen,  which was  where                                                                    
things  like  requiring  a  PDMP  lookup  before  writing  a                                                                    
prescription  could help.  He suggested  an amendment  which                                                                    
could be considered would be  an exemption to the lookup for                                                                    
quantities  less than  three-day supply  (the number  in the                                                                    
CDC guidelines).                                                                                                                
4:30:05 PM                                                                                                                    
Representative Pruitt  asked if there was  an opportunity to                                                                    
engage some  of the providers  with the State  Medical Board                                                                    
to   facilitate  the   conversation   within  the   provider                                                                    
community    with   the    ultimate   goal    of   providing                                                                    
recommendations (taking the CDC  guidelines into account) to                                                                    
the  legislature. He  remarked  that  the legislature  could                                                                    
decide whether it thought the  recommendations should be put                                                                    
in statute or  Dr. Butler could decide  whether a regulatory                                                                    
change was needed.  He stated that some  great providers had                                                                    
provided feedback; however, they were  not talking to all of                                                                    
the providers.  He wondered if  there was an  opportunity to                                                                    
get providers more engaged. He  noted that currently the AMA                                                                    
and  the state  had  not specified  the CDC  recommendations                                                                    
should go  forward. He  wanted to  make sure  the guidelines                                                                    
were addressed. He  referred back to working  to address the                                                                    
root cause  of the [opioid]  problem. He asked if  there was                                                                    
something  the legislature  could do  at present  or whether                                                                    
Dr.  Butler  and  DHSS  could  do  to  help  facilitate  the                                                                    
Dr. Butler answered that he did  not believe any of the work                                                                    
should be done  without engaging providers. One  of the best                                                                    
opportunities to  engage providers  was through  the various                                                                    
professional  societies. He  detailed there  was significant                                                                    
interest  in the  topic;  he had  personally  been asked  to                                                                    
speak  to the  Academy  of Family  Practice,  ASMA, and  the                                                                    
Alaska Nurse Practitioner Association.  He stressed that the                                                                    
groups  provided   marvelous  input.  He  agreed   with  Dr.                                                                    
Rathkopf's  testimony that  the perspective  of the  primary                                                                    
care  provider was  desperately  needed. He  added that  Dr.                                                                    
Rathkopf  was   a  pediatric   allergist  had   a  different                                                                    
perspective;  he   personally  was  an   infectious  disease                                                                    
provider  and  opioids  were the  last  thing  his  patients                                                                    
needed because  opioids led to  the reason they  were seeing                                                                    
him. He  elaborated that providers all  had different points                                                                    
of view;  therefore, input from  as many people  as possible                                                                    
and through  the organizations  was important.  He explained                                                                    
that the  way the CDC  and AMA worked was  fairly collegial;                                                                    
the   entities   operated   to  put   out   guidelines   and                                                                    
information. He believed the AMA  had recently published the                                                                    
guidelines the  same day as  the CDC to get  the information                                                                    
out to their providers. He  noted that all of the guidelines                                                                    
related back to an assumption  there was a functioning PDMP.                                                                    
He agreed it  was a part of healthcare  reform, although the                                                                    
bill included a very specific  piece related to the Medicaid                                                                    
program in  terms of access  for the Medicaid  pharmacist to                                                                    
the PDMP.                                                                                                                       
4:33:57 PM                                                                                                                    
Representative Gattis  had received emails from  a couple of                                                                    
providers who  had a  problem with  the PDMP.  The providers                                                                    
stated  that  the  PDMP  excluded  the  emergency  room  and                                                                    
surgeons  who  dispense  90  percent  of  the  narcotics  by                                                                    
volume. Alternatively, she thought  Dr. Butler had specified                                                                    
the  number was  about 5  percent. She  asked Dr.  Butler to                                                                    
comment on the figures and discrepancy.                                                                                         
Dr.  Butler  would  be  happy   to  provide  the  background                                                                    
publications where the  numbers had been derived;  it was an                                                                    
issue  of the  total number  of prescriptions.  He explained                                                                    
that  when  looking  at  surgeons  or  ER  physicians  as  a                                                                    
proportion of  all the prescriptions they  write, the higher                                                                    
percentage  was  for  opioids,  but  the  total  number  was                                                                    
actually smaller. The primary  care providers, which made up                                                                    
a larger group, wrote a larger number of prescriptions.                                                                         
Representative  Munoz had  a concern  about  opioids in  the                                                                    
hands of young  people below the age of 20  or 21. She asked                                                                    
if there  was any evidence  that addiction was greater  in a                                                                    
younger person than in a much older person.                                                                                     
Dr. Butler answered that it was  a good question, but he was                                                                    
not sure  he was the best  person to answer. He  referred to                                                                    
an  emerging  science  in  neurodevelopment  suggesting  the                                                                    
adolescent  brain was  susceptible  to addiction  to a  wide                                                                    
variety of substances (more so  than the brain of someone 25                                                                    
years of age  or older). He added that a  person's youth was                                                                    
definitely a time of high  risk in terms of experimentation.                                                                    
He believed people struggled with  a perception that opioids                                                                    
were merely  "granny's pills" and they  were perfectly safe.                                                                    
He  believed everyone  in the  room  had heard  some of  the                                                                    
heartbreaking stories in  Juneau about how pills  had led to                                                                    
worse things and ultimately to overdose.                                                                                        
Representative  Munoz asked  if  other states  were able  to                                                                    
limit  the  availability  of pain  narcotics  to  a  younger                                                                    
population with  a prescription limit  of three  days, seven                                                                    
days, or other.                                                                                                                 
Dr.  Butler answered  that he  was not  aware of  any states                                                                    
that had  implemented age  limits related  to the  number of                                                                    
pills  prescribed. The  pediatric component  was one  of the                                                                    
gaps in  the recommendations;  it was  not addressed  in the                                                                    
CDC guideline  and had  been a  criticism from  the American                                                                    
Academy  of  Pediatrics.  He knew  the  pediatric  community                                                                    
recognized the issue of one that needed to be addressed.                                                                        
Representative  Munoz  asked  if  Dr.  Butler  believed  the                                                                    
participation  of  all  prescribers in  the  database  would                                                                    
prevent or  deter over  prescriptive tendencies.  Dr. Butler                                                                    
answered that all  he could do was look at  the other states                                                                    
to see  that the number  of prescriptions had  declined when                                                                    
participation  in the  PDMP was  required. The  data was  in                                                                    
fairly early  stages, but  there was  no evidence  there had                                                                    
been  worse   pain  control  because  of   fewer  number  of                                                                    
Representative Munoz  asked how  much Medicaid  was spending                                                                    
on pain narcotics  in Alaska. Dr. Butler  did not personally                                                                    
know, but  he believed a  colleague would know  (Erin Narus,                                                                    
Lead State Pharmacist,  State Medicaid Pharmacist Healthcare                                                                    
Services, Department of Health and Social Services).                                                                            
Co-Chair Thompson noted that Dr. Narus would testify next.                                                                      
4:39:01 PM                                                                                                                    
Co-Chair  Neuman believed  he  had spent  more  time on  the                                                                    
issue than  anyone in  the building. He  added that  he went                                                                    
back several years with Dr.  Butler and others on the topic.                                                                    
He expressed concerns  about the topic. He  relayed that his                                                                    
wife was a  pharmacy technician, and there  was currently no                                                                    
enforcement except by  pharmacy technicians and pharmacists.                                                                    
He believed when prescriptions were  altered to increase the                                                                    
amount on a  prescription it was done in the  time between a                                                                    
doctor office and  the pharmacy. He noted that  his wife had                                                                    
been faced with telling  an individual the pharmacy believed                                                                    
the written prescription was illegal  it would be destroyed.                                                                    
