Legislature(2015 - 2016)BELTZ 105 (TSBldg)

03/01/2016 01:30 PM Senate LABOR & COMMERCE

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Audio Topic
01:31:02 PM Start
01:32:51 PM SB98
02:57:31 PM Adjourn
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
Heard & Held
+ Bills Previously Heard/Scheduled TELECONFERENCED
-- Public Testimony --
             SB 98-PRESCRIPTION WITHOUT PHYS. EXAM.                                                                         
1:32:51 PM                                                                                                                    
CHAIR COSTELLO  announced the  consideration of  SB 98.  She noted                                                              
that this is the  second hearing, public testimony  is open, and a                                                              
committee substitute (CS) is anticipated.                                                                                       
1:33:48 PM                                                                                                                    
At ease from 1:33 p.m. to 1:38 p.m.                                                                                             
1:39:00 PM                                                                                                                    
DR.  MELINDA   RATHKOMPF  MD,  President,  Alaska   State  Medical                                                              
Association  (ASMA),  thanked  the   sponsor  and  her  staff  for                                                              
working  with  ASMA  to  address  its concerns  with  SB  98.  She                                                              
assured  the committee  that the  primary concern  is the  care of                                                              
patients and  that is  driving her comments  today. She  said ASMA                                                              
supports the  use of  telemedicine, but wants  to ensure  there is                                                              
appropriate  oversight and  regulation  as it  expands in  Alaska.                                                              
ASMA supports the  model where a provider gives care  over a video                                                              
feed while  another health  care provider is  with the  patient to                                                              
help  facilitate  the visit.  Typically,  there is  a  preexisting                                                              
doctor-patient  relationship  or  there's a  relationship  between                                                              
the doctor giving  care and the health care provider  on the other                                                              
end.  There is  also the  ability for  follow up  care either  in-                                                              
person  or a  future telemedicine  visit with  the same  provider.                                                              
She said this model  has great potential to expand  access to care                                                              
and reduce  costs. The Alaska  State Medical Association  supports                                                              
this model.                                                                                                                     
However, ASMA  is concerned  with telehealth  models of  care when                                                              
there  is no  prior established  doctor-patient relationship,  the                                                              
patient doesn't  get to select the  provider, and they  don't have                                                              
easy follow-up  with the  same provider.  ASMA is concerned  about                                                              
providers outside  Alaska that may  not understand  the challenges                                                              
some patients  in Alaska  face. She  described a personal  example                                                              
early  in  her  career  in  Alaska.   A  physician  from  Stanford                                                              
contacted her about  transferring care of an  Alaska Native infant                                                              
who had a  rare immune deficiency and required  ventilator support                                                              
to  breath.  Her family  lived  in  a remote  village  outside  of                                                              
Barrow and  the Stanford  physician hadn't checked  to see  if the                                                              
family  had electricity  or running  water in  the home. She  also                                                              
didn't understand  why the  family wouldn't  have mentioned  these                                                              
impediments to care.                                                                                                            
She questioned  how it would be  possible to ensure the  best care                                                              
for patients if  this new model is adopted, and  stressed the need                                                              
for the  State Medical  Board to  have the  authority to  regulate                                                              
this  new model.  She said  ASMA  appreciates the  new draft  that                                                              
gives  the medical  board oversight  at  the individual  physician                                                              
level, but what's  needed is more oversight at  the company level.                                                              
If a telemedicine  company as a  whole doesn't meet  the standards                                                              
of care that others  deliver, the state needs the  ability to stop                                                              
that  delivery  of  care.  She concluded  that  this  isn't  about                                                              
stopping the  use of  telemedicine, but  about ensuring  it's done                                                              
well and protects the health of Alaskans.                                                                                       
1:44:29 PM                                                                                                                    
DR.  HENRY DEPHILLIPS  M.D., Chief  Medical  Officer for  Teladoc,                                                              
said he wanted  to start his  testimony by responding to  the last                                                              
question  about guaranteeing  to protect  the health of  Alaskans.                                                              
He explained  that clinicians always  look at evidence-based  data                                                              
to  make  treatment  decisions.   For  example,  decades  ago  the                                                              
standard of  care for a heart attack  was bed rest for  two weeks.                                                              
Today  the standard  of care  for  a heart  attack is  to get  the                                                              
patient  up and  out of  bed within  the first  24 hours.  Outcome                                                              
studies comparing  the two  treatment modalities demonstrate  that                                                              
the latter results in much better patient outcomes.                                                                             
