Legislature(2015 - 2016)CAPITOL 106

03/15/2016 03:00 PM HEALTH & SOCIAL SERVICES

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* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+= HB 344 DRUG PRESCRIPTION DATABASE TELECONFERENCED
Heard & Held
+= HB 260 DAY CARE ASSISTANCE & CHILD CARE GRANTS TELECONFERENCED
Moved CSHB 260(HSS) Out of Committee
*+ HB 234 INSURANCE COVERAGE FOR TELEMEDICINE TELECONFERENCED
Heard & Held
-- Testimony <Invitation Only> --
+= HB 237 INTERSTATE MEDICAL LICENSURE COMPACT TELECONFERENCED
Scheduled but Not Heard
-- Public Testimony --
+ Bills Previously Heard/Scheduled TELECONFERENCED
+= HB 262 SENIOR BENEFITS PROG. ELIGIBILITY TELECONFERENCED
Moved CSHB 262(HSS) Out of Committee
                    ALASKA STATE LEGISLATURE                                                                                  
      HOUSE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE                                                                     
                         March 15, 2016                                                                                         
                           3:08 p.m.                                                                                            
                                                                                                                                
MEMBERS PRESENT                                                                                                               
                                                                                                                                
Representative Paul Seaton, Chair                                                                                               
Representative Liz Vazquez, Vice Chair                                                                                          
Representative Neal Foster                                                                                                      
Representative Louise Stutes                                                                                                    
Representative David Talerico                                                                                                   
Representative Adam Wool                                                                                                        
                                                                                                                                
MEMBERS ABSENT                                                                                                                
                                                                                                                                
Representative Geran Tarr                                                                                                       
                                                                                                                                
COMMITTEE CALENDAR                                                                                                            
                                                                                                                                
HOUSE BILL NO. 260                                                                                                              
"An Act relating to the recovery of overpayments of day care                                                                    
assistance and child care grants; and providing for an effective                                                                
date."                                                                                                                          
                                                                                                                                
     - MOVED CSHB 260(HSS) OUT OF COMMITTEE                                                                                     
                                                                                                                                
HOUSE BILL NO. 262                                                                                                              
"An Act relating to eligibility requirements of the Alaska                                                                      
senior benefits payment program; and providing for an effective                                                                 
date."                                                                                                                          
                                                                                                                                
     - MOVED CSHB 262(HSS) OUT OF COMMITTEE                                                                                     
                                                                                                                                
HOUSE BILL NO. 344                                                                                                              
"An Act relating to the controlled substance prescription                                                                       
database; and providing for an effective date."                                                                                 
                                                                                                                                
     - HEARD & HELD                                                                                                             
                                                                                                                                
HOUSE BILL NO. 234                                                                                                              
"An Act relating to insurance coverage for mental health                                                                        
benefits provided through telemedicine."                                                                                        
                                                                                                                                
     - HEARD & HELD                                                                                                             
                                                                                                                                
HOUSE BILL NO. 237                                                                                                              
"An Act relating  to an interstate compact  on medical licensure;                                                               
amending the duties  of the State Medical Board;  and relating to                                                               
the Department  of Public Safety's authority  to conduct national                                                               
criminal history record checks of physicians."                                                                                  
                                                                                                                                
     - SCHEDULED BUT NOT HEARD                                                                                                  
                                                                                                                                
                                                                                                                                
PREVIOUS COMMITTEE ACTION                                                                                                     
                                                                                                                                
BILL: HB 260                                                                                                                  
SHORT TITLE: DAY CARE ASSISTANCE & CHILD CARE GRANTS                                                                            
SPONSOR(s): RULES BY REQUEST OF THE GOVERNOR                                                                                    
                                                                                                                                
01/19/16       (H)       READ THE FIRST TIME - REFERRALS                                                                        

01/19/16 (H) HSS, FIN

01/28/16 (H) HSS AT 3:00 PM CAPITOL 106

01/28/16 (H) Heard & Held

01/28/16 (H) MINUTE(HSS) 02/04/16 (H) HSS AT 3:00 PM CAPITOL 106 02/04/16 (H) Heard & Held 02/04/16 (H) MINUTE(HSS) 03/15/16 (H) HSS AT 3:00 PM CAPITOL 106 BILL: HB 262 SHORT TITLE: SENIOR BENEFITS PROG. ELIGIBILITY SPONSOR(s): RULES BY REQUEST OF THE GOVERNOR

01/19/16 (H) READ THE FIRST TIME - REFERRALS

01/19/16 (H) HSS, FIN

01/28/16 (H) HSS AT 3:00 PM CAPITOL 106

01/28/16 (H) Heard & Held

01/28/16 (H) MINUTE(HSS) 02/04/16 (H) HSS AT 3:00 PM CAPITOL 106 02/04/16 (H) Heard & Held 02/04/16 (H) MINUTE(HSS) 03/10/16 (H) HSS AT 3:00 PM CAPITOL 106 03/10/16 (H) -- Rescheduled to 3/11/16 at 8:00 a.m. -- 03/11/16 (H) HSS AT 8:00 AM CAPITOL 106 03/11/16 (H) -- MEETING CANCELED -- 03/15/16 (H) HSS AT 3:00 PM CAPITOL 106 BILL: HB 344 SHORT TITLE: DRUG PRESCRIPTION DATABASE SPONSOR(s): SEATON 02/24/16 (H) READ THE FIRST TIME - REFERRALS 02/24/16 (H) HSS 03/01/16 (H) HSS AT 3:15 PM CAPITOL 106 03/01/16 (H) Heard & Held 03/01/16 (H) MINUTE(HSS) 03/08/16 (H) HSS AT 3:00 PM CAPITOL 106 03/08/16 (H) Heard & Held 03/08/16 (H) MINUTE(HSS) 03/10/16 (H) HSS AT 3:00 PM CAPITOL 106 03/10/16 (H) -- Rescheduled to 3/11/16 at 8:00 a.m. -- 03/11/16 (H) HSS AT 8:00 AM CAPITOL 106 03/11/16 (H) -- MEETING CANCELED -- 03/15/16 (H) HSS AT 3:00 PM CAPITOL 106 BILL: HB 234 SHORT TITLE: INSURANCE COVERAGE FOR TELEMEDICINE SPONSOR(s): VAZQUEZ