He was  scared that his  wife had to  tell a drug  addict or                                                                    
distributor she  would not fill a  prescription. He stressed                                                                    
that  retribution could  be high  and  extreme. He  recalled                                                                    
that several  years back a  senior couple had  been murdered                                                                    
in Big Lake within a half  mile from his house; the offender                                                                    
had stolen the couple's  prescription drugs. He had concerns                                                                    
about  who was  responsible for  telling drug  addicts their                                                                    
prescription may  be illegal. He  emphasized that  the issue                                                                    
had to  be addressed.  He remarked  on calling  the troopers                                                                    
who emailed  a report - he  added that the troopers  did not                                                                    
respond to the issue. He  detailed there were fewer troopers                                                                    
in Alaska at present than at any time in the past.                                                                              
4:42:05 PM                                                                                                                    
Co-Chair Neuman  continued to  discuss his  concerns, citing                                                                    
pharmacy  theft,  which  was prevalent.  He  specified  that                                                                    
pharmacies were very concerned about  the issue and most had                                                                    
security  cameras.  He  reasoned  that people  who  work  in                                                                    
pharmacies or have access to  drugs were human and stole the                                                                    
drugs -  some to take  care of  their own habits  and others                                                                    
sold  the  drugs.  He  believed the  bill  was  creating  an                                                                    
opportunity  to  increase  access   to  information  in  the                                                                    
database. He surmised  that the database would  show who had                                                                    
received prescriptions, the amounts,  and the address of the                                                                    
individual. He  stated that most  people he had  spoken with                                                                    
about the issue were very  concerned. He relayed that people                                                                    
were surprised  to find  out about  the PDMP  that contained                                                                    
information  about  a  person and  their  prescriptions.  He                                                                    
understood the  database helped emergency room  doctors, but                                                                    
he believed emergency room doctors  were triage and there to                                                                    
get a person to a primary  care provider as soon as possible                                                                    
- generally within one or  two days. He was greatly bothered                                                                    
the  government was  keeping track  of all  the prescription                                                                    
drugs people  took. He reiterated  his opposition  to giving                                                                    
others access to the database.                                                                                                  
Co-Chair Neuman relayed an anecdotal  story about a pharmacy                                                                    
technician  who  was addicted  to  drugs  and who  gave  out                                                                    
information about  people in the  database. He  surmised the                                                                    
people who received the information  could potentially rob a                                                                    
person's  house. He  was extremely  bothered  that when  the                                                                    
Medicaid bill had been before  the legislature and the state                                                                    
had not  spoken to  Medicaid patients. He  emphasized people                                                                    
dealing with the issues were faced with real problems.                                                                          
4:45:09 PM                                                                                                                    
Co-Chair Neuman discussed information  he had heard from his                                                                    
family  doctor, who  was losing  patients. He  detailed that                                                                    
his  doctor had  insurance out  of California  or Washington                                                                    
and  those   two  states   had  implemented   new  insurance                                                                    
regulations requiring patients  to go to a  pain clinic when                                                                    
receiving  medication  for  long-term  pain  management.  He                                                                    
stated the  costs were $550  per visit compared to  $125. He                                                                    
reasoned that  a person  would be  faced with  leaving their                                                                    
family  doctor to  see someone  different who  did not  know                                                                    
their medical  history. He added  that more and  more people                                                                    
were signing  up for  Medicaid; he wondered  what it  did to                                                                    
the cost of  the Medicaid program. He asked  what the change                                                                    
did to the  cost of prescriptions for  Medicaid. He referred                                                                    
to his  past chairmanship  of the DHSS  budget subcommittee.                                                                    
He recalled  that DHSS  had been  getting about  $40 million                                                                    
from   the  federal   government  and   the  Department   of                                                                    
Administration  had been  receiving $20  million in  rebates                                                                    
from pharmaceutical companies. He  stated that the companies                                                                    
were  charging  more  for prescriptions  than  their  actual                                                                    
Co-Chair  Neuman continued  that Alaska's  700,000 residents                                                                    
were    currently   spending    over   $60    million   plus                                                                    
administrative fees,  which he thought easily  accounted for                                                                    
another $10  million to pharmaceutical companies.  He stated                                                                    
that Alaskans  were spending more  for the cost of  drugs so                                                                    
companies  could  get the  money  back  under the  guise  of                                                                    
covering the cost of prescription  drugs for Medicaid, which                                                                    
was about  $1 million per  week. He questioned  whether more                                                                    
government  in people's  lives  made it  right.  He did  not                                                                    
believe  so.  He remarked  that  a  state board  produced  a                                                                    
preferred drug list.  He believed it was  plausible that the                                                                    
drugs on  the list were  from companies who  provided higher                                                                    
rebates. He  had huge  concerns about  the issue.  He opined                                                                    
that  if the  scenario  was possible,  the  state should  be                                                                    
taking  a hard  look. He  spoke  to the  concerns about  the                                                                    
invasion of privacy. He remarked  that the database could be                                                                    
accessed by  the federal government.  He continued  that the                                                                    
federal  government was  taking  long strides  to take  away                                                                    
guns from  honest people. He thought  the federal government                                                                    
could  use  the  database  to identify  people  it  believed                                                                    
should not  have guns. He  did not support taking  guns away                                                                    
from  individuals.  He could  live  with  the current  PDMP,                                                                    
which pharmacists, primary care  and ER doctors could access                                                                    
if they needed.                                                                                                                 
4:50:07 PM                                                                                                                    
Co-Chair  Neuman  could  not  believe  the  legislature  was                                                                    
considering  making  it mandatory  for  doctors  to use  the                                                                    
database. He  reasoned a person could  be long-term patient,                                                                    
but would  still be  included in  the database.  He believed                                                                    
not all doctors would want  to delegate authority to someone                                                                    
in their office  to write scripts. He spoke  to cost drivers                                                                    
and  did not  know  how much  it would  cost  to update  the                                                                    
database  weekly.  He  emphasized   that  the  database  was                                                                    
currently updated  on a  monthly basis.  He believed  it was                                                                    
essentially  worthless.  He  had been  told  weekly  updates                                                                    
would   be  expensive   by  the   director  of   boards  and                                                                    
commissions. He  understood the problem of  opioid abuse and                                                                    
overdoses,  which  was the  reason  he  had worked  hard  to                                                                    
address the  issue. He mentioned  an earlier  question about                                                                    
addressing  the problem.  He  stressed  the legislature  had                                                                    
included $30 million ($10 million  per year for three years)                                                                    
to  start treating  the  problem -  to  treat Alaskans  with                                                                    
addiction problems  without current access to  treatment. He                                                                    
remarked  it had  been specified  in a  gap analysis  he had                                                                    
worked on  with Dr. Butler.  He believed the best  thing the                                                                    
state  could do  was to  try to  treat the  problem and  the                                                                    
addicts  in the  state. He  opined it  was the  cheapest and                                                                    
least intrusive  method. He continued  it would  keep people                                                                    
from  trying  to  break into  homes  to  steal  prescription                                                                    
drugs. The  people he  talked to  wanted less  government in                                                                    
their lives. He  stressed that the PDMP  requirement was not                                                                    
less government.  He emphasized  the personal nature  of the                                                                    
Co-Chair  Neuman continued  to  address  his concerns  about                                                                    
expanding  access  to  the  database.  He  asked  people  to                                                                    
imagine what a  drug gang would do with  the information. He                                                                    
did not know anyone who  felt comfortable with the issue. He                                                                    
stressed that other databases got  hacked and so could state                                                                    
databases. He  wondered what an  insurance company  would do                                                                    
with the  information if  they got the  data. He  added that                                                                    
