This meeting of the House Labor and Commerce Committee will come to order.
The time is 3.16 p.m. on Monday, February 9th.
Members present are Representative Carrick, Representative Colomb,
Representative Freer, representative Nelson, co-chair, Fields, myself, Co-Chair Hall.
We have a quorum.
Please silence cell phones.
We are asking that staff and members of
the audience not approach the table if you need to pass a note to committee members.
Please get the attention of my committee, Joan Wilkerson, and she will take care of it.
I'd like to thank Andrew Magnusson, the Labor and Commerce Committee Secretary, and
Kyla Tupo from the Juneau LAO for Tech and Teleconferencing support.
We have one bill on the agenda today, that bill is HB 293,
licensing and genetic counselors by co-chair fields and staff.
Please take a seat in the front of the room, introduce yourself for
the record and begin your presentation.
Hi, I just want to verify everyone can hear me to whomever is speaking online.
Yes, we can here you and we will be getting to you in just a couple of minutes.
All right, thank you.
Hello, exact field.
South sister 17. Thank you for the opportunity to present house bill 293.
This is the same topic that you all heard about.
a couple of genetic counselors.
The purpose of this bill is pretty simple.
Genetic counselor licensing would establish
a more sustainable financial model, a model for billing
so that genetic counselor's can work as part
of a healthcare team as you all have heard
in the previous hearing right now.
Genetic counselors work for South Central Foundation
slash anti-HC and for Providence.
The lack of licensure means that only the largest healthcare employers can afford to pay for
genetic counselors out of their overhead.
I'm also concerned that healthcare providers will facing financial pressures might consider
reducing the staff of genetic counselor.
I think we heard pretty convincingly that genetic counselers can improve both the quality and
the efficiency of care, for example, avoiding unnecessary diagnostic tests.
Want to turn to genetic counselors, but when we have rapidly advancing medical technology
I think we should take advantage of it to provide both faster more cost-effective care for the benefit of Alaskans. Thank you
And for their record at an Anderson staff to rep fields, I'll be reading the sectional for House Bill 293. This is version a
Section 1 amends AS0802.110A to add genetic counselors to a list of healthcare professions
licensed by the Department of Commerce.
Sections 2 and 3 add genomic counselors
to list healthcare providers who are authorized to provide services via telehealth, both individually
and as part of a multidisciplinary care team.
AS, Chapter 8 with a new chapter, chapter 53, genetic counselors.
There are a number of provisions of this section in Article 1, Section 08.53.100 requires a
license to practice genetic counseling in the state.
Section 08.53.120 provides for temporary licensure for up to one year for an otherwise qualified applicant who has not yet received their exam results.
Temporary licensees must work under the supervision of a licensed genetic counselor or a license physician.
previously licensed in another state. Section 08.53.140 allows genetic
counseling interns to practice some of the direct supervision of a licensed
genetic counselor. In Article 2 of The Bill, section 08 .53 .160 permits
licensed genetic counselors to operate within their scope of practice and
defines the scope a practice to include ordering and interpreting genetic
tests and counseling patients.
Section 08.53.170 gives the state medical board the authority to revoke or suspend the license
of a genetic counselor or to discipline the licensee for any fraudulent, unprofessional, unethical,
or criminal activities.
Article three establishes a genetic counseling advisory council.
This advisory Council would be under the purview of the state medical board.
The council consists of three to five members, majority of whom are licensed genetic counselors with at least one licensed physician.
Article four is the general provisions of this section.
0853.200 affirms that the administrative procedures act applies to any action taken by the board.
Section 0 8.53 .210 provides exceptions for licensure for genetic counselors who are in the
military service or employed by another agency of the federal government. It requires that those
providers hold hold patients to the same standard of care as other licensed providers.
Section 08.53.220 makes violations of this chapter a class b misdemeanor.
Section 08.533.230 allows the state medical board in consultation with the advisory council
to adopt regulations. Section 01.053.300 provides definitions for board and for licensed genetic
Section 5, back to the underlying bill, amendsas.08.64.101 A, giving the state medical board the
authority to impose disciplinary sanctions. Section 6 amensas 0A.54.103 A clarifying the
authority of the board, allowing them to conduct investigations and to review the qualifications
That's alongside the Genetic Counseling Advisory Council.
Section 7 makes a conforming change.
Section 8 amends AS09.55.560.
Subsection 2, adding genetic counselors to the list of healthcare providers who may be
subject to medical malpractice liability.
Section 9.
AS09.65.300 subsection C1 adds genetic counselors to the list of health care providers who receive liability immunity during the provision of healthcare services when they are offered for free.
Section 10 amends AS21.36.090 Subsection D, adding genetic counselors to the list of
healthcare providers who may not practice or permit unfair discrimination based on the type of
health insurance coverage the patient might have. Section 11 amens un-cudified law with a new
currently certified genetic counselors
to continue practicing in the state until July 1st, 2027.
And section 12, the final section
amends un-codified law with a new section,
allowing the board to appoint the initial members
of the genetic counseling advisory council,
and that concludes the sectional.
Thank you.
And let the record reflect that we were joined
by Representative Sadler at 3.19 PM.
With that, we will turn to invited testimony.
On line, I see Anna Johansson,
Certified Genetic Counselor with Sound Central Foundation.
Ms. Johanson, thank you for being here.
Please introduce yourself for the record
and begin your testimony, shoot.
And Ms Johansen, if you need just a moment,
I can take a brief addis.
At ease
And we are, we're back on record, uh, Ms. Johansson.
Um, please proceed with your testimony.
Thank you.
Good afternoon members of the House Labor and Commerce Committee.
My name is Anna.
Right.
You are saying Joe Hanson.
It's going to ask my name as Anna Johansen.
I'm a lifelong Alaskan and a certified genetic counselor with a master's degree in genetic counseling from the Mass General Hospital Institute of Health Professions.
I currently practice at South Central Foundation alongside two other genetic counselors primarily
in pediatric and prenatal genetics.
I am here today in support of House Bill 293.
Although I'm the newest of the seven genetic counselor's currently practicing in Alaska,
I believe it places me in a strong position to speak to both the existing gaps in care
and the future of a genetic workforce in our state.
One of the primary benefits of licensure is reducing patient harm.
I want to briefly underscore that point with lived experience.