01/19/16 (H) PREFILE RELEASED 1/8/16

01/19/16 (H) READ THE FIRST TIME - REFERRALS

01/19/16 (H) HSS, L&C 03/15/16 (H) HSS AT 3:00 PM CAPITOL 106 WITNESS REGISTER SEAN O'BRIEN, Director Division of Public Assistance Department of Health and Social Services (DHSS) Juneau, Alaska POSITION STATEMENT: Responded to questions during discussion of HB 260. JANICE BRADEN, Program Coordinator Child Care Program Office Division of Public Assistance Department of Health and Social Services Anchorage, Alaska POSITION STATEMENT: Answered questions during discussion of HB 260. MONICA WINDOM, Chief Policy & Program Development Division of Public Assistance Department of Health and Social Services Juneau, Alaska POSITION STATEMENT: Answered questions during discussion of HB 260. MONICA WINDOM, Chief Policy & Program Development Division of Public Assistance Department of Health and Social Services Juneau, Alaska POSITION STATEMENT: Answered questions during discussion of HB 262. TANEEKA HANSEN, Staff Representative Paul Seaton Alaska State Legislature Juneau, Alaska POSITION STATEMENT: Presented the summary of changes to the committee substitute for HB 344 for the bill sponsor, Representative Seaton. SUSIE EDWARDSON, Staff Representative Paul Seaton Alaska State Legislature Juneau, Alaska POSITION STATEMENT: Presented the summary of changes to the committee substitute for HB 344 for the bill sponsor, Representative Seaton. JAY BUTLER, MD, Chief Medical Officer/ DPH Director Central Office Division of Public Health Department of Health and Social Services Anchorage, Alaska POSITION STATEMENT: Answered questions during the discussion of HB 344. BARRY CHRISTENSEN, Pharmacist Alaska Pharmacists Association Ketchikan, Alaska POSITION STATEMENT: Testified during discussion on HB 344. JERRY BROWN, Pharmacist Fairbanks, Alaska POSITION STATEMENT: Testified during discussion of HB 344. DANIEL NELSON, President Alaska Pharmacists Association Tanana Chiefs Conference Fairbanks, Alaska POSITION STATEMENT: Testified during discussion of HB 344. ANITA HALTERMAN, Staff Representative Liz Vazquez Alaska State Legislature Juneau, Alaska POSITION STATEMENT: Presented HB 234 on behalf of the sponsor, Representative Vazquez. ACTION NARRATIVE 3:08:02 PM CHAIR PAUL SEATON called the House Health and Social Services Standing Committee meeting to order at 3:08 p.m. Representatives Seaton, Talerico, Stutes, Vazquez, and Wool were present at the call to order. Representative Foster arrived as the meeting was in progress. HB 260-DAY CARE ASSISTANCE & CHILD CARE GRANTS 3:11:12 PM CHAIR SEATON announced that the first order of business would be HOUSE BILL NO. 260, "An Act relating to the recovery of overpayments of day care assistance and child care grants; and providing for an effective date." 3:11:29 PM REPRESENTATIVE VAZQUEZ moved to adopt Amendment 1, labeled 29- GH2769\A.2, Glover, 3/10/16, which read: Page 1, lines 2 - 3: Delete "daycare assistance and child care grants" Insert "benefits for public assistance programs administered by the Department of Health and Social Services" Page 1, lines 4 - 11: Delete all material and insert: "* Section 1. AS 47.05.080(a) is repealed and reenacted to read: (a) Except for overpayments recovered under AS 47.07 that cover the value of services paid from federal sources, benefit overpayments collected by the department in administering public assistance programs under AS 47.05.010 shall be remitted to the Department of Revenue under AS 37.10.050(a)." Page 1, line 14, through page 2, line 2: Delete all material. Insert "APPLICABILITY. This Act applies to the recovery of benefit overpayments for public assistance programs administered by the Department of Health and Social Services under AS 47.05.010, regardless of whether the overpayments occurred before, on, or after July 1, 2016." CHAIR SEATON objected for discussion. REPRESENTATIVE VAZQUEZ explained that this proposed amendment would broaden the ability of the Division of Public Assistance to recoup overpayments of benefits to any of its programs. CHAIR SEATON clarified that this applied to the public assistance programs administered by Department of Health and Social Services. REPRESENTATIVE VAZQUEZ expressed her agreement, and reiterated that the amendment would encompass all the public assistance programs. 3:14:06 PM SEAN O'BRIEN, Director, Director's Office, Division of Public Assistance, Department of Health and Social Services (DHSS), expressed appreciation and offered his support for proposed Amendment 1. He clarified that the proposed bill would allow collection of funds, which was currently only voluntary, and it specifically included an option to allow for garnishment of the permanent fund dividend (PFD). He acknowledged that the proposed amendment would allow PFD garnishment across all of its programs. REPRESENTATIVE WOOL asked whether overpayment to child care grants was recovered from the recipient and not the provider. MR. O'BRIEN explained that currently collection for an overpayment was voluntary. In response to Representative Wool, he stated that repayment was the responsibility of the parents. REPRESENTATIVE WOOL asked about the most common cause of overpayment. He mused that the benefit payment was made to the parent, who in turn paid the provider. He asked if these causes of overpayment were similar to other public assistance programs. MR. O'BRIEN explained that overpayments were recovered for a variety of reasons, which included: fraudulent requests, incorrect applications, or change to income level status of the applicant or family. CHAIR SEATON asked for clarification for whether the benefit payment for child care was paid to the parent or to the provider of the care. MR. O'BRIEN replied that it was paid to the provider. CHAIR SEATON asked who would be garnished in the case of overpayment. 