DR.  DEPHILLIPS recommended  the committee  look at  the data.  He                                                              
first  pointed out  that for  every  1 million  visits to  private                                                              
practice  physicians,  approximately  17  liability claims  go  to                                                              
completion.  The average  payout for  each claim  is $248,000.  By                                                              
comparison, telemedicine  nationwide has  done 2 million  e-visits                                                              
and not one medical liability claim has been filed.                                                                             
DR.  DEPHILLIPS  talked about  the  cost savings  associated  with                                                              
telemedicine.  A Harvard Medical  School researcher  independently                                                              
did a  pre and  post look  at the telemedicine  benefit  a Fortune                                                              
500 employer decided  to implement among its employee  base. After                                                              
18 months  the analysis  of 150,000  employees and their  families                                                              
showed that  every consult done  through the telemedicine  program                                                              
resulted   in  an   average   medical   cost  savings   of   $673.                                                              
Extrapolating  that to  the  575,000 visits  that  Teladoc did  in                                                              
calendar year 2015,  indicates that Teladoc has been  able to save                                                              
all  clients combined,  $387 million  in medical  cost savings.  A                                                              
majority  of those  are  savings  in the  emergency  room for  the                                                              
treatment on non-emergency conditions.                                                                                          
He shared  the data  point that Teladoc  currently operates  in 49                                                              
states,  including Alaska,  and  covers approximately  15  million                                                              
Americans. Clients  in Alaska include  GCI, Alaska  Airlines, Home                                                              
Depot, Lowes, Premera,  Aetna, and Costco. He noted  that Aetna is                                                              
contemplating  extending  the telemedicine  benefit  to all  state                                                              
employees.  These companies buy  the benefit  so Teladoc  has been                                                              
well vetted.                                                                                                                    
DR.  DEPHILLIPS   explained  that   Teladoc's  quality   oversight                                                              
program  looks  at  prescribing  patterns  across  its  prescriber                                                              
network.  An interesting  outlier  popped up  this  month in  that                                                              
program  and  he  wonders  how long  it  would  take  the  private                                                              
practice world to pick up a similar outlier.                                                                                    
DR. DEPHILLIPS  concluded his remarks  saying SB 98 is  focused on                                                              
allowing physicians  that are licensed by the  State Medical Board                                                              
to  practice  the  medicine  they were  trained  to  practice  and                                                              
decide for themselves  what modality to use to  diagnose and treat                                                              
patients.  With all  the safeguards  currently  in place,  patient                                                              
safety  appears  to be  doing  extremely  well under  the  current                                                              
1:51:54 PM                                                                                                                    
SENATOR GIESSEL asked  if there is a limit to the  number of times                                                              
that  a  person  can  call  a  Teladoc   provider  before  they're                                                              
referred to a primary care doctor.                                                                                              
DR. DEPHILLIPS said  any person who uses Teladoc  services 3 times                                                              
in  90 days  or  8  times in  a  12  month period  is  immediately                                                              
flagged and  Teladoc reaches out  and tells the patient  they need                                                              
to get  a primary  care physician.  The patient  is excluded  from                                                              
the  program until  they demonstrate  they  have established  that                                                              
SENATOR GIESSEL  asked what  instructions are  given to  a patient                                                              
in the event they don't get better.                                                                                             
DR.  DEPHILLIPS explained  that there  are discharge  instructions                                                              
after every e-visit,  including what to do if  the patient doesn't                                                              
improve. For  72 hours after the  e-visit there is a  secure email                                                              
communication  between   the  patient  and  the   clinical  staff,                                                              
including  the   physician.  Second,  Teladoc  can   identify  the                                                              
patients that  don't have a primary  care physician and  reach out                                                              
to the health plan  partner to help the patient  find a physician.                                                              
Third,  their   physicians  tell  patients  if   the  telemedicine                                                              
platform is not  appropriate for the illness or  problem. They are                                                              
directed  them to their  primary  care physician  or to call  911.                                                              
This happens 4 percent of the time.                                                                                             
1:57:14 PM                                                                                                                    
DR.  DAVID   POWERS  M.D.,   family  physician   in  practice   in                                                              
Dillingham, mentioned  his previous testimony and  emphasized that                                                              
the  current  telemedicine  model   is  open  to  all  comers.  He                                                              
highlighted the  potential misperception  about what it's  like in                                                              
rural  Alaska and  opined that  SB 98  won't help  a lot of  these                                                              