Even among my own family and friends in Alaska, I've seen well-intentioned
providers give incorrect genetic information simply because genetics
is complex and outside their primary care, their
primary training. In one case, a patient with a strong
paternal history of early breast cancer was incorrectly
told that breast-cancer risk could not be inherited from her father.
In another, a family was told that having three sons with autism meant a future son
would almost certainly be affected, which is not supported by genetics.
These kind of errors can lead to either inappropriate reassurance or unnecessary fear and ultimately
result in missed opportunities for appropriate care.
Licensure helps ensure that patients receive guidance from professionals with verified,
specialized training in genetics
Second, licensure would significantly improve access to genetic counseling services across
Alaska.
Currently, the lack of licensor makes it difficult for clinics to build genetic Counseling Services,
to bill 4 genetic counseling services, which in turn makes this difficult to justify hiring
genetic counselors.
When I joined South Central Foundation, it immediately increased our clinic capacity
and helped reduce wait times for patients who have been waiting months and often even
years to DC.
and that is only for Alaska Native and American Indian pediatric patients.
Other children, as well as any adults outside the prenatal or cancer settings,
generally do not have access to in-state genetic services at all,
and must instead travel out of the state, rely on out-of- state telehealth services,
or receive care from non-genetics providers who may have limited genetics expertise.
From a workforce perspective, licensure is also critical for recruitment and retention.
I knew I wanted to return home to Alaska after graduate school, but I struggled to find available positions or clinics able to consider creating one, largely because they could not support or bill for this role.
It took over a year from graduation for me to be hired here, and while I'm deeply grateful it worked out, I very nearly accepted an out-of-state position before it did.
Finally, I want to briefly address the economic and systems level impact of this bill.
Prior to graduate school,
I worked for about three and a half years at the Alaska Native Tribal Health Consortium
in roles involving Medicaid, prior authorizations, and medically necessary travel.
That experience gave me insight into how costly, inefficient care and out-of-state referrals
can be, especially for rural patients.
could support the hiring of genetic counselors in additional communities such as Fairbanks and
Juneau, helping to reduce wait times and lower the overall costs associated with accessing these
services. More broadly, when genetic testing is ordered incorrectly, as a well recognized
issue in genetics, insurance often will not cover the corrected test, leaving patients to
Even when patients are not directly charged,
as is often the case in IHS and tribal health settings,
wasteful or duplicative testing still diverts
limited healthcare dollars away from other areas of care,
ultimately impacting access and quality
across the system.
Genetic counselors are specifically trained
to prevent these errors,
saving both patients and healthcare systems time and money.
Life Center helps integrate this expertise earlier
and more effectively into care.
House Bill 293 establishes clear standards,
accountability and recognition for genetic counselors
in Alaska.
It aligns our state with the majority of the country
and supports safer care, improved access
and a stronger healthcare workforce for Alaskans.
I respectfully urge you to support House bill 293.
Thank you for your time
and I'm happy to answer any questions.
Thank you, Ms. Johansson and thank you for the clarity and how to pronounce your last name
If you would stay on the line, we're gonna go ahead with the next
Invited testifier and then we'll be wrapping around back for questions from the committee
So also online is April O'Connor who is a certified genetic counselor. I'm so Connor, please
Put yourself on their record and begin your testimony
Hello. Hi, yes. Chair members, I spoke with you last Wednesday at this committee meeting
as well. My name is April O'Connor and I'm a certified genetic counselor. I graduated
in 2005 and have worked in multiple states across the country and currently a genetic
counselor at Providence Cancer Center in Alaska here at Anchorage. And I am currently sort
of licensed in all 35 states that have licensure. So I have been working very diligently in
Anna, as well as Monty, who you've also spoke with when we testified last Wednesday.
And so I was not planning on giving a formal testimony as I
was part of the meeting one last week, but I would like to be here to
be able to answer questions if there's anything I can do to further
answer question you have or further support Anna and my colleagues in this
Thank you, Ms. O'Connor. With that, we will turn to questions from the committee, and
I also want to let folks know that we have Sylvan Rob here in person in the Committee
Room as well. She's from The Department of Commerce, she's available for questions. Thank
you Ms Rob for being here. Do we ask questions? Representative Sadler.
I believe we heard the last time we engaged in this bill that there is a national qualification
test or license.
What licensing do you currently have?
Yeah, so there's a National Board to become board certified, which I do have.
Licensure is more on a state to state level and like board certification kind of gives
you learned what you're needing to learn whereas licensure would be more helping regulate and
as kind of discussed previously things like if you
do something wrong to where we need to consider revoking your license or suspending it any kind
of punishment. There's nothing in place right now to do any of those things or to come down on
Could and could you follow-up representative sound up with my question. Could you let me know the proper name of the national board?
Which is certified you?
The American Board of Medical Genetics American board of medical certification
Who I'm sorry one more time all the way just just the board certification through them
I am sorry, Mr. Einstein. Sorry. Can you say the whole thing all at once, please?
American, Board, of, Medical, Genetics
certification exam? I can look up exactly what it's called.
I think for the record American Board of Medical Genetics Certification.
Okay. Thank you.
Are there other questions from the committee? Representative Colomb.
Thank You Chair or co-chair through the co chair.
Johansen. Johansson. Thanks. So what I heard was you said that you practice prenatal genetics?
Some. I mostly am in the pediatric setting but I do two mornings a week in prenatal.
So when you do prenatal is this are you counseling parents that are already pregnant or have not been
pregnant? They're looking for markers or what are some of the things? What's the information that
Parents are looking for when they come to you
Yeah, um, I actually'm gonna let April handle this one because my understanding is she's has years of this experience
And you probably speak better
Okay, miss O'Connor
Yes, hello. Thank you Anna and through the co-chair. Yes. I've been a genetic counselor
in prenatal genetics for all 21 years of my career. Happy to answer the question. And
so yes, in pre-natal genetics, it's a combination of discussing concerns in the family history
of family members maybe having genetic conditions that the child could inherit with patients
who are currently pregnant, also abnormalities that may be seen on an ultrasound that is
sedentary genetic condition.
What does that mean for prognosis of the pregnancy as well as abnormal screening testing that is conducted during the
pregnancy? As well the indicators on that if there's an indicator of a possible concern on the
pregnancy, how do we navigate that? What is that means for the child at that point?