3:20:04 PM JANICE BRADEN, Program Coordinator, Child Care Program Office, Division of Public Assistance, Department of Health and Social Services, explained that if the day care assistance payment was made to the provider on behalf of the family, and it was determined to be an incorrect benefit payment, recoupment would be from the family, if this was a family caused error, such as failure to report changes in circumstances which made the benefit more than allowable. However, if the provider incorrectly filled out the billing form, overpayment collection would be from the child care provider. She stated that the child care grants were only paid to child care providers, so any error for overpayment would be collected from the child care provider. REPRESENTATIVE WOOL mused that, although the overpayment was made to the provider, the garnishment would be from the parent as they had already received the benefit for lower child care costs, hence the necessity to reimburse the costs. CHAIR SEATON shared that the child care grant, which was made directly to the provider, would be reimbursed by the provider. However, any mistake made by the parent was reimbursed by the parent. REPRESENTATIVE WOOL asked if this proposed amendment would include other public assistance programs. MR. O'BRIEN replied that the amendment would expand the garnishment using the PFD to the senior benefits program and the general relief program. REPRESENTATIVE VAZQUEZ recounted that any overpayment request was initiated with a letter to the individual requesting overpayment, and then the individual could ask for an administrative hearing to contest that amount. She explained that there was an administrative process that allowed a further appeal to the court. She touted the garnishment of the PFD as a "great tool in getting back overpayments." She pointed out that monthly payments were also a means of repayment. REPRESENTATIVE WOOL asked if there were any fines, penalties, or multipliers that could increase the repayment. REPRESENTATIVE VAZQUEZ said that historically the Division of Public Assistance had not charged any interest. 3:25:44 PM MONICA WINDOM, Chief, Policy & Program Development, Division of Public Assistance, Department of Health and Social Services, in response, expressed agreement that there was not any penalty added. 3:26:07 PM CHAIR SEATON removed his objection. There being no further objection, Amendment 1, labeled 29-GH2769\A.2, Glover, 3/10/16, was adopted. CHAIR SEATON pointed out that Amendment 1 was quite extensive and replaced original language of the proposed bill. 3:27:18 PM REPRESENTATIVE VAZQUEZ moved to report HB 260, Version 29- GH2769\A, as amended, out of committee with individual recommendations and the accompanying fiscal notes. There being no objection, CSHB 260(HSS) was moved from the House Health and Social Services Standing Committee. 3:27:52 PM The committee took an at-ease from 3:27 p.m. to 3:30 p.m. HB 262-SENIOR BENEFITS PROG. ELIGIBILITY 3:30:29 PM CHAIR SEATON announced that the next order of business would be HOUSE BILL NO. 262. "An Act relating to eligibility requirements of the Alaska senior benefits payment program; and providing for an effective date." He reminded the committee that, on February 4, there had been discussion regarding the lack of an asset test for this benefit program. The Division of Public Assistance had agreed to compare these senior benefits recipients with the recipients of those programs which did have an asset test. He directed attention to the response, titled "Department Response to 2-04-16 question on HB 262." [Before the committee was the committee substitute (CS) for HB 262, labeled 29-GH2770\W, Glover, 2/2/16, which had been adopted as the working draft on February 4, 2016] 3:31:59 PM MONICA WINDOM, Chief, Policy & Program Development, Division of Public Assistance, Department of Health and Social Services, stated that the committee substitute, Version W, added a citizenship requirement to the senior benefits program, which had not been in the original bill creating this program. CHAIR SEATON directed attention to the handout titled "Senior Benefits Program" [included in members' packets] which compared the programs for income limits and asset tests. MS. WINDOM, directing attention to the senior benefits cases, reported that, as 42 percent of the recipients were not receiving another benefit, there was not any asset information for those cases. She added that 27 percent of the recipients were receiving adult public assistance and that 25 percent of the recipients were receiving food stamps, both of which did have an asset limit of $2,000 for an individual and $3,000 for a couple. She noted that 610 individuals were receiving food stamps and senior benefits, although the food stamp resource limit was a bit higher for a household, $2,250; however, if one member of the household was 60 years or older, the asset limit was then $3,250. CHAIR SEATON reflected that about 5,000 people only received the senior benefits, whereas about 3,200 people received adult public assistance and senior benefits. He questioned whether there was a difference in the number of people receiving benefits from a program with an income limit versus a program with an income and an asset limit. He pointed out that 42.5 percent of those individuals receiving senior benefits did not receive any benefits from programs with an asset test. He acknowledged that it was unknown whether those 42.5 percent would not qualify to an asset test or whether there was another reason not to apply for the adult public assistance or food stamps. He pointed out that, as there was not sufficient funding for the senior benefits program, it would be necessary for the department to reduce payments to those individuals with the highest income levels, while maintaining the payments to those lower income levels. He opined that the monthly cash benefit of $125 had been reduced to $47 in the current fiscal year. He asked to ensure that those who were the most in-need were being reached, if this was the intent of the senior benefit program. He pointed out that individuals with large assets, but without much income, would qualify for this cash benefit program. He stated that the intention for asking this question was to make sure that the information surrounding the proposed bill was forwarded to the House Finance Committee, as this committee made the difficult decisions for the levels of allowable payment. CHAIR SEATON directed attention to the aforementioned Senior Benefits Program worksheet. REPRESENTATIVE VAZQUEZ pointed to the dramatic difference in the third tier resulting from the deduction effective March 1, 2016. She acknowledged that, although 42 percent of the recipients were not receiving adult public assistance or food stamps, those programs had an extremely low asset limit. She proposed that there should be a return to the prior monthly payment, noting that it was "not a very good situation to be elderly and have low income, that means they have low cash flow." She stated that the price of food, housing, and energy all went up and were higher than in other parts of the country. She reported that, as the average recipient age was 75 years, it was difficult to find a job to supplement income. She stated that this was a particularly vulnerable age, and that many individuals in this age bracket did not have the energy, stamina, and physical fitness to do many jobs, and often had some sort of illness. She pointed out that this money did not go far in Alaska. CHAIR SEATON stated that the committee was not proposing to make any changes, but was addressing the program because the Alaska State Legislature had asked the department to offer a way to reduce this highest asset group, as the program was not being fully funded. He acknowledged that, although the income level was eligible, statistics showed that the largest wealth was accumulated in the senior population. He noted that there were also a lot of not wealthy individuals, a lot of disparity in this population. He stated his desire to have the information to pass on to the House Finance Committee to make those decisions, in order to target the desired population. 