every doctor who  had called in during  public testimony had                                                                    
specified various points that needed to be amended.                                                                             
4:54:50 PM                                                                                                                    
Co-Chair Neuman continued to speak  to his concern about the                                                                    
issue. He  referred to discussion  during the  meeting about                                                                    
limiting the  amount of pills  a doctor could  prescribe. He                                                                    
asked if that  was really where people  wanted government to                                                                    
go. He understood  it saved lives. He stated  that there had                                                                    
been over 1  million prescriptions in the  PDMP the previous                                                                    
year.  He questioned  whether the  committee  was asking  to                                                                    
erode the  personal rights of  more Alaskans.  He understood                                                                    
that people overdosed  on drugs. He referred  to his earlier                                                                    
question  about whether  the 80  Alaskans who  had overdosed                                                                    
had been getting prescription drugs  by their doctor who had                                                                    
not been prescribing correctly.  He recalled that Dr. Butler                                                                    
had agreed  for the majority  of the cases it  was probable.                                                                    
He reiterated  that he could  live with the  current system.                                                                    
He  believed the  topic needed  much more  discussion before                                                                    
leaving  the committee.  He was  upset at  the idea  of more                                                                    
intrusion into  people's rights,  which he believed  was not                                                                    
the  government's role.  He  remarked  that the  requirement                                                                    
would increase the  cost of government; he  thought the bill                                                                    
would require an increase of 5  or 6 new state positions for                                                                    
enforcement.  He  reiterated  his  other  concerns.  He  had                                                                    
spoken with a  doctor at a pain clinic who  had specified he                                                                    
would  not   access  the   database.  He   restated  earlier                                                                    
testimony. The doctor had specified  that if he saw the name                                                                    
of one  of his patients  on the list he  may not be  able to                                                                    
treat  the person.  He wondered  how many  other doctors  in                                                                    
Alaska would  feel the same  way. He mentioned  the shortage                                                                    
of doctors in Alaska.                                                                                                           
4:58:19 PM                                                                                                                    
Representative  Guttenberg   remarked  that  SB  74   was  a                                                                    
Medicaid  reform  bill,  which  he believed  was  about  the                                                                    
process of medicine. He surmised  the conversation seemed to                                                                    
be "walking back  and forth" over the  practice of medicine.                                                                    
He  furthered   that  one  of   the  goals  was   to  create                                                                    
efficiencies  and   to  reduce   the  escalating   costs  of                                                                    
medicine,  which were  out  of control.  He  added that  the                                                                    
costs were out of control  in Alaska even with the expansion                                                                    
of Medicare. He  reasoned the bill was  about taking control                                                                    
of  those  costs.  He  continued that  the  state  had  more                                                                    
control  over  the Medicare  environment  than  it did  over                                                                    
anyone else.  He did not want  to get into the  practice and                                                                    
reasoned  that the  state  had almost  no  control over  the                                                                    
area.  He elaborated  that it  was  not possible  to tell  a                                                                    
physician what  to do.  He stressed that  the state  did not                                                                    
want  government in  the  room telling  a  physician how  to                                                                    
practice  medicine. He  believed the  PDMP would  enable the                                                                    
discovery of  things as  a "side version  of what  that is,"                                                                    
whether it was  about prescribing things that  should not be                                                                    
prescribed  in   certain  amounts  to  certain   people.  He                                                                    
mentioned efficiencies  in telemedicine and other  areas. He                                                                    
addressed the issue of privacy.  He discussed when he walked                                                                    
into  a  clinic  he  saw   schedulers,  people  filling  out                                                                    
insurance  forms,   and  filing.  He  reasoned   there  were                                                                    
national   HIPAA    [Health   Insurance    Portability   and                                                                    
Accountability Act]  laws dealing with the  issues. He asked                                                                    
if there was  a history of abuse,  prosecutions, or behavior                                                                    
that  was out  of  the  norm that  the  committee should  be                                                                    
concerned about. He referenced  expanding for individuals in                                                                    
a  pharmacy  or  doctor's  office  to  access  the  database                                                                    
(outside of the pharmacist  or doctor). He always questioned                                                                    
who had  access to what  in a  doctor's office. He  asked if                                                                    
the issue had been a problem.                                                                                                   
Dr. Butler  answered that the security  issue was critically                                                                    
important.  He  had spoken  with  DCCED  and state  troopers                                                                    
about whether or  not there had been breeches  in the Alaska                                                                    
PDMP. He  was particularly concerned about  linking the PDMP                                                                    
to homicides and releases of  data because the troopers were                                                                    
not aware of this. He stressed  that if people were aware of                                                                    
crimes  of that  nature they  needed to  report them  to law                                                                    
enforcement.   The  national   experience   had  been   that                                                                    
disclosures  occasionally occurred  -  he was  aware of  two                                                                    
occurrences. The  first involved a law  enforcement official                                                                    
in a  state with open  access to law enforcement,  which was                                                                    
not  listed among  the best  practices  and was  not a  good                                                                    
idea. The  second occurrence involved a  healthcare provider                                                                    
with  access to  the medical  record  who had  tried to  get                                                                    
information on  an ex-spouse  in Ohio. He  was not  aware of                                                                    
any  similar  issues  occurring   in  Alaska  based  on  the                                                                    
conversations he had  with DCCED and the  state troopers. He                                                                    
encouraged other  department officials available  to testify                                                                    
to weigh in on the issue if they had something to add.                                                                          
Dr.  Butler continued  that the  concern about  hacking into                                                                    
private information  was valid (the same  went for financial                                                                    
institutions),  but no  national experts  were aware  of any                                                                    
occurrences  where  data from  the  PDMP  had been  used  to                                                                    
target  people for  robberies. He  stated that  "it gets  to                                                                    
that  question of  just  how prevalent  opioids  are in  the                                                                    
community  because you  don't really  need to  do that."  He                                                                    
detailed that a  number of the larger  national relators had                                                                    
issued advisories  to their agents  to make them  aware that                                                                    
people often  times showed  up at open  houses and  asked to                                                                    
use  the restroom  because it  was  a chance  to pilfer  the                                                                    
medicine cabinet. He  stressed that the PDMP  was not needed                                                                    
to  find those  opportunities.  He continued  that a  person                                                                    
could monitor  the obituaries to  look for someone  who died                                                                    
at home after  a long illness and could break  in during the                                                                    
person's memorial service. There were  all kinds of ways for                                                                    
crimes to  be committed  that did not  involve the  PDMP. He                                                                    
had not been  able to find documentation of  crimes that had                                                                    
been proposed involving the PDMP.  He stressed that security                                                                    
was critical and  he deferred to DCCED or  other for further                                                                    
detail into  security precautions  against hacking  into the                                                                    
PDMP. He was  curious how the precautions  compared to those                                                                    
for  the Alaska  Permanent  Fund Corporation  and other.  He                                                                    
provided a scenario about online  hacking to steal money. He                                                                    
reasoned those  hacking interests  would not care  about the                                                                    
5:05:35 PM                                                                                                                    
Representative Guttenberg  asked if  troopers had  access to                                                                    
the  database. Dr.  Butler clarified  that troopers  did not                                                                    
have access  to the  database without  a subpoena  or search                                                                    
warrant. He had  asked state troopers whether  they had ever                                                                    
investigated a crime related to  release of information from                                                                    
the PDMP.                                                                                                                       
Representative Edgmon  asked about  the genesis of  the bill                                                                    
section. Dr. Butler  believed the section had  been added in                                                                    
a Medicaid  Reform Subcommittee in Senate  Finance. He noted                                                                    
confirmation from the sponsor.                                                                                                  
Representative Edgmon remarked  on the compelling viewpoints                                                                    