So that it is most of consultations in prenatal genetics. Also, there is preconception genetic counseling that
is often conducted with couples who are considering becoming pregnant and would like to talk through either a known family history of
they're concerned about that for their future pregnancy,
as well as potential testing that can be done in addition to,
or in advance, I should say, of pregnancy aswell.
So, does your practice,
does education include,
does counseling include counseling to end the pregnancy
if there are deformities detected, or
how do you handle something like that?
Good question. Through the co-chair, no. Our counseling is not counseling of the ending of their pregnancy if there are concerns.
This is something that routinely comes up in genetic counseling. However, occasionally it is a question that is asked of
the parents in terms of if the there is medical concern to the mother's health, is that something could be pursued?
Then at that point, the patient is then referred back for conversation with that with their maternal fetal medicine specialist typically.
who is most educated to be able to give more indicators and discussion points on prognosis
of the pregnancy in the mother's health as it pertains.
Follow-up, Representative Klom.
So let's say it has nothing to do with the life of mother.
Let's you detect deformities and then you discuss that and they want to end the
pregnancy.
Would you counsel them where to go or how to
end that pregnancy or do you refer them back to the primary care doctor?
I would refer them back to the maternal,
fetal medicine specialists.
Those are the specialists that refer
them to us genetic counselors.
We have to work in clinic with them.
So we are a component of that consultation
would be to discuss the, at that point,
what is the diagnosis, what does the prognosis,
what this mean for a child,
what it means for patient,
all of the information about that.
And in terms of what they would like to do moving forward
then that at this point is facilitated
through their physicians.
Thank you, Representative Klum.
Thank You, Ms. O'Connor.
Representative Nelson has a question.
Thank and through the chair to the bill sponsor.
Do you know, just off the top of your head,
how many people currently have board certification
in the state for Genet Counseling?
Through the co-chair, I would ask the testifiers if all of the genetic counselors in the state and I believe there are seven have board certification.
I don't know.
That is a pretty small number of people are currently working in genetic counseling.
Thank you.
I can answer that.
Please go ahead, Ms. O'Connor.
Or is that Ms..
Oh, sorry.
I'm so sorry, that was the Anna.
Okay.
Thank You, Miss Johansson.
Please proceed with the answering the question.
Thank you, so there are currently eight genetic counselors in Alaska
Although one is not practicing in the last guy she's practicing to telehealth out of state
But all of all seven of us that practice here as well as her are board certified
Follow-up representative Nelson. Yes. Thank You and through the chair to the bill sponsor
So you here have five members of the council with only seven in a state being board-certified
wouldn't it make more sense to add an inclusion to pre-existing board that one
of the seats has to have a history of genetic counseling than having a large
fiscal note for a whole council of members that essentially make up the
entirety of certified board members in the state?
Thanks Representative Nelson through the chair. I guess I don't have
building model to make sure that care is available and I might turn back to the
genetic counselors to ask about what preferences they would have in terms of
structure. My goal is just that the care be accessible to Alaskans. Thank you.
Thank You, Co-Chair Fields. We're going to go to Representative Karak, then
Representative Sadler. Yes, thank you through the co-chair. That was actually
Um, and I think this might be a question for Sylvan Rob, actually, do we have any licensed
professions in Alaska which don't have a board that regulates them currently where the department
just issues licenses and handles follow-up complaints? I see Sylvain Rob coming up.
Thank you for joining us, Ms. Rob. We appreciate you being here. Please put yourself on the record
Thank you, Madam Co-Chair.
For the record, Sylvan Rob Director of the Division of Corporations, Business and Professional
Licensing, through the Co Chair to Representative Carrick.
We do.
There are currently 24 programs that are regulated by the division that don't have boards that
And a follow-up follow up. Thank you through the co-chair to Ms. Rob
Do you think that this is a profession given its small size currently that the division could do the same as the other professions where there's
Just division oversight
Through the chair co chair to representative Carrick
There are several health care professions currently the don't have boards that we do regulate natural paths
comes to mind immediately, it's really up to the sponsor
what the desired outcome is.
We do have 11 of our programs that have fewer
than 100 licensees.
So there are a number of quite small programs.
Most of those do not have boards.
Thank you.
Thank You.
Representative Sadler.
Thank-you, Madam Chair.
It's a kind of a head scratcher.
I think my major first take of this is
How do you have a board that regulates the practice
when almost all the members of the
practice will be on the board?
It's the Fox guarding the hen house,
disciplinary sanctions, it's you're asking people
to threaten to suspend or revoke the license
of their colleagues in a very small professional community
and that just creates some inherent conflicts and challenges.
But I do have question for Ms.,
make sure is it Ms. O'Connor who has licenses
in all 35 states, you might be probably the best person
we can ask for the national perspective.
How many genetic counselors are there in the country?
Do we know?
Ms. O'Connor?
Yes, thank you to the co-chair. Yes. Currently across the country, yes, there are 35 states that have licensure.
There are about, let me see, I just pulled the recent data 7,514 board certified genetic counselors in the
country. I know those that are board-certified,
there's approximately 3,287 that currently have
licensures in one or multiple of the 35 state's requiring licensur.
though that's data points back from, excuse me,
that data point back for mid-year last year.
So that is actually before two boards head licensure.
So it is about half or a bit more than the average.
While we're on the subject, I did want to give a little color to what you were just speaking
about there.
And yes, there is.
There are eight current genetic counselors board certified in the state of Alaska, seven
practice in Alaska.
However, and Montia mentioned this in his testimony, it's very important to remember
that anyone who would practice genetic counseling with patients who are physically in this
state, you have to be licensed when they're physically, in a state speaking with you through
telemedicine even.
would have to be licensed in the state of Alaska.
So for example, just one of the singular laboratories
that we use just for cancer genetics alone
employs 60 genetic counselors.
All 60 of those individuals would
have be license in Alaska to provide genetic counseling.
So all of these laboratories, and there
is a good probably 10 across cardio, neuro,
PEDs, pediatrics, or cancer, genetics
that would then need to have their genetic counselor's
licensed, in Alaskan.
Other states, the way they've handled this, when they have a small group, for example, Idaho is a very small
group. I believe they had 10 genetic counselors currently, and they're trying to move to 12 for
an advisory board, which is usual in customary in this space, to have the genetic counseling
licensure advisory boards, of which there are genetic counselor's yes on.