3:44:22 PM REPRESENTATIVE VAZQUEZ moved to report the committee substitute (CS) for HB 262, labeled 29-GH2770\W, Glover, 2/2/16, out of committee with individual recommendations and the accompanying fiscal notes. There being no objection, CSHB 262(HSS) was moved from the House Health and Social Services Standing Committee. 3:45:11 PM The committee took an at-ease from 3:45 p.m. to 3:48 p.m. HB 344-DRUG PRESCRIPTION DATABASE 3:48:31 PM CHAIR SEATON announced that the next order of business would be HOUSE BILL NO. 344, "An Act relating to the controlled substance prescription database; and providing for an effective date." 3:48:48 PM REPRESENTATIVE VAZQUEZ moved to adopt the proposed committee substitute (CS) for HB 344, labeled 29-LS1378\N, Bruce, 3/14/16, as the working draft. CHAIR SEATON objected for discussion. 3:49:25 PM TANEEKA HANSEN, Staff, Representative Paul Seaton, Alaska State Legislature, stated that this version added a seven day limit to initial opiate prescriptions; it limited the prescription drug monitoring program to only Schedule II, III, and IV drugs; changed the reporting requirement for the database from "near real time" to "at least weekly;" changed the mandatory review of the database from only dispensers to include dispensing, prescribing, or administering of controlled substances, with some exceptions; restricted the delegation of authority or access or the ability to submit information to the database to only licensed or registered employees; directed the Department of Commerce, Community & Economic Development to establish registration fees to cover the costs of data base operation, if no federal grants are established; and changed transition language to give regulatory authority to the Department of Commerce, Community & Economic Development, with a more immediate effective date. She paraphrased from the "Summary of Changes: Version H to Version N" [included in members' packets], which read: Title On lines 2- 4 the title has been expanded to include 'relating to the prescription f opiates; relating to the practice of dentistry; relating to the practice of medicine; relating to the practice of nursing; relating to the practice of optometry; relating to the practice of veterinary medicine' to reflect the inclusion of seven day prescription restriction. Section 1-12 New sections 1-12 were added to limit opiate prescriptions under the following boards; dentistry, medicine, nursing, and optometry. Under each board, an initial opiate prescription is limited to seven days unless the practitioner documents a logistical or medical need for a longer supply, and prescriptions in excess of the dosage without documented reasons can be grounds for disciplinary action. Additional language was added to section 1 (Board of Dental Examiners), section 7 (Board of Nursing), and section 10 (Board of Optometry) allowing disciplinary action if drugs are dispensed, prescribed or sold drugs in violation of law regardless of whether there has been criminal actions. This mirrors existing language in the State Medical Board (section 4). 3:53:32 PM REPRESENTATIVE WOOL asked why the Board of Veterinary Medicine had been included. MS. HANSEN explained that the adult seven day limit had not been added to Board of Veterinary Examiners, although the disciplinary language had been added because, as all practitioners were required to submit information on controlled substances to the boards, this included the Board of Veterinary Examiners as they are able to provide opiates. She relayed an anecdote about the increase in opiates being prescribed for animals. CHAIR SEATON referenced the maximum dosage and asked whether this was for the number of pills prescribed or for a milligram limitation. MS. HANSEN replied that the limitation was for the number of pills, and not for the dosage level. CHAIR SEATON reported that, although some states had limited the milligrams per pill as recommended by the CDC, the focus of the proposed bill was a concern for opioid addiction and the duration of the prescriptions. 3:56:54 PM MS. HANSEN moved on to address Section 13 and Section 14, which read: Section 13 This new section adds language to the Board of Veterinary Examiners allowing disciplinary action if drugs are dispensed, prescribed or sold drugs in violation of law regardless of whether there has been criminal actions. This mirrors existing language in the State Medical Board (section 4). Section 14 Language referencing the state controlled substance schedules and federal schedules I and V has been removed; this will limit the database to only drugs in the federal schedules II, III, and IV. Language regarding the Department of Commerce, Community, and Economic Development assisting the board of pharmacy with implementing the database has been moved to a later section. 3:57:44 PM MS. HANSEN discussed Section 15 and Section 16, which read: Section 15 Language referencing the state controlled substance schedules and federal schedules I and V has been removed; this means the database will only be accessed for drugs in the federal schedule II, III, and IV. The reporting requirement in this section has changed, from near-real-time to at least weekly. Section 16 AS 17.30.200(d)(3) has been amended to state that a licensed or registered practitioner with prescription authority is allowed access to the database. This is intended to capture practitioners in federal facilities that are not required to be licensed with the state but that may be registered. 3:59:04 PM MS. HANSEN addressed Section 19, which read: Section 19 Language directing dispensers to access the database prior to dispensing and to report the prescription at near real time has been deleted and replaced with subsections k (3), k (4), and k (5) requiring all practitioners to check the database prior to dispensing, prescribing, or administering schedule II, III, or IV controlled substances but creating exemptions for emergent situations, surgery or medical procedures. This section also creates alternate procedures for practitioners with technological barriers, previously included in a later section. 