people get  medicines if  they're prescribed.  The medicine  would                                                              
have  to be  mailed from  a pharmacy  in Anchorage  or the  person                                                              
could go  to the village health  aide. The latter is  how medicine                                                              
is dispensed  in the existing  telemedicine model. He  opined that                                                              
SB  98 will  mostly impact  Alaskans  that live  in larger  cities                                                              
where pharmacies are available.                                                                                                 
DR.  POWERS gave  the bill  high  marks for  convenience and  cost                                                              
savings,  but said  it  will never  meet the  standard  of an  in-                                                              
person  visit. He  assured the  committee that  the State  Medical                                                              
Board  has no  financial  irons  in this  fire.  The board  simply                                                              
wants the best health care for Alaskans.                                                                                        
CHAIR  COSTELLO   noted  the   individuals  available   to  answer                                                              
2:00:35 PM                                                                                                                    
BILL ALTLAND,  member, Board of  Pharmacy, said he's  a registered                                                              
pharmacist  who has  worked in rural  Alaska.  He mentioned  a new                                                              
regulation  and attorney  general  opinion  related to  non-public                                                              
health  service  providers  in  rural Alaska  not  needing  to  be                                                              
licensed if  they work for the  Native health system.  He believes                                                              
this will  become the  rule for pharmacy,  dental and  nursing and                                                              
wonders how professional boards in the state will address that.                                                                 
CHAIR  COSTELLO asked  Ms. Hovenden  to respond  to Mr.  Altland's                                                              
2:04:36 PM                                                                                                                    
JANEY HOVENDEN,  Director, Division of Corporations,  Business and                                                              
Professional  Licensing,  Department  of Commerce,  Community  and                                                              
Economic  Development (DCCED),  said Mr.  Altland is referring  to                                                              
the federal  law that  exempts medical  professionals working  for                                                              
tribal   corporations  or   the   federal   government  from   the                                                              
requirement to be licensed in Alaska.                                                                                           
SENATOR GIESSEL  advised that Indian Health Service  employees are                                                              
federal  and   they  must  be  licensed   in  a  state,   but  not                                                              
necessarily  the  state  where they're  practicing.  She  recalled                                                              
that  has been the  case for  about 20  years, but  it's new  that                                                              
employees of Native  corporations would be exempt.  She emphasized                                                              
the importance of clarifying the issue.                                                                                         
MS. HOVENDEN agreed to provide follow-up information.                                                                           
2:06:31 PM                                                                                                                    
CHAIR  COSTELLO closed  public  testimony on  SB  98. She  advised                                                              
that  the committee  received  a  draft committee  substitute  and                                                              
would recess until 2:30 to give staff time to review it.                                                                        
2:35:59 PM                                                                                                                    
CHAIR COSTELLO  reconvened the meeting  and asked for a  motion to                                                              
adopt the committee substitute (CS).                                                                                            
2:36:16 PM                                                                                                                    
SENATOR  GIESSEL moved  to  adopt the  work  draft CS  for SB  98,                                                              
labeled 29-LS0838\E, as the working document.                                                                                   
CHAIR COSTELLO  objected for discussion  purposes and  invited Mr.                                                              
Eiler to explain the changes.                                                                                                   
2:36:40 PM                                                                                                                    
WESTON  EILER, Staff,  Senate  Labor  and Commerce  Committee  and                                                              
Senator  Mia  Costello,  explained  the  changes  that  appear  in                                                              
version E of SB 98.                                                                                                             
Page  2, lines  16-19,  primarily  adds  the words  "standards  of                                                              
care"  and  other  drafting  conventions.  Section  3  amends  the                                                              
duties  of the  board  to include  text provided  by  some of  the                                                              
stakeholders.  He read  the  language on  page  3, paragraph  (6),                                                              
about adopting  regulations establishing  standards of  care under                                                              
AS  08.64.364. Page  3,  line 9,  starts  the  renumbering of  the                                                              
sections. Page  4, lines  5-10, subsection  (d), clarifies  that a                                                              
physician  may   not  prescribe   an  abortion-inducing   drug  or                                                              
prescribe  a  controlled  substance  without  a  prior  physician-                                                              
patient relationship.                                                                                                           
MR. EILER  advised that  these changes  were made in  consultation                                                              
with   stakeholders   to   provide   additional   safeguards   for                                                              
telemedicine.  He noted  that  Legislative  Legal Services  opined                                                              