from both  sides of  the issue. He  asked if  the discussion                                                                    
was at the  nascent stage. He wondered if the  issue had not                                                                    
been thought through  about cost to the  provider and issues                                                                    
of  privacy infringements  versus  the greater  good of  not                                                                    
having a centralized database.                                                                                                  
5:07:38 PM                                                                                                                    
Dr. Butler  replied that if  part of the question  was about                                                                    
why he was speaking to the  issue, the answer was he was not                                                                    
actually  sure.  He reasoned  the  program  was not  in  his                                                                    
department.  He answered  that the  process was  ongoing and                                                                    
the state's PDMP was not new.  He continued that it had been                                                                    
one of  the topics  of discussion  in looking  at healthcare                                                                    
reform  as  a  quality  of  care  issue  by  the  healthcare                                                                    
commission  before  it  had  been  disbanded.  Some  of  the                                                                    
discussion  had  been  fulfilling  the  will  of  the  House                                                                    
Finance Committee  to implement  the recommendations  of the                                                                    
healthcare commission.  He explained the discussion  was not                                                                    
Representative  Edgmon referred  to  Dr. Butler's  testimony                                                                    
that the state  did not have the ability  to compile numbers                                                                    
or meaningful  statistics on  opioid addictions  or possible                                                                    
overdoses.  He  asked  for   verification  that  Dr.  Butler                                                                    
believed the  state was hindered  because it did not  have a                                                                    
centralized drug database.                                                                                                      
Dr.  Butler responded  that the  state was  able to  monitor                                                                    
overdose  deaths and  to  some  degree hospitalizations  for                                                                    
overdose. He noted those issues  did not relate to the PDMP.                                                                    
The discussion  was about  considering how  to do  more than                                                                    
the testing  and count the numbers.  For example, addressing                                                                    
questions like treatment. The discussion  was also about how                                                                    
to  reduce  the number  of  people  requiring treatment.  He                                                                    
considered whether  it would be  sustainable to  continue to                                                                    
pour funding into  treatment if there was  an opportunity to                                                                    
address  the problem  at  its root  cause,  which was  often                                                                    
related to  the combination  of stress and  the availability                                                                    
of an addictive  substance. In terms of the  utility of data                                                                    
in the PDMP  it was primarily as a  communication tool among                                                                    
providers.  He  speculated  that  part  of  the  reason  the                                                                    
subject had been  added to SB 74 was its  involvement in the                                                                    
Medicaid program  - the access  for the  Medicaid pharmacist                                                                    
was  part of  stewardship for  public funding  that went  to                                                                    
Medicaid  beneficiaries  -  in  order to  reduce  fraud  and                                                                    
provide   improved  care.   Access  to   the  database   was                                                                    
concerning   because  privacy   was  critically   important;                                                                    
however, he believed the limited  expansions and access were                                                                    
on  a need-to-know  basis (similar  to  a national  security                                                                    
issue)  in  terms  of  who  was  currently  unable  to  make                                                                    
important  decisions  that  would   improve  the  health  of                                                                    
Alaskans absent the data in the PDMP.                                                                                           
5:11:18 PM                                                                                                                    
Representative  Edgmon believed  the vastness  of the  issue                                                                    
was engendered  more discussion.  He vocalized  his interest                                                                    
in  hearing from  the bill  sponsor on  the benefits  of the                                                                    
provision, which seemed to be  apparent. He added there were                                                                    
also  costs   and  implications   that  may  not   be  fully                                                                    
understood. He was trying to weigh both sides of the issue.                                                                     
Co-Chair Thompson thanked Dr. Butler for his testimony.                                                                         
5:12:26 PM                                                                                                                    
ERIN   NARUS,   LEAD   STATE  PHARMACIST,   STATE   MEDICAID                                                                    
PHARMACIST  HEALTHCARE SERVICES,  DEPARTMENT  OF HEALTH  AND                                                                    
SOCIAL SERVICES  (via teleconference), relayed that  most of                                                                    
the points  she had planned  to address had been  covered by                                                                    
Dr. Butler.  She provided  a brief overview  of the  one the                                                                    
role  of   the  Alaska  Medicaid  drug   utilization  review                                                                    
process. Currently  under federal law the  nation's Medicaid                                                                    
programs  were required  to provide  for a  drug utilization                                                                    
review   program   for   covered   outpatient   drugs.   The                                                                    
requirement was primarily to  ensure that prescriptions were                                                                    
appropriate, medically  necessary, and not likely  to result                                                                    
in adverse medical results. The  federally mandated drug use                                                                    
review  program   had  two   broad  components.   The  first                                                                    
component   was  a   prospective  drug   utilization  review                                                                    
program,   which   looked   at   the  point   of   sale   of                                                                    
prescriptions. She  detailed that when an  individual filled                                                                    
a prescription at  the pharmacy there were  rules within the                                                                    
claims adjudication system to help  the pharmacy to be aware                                                                    
of other  medications the patient  may currently  be taking.                                                                    
After being  entered into  the point of  sale the  claim was                                                                    
sent to  the Medicaid  claims processing system.  The second                                                                    
component was  a retrospective drug utilization  review. She                                                                    
specified  her  office  worked  with  the  drug  utilization                                                                    
review  committee   -  an  interdisciplinary   committee  of                                                                    
practitioners throughout Alaska  (e.g. physicians, mid-level                                                                    
practitioners,  and pharmacists)  - and  reviewed trends  of                                                                    
medications and  looked for ways  to reduce fraud  and abuse                                                                    
and to  guide clinical prescribing  utilizing evidence-based                                                                    
medicine tenets.                                                                                                                
Representative Pruitt  asked if  Dr. Narus saw  the database                                                                    
as  a  key part  in  helping  the  state  to save  money  on                                                                    
pharmaceuticals in the Medicaid  program. Dr. Narus answered                                                                    
that access to  the PDMP by licensed  pharmacists within the                                                                    
Alaska  Medicaid program  was critical  in order  to prevent                                                                    
hospitalizations and  to ensure the  appropriate utilization                                                                    
of funds.                                                                                                                       
5:16:12 PM                                                                                                                    
Representative  Pruitt believed  the  answer  was "yes."  He                                                                    
thanked Dr. Narus for her response.                                                                                             
Representative  Munoz   asked  about   the  cost   spent  on                                                                    
narcotics in  the Medicaid program.  Dr. Narus  replied that                                                                    
she did not have the  specific number, but she could provide                                                                    
it. She  added that in December  [2015], narcotic analgesics                                                                    
had been  the top  number of claims  in the  Alaska Medicaid                                                                    
Representative  Munoz  asked  for  the  total  cost  of  all                                                                    
Medicaid  pharmaceuticals had  been during  that month.  Dr.                                                                    
Narus   replied  that   she   would  follow   up  with   the                                                                    
Co-Chair Thompson thanked Dr. Narus for her testimony.                                                                          
5:18:25 PM                                                                                                                    
AT EASE                                                                                                                         
5:30:16 PM                                                                                                                    
Co-Chair Thompson asked DCCED to address the committee.                                                                         
JANEY   HOVENDEN,   DIRECTOR,  DIVISION   OF   CORPORATIONS,                                                                    
BUSINESS   AND   PROFESSIONAL   LICENSING,   DEPARTMENT   OF                                                                    
COMMERCE,  COMMUNITY  AND ECONOMIC  DEVELOPMENT,  introduced                                                                    
herself  and other  department staff  available to  testify.                                                                    
She  clarified that  the department's  fiscal note  included                                                                    
the cost for  telemedicine and the PDMP  expansion; the PDMP                                                                    
only  accounted  for one-fifth  of  the  fiscal note,  which                                                                    
would  fund a  program  coordinator and  a  small amount  of                                                                    
travel  for  the coordinator  to  attend  Board of  Pharmacy                                                                    
meetings.  She relayed  that  the cost  to  update the  PDMP                                                                    
weekly or  daily (instead  of monthly)  would be  $2,175 per                                                                    
Co-Chair Thompson asked for clarification.                                                                                      