4:00:36 PM MS. HANSEN directed attention to Section 20, which read: Section 20 The language previously in subsection (o), creating a technology exemption, has been moved to section 18. The remaining subsections have been reordered. Subsection (p) (previously subsection q) has been amended to reflect that the database has been limited to only schedule II, III, or IV controlled substances. A new subsection (q) has been added to state that a practitioner may only delegate database access or information submittal to an agent or employee who is who is licensed or registered in the state. Subsection (r) directs the Department of Commerce, Community, and Economic Development to notify each board when a practitioner registers with the database (previously required of the Board of Pharmacy). The Board of Veterinary Examiners was added to assist the Board of Pharmacy in implementing this section, language that was previously under AS 17.30.200(a). Additionally, the department shall establish regulations for registration with the database, which will cover the cost of the database minus all federal funds. 4:02:01 PM MS. HANSEN discussed Section 21, which read: Section 21 The transition regulatory authority has been expanded from just the Board of Pharmacy to now include the Department of Commerce, Community, and Economic Development and each board whose licensees will be required to register. 4:02:24 PM MS. HANSEN paraphrased Section 22, the new Subsection 23, and Section 24, which read: Section 22 The transition language has been amended to require the Board of Pharmacy to provide information and training on this act to the other boards. Subsection (b) has been deleted. New Subsection 23 New subsection 23 has been added which will enact AS 17.30.200(r) in September 1, 2016. This is the section the Department to establish registration fees. Section 24 The effective date (relating to transition language) has been amended to take effect immediately. 4:03:42 PM MS. HANSEN concluded with Section 25, which read: Section 25 The effective date of the bill has been amended to July 1, 2017. MS. HANSEN, in response to Representative Wool, said that previously all state and federally controlled substances were included, whereas now it was limited to Schedule II, III, and IV drugs of the federal schedule. She stated that all the drugs in the federal Schedule I were illegal, and Schedule V drugs included cough medicine and Tylenol with Codeine. CHAIR SEATON relayed that Schedule IV included benzodiazepine, whereas Ritalin was a Schedule II drug. REPRESENTATIVE WOOL asked for clarification that benzodiazepine was previously on the database requirement, pointing out that earlier testimony had indicated that it, in combination with opiates, "was a very bad combination." He asked if many of these drugs would fall into the category for an initial 7-day limit to the prescriptions. MS. HANSEN relayed that the 7-day limit was specific to opiates; however, reporting to the database included all controlled substance in Schedules II, III, or IV. She pointed out that the 7-day limit would not apply to any refill for a chronic illness. REPRESENTATIVE VAZQUEZ asked how the 7-day limit would work in the rural villages. MS. HANSEN directed attention to Section 2 of the proposed CS, Version N, which described the maximum dosage for opiate prescriptions. Pointing to page 3, line 27, she read: a patient who is unable to access a practitioner within the time necessary for a refill of the seven- day supply because of a logistical or travel barrier; the licensee may write a prescription for an opiate for the quantity needed to treat the patient for the time that the patient is unable to access a practitioner. MS. HANSEN relayed that, for an adult, this would just apply to the initial prescription, and if diagnosed with a chronic issue requiring a longer prescription, the refills would not have this same requirement. 4:09:01 PM SUSIE EDWARDSON, Staff, Representative Paul Seaton, Alaska State Legislature, reported on the recommendations from Centers for Disease Control and Prevention (CDC), which included that 3 days or less was sufficient for opiate prescriptions, while more than 7-days would rarely be necessary. She shared that a recent bill in Massachusetts limited initial opioid prescriptions to a 7-day supply, while also requiring practitioners to check the database for drugs which have a high potential for abuse, and that Maine was working on a similar bill which would set a 3-day limit. She stated that another CDC recommendation was for clinicians to review a patient's history for controlled substance prescriptions. She noted that a CDC recommendation not included in the proposed bill was to limit dosage to 5 morphine milligram equivalent (MME) daily, while limiting any increase of dosage to 90 MME. CHAIR SEATON pointed out that, although CDC had also recommended that any dosage over 90 MME should be noted on the prescription, the proposed bill did not include this recommendation. REPRESENTATIVE WOOL suggested that the prescription for a horse may exceed this. CHAIR SEATON added that federal practitioners were not required to be licensed in Alaska, hence the addition of "registered" to the proposed bill. 4:12:54 PM CHAIR SEATON removed his objection. There being no further objection, the proposed committee substitute Version N was adopted as the working draft. 4:13:45 PM CHAIR SEATON moved to adopt proposed Amendment 1, labeled 29- LS1378\N.1, Bruce, 3/14/16, which read: Page 13, lines 18 - 19: Delete "database at least weekly [BOARD]" Insert "board, at least weekly" Page 13, line 20: Delete "[FOR INCLUSION IN THE DATABASE]" Insert "for inclusion in the database" Page 18, following line 3: Insert a new subsection to read: "(s) The board shall, on a weekly basis, update the database with the information submitted to the board under (b) of this section." REPRESENTATIVE VAZQUEZ objected for discussion. 4:13:59 PM MS. HANSEN explained the proposed amendment, stating that it clarified that practitioners and dispensers would submit information to the board at least weekly, and that the board was required to update the database with the submitted information at least weekly. 