that  changing the  preambulatory  language in  each section  from                                                              
prohibitions to  the positive could  be inferred by the  courts as                                                              
the legislature  specifically limiting  authorizations to  what is                                                              
He noted a  memorandum from the Department of  Commerce, Community                                                              
and  Economic  Development  (DCCED)   that  responds  to  previous                                                              
questions about  the financial  impact of  the boards  affected by                                                              
SB 98.  The packets also  contain an April  17, 2012  opinion from                                                              
the Department  of Law that gives  context to the  question raised                                                              
about licensing  requirements for  pharmacists working  for Alaska                                                              
Native tribal health programs.                                                                                                  
2:40:37 PM                                                                                                                    
CHAIR COSTELLO removed her objection.                                                                                           
2:40:46 PM                                                                                                                    
SENATOR  GIESSEL  moved  a conceptual  amendment  to  rewrite  the                                                              
language on  page 4, lines 7-10,  paragraph (2). It would  read as                                                              
                     CONCEPTUAL AMENDMENT 1                                                                                     
          (2)   prescribe,   dispense,    or   administer   a                                                                   
     prescription   drug   in   response   to   an   Internet                                                                   
     questionnaire or  electronic mail message with  whom the                                                                   
     physician  does  not  have   a  prior  physician-patient                                                                   
CHAIR COSTELLO found  no objection and Conceptual  Amendment 1 was                                                              
adopted. She asked  if there was further objection  to the amended                                                              
committee substitute.                                                                                                           
2:42:26 PM                                                                                                                    
SENATOR  ELLIS asked  Mr.  Eiler to  reference  the five  concerns                                                              
expressed  by  the  Alaska  State  Medical  Association,  and  the                                                              
extent  to which  the  CS addresses  those  concerns. "That  would                                                              
determine if I  maintain further objection to the  adoption of the                                                              
committee substitute," he said.                                                                                                 
2:43:03 PM                                                                                                                    
MR. EILER  said the  committee worked  closely  with ASMA  and the                                                              
sponsor to  implement provisions  of the  letter dated  2/25/2016,                                                              
most of  which relate to providing  safeguards and  sideboards. He                                                              
listed  the concerns  on  page 1:  1) the  prescription  not be  a                                                              
controlled substance,  2) the physician  be located in  Alaska, 3)                                                              
the  physician   or  another  physician   in  group   practice  is                                                              
available to  provide follow-up  care, 4)  the patient  consent to                                                              
sending  a copy  of  the records  to  the patient's  primary  care                                                              
provider.  He  offered his  belief  that  the CS  addresses  those                                                              
SENATOR ELLIS again  asked if all the concerns  articulated by the                                                              
Alaska  State  Medical  Association  are fully  addressed  in  the                                                              
committee substitute.                                                                                                           
MR. EILER  replied: "I think we  have achieved the  provision they                                                              
would  like to  see amended  in  advancing or  moving forward  the                                                              
2:45:08 PM                                                                                                                    
SENATOR GIESSEL  directed  attention to Section  3 that  addresses                                                              
the  duties of  the  board. She  said  she suspects  the  language                                                              
regarding standards  of care  comes from the  model policy  of the                                                              
Federation of State  Medical Boards organization.  She opined that                                                              
it  would provide  the board  the  latitude to  be specific  about                                                              
telehealth services.                                                                                                            
CHAIR  COSTELLO said  she'd  like someone  from  the Alaska  State                                                              
Medical Association to answer Senator Ellis's question.                                                                         
2:46:34 PM                                                                                                                    
At ease                                                                                                                         
2:48:03 PM                                                                                                                    
CHAIR COSTELLO reconvened  the meeting and asked  Senator Ellis to                                                              
restate his question for Dr. Rathkompf.                                                                                         
SENATOR ELLIS  asked the  extent to  which the proposed  committee                                                              
substitute  addresses the  five  concerns outlined  in the  Alaska                                                              
State Medical Association letter.                                                                                               
2:49:43 PM                                                                                                                    
DR.  MELINDA   RATHKOMPF  MD,  President,  Alaska   State  Medical                                                              