Ms. Hovenden  replied that  for the  division to  update the                                                                    
PDMP  weekly   or  daily  with  information   received  from                                                                    
pharmacists  it would  cost $2,175  annually. Currently  the                                                                    
database was updated monthly.                                                                                                   
Co-Chair  Thompson  asked  for  verification  the  cost  was                                                                    
associated   with  updating   the  database   weekly  versus                                                                    
monthly.  Ms.  Hovenden  answered  in  the  affirmative  and                                                                    
explained it was a software issue.                                                                                              
SARA CHAMBERS,  ADMINISTRATIVE OPERATIONS  MANAGER, DIVISION                                                                    
OF  CORPORATIONS,   BUSINESS  AND   PROFESSIONAL  LICENSING,                                                                    
DEPARTMENT OF COMMERCE,  COMMUNITY AND ECONOMIC DEVELOPMENT,                                                                    
spoke  to  questions  and  concerns  that  had  been  raised                                                                    
earlier. She clarified  that the PDMP had  been in existence                                                                    
for  several  years;  a  list  of  people  receiving  opioid                                                                    
prescriptions  currently existed  and was  purged every  two                                                                    
years. She  detailed that the information  was accessible by                                                                    
a very limited number  of licensed prescribers and providers                                                                    
in  the  state and  the  authority  could not  currently  be                                                                    
delegated to  anyone (e.g. a  pharmacy technician,  or other                                                                    
office personnel).  She stated that the  ability to delegate                                                                    
the  authority  was  included  in   the  current  bill.  She                                                                    
furthered that what  the provision would look  like and what                                                                    
side  rails  may   be  included  to  achieve   some  of  the                                                                    
protections  concerns  was  certainly open  for  discussion.                                                                    
Federal  government access  to  the PDMP  was restricted  to                                                                    
licensed medical  providers with a right  to access specific                                                                    
patient  data  (their  own patients).  She  noted  that  the                                                                    
Veterans Administration (VA) and  IHS would have a different                                                                    
definition than  in the State  of Alaska, but it  would boil                                                                    
down to  what the  federal and state  licensing requirements                                                                    
were for  qualified doctors and pharmacists.  She referenced                                                                    
the  seven-page signature  form  [mentioned  earlier by  Co-                                                                    
Chair Neuman] and relayed the division was working with Co-                                                                     
Chair  Neuman  to  determine  what  the  form  may  be.  She                                                                    
detailed that  it did not appear  to be a PDMP  form; it was                                                                    
perhaps a DEA form. The  division was dedicated to increased                                                                    
efficiencies -  all of its  licensing programs had  moved to                                                                    
online  renewal capability  in the  current year.  She noted                                                                    
the  division  had  received significant  positive  feedback                                                                    
from licensees.                                                                                                                 
5:36:02 PM                                                                                                                    
Ms.  Chambers  relayed that  the  division  had worked  with                                                                    
Doctor Butler; she thanked him  profusely for his assistance                                                                    
and  education on  the subject.  Additionally, the  division                                                                    
had worked with the bill  sponsor to continue its commitment                                                                    
to  making  the  processes  as  efficient  as  possible  for                                                                    
Co-Chair Thompson  referred to  an earlier question  that he                                                                    
did  not believe  had been  answered. He  asked if  the PDMP                                                                    
data on  patients with opioid prescriptions  shared with the                                                                    
federal government.                                                                                                             
Ms. Chambers answered that access  to the PDMP was currently                                                                    
available to  the federal government  only when an  agent of                                                                    
the  federal government  was  a  qualified licensed  medical                                                                    
provider;  those individuals  had  the ability  to the  data                                                                    
regarding  their  own  patients  just like  any  other  non-                                                                    
government  private  doctor. Additionally,  the  information                                                                    
was  available  to law  enforcement  through  a subpoena  or                                                                    
warrant issued in  a court order process. She  was not aware                                                                    
of any other current or proposed federal government access.                                                                     
Vice-Chair  Saddler spoke  to  a letter  from  the Board  of                                                                    
Pharmacy   [dated  February   11,  2016   (copy  on   file)]                                                                    
indicating  the federal  funding for  the PDMP  ended August                                                                    
31,  2013. He  continued  that currently  there was  another                                                                    
grant DHSS was  receiving. He asked what  the funding source                                                                    
would be  past 2021.  He asked Ms.  Hovenden for  details on                                                                    
the current  cost of  the PDMP  and what  the cost  would be                                                                    
after the expansion.                                                                                                            
Ms.  Hovenden  replied  that   the  cost  was  approximately                                                                    
$100,000  for  the PDMP  expansion.  The  cost included  one                                                                    
personnel and some travel costs.                                                                                                
Vice-Chair Saddler asked for the  current cost. Ms. Hovenden                                                                    
replied that the cost was currently $85,000.                                                                                    
Vice-Chair  Saddler surmised  that the  total cost  would be                                                                    
$185,000. Ms. Hovenden affirmed.                                                                                                
Vice-Chair  Saddler  asked  if  the  funding  was  available                                                                    
through a federal grant up  to 2021. Ms. Hovenden replied in                                                                    
the affirmative.                                                                                                                
Ms. Chambers clarified that  currently the division received                                                                    
$120,000 annually  through federal  funding. The  funds paid                                                                    
for the  database at approximately  $80,000 to  $85,000 [per                                                                    
year]. The additional  funding was set aside  to pay support                                                                    
staff assisting  with the PDMP.  She explained  the division                                                                    
did not receive the grant money  if it was not utilized. The                                                                    
division received adequate funding  for the PDMP at present.                                                                    
She detailed that the division  had applied in a partnership                                                                    
with DHSS for  another grant, but it had not  quite made the                                                                    
cut. Subsequently,  the division  had been working  with Dr.                                                                    
Butler and  his team  on enhancing  the grant.  She detailed                                                                    
that  if received,  the grants  would  cover the  additional                                                                    
expenses  anticipated in  the  fiscal  note; therefore,  the                                                                    
cost would be fully funded  by a grant, which she understood                                                                    
was  the  original  legislative intent  for  the  PDMP.  The                                                                    
funding  would  prevent  the  division  from  being  in  the                                                                    
quandary  of having  to go  to its  licensees or  registered                                                                    
users to charge a licensing  fee. The division had been very                                                                    
active in  partnership with DHSS  to continue to  seek grant                                                                    
opportunities; the  grant opportunities moved the  PDMP from                                                                    
a  list  of   numbers  and  data  -   which  was  critically                                                                    
important, especially to  grant access to Medicaid  - into a                                                                    
robust statewide opioid control program.                                                                                        
5:41:27 PM                                                                                                                    
Vice-Chair   Saddler  pointed   to  the   letter  mentioning                                                                    
legislative  intent  put in  by  former  Senator Lyda  Green                                                                    
specifying  it was  not the  intent of  the legislature  for                                                                    
professional users  of the database  to absorb the  cost; it                                                                    
was  the intent  that the  PDMP would  be funded  by federal                                                                    
grants  and state  appropriations. He  asked if  it was  the                                                                    
legislation that had created the database.                                                                                      
Ms. Chambers answered in the affirmative.                                                                                       
Representative  Pruitt  returned  to  the  discussion  about                                                                    
federal  government  access to  the  database.  He spoke  to                                                                    
concern  about people  who were  not  doctors accessing  the                                                                    
database. He  asked if a  federal law required the  state to                                                                    
give the  federal government  access to  the PDMP  through a                                                                    
subpoena.  Alternatively,  he asked  if  the  state felt  it                                                                    
needed to provide the data in those circumstances.                                                                              
Ms. Chambers  answered that the  law was currently  in state                                                                    
Representative Pruitt surmised that  the state's own statute                                                                    
could be  changed in  order to  appease some  concerns about                                                                    
giving  the federal  government  access  to information.  He                                                                    
suggested prohibiting  the transfer or cooperation  with the                                                                    