Other states have opened it up to having genetic counselors serve on that board who do not physically reside in the state that they're on the board for but that
they are licensed in good standing in that Board.
So yes, there's only eight of us, but there are going to be hundreds that will be licensed
in Alaska if we have a licensure and we could offer them to sit on our Board as well as some other states do too who have
a small, very internal state group.
follow-up. That was a lot of information. A lot
of numbers, ma'am. Are you saying that? Yeah, I'm just
trying to track. So you said there are 3000 turn 87
genetic counselors who have licenses. There are 7514
who, have what or who do what, please? Currently board certified. Yes.
As the end of the speaking to, yes. All right. And that's the
Correct certified genetic counselor. Yes, when a genetic counselors licensed it can be designated multiple ways
But most common you'll see is LCGC, which is licensed certified
Yes
And the follow-up on that so I think our representative Sadler
Thank you, man chair. I believe I heard that you made a statement to something the fact that everybody
Who touches genetic counseling is gonna have to be licensed. You said 50 I'm not quite sure what those numbers were
But I thank you said that
We could have members of the board of
the Alaska Board of Janet Counseling who would not reside in Alaska,
but we're just licensed to practice in
Alaska who could live in Nebraska or California or Ohio, is that correct?
Yes, you are correct. Other states that have a very small group of genetic counselors internal into the state like Idaho is a
very good example of that. On their advisory board to kind of decrease that concern for as you alluded to, how do we invoke
reprimanding someone if they need be if we personally know them because we work with them. Because we're a small
group. They do have genetic counselor from other states, the Physically Resigned and Other States who are licensed in that state.
and in good standing the advisory board in that state has deemed it okay for them to be
on the board assuming they are elected to that board and have the proper prerequisites completed
to do so. So that means that you can branch out beyond just having the genetic counselors
to physically reside in Alaska on that Board. To answer your other question the number I was
For example, one of them, Ambre genetics.
It's AM, B-R-Y, genetics in California.
They do cancer genetic counseling.
They also do cardio genetic
counseling in genetic testing their counselors do.
There are 60 of
them and so they would all need licensure
in the state of Alaska.
So if we're talking licensur for our state,
it definitely is further reaching
to then adjust the genetic counselors
that reside here that would need license
in this state if they were to conduct
telehealth consults or in-person consult
with patients residing here.
Okay, I think you maybe you use the term board a couple times and in the definitions board refers to the medical board
Just for clarity of the record here when you say board are you speaking of a genetic counseling council advisory councils?
Which mean by board or do you mean something else?
What I mean by board is board certified genetic counselors.
So, yes, that we have our board certification.
Okay, very good and follow it.
One moment, I believe we
have a comment from Representative Fields and or his staff.
Through the chair, both this is Zach Fields.
So on terms of options in terms
of costs I would like to listen to
genetic counselor's about what they think makes the most sense.
If you look at lines 20 and 21 on page 9, we can certainly delete per diem and
travel expenses, that would be an easy way to eliminate costs.
If we want to keep the voice of genetic counselors, reduce the costs, and
I do want it turned to my staff Evan Anderson to talk a little bit more about
what's actually in the bill versus other policy options that are out there.
Does page nine will line, sir?
20 in 21.
Gotcha.
So we've already requested language to take that out.
Actually, and for the record Evan Anderson staff to rep yields. I just wanted to clarify.
I think what missile Connor was offering was a potential policy option for this body to consider.
If if this party wanted, to keep that five member advisory council, but allow out of
status, you know, a seat on the council that's a choice that could be made to this bill via
That's, that's not the way that this is designed, um, it's meant, uh, for Alaskans to sit on those seats.
Right.
So,
Representative Sadler.
So currently for the record,
it says it was a long bill.
Uh, so right now, the, way the bill is drafted, non-Alaskan's could not serve in the advisory
council.
Is that what I'm hearing?
That is my understanding.
And I just wanted to clarify, on the seats on advisory council, if I might.
Makes me interested.
Yeah.
I think, thanks.
Go to your hall.
So there's it's currently structured as three seats for General Counselors one public seat and one physician so yes
Three three sheets for genetic counselors is the way it structured right now
Thank you
Next we will go to representative Nelson and thank you coach air
Looking at the five advisory council members
Would the bill sponsor be open to having an amendments to change that to say
different alternatives, so either just strictly online meetings or having like I mentioned earlier having one board member at
AMA have history with genetic counseling instead of having entire bill dedicated to a new
Establishing a New Advisory Council
Through the chair. Yes, and my only suggestion is that we
Just listen to the group of genetic counselors
who are in Alaska about strengths and weaknesses
of different models and how we structure it.
Again, I don't really have preferences in terms of
whether we have a board, whether it's not a Board,
if the Board only meets remotely,
it makes sense to keep the costs down.
So I would just ask the counselors to come back to us
with strengths, and weakness of each model
and happy to support whatever the committee wants to do.
Follow-up representative Nelson. Thank you. Uh, I guess I'll direct that through the chair to
Miss Johansson or miss O'Connor. Do you think that?
The state medical board
Should have a chair or have member that has history with Jenna counseling or do you thing? There should be an entire?
Council for genetic counselors
Mizzo Connor or Miss you Hanson
I think this is Ms. O'Connor through the co-chair.
Just in having worked with other states,
obtaining my own licenses and such,
I can tell you it's the more usual customary shall we say,
way of this, is having an actual advisory board,
an advisory committee of genetic counselors
as the original kind of proposal
of five members structured that we just spoke of there.
That is how most states do this.
Now, certainly that's not the only way this can be done.
I just believe where we could have a concern if we do not have an actual advisory committee versus just one person who is representative on the, the medical board for this is when we start talking about genetic counseling by credential, which is in the bill as a means by which individuals credentialed
I would prefer there be multiple eyes on that previous state's regulations and rules around
that credential to make sure that they are in line with what we have as our prerequisites
and Rules of Regulations for our credentialing.
That's likely something that would need the review done by multiple individuals, not just
A compatible license from another state that we are willing to grant based on solely that that information
So that's where I feel like a committee of multiple individuals would be a very good use
That's just one example that comes to mind
Miss Johansson, do you have anything to add?