Association,  said  ASMA is  appreciative  that the  CS  addresses                                                              
many of the concerns,  but the issue that is not  addressed is the                                                              
suggestion  to   create  a  registry   for  businesses   that  are                                                              
conducting  telemedicine  in  order  to  provide  oversight  at  a                                                              
business   level.  ASMA   feels  it's  important   to  have   some                                                              
capability  to regulate or  provide business  oversight,  since it                                                              
is a  different model  of telemedicine  that is strictly  company-                                                              
CHAIR COSTELLO  asked if the provisions  in the bill  allowing the                                                              
board to  adopt regulations  provides the  authority for  business                                                              
oversight. If not, would she like that to be added.                                                                             
DR.  RATHKOMPF answered  yes, that  needs  to be  added. There  is                                                              
oversight  at the  individual  physician level,  but  there is  no                                                              
assurance  that  telemedicine  businesses  coming into  the  state                                                              
will adopt that  same standard. She questioned  what the oversight                                                              
would be if a business didn't adopt the same standard.                                                                          
CHAIR  COSTELLO   asked  Senator   Ellis  if  he   maintained  his                                                              
2:51:43 PM                                                                                                                    
SENATOR  ELLIS answered  yes.  He added  that  he appreciates  the                                                              
work that's  been done to  address four  of the five  concerns but                                                              
it seems  that the Labor  and Commerce  Committee is the  place to                                                              
address the issue of business oversight.                                                                                        
CHAIR COSTELLO  said it's the intent  of the chair to  deliver the                                                              
best work product possible to the next committee.                                                                               
She asked Ms.  Hovenden if she had  language to suggest  for a new                                                              
paragraph  (7)  in  Section  3 that  allows  the  board  to  adopt                                                              
regulations to provide appropriate business oversight.                                                                          
SENATOR GIESSEL said  she appreciates what ASMA  is proposing, but                                                              
she  believes   that  authority   belongs   to  the  Division   of                                                              
Corporations, Business  and Professional Licensing,  not the State                                                              
Medical Board.                                                                                                                  
2:53:32 PM                                                                                                                    
JANEY HOVENDEN,  Director, Division of Corporations,  Business and                                                              
Professional  Licensing,  Department  of Commerce,  Community  and                                                              
Economic Development,  said she believes  this can be  fleshed out                                                              
in  regulations.  Her  belief  is  that  it  would  be  under  the                                                              
jurisdiction  of the  State Medical  Board but  she would  have to                                                              
research  that  further.  She deferred  further  comment  to  Sara                                                              
2:54:22 PM                                                                                                                    
SARAH  CHAMBERS,  Operations Manager,  Division  of  Corporations,                                                              
Business  and  Professional  Licensing,  Department  of  Commerce,                                                              
Community   and    Economic   Development   (DCCED),    said   her                                                              
understanding is  the statutory  authority to develop  a mandatory                                                              
registry  would need  to  be housed  in  the  State Medical  Board                                                              
under AS  08.64.101, or  an appropriate  subsection. The  division                                                              
would  need to be  granted the  authority to  support the  board's                                                              
development of such a registry.                                                                                                 
SENATOR GIESSEL  recapped the answer  and said that  seems outside                                                              
the expertise of the State Medical Board.                                                                                       
MS.  CHAMBERS  replied  her  understanding  is that  any  sort  of                                                              
license  or registry  that would  fall  under the  purview of  the                                                              
State Medical  Board would  need to reside  under that  board. The                                                              
division  could  regulate the  registry  but  then it  would  fall                                                              
outside  the State  Medical Board's  jurisdiction.  They would  be                                                              
unable to  pass judgement  on whether  a telemedicine  company had                                                              
the protocols  to ensure their  employees are acting  according to                                                              
the  standards  of the  Federation  of  State Medical  Boards  and                                                              
American  Medical Association  for telemedicine  that are  already                                                              
in place.                                                                                                                       
2:57:15 PM                                                                                                                    
CHAIR COSTELLO  stated that the  amended committee  substitute for                                                              
SB 98 has not  been adopted, and she would hold  the bill awaiting                                                              
a new committee substitute.                                                                                                     

Document Name Date/Time Subjects
Director Hovenden's Letter to Sen Costello SB 98 3-1-16.pdf SL&C 3/1/2016 1:30:00 PM
SB 98
CS SB 98 (L&C) - Ver. E.pdf SL&C 3/1/2016 1:30:00 PM
SB 98
AK-PA Letter concerning SB 98 - 02-25-2016.pdf SL&C 3/1/2016 1:30:00 PM
SB 98