federal government on access to the database.                                                                                   
Ms. Chambers answered  she would need to  review the statute                                                                    
to determine exactly how law  enforcement was clarified. She                                                                    
tended to agree  with the tone mentioned by  Dr. Butler that                                                                    
the  state's own  Department of  Public Safety  and troopers                                                                    
would have that  level of access. She could  not say without                                                                    
researching the  statute, whether  it allowed  or prohibited                                                                    
federal law  enforcement to have access  to the information.                                                                    
She would look into the issue.                                                                                                  
Representative Gara understood the  purpose of the database,                                                                    
which would  enable one  physician to  see if  an individual                                                                    
was   shopping  around   and   seeking   large  amounts   of                                                                    
prescription drugs. He  referred to page 16 of  the bill and                                                                    
wondered  why  the   pharmacist  had  to  send   a  list  of                                                                    
individuals they prescribed drugs  to the board. He wondered                                                                    
about the purpose.                                                                                                              
Ms. Hovenden  replied that the board  administered the PDMP.                                                                    
The  information  was not  literally  sent  directly to  the                                                                    
board; it went to the PDMP, which was managed by the board.                                                                     
Representative   Gara  asked   for  verification   that  the                                                                    
language requiring pharmacists to  submit information to the                                                                    
board meant  the pharmacists were to  submit the information                                                                    
into the database. Ms. Hovenden replied in the affirmative.                                                                     
Representative  Gara  referred  to the  provision  requiring                                                                    
pharmacists to  submit the information  a minimum of  once a                                                                    
week.  He thought  there had  been a  provision requiring  a                                                                    
pharmacist to  enter the information  quicker. He  asked for                                                                    
verification that the submittal  of information was required                                                                    
on a weekly basis. Ms. Hovenden replied in the affirmative.                                                                     
5:46:18 PM                                                                                                                    
Representative Munoz  referred to  testimony from  the prior                                                                    
evening by  a pharmacist who  was concerned about  having to                                                                    
recheck the  database after  the initial  prescribing doctor                                                                    
had  checked  the database.  She  wondered  if it  would  be                                                                    
appropriate  to have  the Board  of Pharmacy  overseeing the                                                                    
program if  the state  only required the  prescribing doctor                                                                    
to  check the  database. She  wondered if  it would  be more                                                                    
appropriately housed in the State Medical Board.                                                                                
Ms.  Chambers   answered  that  the  division   oversaw  all                                                                    
professional  licensing   boards  including  the   Board  of                                                                    
Pharmacy and the  State Medical Board. She  detailed that it                                                                    
was "six  of one,  half dozen of  another" -  any particular                                                                    
board  may   be  given  the   statutory  authority   by  the                                                                    
legislature  to   govern  the  process,  but   the  division                                                                    
administered the program from a day-to-day standpoint.                                                                          
Representative  Munoz   asked  if   the  PDMP   was  managed                                                                    
currently by  the Board of  Pharmacy. Ms.  Chambers answered                                                                    
in the affirmative.                                                                                                             
Representative Edgmon  asked if  the concept  flowed through                                                                    
the Board of Pharmacy and  State Medical Board. Ms. Chambers                                                                    
answered  that  the idea  of  expanding  the PDMP  had  been                                                                    
generated outside  of the  division; the  proposed expansion                                                                    
had not initiated by the  Board of Pharmacy or State Medical                                                                    
Board. She  furthered that the division  had become involved                                                                    
in answering  technical and impact  types of  questions when                                                                    
the legislation had been drafted.                                                                                               
5:48:28 PM                                                                                                                    
Representative  Edgmon  asked  discussing  the  issue  as  a                                                                    
policy measure  would be  in the  normal course  of business                                                                    
for the board.                                                                                                                  
Ms. Chambers  answered in the affirmative.  She detailed the                                                                    
Board of  Pharmacy discussed the  PDMP regularly and  was an                                                                    
engaged partner  in its  governance and  administration. She                                                                    
specified  that  because the  State  Medical  Board was  not                                                                    
responsible for  governance of the  PDMP, it had not  to her                                                                    
knowledge  had such  a robust  discussion;  however, it  had                                                                    
thoroughly discussed the telemedicine aspect of the bill.                                                                       
Vice-Chair Saddler asked if there  had ever been a breach of                                                                    
the  integrity of  the  PDMP. Ms.  Hovenden  replied in  the                                                                    
Vice-Chair Saddler asked what  the practical effect would be                                                                    
if the  pharmacist was  removed from  the redundant  task of                                                                    
doing  a pre-check  of the  database. He  asked if  it would                                                                    
tend  to diminish  the effectiveness  of  the database.  Ms.                                                                    
Chambers  answered that  the conversation  was  a result  of                                                                    
testimony  the  heard by  the  committee.  She detailed  the                                                                    
conversation  was  being held  with  the  bill sponsor,  Dr.                                                                    
Butler, and other engaged personnel.                                                                                            
Co-Chair Neuman  asked if there  had never been a  breach of                                                                    
information that  was obtained  from the PDMP.  Ms. Hovenden                                                                    
deferred the question to the database manager.                                                                                  
Co-Chair  Neuman  believed  there  was no  way  to  know  if                                                                    
someone with access to the  database told someone else about                                                                    
the information.                                                                                                                
5:52:01 PM                                                                                                                    
Co-Chair Thompson asked the database  manager to address the                                                                    
question related to system security.                                                                                            
BRIAN HOWES,  PROGRAM MANAGER, PRESCRIPTION  DRUG MONITORING                                                                    
PROGRAM,  DEPARTMENT  OF  HEALTH AND  SOCIAL  SERVICES  (via                                                                    
teleconference), relayed  that there  had been no  breach of                                                                    
the  database;  the   data  had  not  been   shared  to  his                                                                    
knowledge.  He  relayed there  had  never  been a  complaint                                                                    
regarding a breach. He explained  that someone would have to                                                                    
make a complaint that the  data had been obtained illegally.                                                                    
He furthered that through  different complaint processes the                                                                    
division  could  have  the  ability  to  determine  who  had                                                                    
accessed  the information  and whether  or not  it was  used                                                                    
Co-Chair Thompson  surmised that  if there  was a  breach it                                                                    
would have  been by  someone with legal  access to  the PDMP                                                                    
involving  printing  off  the  data and  passing  it  on  to                                                                    
someone illegally. Mr. Howes answered in the affirmative.                                                                       
Vice-Chair Saddler  stated that  there may  not have  been a                                                                    
breach of the  database there may have  been a non-technical                                                                    
human breach. Mr. Howes answered in the affirmative.                                                                            
5:54:00 PM                                                                                                                    
Representative Guttenberg surmised the  state would not know                                                                    
if there was or was not  a breach. He wondered how the state                                                                    
would  know either  way.  Mr. Howes  replied  that it  would                                                                    
require a complaint  that data had been  shared with someone                                                                    
else.  He  furthered  at  that   point  the  division  would                                                                    
determine which  provider had looked  up the  patient. There                                                                    
was an audit trail within  the program, which would enable a                                                                    
lookup of  the information. From  that point, they  would go                                                                    
through an interview process to  determine what had happened                                                                    
and what the person had done with the data.                                                                                     
Representative  Guttenberg asked  how many  complaints there                                                                    
had been. Mr. Howes replied there had been no complaints.                                                                       
Representative Guttenberg  asked if that was  throughout the                                                                    
history  of   the  database.  Mr.  Howes   answered  in  the                                                                    
Representative Edgmon asked referred  to testimony there had                                                                    
been no  breaches or sharing of  the data from the  PDMP. He                                                                    
referred to  the human intelligence  factor. He  remarked on                                                                    
