Legislature(2003 - 2004)

03/30/2004 09:04 AM Senate FIN

Audio Topic
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
     SENATE BILL NO. 306                                                                                                        
     "An Act relating to the practice of naturopathic medicine; and                                                             
     providing for an effective date."                                                                                          
This was  the second  hearing for  this bill in  the Senate  Finance                                                            
Co-Chair  Wilken explained  that this  bill, which  is sponsored  by                                                            
Senator Ralph  Seekins, would enact an Act relating  to the practice                                                            
of naturopathic  medicine.  Initially,  consideration  was given  to                                                            
implementing  a Board  to oversee  naturopathic  medicine;  however,                                                            
that is not  now being considered.  The Department of Community  and                                                            
Economic Development was  asked to explain the Department's Division                                                            
of Occupational  Licensing  flow  chart, titled  "Implementation  of                                                            
CSSB306(FIN)" [copy on  file] that depicts how licensed Naturopathic                                                            
Physicians would be monitored.                                                                                                  
RICK   URION,  Director,   Division   of   Occupational   Licensing,                                                            
Department  of Community  and Economic Development,  clarified  that                                                            
the  Governor Frank  Murkowski  Administration  has  no position  in                                                            
regards  to  this   legislation.  Were  the  Legislature   to  adopt                                                            
regulations  in regards  to Naturopathic  medicine,  the  Department                                                            
would  implement  supporting  rules and  regulations.  However,  the                                                            
Department has  been regulating this profession and  numerous others                                                            
without assistance  from a Board, for approximately  seventeen years                                                            
and could continue to do so absent any new legislation.                                                                         
Co-Chair Wilken asked the  current process through which a complaint                                                            
against a Naturopath might be reviewed.                                                                                         
Mr. Urion responded that  the Department's investigative staff would                                                            
address the  complaint, and, were  it deemed necessary, it  might be                                                            
forwarded to a hearing  officer. A multitude of different processes,                                                            
including  such  things  as  memorandums  of  agreement,  have  been                                                            
established  through  which  issues regarding  each  profession  are                                                            
Co-Chair  Wilken  asked  whether  the flow  chart  provided  by  the                                                            
Department  [copy  on  file]  would  depict  the  process  involving                                                            
Mr. Urion affirmed.                                                                                                             
Co-Chair Wilken asked that the flow chart be explained.                                                                         
Mr. Urion explained  that currently  when a complaint is  filed, the                                                            
Division's  investigative staff who,  based on a priority  list that                                                            
heavily ranks  Life/Safety issues,  would determine whether  charges                                                            
should be filed addresses  it. Were that the case, a hearing officer                                                            
would be  assigned,  a trial might  ensue, and  the hearing  officer                                                            
would  render a decision  including  the level  of punishment.  This                                                            
could include such things  as license removal, suspension and fines.                                                            
Were the defendant  to reject the  decision of the hearing  officer,                                                            
they have the right to appeal to a higher court.                                                                                
Mr. Urion shared  that in situations in which there  is a Board, the                                                            
Board would have the authority to act on the complaint.                                                                         
Co-Chair Wilken  asked whether the  Department, in conjunction  with                                                            
Naturopaths, developed the chart.                                                                                               
Mr. Urion concurred.                                                                                                            
Co-Chair  Wilken  asked whether  the  Division's  investigators  are                                                            
trained professionals.                                                                                                          
Mr. Urion responded that  while none of the Division's investigators                                                            
are trained  in any of  the fields that  they investigate,  they are                                                            
trained investigators.  He noted however, that they  do consult with                                                            
the appropriate  medical professional  pertinent to each  situation.                                                            
He noted that  the Medical Board recently  adopted a procedure  that                                                            
specifies that complaints  dealing with such things as sexual abuse,                                                            
alcohol, or drug  misuse be immediately forwarded  to the Division's                                                            
investigators.  However, determinations regarding  standards of care                                                            
complaints  are determined  by the Board and  then forwarded  to the                                                            
investigators, who could  independently make a determination if they                                                            
so chose.                                                                                                                       
Co-Chair  Wilken asked  for confirmation  that this  is the  current                                                            
practice relating to Medical Board.                                                                                             
Mr. Urion affirmed.                                                                                                             
Co-Chair Wilken  opined therefore that a procedure  akin to a triage                                                            
occurs at the investigative  level in that the investigator consults                                                            
with  a medical  professional.  The  investigator  would  receive  a                                                            
complaint from  a patient, and then the triage would  occur in which                                                            
it would be  determined whether the  complaint is serious  enough to                                                            
advance immediately to a hearing officer.                                                                                       
Mr. Urion clarified  that in serious  cases, the state investigator                                                             
would  have the  authority  to make  the determination.   Complaints                                                            
regarding standards  of care might  require an investigative  review                                                            
that might include a medical professional.                                                                                      