4:15:10 PM The committee took an at-ease from 4:15 p.m. to 4:17 p.m. 4:17:11 PM REPRESENTATIVE VAZQUEZ removed her objection. There being no further objection, Amendment 1, labeled 29-LS1378\N.1, Bruce, 3/14/16, was adopted. MS. HANSEN explained that some of the written testimony had mentioned that the requirement for a mandatory review for all controlled substances could be onerous for some practitioners. There had been a suggestion to limit the review of Schedule IV to just benzodiazepine because of its aforementioned interaction with other drugs, although further review had indicated that other Schedule IV drugs had adverse interactions with opiates. CHAIR SEATON declared that he wanted to ensure that the public comments had been considered. He offered his belief that it was better, and less confusing, to include all the Schedule II, III, and IV drugs. REPRESENTATIVE WOOL asked to hear from the Alaska Pharmacists Association, noting that some of the drugs in and of themselves were not dangerous. He expressed the need for a database for opiates. CHAIR SEATON said that public testimony would be opened up again. He stated that he wanted to get the issues on the record for consideration prior to public testimony. MS. HANSEN suggested that the proposed bill state that the database must be reviewed prior to dispensing, prescribing, or administering a controlled substance. The regulation must provide that the practitioner is not required to review the information in the database before dispensing, prescribing, or administering a controlled substance for less than a 3-day supply. She stated that this would include all controlled substances, and should alleviate some of the concerns for the burden. CHAIR SEATON reflected that a 3-day supply was enough for most people, and asked whether doctors would prescribe the lesser amount. He offered his belief that the issue was a result of too long a course for opioid prescriptions. He asked for input from the committee. REPRESENTATIVE WOOL mused that some drugs were stronger than others, and, as not all drugs were measured in MME, it was difficult to micromanage the prescriptions. CHAIR SEATON pointed out that this was an exception and, by controlling the initial prescription, was an attempt to limit opioid addiction in the state. REPRESENTATIVE VAZQUEZ asked for testimony from Dr. Butler. 4:28:16 PM JAY BUTLER, MD, Chief Medical Officer/DPH Director, Central Office, Division of Public Health, Department of Health and Social Services, opined that it was a difficult issue to maintain access to appropriate care for pain yet prevent misuse of the drugs, with the unintentional risk for overdose. He suggested an additional exemption for a supply of less than x number of days, pointing out that the CDC guidelines for 3-days or less were often sufficient, whereas more than 7-days was rarely needed. This exemption for less than 7-days could be more acceptable to many providers, while not creating any unintentional barriers to the treatment of pain. CHAIR SEATON mused that the proposed bill stated that the initial prescription could not be longer than 7-days, and asked if anything under 7-days should be exempt. DR. BUTLER relayed that he was speaking specifically to the requirement for the review of the database. He acknowledged that this could be for a shorter time frame, although he was trying to strike a balance for not being overly burdensome or creating barriers to treatment for acute pain. He said that it was not entirely clear for prescriptions to outpatient procedures in advance of the procedure. CHAIR SEATON suggested that this would be covered under a less than 3-day exemption. REPRESENTATIVE VAZQUEZ asked for clarification, was this less than 3 days, or 3 days or less. DR. BUTLER replied that there was nothing really magic in either, that the reference had been to the CDC guidelines, which read, 3 days or less will often be sufficient in treatment of acute pain. CHAIR SEATON pointed out that this only applied to the initial prescription for 7-days, not to renewals. He reported that the prescriptions for 3-days or less without refills could also be an issue. He stated that the exemption was not intended to allow for open ended prescription refills of 3-days or less. REPRESENTATIVE WOOL asked whether to include Schedule IV drugs for the mandatory database review. DR. BUTLER reminded the committee that there was an increased risk of fatal overdose when opioids and benzodiazepine were co- administered. He shared that many prescribers had stated they prescribed Schedule IV drugs more frequently than Schedule II drugs. He reported that the 2015 annual report had listed 238,000 prescriptions for Schedule II and III drugs, with 429,000 for Schedules II, III, and IV in the Prescription Drug Monitoring Program (PDMP), even as the PDMP was fairly incomplete. CHAIR SEATON asked for clarification that the medical recommendations was for Schedules II, III, and IV. DR. BUTLER stated that this was a difficult question. If the outcome were solely to reduce the risk of overdose, including the Schedule IV drugs made a lot of sense; however, in looking at the practicality of what could actually be done and what providers would adopt and do, there were some reservations for this. REPRESENTATIVE WOOL asked if all the Schedule IV drugs, such as Robitussin for a cough or Tylenol with codeine, would have to be entered into the database. He asked whether it would be best to include all of them, or limit it to select drugs, in order to decrease the possible burden. DR. BUTLER clarified that Robitussin was a Schedule V drug, as was gabapentin which was used for chronic pain syndrome as it had a very low abuse potential, and both of these were excluded. CHAIR SEATON questioned whether 3-days or less, without refills and exempt from the requirements, would be beneficial to the practice of medicine. He asked about the risk for overdoses. DR. BUTLER replied that this would be less burdensome on providers. He stated that a situation where a very small quantity was prescribed had a lower risk for overdose or addiction. 4:42:00 PM CHAIR SEATON opened public testimony. 