federal  access   by  qualified   medical  agents   and  law                                                                    
enforcement.  He asked  who  had state  access  to the  PDMP                                                                    
outside the division.                                                                                                           
Mr.  Howes  answered  that  any access  was  by  a  licensed                                                                    
prescriber  or dispenser  regarding a  patient or  a patient                                                                    
they   anticipated  seeing.   The  statute   specified  that                                                                    
federal,  state,  and  local  law  enforcement  may  receive                                                                    
printouts  from  the database  based  on  a court  order  or                                                                    
search warrant demonstrating probable cause for the action.                                                                     
Representative Edgmon asked if  currently every provider had                                                                    
to participate. Mr. Howes answered  that there was currently                                                                    
no requirement for providers to look at the database.                                                                           
Representative Edgmon asked how  many practitioners used the                                                                    
database.  Mr.  Howes  answered   the  percentage  was  low.                                                                    
Approximately 700 to  800 out of the  6,400 prescribers used                                                                    
the database.  He detailed that whether  a prescriber needed                                                                    
to access the system depended on their type of practice.                                                                        
5:57:23 PM                                                                                                                    
Representative  Edgmon  surmised that  the  characterization                                                                    
that  the  database was  centralized  was  not accurate.  He                                                                    
believed  the  bill sponsor  wanted  the  database to  fully                                                                    
encapsulate the providers and dispensers.                                                                                       
Co-Chair Thompson surmised that  10 percent of the providers                                                                    
were registered and utilizing the database.                                                                                     
Ms.  Hovenden answered  that currently  a low  percentage of                                                                    
the users would be correct.                                                                                                     
Ms. Chambers  clarified that the  bill would make  the shift                                                                    
from what  could arguably be  termed a pilot program  into a                                                                    
centralized  repository of  data  to  connect providers  and                                                                    
prescribers  across the  state and  to shift  into a  robust                                                                    
opioid control  program. The connection  to Medicaid  was to                                                                    
provide DHSS and Medicaid personnel  the opportunity to save                                                                    
Medicaid costs  and better manage  those elements  through a                                                                    
small sliver of  a wider Medicaid reform  bill. She believed                                                                    
the intent  was to  move from a  voluntary, not  widely used                                                                    
program, to a more official  program that would provide more                                                                    
reliable data to accomplish the variety of goals.                                                                               
6:00:00 PM                                                                                                                    
Representative Gara  remarked that  he did  not particularly                                                                    
have a concern about the  security of the database; however,                                                                    
he surmised there  was no signal to specify if  a breach did                                                                    
occur. He referred to testimony  the division would not know                                                                    
if there was a breach  unless someone knew their information                                                                    
had been  breached and they  complained to the  division. He                                                                    
believed that would not happen.  He opined that the fact the                                                                    
division  would not  know if  a breach  occurred would  have                                                                    
been  a   fairer  response  to  Co-Chair   Neuman's  earlier                                                                    
question.  He reasoned  it mattered  how  good the  system's                                                                    
security was.                                                                                                                   
Vice-Chair Saddler asked if having  a mandatory database was                                                                    
likely to be  a condition of any existing  or future federal                                                                    
benefit or funding.  He remarked there had been  a number of                                                                    
provisions  from  the  Affordable   Care  Act  with  delayed                                                                    
implementation. He could imagine  the federal government may                                                                    
want the data.                                                                                                                  
Ms.  Chambers deferred  the  question to  DHSS  and was  not                                                                    
aware of anything of that nature coming down the pike.                                                                          
6:02:20 PM                                                                                                                    
Ms.  Shadduck  spoke to  the  question  asked by  Vice-Chair                                                                    
Saddler.  She discussed  that  on March  10,  2016 the  U.S.                                                                    
Senate had  passed the comprehensive Addiction  and Recovery                                                                    
Act (SB  524). She detailed  that Alaska's two  senators had                                                                    
voted in support of the  act. She furthered that Section 601                                                                    
of  the bill  included language  requiring states  to use  a                                                                    
PDMP in  order for  states to access  the federal  grants to                                                                    
combat opioid  and other addiction  problems; it  would also                                                                    
be required for prescribers to  look up federal Schedule II,                                                                    
III, and  IV drugs  before prescribing and  dispensers would                                                                    
be  required   to  input   the  same   data.  Some   of  the                                                                    
recommendations had  been reinforced by the  passage of U.S.                                                                    
Senate Bill 524.                                                                                                                
Co-Chair Thompson asked  if the required the  state to share                                                                    
access to  the information with the  federal government. Ms.                                                                    
Shadduck did not believe so, but she would follow up.                                                                           
Ms. Shadduck relayed  that based on the  testimony, the bill                                                                    
sponsor  was very  willing  to work  with  the committee  on                                                                    
final tweaks  to the sections under  discussion. The sponsor                                                                    
realized there were concerns and was open to some of them.                                                                      
Representative  Gara  referred  to the  concept  of  sharing                                                                    
state  savings with  emergency rooms.  He spoke  to concerns                                                                    
about people going  to an emergency room for  care when they                                                                    
did not need  an emergency room. He  addressed the expensive                                                                    
nature of the  care. He continued that part of  SB 74 helped                                                                    
solve the problem, which would  result in fewer people going                                                                    
to the  emergency room for  inappropriate care.  He wondered                                                                    
why  the state  would pay  hospitals money  for the  reduced                                                                    
number of  patients, especially  when the  state had  a $4.4                                                                    
billion deficit.                                                                                                                
VALERIE  DAVIDSON, COMMISSIONER,  DEPARTMENT  OF HEALTH  AND                                                                    
SOCIAL SERVICES,  replied that  the program included  in the                                                                    
bill was  modelled after a Washington  State program. During                                                                    
the last and  current budget processes, DHSS  had heard from                                                                    
the  Ketchikan   hospital  that   it  had  applied   for  an                                                                    
innovation  grant from  CMS. She  believed the  hospital had                                                                    
spent $700,000  to decrease its  ER overutilization,  but it                                                                    
had  cost  $1.5  million  in  lost  revenue  if  those  same                                                                    
patients had come  to the ER. The  hospital had communicated                                                                    
there  was not  much  financial incentive  for providers  to                                                                    
look  at the  ER overutilization  when it  ended up  costing                                                                    
them  money. The  program  in Washington  State  had been  a                                                                    
public private  partnership between  several parties;  SB 74                                                                    
included the same concept making  sure all parties worked as                                                                    
hard  as possible  to be  able to  achieve the  savings. She                                                                    
reiterated  that  the  Ketchikan hospital  had  reported  it                                                                    
spent  $700,000 to  lose $1.5  million, which  was not  much                                                                    
incentive  for  facilities  to   change  the  way  they  did                                                                    
business. She surmised if there was  a way to change the way                                                                    
healthcare was  delivered in a  more appropriate way  and to                                                                    
have  the  opportunity to  share  the  savings, perhaps  the                                                                    
savings shared could be applied  more appropriately in other                                                                    
settings (e.g.  developing better partnerships  with primary                                                                    
care providers, utilizing support services, and other).                                                                         
6:08:58 PM                                                                                                                    
Representative  Gara  stated  that  the loss  was  based  on                                                                    
hospitals not  receiving very  large charges  in the  ER for                                                                    
non-emergency  care.  He  surmised the  hospitals  were  not                                                                    
getting the  higher amount  of money  because they  were not                                                                    
able to  charge non-ER  patients with ER  rates. He  was not                                                                    
convinced  by  the  argument. He  continued  that  hospitals                                                                    
would benefit  in the ER  setting by having  Medicaid reform                                                                    
cover  people who  they had  not  previously been  receiving                                                                    