Co-Chair Wilken  understood that an  investigator would be  expected                                                            
to consult with the appropriate medical professional.                                                                           
Mr. Urion  agreed.  He stated  that this  is the  current  procedure                                                            
utilized when reviewing complaints against naturopaths.                                                                         
SENATOR RALPH  SEEKINS, the bill's  sponsor, noted that language  on                                                            
the bottom of the flow chart specifies that in the case of non-                                                                 
threatening  public safety issue or  a Standards of Care  complaint,                                                            
investigators could consult  with the Qualified Trade Association of                                                            
Naturopathic Physicians  (NP/QTA), which would consist of volunteers                                                            
from the field.                                                                                                                 
Co-Chair  Wilken asked  whether this  organization  exists today  or                                                            
would be established by this legislation.                                                                                       
Senator  Seekins responded  that while  this  organization does  not                                                            
currently  exist, its establishment  would  be clearly defined  in a                                                            
forthcoming committee substitute.                                                                                               
Mr.  Urion declared  that  this would  be  an opportunity  in  which                                                            
government  and private enterprise  could work together to  regulate                                                            
an industry.  No professional entity  would benefit from  "condoning                                                            
bad behavior" within its profession.                                                                                            
Co-Chair Wilken summarized  that the complaint process would be that                                                            
a wronged patient  would go to the State, It would  then be directed                                                            
to an investigator.  The investigator could consult  with the three-                                                            
member NP/QTA panel.                                                                                                            
Senator  Olson questioned  "the wisdom" of  allowing naturopaths  to                                                            
have  their  own  board,  as  currently   the  process  provides  an                                                            
investigator   the  ability  to  consult   with  professionals.   In                                                            
addition,  he asked  whether  there could  be the  option of  having                                                            
naturopathic complaints heard by the eight-member Medical Board.                                                                
Mr. Urion  voiced  concern to the  appropriateness  of having  these                                                            
complaints  heard  before  the Medical  Board  due to  the  negative                                                            
comments  the  medical field  has  made in  regard  to naturopaths.                                                             
Continuing, he noted that  at this point, the Division could monitor                                                            
the Naturopathic profession without implementation of a Board.                                                                  
Senator Bunde  countered that  currently the  Board of Medicine  has                                                            
oversight  over  a  wide  range  of medical  professions   including                                                            
Physician Assistants  (PAs), Nurse  Practitioners (NPs),  Registered                                                            
Nurses  (RNs),  Oseopathics,  dentists,  and paramedics.  All  these                                                            
professions are included  under the term "physician" and, since this                                                            
bill would  expand that  term to  include Naturopaths,  it would  be                                                            
logical that they be included  in those professions monitored by the                                                            
Senator Seekins responded  that he would not object to the inclusion                                                            
of a naturopath  on the Medical Board, were it suggested.  Inclusion                                                            
of a  naturopath  on the  Board would  provide some  insight to  the                                                            
Board regarding  Standards of Care for the profession.  However, due                                                            
to  the  fact  that  naturopathic  medicine  presents  competition,                                                             
naturopaths "have a fear  that there may be some objection "from the                                                            
more recognized medical professions.                                                                                            
Co-Chair Wilken recalled  that, until a few years ago when they were                                                            
granted voting rights,  Physician Assistants were ex officio members                                                            
of  the  Medical  Board.  Perhaps  this  might  be  an  option  with                                                            
AT EASE 10:28 AM / 10:28 AM                                                                                                     
Senator  Olson   clarified  earlier   information  regarding   which                                                            
professions the State Medical  Boards oversees. While it does govern                                                            
paramedics, physicians,  and physician assistants,  it does not have                                                            
direct  regulatory oversight  in regards  to  dentists, nurses,  and                                                            
nurse practitioners.                                                                                                            
Senator Olson also noted  that when he, a medical doctor, was on the                                                            
State Medical  Board, its seven-person membership  consisted of five                                                            
physicians  and  two  lay  people.  He  subsequently  supported  the                                                            
representation of a PA  on the Board due to their increasing numbers                                                            
in the State.  He noted that the number of naturopaths  in the State                                                            
is limited.                                                                                                                     
Co-Chair  Wilken noted that  there are currently  27 Naturopaths  in                                                            
the State.                                                                                                                      
Senator  Seekins   countered  that   any  board  that  regulates   a                                                            
profession should have,  as part of its membership, a representative                                                            
of each  profession in order  to negate such  things as "hostility"                                                             
against that profession.                                                                                                        
Co-Chair Wilken  asked for confirmation that PAs were,  at one time,                                                            
ex officio members of the Board.                                                                                                
Senator Olson  specified that PAs  were diligent in attending  every                                                            
meeting even  before they had representation  on the Board.  In that                                                            
regard, once  they were admitted  to the  Board, they became  voting                                                            
members. He agreed  with Senator Seekins that representation  at the                                                            
Board level is important.                                                                                                       