4:42:17 PM BARRY CHRISTENSEN, Pharmacist, Alaska Pharmacists Association, reported that he was also the co-chair of the Legislative committee for the Alaska Pharmacists Association. He said the association represented over 200 pharmacists and pharmacy technicians in the state. He declared that proposed HB 344 was a "step in the right direction for helping opiate abuse and prescription drug abuse in the State of Alaska." He applauded the change from real time to weekly down loads as being more cost effective and technologically available. He expressed agreement that all users of the database should be licensed, pointing out that all the pharmacy technicians working around medications were licensed. He expressed concern that the requirement for both prescribers and pharmacists to check the database prior to every controlled substance prescription was duplicative and time consuming. He pointed out that the PDMP was only one tool used by pharmacists when trying to rule out possible narcotic abuse. He pointed out that this would have a big impact. He reported that real time prescription insurance data checks were performed when processing prescriptions, as almost 90 percent of prescriptions were done through insurance. He stated that the 3-day prescription may have some merit. REPRESENTATIVE WOOL asked for clarification for the statement that it was duplicative for both the prescriber and the dispenser to check the PDMP database. He offered his belief that this was a good safe guard. MR. CHRISTENSEN replied that the pharmacists have been using the database since its onset, but that the best time to utilize the database was before a prescription was written. He acknowledged that there were instances when both should be checking the database, but that professional judgement should dictate when. REPRESENTATIVE WOOL asked which end of the database check to make optional. MR. CHRISTENSEN offered his belief that the pharmacist end should be optional, as "it makes sense that it be dealt with before the prescription is written rather than after in terms of checking for potential abuse by the patient." He allowed that it should be possible for pharmacists to double check when "we do have warning flags come up." CHAIR SEATON asked if the option for the pharmacist to delegate the database check would alleviate the situation. MR. CHRISTENSEN expressed appreciation for the option, and although it did help the situation, it still affected work flow. REPRESENTATIVE VAZQUEZ asked when it made sense for the pharmacist to review the database. MR. CHRISTENSEN replied that there were several times, including when there was a new patient, multiple prescriptions for narcotics, or a large quantity of narcotics. He added that patient refusal to use insurance also raised concerns. CHAIR SEATON shared the concern that availability of the database, without any requirement to check it, had not been sufficient to stop the availability of many prescription medications. He reported that the proposed bill was also an attempt to include the prescribers. REPRESENTATIVE VAZQUEZ asked for his opinion about the 3-day or less exemption. MR. CHRISTENSEN relayed that, although this would ease the burden "on a certain number of prescriptions," he was unsure for how much it would decrease the work load. He pointed out that they would most likely have not looked at the database for those prescriptions anyway. REPRESENTATIVE WOOL asked if the aforementioned "flags" were in the database. MR. CHRISTENSEN replied that most flags were through the insurance system, reiterating that almost 90 percent of the prescriptions were processed on-line at the time of dispensing. He agreed that those flags would also show up on the PDMP database. 4:54:59 PM JERRY BROWN, Pharmacist, echoed some of the earlier comments, including the removal of pharmacists for the mandatory requirement to check the database for every narcotic prescription. He offered his belief that it was not necessary to be checked every time. He stated that he had problems with the 7-day and the 3-day quantity, as prescribers would not check the database. He suggested to use a 5-day supply instead. He declared that there would always be a flag when checking the data base because of the limited initial prescription amount, and that additional time would be spent making a determination for whether this was overprescribing or a restriction on the prescription. He reported that, under Medicaid, the first pharmacist was paid a dispensing fee for the first prescription, but a second pharmacy did not receive any dispensing fee, thereby being placed at a greater financial disadvantage. He pointed to the difficulties presented by shorter initial prescriptions when living in a remote area. He suggested that 5-day prescriptions were not so onerous for the patient. MR. BROWN said that exempting emergency rooms and the prescribers for a 3-day or 5-day supply would remove the database checks. He stated that the proposed bill was micro managing the professions of medicine and pharmacy, but it did not help for the actual problem, the writing of the prescription. He stated that the proposed bill actually exempted that group from compliance for checking the database, which was its purpose. 5:02:31 PM DANIEL NELSON, President, Alaska Pharmacists Association, Tanana Chiefs Conference, echoed the earlier comments, stating that the requirement for mandatory PDMP queries by pharmacists and prescribers was overly onerous and micro managing the practice of medicine and pharmacy. He recommended that the language be removed from the proposed bill. He stated that this was a duplicative process, and there was not any rationale for the pharmacist to check after the prescriber had done so. He stated that 10 - 12 percent of prescriptions written were for controlled substances. He estimated that it would take two to three minutes per query, which was 3 - 4.5 hours daily in his pharmacy. He reported that Alaska had one of the lowest per capita prescriptions of opioids in the United States. 5:05:49 PM CHAIR SEATON closed public testimony on HB 344 after ascertaining no one further wished to testify. [HB 344 was held over.] HB 234-INSURANCE COVERAGE FOR TELEMEDICINE 5:06:18 PM CHAIR SEATON announced that the final order of business would be HOUSE BILL NO. 234, "An Act relating to insurance coverage for mental health benefits provided through telemedicine." REPRESENTATIVE VAZQUEZ stated that the proposed bill was a very short, focused bill which did not expand mandates. ANITA HALTERMAN, Staff, Representative Liz Vazquez, Alaska State Legislature, stated that the proposed bill was a parity bill to level the playing field, and required the insurance industry to reimburse for the coverage of mental health services provided via telemedicine. She explained that there was only one insurer in the state reimbursing for mental health through telemedicine. She reported that Medicaid had reimbursed for mental health services and substance abuse coverage for those Medicaid covered individuals. She stated that the proposed bill could impact up to 15 percent of people in Alaska, by providing the option for them to access telemedicine and mental health services via this means. She emphasized that it did not provide new services, as mental health was already a coverage component of insurance. It just required that the insurance industry allow for the reimbursement without requiring a face to face encounter. [HB 234 was held over.] 5:09:46 PM ADJOURNMENT There being no further business before the committee, the House Health and Social Services Standing Committee meeting was adjourned at 5:09 p.m.