compensation for  (people without children and  the expanded                                                                    
Medicaid   population).  He   asked  for   verification  the                                                                    
hospitals  were  receiving  much  more  money  for  ER  care                                                                    
through Medicaid expansion.                                                                                                     
Commissioner Davidson answered in  the affirmative. The goal                                                                    
was to  make sure people  were using the ER  appropriately -                                                                    
for  ER  care. The  challenge  was  that under  the  current                                                                    
federal EMTALA  [Emergency Medical Treatment and  Labor Act]                                                                    
emergency  rooms did  not  have  a choice  when  it came  to                                                                    
letting a person in the  door; emergency rooms were required                                                                    
to  provide  a  certain  level  of  care  prior  to  sending                                                                    
individuals on their way.                                                                                                       
Representative Gara  reasoned that individuals  would either                                                                    
receive  coverage  through  private  insurance  or  Medicaid                                                                    
expansion.  He spoke  to  the concept  of  no incentive  for                                                                    
hospitals to  reduce ER care.  He stated that  a significant                                                                    
part of the bill was about  creating a managed care plan and                                                                    
establishing  people with  a primary  physician in  order to                                                                    
avoid using the ER  [for inappropriate reasons]. He believed                                                                    
that even without  incentives to the hospital,  the bill was                                                                    
intended to  steer people away from  the ER. He did  not buy                                                                    
the lack  of incentive as  a justification to ask  the state                                                                    
to compensate emergency rooms for  no longer treating people                                                                    
who should not be in an ER.                                                                                                     
Vice-Chair Saddler  asked if  Commissioner Davidson  saw any                                                                    
other  situations  in  which the  federal  government  would                                                                    
require  the state  to have  mandatory PDMP  reporting as  a                                                                    
condition  of   a  federal   payment,  grant,   benefit,  or                                                                    
Commissioner  Davidson answered  that she  was not  aware of                                                                    
any additional requirements.                                                                                                    
6:12:09 PM                                                                                                                    
Representative Edgmon  asked if there was  an existing model                                                                    
that  could help  the  state reform  Medicaid  that did  not                                                                    
involve a public private sector relationship.                                                                                   
Commissioner Davidson asked if  the question was specific to                                                                    
ER overutilization or broader.                                                                                                  
Representative  Edgmon  discussed  whether  the  state  went                                                                    
through   a    managed   care   and/or    accountable   care                                                                    
organizations.  He surmised  that it  appeared necessary  to                                                                    
have the private  sector involved in terms of  being able to                                                                    
make Medicaid more  efficient and cutting down  on ER super-                                                                    
utilizers that cost  the program more. He  reasoned that the                                                                    
ER  was a  business entity;  therefore, if  they were  given                                                                    
some incentive  they would comply accordingly.  Likewise, if                                                                    
the incentive was removed, the need to comply dissipated.                                                                       
Commissioner   Davidson   answered   that   the   department                                                                    
appreciated  the bill's  broad flexibility  and the  options                                                                    
available for  DHSS to work with  providers and stakeholders                                                                    
on ways to  test certain theories. She pointed  to the broad                                                                    
demonstration  authority   described  in  the  bill   as  an                                                                    
example, such  as a  public private  partnership for  the ER                                                                    
overutilization  project. The  department  could  opt to  do                                                                    
some of  the things on its  own, but she did  not believe it                                                                    
achieved the  right result. She  wanted to  ensure providers                                                                    
giving good and appropriate  care to patients could continue                                                                    
to  do so.  She did  not have  all of  the answers,  but she                                                                    
believed the  bill provided more  tools to work  with people                                                                    
in  Alaska to  design a  healthcare system  that worked  for                                                                    
everyone. She  continued that there  were lessons  the state                                                                    
could learn from other states,  but some may not necessarily                                                                    
work in  Alaska. The state could  elect to use a  model from                                                                    
another state, but the challenge  was selecting a model that                                                                    
worked for Alaska, for as  many people as possible, and that                                                                    
met the  state's unique challenges. She  pointed issues such                                                                    
as access  to care (travel  would always be a  concern). She                                                                    
continued that during  certain times of the  year in certain                                                                    
regions, infants  and children were impacted  by respiratory                                                                    
syncytial  virus,   which  would  result  in   increased  ER                                                                    
utilization and Medivacs. She noted  her daughter had fallen                                                                    
into  the category  when she  was  an infant.  She spoke  to                                                                    
improving  the  delivery  of healthcare,  while  recognizing                                                                    
efficiencies   were  necessary   to   continue  to   provide                                                                    
healthcare   into   the   future.  She   believed   everyone                                                                    
recognized that Medicaid was not  sustainable in its current                                                                    
form. She stressed the need  to reform Medicaid and believed                                                                    
the state's  best opportunity to  implement reform  was with                                                                    
its partners.                                                                                                                   
6:16:56 PM                                                                                                                    
Representative   Guttenberg   asked  about   the   ER-shared                                                                    
reimbursement.  He understood  the issue  in the  short-term                                                                    
and that  hospitals would change  their business  models. He                                                                    
asked  if  it  would  be  appropriate  to  put  a  five-year                                                                    
timeline  on  the  shared reimbursement.  He  reasoned  that                                                                    
after  five years  the hospitals  would  have changed  their                                                                    
business  model.  He  detailed  that reform  to  the  system                                                                    
included efficiencies  the hospitals recognized  were needed                                                                    
as well. He spoke to  providing incentives for several years                                                                    
for  hospitals to  remodel,  retooling, changing  processes,                                                                    
and  other. He  wondered if  a timeline  was appropriate  to                                                                    
allow hospitals time to transition.                                                                                             
Ms. Shadduck  replied that  one of the  parts of  Section 31                                                                    
required  the   Alaska  State  Hospital  and   Nursing  Home                                                                    
Association  (ASHNHA) to  report back  on the  successes and                                                                    
challenges. She did not want to  put an arbitrary end to the                                                                    
shared savings, but  she surmised that ASHNHA  could also be                                                                    
asked  to  report  on  the  processes  and  shared  savings.                                                                    
Section  28  on  Medicaid  reform asked  the  department  to                                                                    
report on savings based on  reforms implemented by the bill.                                                                    
She  detailed there  were a  couple of  reporting mechanisms                                                                    
throughout the bill. She did not  want to speak on behalf of                                                                    
emergency rooms and  their doctors because she  did not know                                                                    
their business practices inside and out.                                                                                        
Co-Chair  Thompson  relayed  that  amendments  to  the  bill                                                                    
should be submitted  to his office by April 1,  2016 at 5:00                                                                    
CSSB 74(FIN) am was HEARD  and HELD in committee for further                                                                    
Co-Chair Thompson  discussed the schedule for  the following                                                                    

Document Name Date/Time Subjects
SB74 telehealthtelemedicine HFIN 033016 - FSMB_Telemedicine_Policy.pdf HFIN 3/30/2016 1:30:00 PM
SB 74
SB74 telehealthtelemedicine HFIN 033016- ANTHC Presentation to SFIN Feb 2016 as presented.pdf HFIN 3/30/2016 1:30:00 PM
SB 74
SB74 telehealthtelemedicine HFIN 033016- NCSL Telehealth Policy Trends.pdf HFIN 3/30/2016 1:30:00 PM
SB 74
SB74 telehealthtelemedicine HFIN 033016- Telehealth NASHP.pdf HFIN 3/30/2016 1:30:00 PM
SB 74
SB74 Rx Database HFIN 033016 - CDC Guidelines for Prescribing Opioids for Chronic Pain - 3.18.2016.pdf HFIN 3/30/2016 1:30:00 PM
SB 74
SB74 Rx Database HFIN 033016 - Controlled Substance Advisory Committee White Paper 01-29-2016.pdf HFIN 3/30/2016 1:30:00 PM
SB 74
SB74 Rx Database HFIN 033016- AKPDMP Report to 29th Legislature 02-11-2016.pdf HFIN 3/30/2016 1:30:00 PM
SB 74
SB74 Rx Database HFIN 033016- DEA Drug Schedules.pdf HFIN 3/30/2016 1:30:00 PM
SB 74
SB 74 FTC Staff Comment, Alaska Telehealth - SB 74.pdf HFIN 3/30/2016 1:30:00 PM
SB 74
SB74 Supporting Doucments -Rx Datatbase PDMP 2016 Notary Form.pdf HFIN 3/30/2016 1:30:00 PM
SB 74
SB74 Supporting Document Rx Datatbase- NEJM 2016 Pain Management and CDC Guidelines.pdf HFIN 3/30/2016 1:30:00 PM
SB 74
SB74 Briefing on PDMP EffectivenessRx Datatbase.pdf HFIN 3/30/2016 1:30:00 PM
SB 74
SB74 - Supporting Documents - PDMP_Rx Datatbase Shatterproof Recommendations for State Legislation_March 2016.pdf HFIN 3/30/2016 1:30:00 PM
SB 74
ANTHC Presentation to House Finance Committee Mar 2016 v2a (002).pdf HFIN 3/30/2016 1:30:00 PM
SB 74
SB 74 telehealth LiveHealth Online Overview Alaska 2016.pdf HFIN 3/30/2016 1:30:00 PM
SB 74
SB 74 Senior Input on Medicaid Reform, House Finance.pdf HFIN 3/30/2016 1:30:00 PM
SB 74
SB 74 Responses HFIN 3-30-16.pdf HFIN 3/30/2016 1:30:00 PM
SB 74
SB 74 Letters Public.pdf HFIN 3/30/2016 1:30:00 PM
SB 74