No, not at this time. Thank you.
Thank You
Next we're gonna go to representative Cologne followed by representative settler
Okay, thank you co-chair through the chair. So a couple of questions
First I guess to the bill sponsor does AMA support this bill
Through the Chair, I don't think we've seen a formal statement of support from the Alaska State Medical Association is that
And I would turn to my staff. They're certainly aware of it and we have a doctor testifying at the next hearing
Okay, follow up. So why ask has because well, first of all, there's a doctor on the board,
right? Even if you did the Board as written,
there is a medical doctor out there. And also, the medical board sits the first
The medical doctors in these genetic counselors seem to interact quite a bit.
Is it common for them to like oversee genetic counseling?
Like it's feeling like here?
In terms of how genetic counselor and doctors interact,
I would actually want to turn to the invited testifiers.
Okay.
Ms. O'Connor, shall we start with you?
Yes, thank you through through the chair co-chair. Yes. So genetic counselors, especially in states like Alaska where we have our national board certification, but we are not licensed. We then essentially are part of the care team with a physician guiding that so the physician refers to the genetic counselor.
So, essentially the physician, the provider that could be a nurse practitioner, could
be an MD physician or DO, is driving care where part of their care team, as their mid-level
sort of incidents who care.
In a licensed state, that genetic counselor can drive that care completely.
They do not need the referral from the Physician or Patient can self-refer, for example, or
Um, so given that, yes, we were very closely with physicians. I was in part of a care team anyway, but certainly in a state where we do not have licensures and even closer connection, which is, um,
yes. Why the medical board is aware of this life. This, this licensure bill, they have discussed it. It's my understanding. They were going to formally discuss it and the physicians that I work with certainly at Providence do know about this and are very excited for this for us.
Part of the reason why I ask is because usually the AMA, like there's always seems to be a turf war with these things with like chiropractors and natural paths and pharmacists and so just kind of trying to figure out why they seem to they seemed to
be supporting this but there is a medical doctor that's going to testify in another time through the chair. Correct. I believe from SCF at the next hearing and I'm happy to go back to.
asthma and just check in on check-in on the extent to which they've discussed it, but I
Believe that we haven't seen any kind of turf war because genetic counselors
Function as part of a team. So it's not a question of taking turf from a doctor at all. It's a questions
Making sure that the doctors have the best information to make informed decisions is really the lead in a care team
And can I have one more question or is enough great. Thank you. So I want to be clear. There's a couple of parts in the bill
It sounds like it's kind of a licensure compact.
So if someone's licensed somewhere else they can practice here and vice versa
But then I heard the testifiers say that they would have to license in Alaska. Can someone clarify?
Sure, maybe I'll go to Evan Anderson.
Yeah, through the chair to Representative Colomb.
I think what you're referring to is there's kind of three
or four ways in which someone can receive their license.
And so it's section four of the bill,
which if you were reading along my section analysis,
I'm mislabeled.
So there was a typo in that one.
That's all right.
Section four, the bills.
So you?
So.
It's the Section 085, page 3, and to 4 qualifications for license.
So the first possibility for someone to receive licensure is to follow all of the steps.
They're certified.
They've taken the exam and there's a review of any licensured or disciplinary actions
that may have taken place in any other state.
So that's sort of a standard licensher.
two other pathways towards licensure.
So the second starts on page five,
it's the temporary license.
And I think that may be where you were calling
Representative Colum that.
If I can interrupt.
I'm sorry.
I am sorry, I hear.
Representative, Col.
So what I was referring to was the verbiage
on the top of page six, as well it was.
Yep, yep.
I don't think I understand the
temporary licensed stuff,
Yeah, I think that's so on page six, this section provides for.
Oh, and when it says the applicant line to the application holds an equivalent valid license issued by another state.
Yep. So this so the section begins on Page five and moves into Page six. Yeah.
And what this says is that they would follow the standard licensing process,
but instead of providing their.
transcripts from college, their results on the examination.
All they have to do is show that license to our corporations,
business professional licensing department or division, excuse me.
And then that is essentially the qualifications for their licensure.
So my understanding of this bill is not that it's a compact, but
that provides a couple of different pathways to licensures.
That makes sense. Thank you.
Thank.
Next we have Representative Sadler.
Thank you Madam Chair.
I guess this is probably a question for the sponsor.
So my understanding I have to dig into the language of the bill is the genetic counseling
advisory council is essentially a creation of a state medical board and would write regulations
on behalf of genetic counselors and I see the words occasionally in consultation with
I think working together with.
Is that a correct understanding of authority under which this advisory Council will be
created?
I'm gonna turn to my staff. I haven't yet through the chair to representative Sadler. Yes.
I think that's a that is a correct understanding and
the question about number of meeting dates came up earlier than representative Nelson
I maybe this is relevant I wanted to chime in I
Think there's just one requirement for an annual meeting here by the genetic council advisory council with the ability for them to meet more regularly
if they so choose and I
Okay follow-up then follow up. Yeah, and so I'm looking at page 10 of the bill line 25
Saying the the board mean the medical board shall have subpoena power
It does the Board currently have that power
And if they do have it why is it necessary to restate it in this in the section of a bill
Through the chair to representative Sadler for the record Avenue Anderson stuff to our fields
My understanding is that I can't answer about the mistake medical Board. I am not sure
I might assume that they would already have that power, but this language gives that
power authority specifically to the advisory council.
Follow-up.
Thank you. The language I read says that it gives the authority to
the board, not the Advisory Council. I need to clarify that.
The Board shall have the power to Minister Ospino witnesses.
So which leads to my point, I think it's important
that we do have a representative
from the State Medical Board
and the state medical association
in front of the committee to ask their views
for the record as to what they think about this,
where if this council is to be a creation of The Boards,
we're on her bound to hear from The board
what the think of it and how well they
think would work or not work.
So I might make that request that you have that.
Represent representatives from the board and the association before us sometime chair fields. This is Zach fields
That's a great idea and happy to follow up with them
You know somebody
Are there additional questions from The Committee
Representative
Representative Colomba will follow by Representative Sadler, but thank you
I think this is probably a question for either person online test fires.
So in the bill it says that they would need to follow the National Code of Ethics for
genetic counselors and I have to just look it up.