Document Name Date/Time Subjects
HB234 ver A.PDF HHSS 3/15/2016 3:00:00 PM
HB 234
HB234 Sponsors statement telemedine.pdf HHSS 3/15/2016 3:00:00 PM
HB 234
HB234 Fiscal Note_DCCED-DOI_03.11.16.pdf HHSS 3/15/2016 3:00:00 PM
HB 234
HB234 Background_ Article- My Statesman from Austin American.pdf HHSS 3/15/2016 3:00:00 PM
HB 234
HB234 Background_FSMB_Telemedicine_Policy.pdf HHSS 3/15/2016 3:00:00 PM
HB 234
HB234 Background_Hudson-Presentation _ISER-UAA _Rural Telemedicine.pdf HHSS 3/15/2016 3:00:00 PM
HB 234
HB234 Background_telehealth & teleconsult_ NASHP_2015.pdf HHSS 3/15/2016 3:00:00 PM
HB 234
HB234 Background_telehealth factsheet_CMS.pdf HHSS 3/15/2016 3:00:00 PM
HB 234
HB234 Background_telehealth2015 NCSL.pdf HHSS 3/15/2016 3:00:00 PM
HB 234
HB234 Background_ANTHC-AFHCAN_Trail by Tundra-July-25-2014.pdf HHSS 3/15/2016 3:00:00 PM
HB 234
HB234 Background_ATA_50-state-telemedicine-gaps-analysis--physician-practice-standards-licensure American Telemedicine Association.pdf HHSS 3/15/2016 3:00:00 PM
HB 234
HB234 Background_AFHCAN - telemedicine project evaluation.pdf HHSS 3/15/2016 3:00:00 PM
HB 234
HB234 Support_AK-PA Letter_ 03-06-2016.pdf HHSS 3/15/2016 3:00:00 PM
HB 234
HB234 Support_Anne Norton_01.18.2016.pdf HHSS 3/15/2016 3:00:00 PM
HB 234
HB234 Support _ Anne Henry Letter_01.19.2016.pdf HHSS 3/15/2016 3:00:00 PM
HB 234
HB234 Support_ JAMHI letter_01.18.2016.pdf HHSS 3/15/2016 3:00:00 PM
HB 234
HB 234 Support_various emails.pdf HHSS 3/15/2016 3:00:00 PM
HB 234
HB234 Testimony _John DeRuyter - face to face concerns.pdf HHSS 3/15/2016 3:00:00 PM
HB 234
HB260 Proposed Amendment A.2_Vazquez.pdf HHSS 3/15/2016 3:00:00 PM
HB 260
HB 344 Sponsor Statement 3.11.16 ver N.pdf HHSS 3/15/2016 3:00:00 PM
HB 344
HB 344 preoposed cs ver N.pdf HHSS 3/15/2016 3:00:00 PM
HB 344
HB 344 Summary of Changes_Ver H to Ver N_3.14.2016.pdf HHSS 3/15/2016 3:00:00 PM
HB 344
HB 344 Sectional_version N_3.14.2016.pdf HHSS 3/15/2016 3:00:00 PM
HB 344
HB 344 Proposed amendment N.1_Seaton.pdf HHSS 3/15/2016 3:00:00 PM
HB 344
HB260 Sectional Analysis.pdf HHSS 1/28/2016 3:00:00 PM
HHSS 3/15/2016 3:00:00 PM
HB 260
HB260 Hearing Request H-HSS 012016.pdf HHSS 3/15/2016 3:00:00 PM
HB 260
HB260 Fiscal Note_DHSS-CCB-1-16-16.pdf HHSS 1/28/2016 3:00:00 PM
HHSS 3/15/2016 3:00:00 PM
HB 260
HB260 ver A.pdf HHSS 1/28/2016 3:00:00 PM
HHSS 3/15/2016 3:00:00 PM
HB 260
HB260 Sectional Analysis.pdf HHSS 3/15/2016 3:00:00 PM
HB 260
HB260 Sponsor statement_Governor Transmittal Letter.pdf HHSS 1/28/2016 3:00:00 PM
HHSS 3/15/2016 3:00:00 PM
HB 260
HB260 Fiscal Note_DHSS-CCB-1-16-16.pdf HHSS 3/15/2016 3:00:00 PM
HB 260
HB260 Hearing Request H-HSS 012016.pdf HHSS 3/15/2016 3:00:00 PM
HB 260
HB260 Fiscal Note_DOR-PFD-01-19-2016.pdf HHSS 1/28/2016 3:00:00 PM
HHSS 3/15/2016 3:00:00 PM
HB 260
HB262 ver A.pdf HHSS 1/28/2016 3:00:00 PM
HHSS 3/15/2016 3:00:00 PM
HB 262
HB262 Sponsor Statement_Governor Transmittal Letter.pdf HHSS 1/28/2016 3:00:00 PM
HHSS 3/15/2016 3:00:00 PM
HB 262
HB262 Fiscal Note_DHSS-SBPP-1-16-16.pdf HHSS 3/15/2016 3:00:00 PM
HB 262
HB262 Fiscal Note_DHSS-SBPP 1-23-16.pdf HHSS 1/28/2016 3:00:00 PM
HHSS 3/15/2016 3:00:00 PM
HB 262
HB262 Sectional Analysis.pdf HHSS 1/28/2016 3:00:00 PM
HHSS 3/15/2016 3:00:00 PM
HB 262
HB 262 Response to HB 262 Questions in 012816 H-HSS.pdf HHSS 2/4/2016 3:00:00 PM
HHSS 3/15/2016 3:00:00 PM
HB 262
HB 262 proposed cs_ver w.pdf HHSS 2/4/2016 3:00:00 PM
HHSS 3/15/2016 3:00:00 PM
HB 262
HB 262 Background Senior Benefits Fact Sheet.pdf HHSS 3/10/2016 3:00:00 PM
HHSS 3/15/2016 3:00:00 PM
HB 262
HB 262 DHSS to assest test question on 2.04.2016.pdf HHSS 3/10/2016 3:00:00 PM
HHSS 3/15/2016 3:00:00 PM
HB 262
HB 262 Background 2016 federal poverty level_Alaska.pdf HHSS 3/10/2016 3:00:00 PM
HHSS 3/15/2016 3:00:00 PM
HB 262
HB 237 Background_Compact FAQ_FSMB.pdf HHSS 1/26/2016 3:00:00 PM
HHSS 3/15/2016 3:00:00 PM
HB 237
HB 237 Fiscal Note_DCCED-CBPL_01-22-16.pdf HHSS 1/26/2016 3:00:00 PM
HHSS 3/15/2016 3:00:00 PM
HB 237
HB 237 Version A.pdf HHSS 1/26/2016 3:00:00 PM
HHSS 3/15/2016 3:00:00 PM
HB 237
HB 237 Background_Compact - state map and home page_FSMB.pdf HHSS 1/26/2016 3:00:00 PM
HHSS 3/15/2016 3:00:00 PM
HB 237
HB 237 Fiscal Note_DPS_DSS_01-13-16.pdf HHSS 1/26/2016 3:00:00 PM
HHSS 3/15/2016 3:00:00 PM
HB 237
HB 237 Sponsor Statement_01.25.2016.pdf HHSS 1/26/2016 3:00:00 PM
HHSS 3/15/2016 3:00:00 PM
HB 237
HB 237 Sectional Analysis.pdf HHSS 1/26/2016 3:00:00 PM
HHSS 3/15/2016 3:00:00 PM
HB 237
HB 237 Background_Medical Licensing timeframes_Research report_10.16.2015.pdf HHSS 1/26/2016 3:00:00 PM
HHSS 3/15/2016 3:00:00 PM
HB 237
HB 237 Background_Letter Dr Kusano_Licensing issues.pdf HHSS 1/28/2016 3:00:00 PM
HHSS 3/15/2016 3:00:00 PM
HB 237
HB 237 DCCED response to Rep Vazquez questions_3.13.2016.pdf HHSS 3/15/2016 3:00:00 PM
HB 237
HB 344 Testimony_AKPhA Letter of Concern.pdf HHSS 3/15/2016 3:00:00 PM
HB 344
Hb 344 Testimony Ryan Ruggles_3.15.2016.pdf HHSS 3/15/2016 3:00:00 PM
HB 344
HB 344 Letter_Express Scripts_2.29.2106.pdf HHSS 3/15/2016 3:00:00 PM
HB 344
HB 344 Proposed amendment N.2_seaton.pdf HHSS 3/15/2016 3:00:00 PM
HB 344
HB344 Testimony_ AK dental_3.15.2016.pdf HHSS 3/15/2016 3:00:00 PM
HB 344