It looked pretty standard, but the last one kind of gave me pause and
I'd like to read it and you guys interpret.
to me what this means. So the last one says adhere to applicable laws and regulations.
However, when such laws are in conflict with the principles of the profession,
genetic counselors work toward change that will benefit the public interest.
What are they referring to there?
Yes, thank you to the co-chair. Yes. I would like to speak to that
Largely kind of traditionally in genetic counseling where this has come from is most genetic counselors have practiced in major cities and large institutions
Kind of as we have discussed before in front of this board a lot of it due to not being able to financially afford a genetic
Counselor and have them as part of the care team. So a
lot
community, or individuals who've been served by genetic counselors, have been of certain
population demographics and such, and there's been a lot of underserved populations as well
in demographics across the United States. And so a
lot this has been that, for example, in 23andMe's data,
for instance, people who are of European ancestry have an overwhelmingly
well-turned-it-out, certain genetic variants,
and what disease progression occurs in cases,
sort of not as well represented populations. For example, those of the Alaska Native population
is very significantly important in that they do have under-representation in genetics and
in genetic counseling and in counseling appropriately about disease states and such in the population.
So genetic counselors, it's basically said to say when there is a disparity, if it is not something,
as we know, 23 median data is accurate for certain individuals. Certain genetic testing is
want to test certain genes a different way
and a methodology needs to be used
to able to go out beyond the standard practice of,
this is the genetic test we typically would order.
No, we need to realize that's not what we would
order in this demographic, this population,
because there is an underserved disparity there.
So that is example of kind of modifying your practice
to meet the care of the needs of patient,
but not in the standards quo,
kind how business is done
if you will as genetic counseling.
So I guess what's tripping me up is when they say when such laws are in
conflict with the principles of the profession that doesn't sound like is
there a specific law that's keeping you from testing underserved people the way
you want I'm trying to what is the law
that come in conflict but the
I would say laws in the sense of more of, you know, it's kind of exactly like the
critic of the physician or care is going to take a doodle harm.
It's the same idea. So there is some barrier that you have to with the appropriate care
of your patient that if it is the
appropriate
care to the patient
that
you do your best by that patient to
circumnavigate the barrier and care for them appropriately.
I'm not exactly certain why it says law because there's no specific law on the
books anywhere in the United States or in any state that I know of.
Alaska's
the 10th state I've lived in. I practice in every corner of the country.
across that. So to answer your question specifically, I don't know. I believe it's
more kind of in the spirit of the law is to do what best by your patient no matter
the means if that is correct for you to be doing. Okay. Miss Johansson, do you
You know, I feel like April covered the same thing that was coming to mind for me
Like I definitely don't think it's implying that we should be breaking the law
But that if there are ever any circumstances where?
the best care for a patient goes against
some arbitrary law that a state may have that
we
Take it on the part of this part our duty to advocate for change of that
Thank you, do you have any follow-up representative call?
Um, no, I mean, not only does it say law, but it also says they're required to work toward change that will benefit the public interest. I just, it's a very specific code of ethic there and I know that, um, this does have this, does touch on the abortion controversy.
Worked towards change in that arena. They can do that. That's fine
I just I'm trying to figure out is that what they're talking about or is it some because I've not super familiar with the profession, so
I I think I
Think they've answered it. So thank you. I believe coach airfields has a comment. He'd like to make through the chair
I was just going to offer to follow up with allegedly go and see why they wrote it that way
I don't when we requested this bill
I don't remember a specific discussion around that phrase and wonder if it was just one of these
Things were leg legal rights it and we don' exactly know why it's phrased that way it
Was certainly not intended to wait into abortion rights, which are not at all the purpose of this bill
So can I answer that? Yeah, so it is a co-chair
Leg legal didn't write it in the bill
It says they will adhere to the national code of ethics. It's the National Genetics House or code-of ethics it wasn't
It wasn't your bill it just it refers to the code of ethics
So I was like what are the coding ethics? So that was it. Thank you representative clum
representative Sadler
Thank you, Madam Chair.
I've got a couple of lines of questioning,
but looking on page six, starting with line 26
about genetic counseling interns.
We have heard from the environmental testifiers
that genetic Counseling is a fairly complicated practice.
It has to be practiced by licensed
and certified genetic counselors,
but the bill would allow interns
to work as genetic counselor interns,
as long as they were enrolled in a program
and under the direct supervision.
So I guess my question would be,
who would hire an intern?
to receive genetic counseling services.
Where would such a person fit in the chain of medical practice?
And whoever wants to take that, I'd be our experts or the sponsor.
Ms. O'Connor, would you like to begin?
And then we'll train.
We'll see if Ms Johansson has any comments.
Yes, thank you through the co-chair. I believe that what they are referring to here is that
Oftentimes like I can speak to our practice at Providence Alaska Medical Center in the cancer center
We do have genetic counseling students who rotate with us
During their spring semester and sometimes their their fall winter semester as well
And we are basically seeing genetic Counseling patients with them
We help them to obviously certainly further foster their education and such as they are
Preparing to graduate from their accredited program and come genetic counselors. So at Providence. We often refer to them as interns
They are individuals going through a master's trained
University program to become a genetic counselor though
They have not yet passed their boards and are not a board certified genetic Counselors. They've not graduated their program yet.
So
That is in the sense of what at least it providence we see as interns and where that language was written on the bill kind of toward Miss Johansson. Do you have anything to add?
Not really April covered it. It's I understand it in turn sounds like it's an internship, but it really is just the rotation so that we're not graduating with strictly textbook knowledge and we have that real world experience with patients.
Thank you, Mr. Johansson. Representative Sadler. Yeah, just to pop up in that but again the language says that a
person may perform genetic counseling services using the title of genetic
counseling intern
It's still not quite clear what services they would provide or if they're simply observing or are there practicing and being observed by?
It does appear it's a very thorough bill and I suspect that those who are advocating for
genetic counseling practice in America have had a hand in drafting it so I think it gives
them a lot of what they might want but I'm still not quite clear on what the interim would
be doing.
Could they bill for their services?
Would they be just ancillary to the other sort of fine genetic counselors?
So that's the question I have and if we can answer that sometime in the record that would
be good.
Any thoughts on that?
Ms. O'Connor, do you have any response to Representative Thassadler's clarifying question?
Yes, representative seller through the co-chair. I do have a response to that. Yes. So
It can it can be one of two things as the genetic counseling intern shall we say or their genetic
counseling student currently at a university program in the lower 48 as we don't know have
any of the programs in Alaska. Sometimes they are seeing that the patient always with the
board certified genetic counselors so like myself, Monty, who you've met and my other colleague Maggie,
we would be there observing them either counseling the patients and we're observing and it's really
certain parts of that session or other times we are doing the complete
counseling and they are observing us. It just depends. If this is a two-year
program typically with clinical rotations in the summer, if they're their
first year then oftentimes they or not leading any parts
of the session we're observing them.
complete, excuse me, they are observing us completely.
If they're a second year student and near graduation,
then at that point,
they required to have a certain amount of cases
that they have counseled the patient
with supervision of a board certified genetic counselor
while they were counseling the patients
to be able to graduate from the program
and sit for their board exam.
So a sort of on a clinical experiences Anna was referencing.
And no, you cannot bill for there services.
Even if we were licensed,
at a counselor who's not licensed in that state,
and you cannot obtain licensure in a state
if you are not a board certified genetic counselor,
which they cannot become board-certified,
they have not yet graduated from an accredited program.
Okay.
Thank you, Ms. O'Connor.
Follow-up.
Thank it with pursuing a line here.
So actually, through the chair,
the question about billing came up.
Is there a place in this,
in the bill that allows a genetic counsellor
to bill Medicaid for services?
I guess that's to be for the sponsor.
Through the chair, I guess I would ask the testifiers to explain again why licensure enables billing.
Ms. O'Connor?
Yes, through the chair. Excuse me. Yes. So licensure enables billing because if you were a licensed health care provider then from the private insurance perspective, for example, then you are seen as a license profession and you're able to build what they call professional fees or
If you are not, then you're seen as incident to billing, where you were the
incidents to the physician time. The physician can build time if they see
the patient with you, which in some models they do, and then
you will build a facility fee for the genetic counselor time,
which a lot of times costs more to bill for than what you recoup, so billing is
just not done.
That is from a private insurance standpoint. Medicare currently
We are not able to build Medicare Medicare does not recognize genetic counselors as
professionals that are to be reimbursed. Currently, there has been a bill set
forward to the U.S. House and Senate to discuss this and it did not pass. It is
now being reintroduced by the National Society of Genetic Counselors to
the Capitol to get us accredited with CMS and be able to build Medicare. So,
currently, even licensed genetic counselors cannot build
Okay, so far.
Representative Sandler.
So just to clarify,
so right now Medicare does not reimburse for services
for genetic counseling.
Medicaid was my question.
Does Medicaid cover genetic housing?
Good question. Medicaid covers genetic counseling in states that are licensed
depending on the state's Medicaid program. There are some states where
Medicaid, Medicaid individuals, licensed genetic counselors are reimbursed.
There other states, where they do not believe that that is something that they
have moved for. They follow the CMS rule with Medicare. So it's really state-by-state
with Medicaid. Gotcha.
follow-up. So again, so if Medicare the licensure would allow Medicaid to bill
for and get reimbursed for services for gender counseling, but the state would
have to modify its Medicare Medicaid plan. Is that what I was saying?
Yes, that would be up to the state and to be honest with you
I don't know what goes on beyond that discussion
But I can tell you that yes some states allow for billing as a licensed professional as the genetic counselor others do not see that
They see you as more of a
Incident to member of the care team and they do NOT cover billing even for licensed genetic counselors
So it's state-state-centric Alaska would have to decide their stance
I got different tactics. Are there other questions from the committee other than representative seller?
I don't know, I'm not representative Colone.
We will return to representative Sandler's question.
Thank you, Co-Chair, through the co-chair.
I think it's probably for the bill sponsor staff.
I just want to make sure, so on in Article 4,
on page 9, the bottom, it has a list of exceptions
to application of this chapter.
It includes the military, U.S., the federal government.
Indian Health Service so under this bill will those those federal positions that's all exempt still
They do their own thing with license, and they wouldn't they would have to do anything different if this passed
For the record I'm Anderson through the chair to rep clone. Yes. That's my understanding. Okay. Thank you
Thank You
Other committee members before we return to representative Sadler
Seeing none representative sadler
Well, thank you, Mr. Chair. I just tumbled to section 11 on page 13 starting line 23
Transition, which I believe indicates that if you're practicing genetic counseling
Before this bill goes into effect you can keep doing though. So without a license
I'm not quite sure how you could practice genetic counselor that a licensed
Could someone could this sponsor please explain to me quite with the intent of that transition languages on pages 13
Through the chair, it just says until July 1st, 2027, so it's simply intended to
Allow them to get licensed and not have their
Ability to provide care cut off while we stand up the structure. That's all
Thank you different different question
Representative Sadler
Through The Chair to miss O'Connor I believe
Genetic counselors, we're told, will consult with a lot of information, family history, and so forth in order to counsel somebody
with questions about their genetic makeup in their future.
Is there a database of genetic information that exists?
Does somebody have to submit to the chief swabbing?
Does a family member have
to give permission to have their genetic material sampled and stored
in order for genetic counselor to do their work with?
I guess the question is what kind of information would a genetic
counselor have
to work
with and is there any kind
of database that saved
of this information?
Ms. O'Connor?
Yes, thank you through the co-chair. Yes. Um, so a couple of things there as genetic counselors the information you're going on is the
information that
in part provided to you through the testing laboratory, so by the test results.
The laboratories all have their own, what we call genetic variants,
are the changes in the gene structure and sequence that impact the disease function.
These genetic laboratories have all their
own variant classification scientist teams, full of MD's, PhD's and genetic counselors,
that review all of these variants in terms of structurally, functionally, and such.
They have access, as do we.
Um, to certain national databases, for example, ClinVar is a national database that's maintained
by the National Institutes of Health, where you can input a genetic variant and see what
current research, what laboratories in the United States potentially abroad if they do
release their de-identified data about this variant, how it behaves, is it tracked with
disease, does it not, be able to get more information?
do not have to do that, I've always been in good practice of doing that as my
colleagues I believe do as well to get the most information on this so I'm
giving the patient current information but also the laboratory reports from the
labs when they report on a result will have all of that information there too.
So to answer your question about
you know, provide does a patient have to give information like such?
No, because most pathogenic variants that would be disease causing are known at this point
based off of years of genetic testing, occasionally we come across things that we're not certain of
that still need additional work being done in terms of patients giving permission.
Laboratories, the majority of laboratories in the United States do release to these sort of
information about the variant and the disease state. There's nothing you could trace back to the
patient through that data that is released. Patients through signing the consent forms and doing
genetic testing, consent to being tested at a laboratory that shares data nationally for the
furtherment or furthering of genetic test and genetic practice. Does that fully answer your question?
It does. That was a plethora of information. I'm going to try and pick it apart with another
follow-up question, if I may. Some of the terminology you're using this is not language
I use every day. So, a genetic variant. What is a generic variant or a pathogenic variant?
Please put it in English. Speak slowly, please.
Yes, yes. A genetic a variant is change in the DNA sequence. The gene is made up of DNA.
And the DNA sequence, the spelling of the gene,
a variation that occurs, like is it an extra letter
or a missing letter or letter in the wrong place,
is a genetic variant.
Now, not every variation in human DNA can cause a problem
for the way that gene functions,
meaning can lead to what we would call the disease state.
So, variants can be harmless.
Some variants are not.
They can caused disease.
And so, by definition, pathogenic means disease causes
Meaning that variation that was found in the DNA sequence has a risk or is, depends on where it's at, what gene it is in, and kind of all of that function.
But those are the ones that have a risks to cause disease.
Those are those that are impactful for patients care.
Thank you.
One more follow-up, please, Representative Sadler.
Thank You.
This is my one chance to learn about genetic tech counseling.
Okay.
Vote Representative sadler, there's also the opportunity to work offline with this sponsor.
This as well.
Then I guess the last one I get to ask for the record is you mentioned Miss O'Connor that
information is shared with laboratories that do this.
I'm not quite sure if the laboratories simply process and give data back or do they process
Are the laboratories neutral?
Do they just reflect facts?
Or do they have suggest interpretations or conclusions?
Through the co-chair, that's a very good question.
So they are effectively neutral in the sense
that what they reflect back is telling you.
where the variant is, what gene it's in, and then based off of published research studies,
clinical case studies. So in PubMed, for example, PubMed is a central repository in the United States
again through the NIH where you can search, you know,
what genes cause sickle cell anemia,
for an example.
So laboratories as part of their variant classification scientist's team will,
pull what genetic conditions associated to that gene.
What has been experientially seen in the data with that
gene, meaning have there been case reports of patients
affected, what symptoms did they have,
what was the inheritance pattern,
meaning what's the likelihood this was inherited
from their parents or not,
what is the risk to future other family members and such.
So they do give you.
All of the current information as they can gather and glean through current published
data, research data medical data on that variant and what it is expecting to sort of cause potentially
for the person.
In terms of then it's up to the genetic counselor to extrapolate that.
Do additional research which a lot of times we do just to make sure that there's nothing
more out there than what we've been provided because of course it the summary report so
and then put that in the context of our patient.
Like that may matter.
The gender assigned at birth for the patient may
matter in terms of what the potential outcome could be,
if that is a sex-linked gene, for example.
Various things like that, then we interpret and put
that into the contact for patient to use
and move forward in their care.
I do have one more question.
Thank you, Ms. O'Connor.
We have a question from Representative Colomb.
Thank You, Co-Chair.
One more questions.
Ms O-Connor, does, and these test results
can insurance companies access these results, request them,
insist on them?
Is there any connection between insurance
companies and the results of the test?
Yes, through the co-chair. Yes. In terms of that is that has been an ever-changing kind
of landscape, but essentially the law currently that protects from medical health insurance
or it's like the name Gina. G-I-N-A is the acronym. It is a federal law that was passed in 2000 and
the states have adopted it rather quickly after that occurred. Prior to that, a lot of individuals
were doing genetic counseling as self-pay keeping it out of the medical record because insurance
companies were asking if genetic testing was ordered, what were the results, and then bringing
people in as a pre-existing condition. So not dropping coverage or denying coverage but bringing
And so that was seen as unacceptable because the majority of genetic variants
where people are positive for them do not guarantee the individual
will develop the condition.
It simply becomes a risk factor.
And, so, that kind of a slippery slope for him to be on,
which is why the federal government and the state stepped in.
So, to answer your question, there are protections under Gina, but they're not protections across the board.
So for example, a full-time military individual who is active duty under Tricare, they are not covered under GINA.
their medical records could be accessed, could
be asked, and they could potentially discharge based on that information deemed
by the military if they're fit to serve. Individuals who work for very small
business that employ 15 employees or less are and the letter the law and Gina
not covered. Admittedly, having been a genetic counselor for some time, I have
active duty military? Yes, there's a whole rubric of qualifications there by genetic test results,
but not in the private sector. To take that one further and answer your question completely,
there are not laws on the books to protect patients from genetic discrimination of their
test result with long-term disability insurance or life insurance. It has not been quite the
concern that we were seeing in health insurance, which is why there is likely no actual structural
When we counsel patients about in the pre-test session to do genetic testing, excuse me or not,
we review with them that if they do want to
do genetics testing and they're concerned about potential discrimination against
seeing this as the preexisting condition and coming at a higher rate,
let's say for long-term disability care life insurance,
to have those policies in place at the time that they test.
so that they cannot be retroactively amended
if they do test positive.
Some patients do choose to get their policies in place
before they test to just be sure.
Others are not concerned, but that is something
that as part of the pretestion and accounts in session,
we always review risk benefits limitations with patients
and that's part the conversation.
Great, thank you.
Thank you, Mr. Parker.
With that I would ask if there are additional questions to please follow up with the bill's sponsor there in their office
And we will share answers when they become available with a rest of the committee
Thank you everybody for the presentation representative fields. Do you have any closing remarks? You'd like to share in the Bill?
Thank You for all the thoughtful questions
Thank you co-chair fields and thank you to those who provided testimony today
The Lowell Connor and Miss Anna Johansson. Thank You also to director Rob for participating in the Q&A as well
We will hold hb 293 over and discuss it again later this week. This this concludes our business for today
The House labor and commerce committee will meet next on Wednesday February 11th at 3 15 p.m
This meeting is adjourned at 4 27 p p m