Co-Chair Wilken pointed  out that the definition of minor surgery is                                                            
included in the  bill in Section 13, subsection (6),  page six, line                                                            
19 and reads as follows.                                                                                                        
     (6) "minor surgery"                                                                                                        
          (A) means the use of                                                                                                  
                (i) operative, electrical, or other methods for                                                                 
     surgical repair and  care incidental to superficial lacerations                                                            
     and  abrasions  or  superficial  lesions,  and the  removal  of                                                            
     foreign bodies located in superficial tissues; and                                                                         
                (ii) antiseptics and local anesthetics in connection                                                            
     with  methods  authorized   under  (i)  of this  subparagraph;                                                             
          (B) does not include use of general or spinal                                                                         
     anesthetics,  major surgery,  surgery of the body cavities,  or                                                            
     specialized   surgery,   such  as  plastic   surgery,   surgery                                                            
     involving  the eyes, or surgery  involving tendons,  ligaments,                                                            
     nerves, or blood vessels.                                                                                                  
Co-Chair  Wilken   asked  Senator  Olson  to  address   his  concern                                                            
regarding allowing naturopaths to conduct "further tests."                                                                      
Senator Olson voiced the  understanding that one of the reasons that                                                            
naturopaths are  requesting prescriptive authority  is because their                                                            
position is that they have  similar education and training levels to                                                            
that  of  medical  doctors.  However,  while  many  of  the  initial                                                            
educational  courses were  the same, there  was a "divergence  later                                                            
on" as the  foundation of the naturopathic  delivery system  was one                                                            
of being "basically drug free."                                                                                                 
Senator Olson  voiced that,  with the care  of the patient  in mind,                                                            
there is  concern that in  the continuance  of their care,  limiting                                                            
prescriptive  treatment to medical  doctors would be appropriate  to                                                            
the balance. He noted that  there has been an abiding identification                                                            
within  the  medical  profession  that  medical  doctors   prescribe                                                            
medication.  In order  to  expand rather  than  restrict  naturopath                                                            
prescriptive  authority,  it  could be  suggested  that naturopaths                                                             
should be required  to qualify for  Part One, Two, and Three  of the                                                            
National  Medical Board examination  rather  than being required  to                                                            
pass only Parts  One and Two. Part  Three is the section  that tests                                                            
prescriptive knowledge.  Therefore, their ability  to pass all three                                                            
sections of the  examination would indicate that their  training was                                                            
comparable to that of a  medical doctor and would allow them to have                                                            
prescriptive authority.                                                                                                         
Senator Seekins,  being respectful of Senator Olson,  clarified that                                                            
rather   than  seeking  to   be  recognized   as  medical   doctors,                                                            
naturopaths  are seeking to have prescriptive  rights that  are less                                                            
than a  PA and  NP. This  was clarified  in Amendment  #1 which  the                                                            
Committee  during its  first  hearing on  the bill.  That  amendment                                                            
inserted  a  new  subsection   into  Section  11,  subsection   Sec.                                                            
08.45.120 on page five, line 16 that reads as follows.                                                                          
     (4) after becoming registered with the federal Drug                                                                        
     Enforcement Administration, prescribe only those controlled                                                                
     substances allowed under Schedules III, IV, and V.                                                                         
Senator  Olson clarified  that  a PA  could only  practice  medicine                                                            
under a collaborative  agreement and  direct oversight by  a medical                                                            
doctor (MD). Were  something to go wrong, the MD would  also be held                                                            
Senator Bunde  asked how an NP's training would differ  from that of                                                            
a PA in this regard.                                                                                                            
Senator Olson stated that  while he is familiar with PA requirements                                                            
and the associated  prescriptive limitations, he is  unfamiliar with                                                            
the requirements for a NP.                                                                                                      
Senator Seekins shared  that he is familiar with the NP requirements                                                            
as his wife is a nurse and a close friend is a NP.                                                                              
SFC 04 # 63, Side B 10:40 AM                                                                                                    
Senator  Seekins  noted  therefore,  that NPs  could  prescribe  all                                                            
levels of prescriptive  medications  as they have a higher  level of                                                            
training   than  PAs.   "It  would   be  inconceivable"   that   any                                                            
practitioner … would not  seek assistance from other caregivers when                                                            
encountering serious situations.                                                                                                
Co-Chair  Wilken noted  that concerns  have been  raised due  to the                                                            
understanding that Naturopathic  Doctors (ND) would not have medical                                                            
malpractice insurance.  He referred the Committee to Item #3 on page                                                            
two of  a letter [copy  on file]  dated February  24, 2004 from  Dr.                                                            
Scott Luper,  ND that Co-Chair  Wilken had  received in response  to                                                            
comments in a letter [copy  on file] dated February 9, 2004 that Co-                                                            
Chair Wilken  had received  from Tom Wilson,  PA-C. The comment  and                                                            
response, as written in Dr. Luper's letter are as follow.                                                                       
     #3.  The  bill is  too  broad. Currently  one  could  prescribe                                                            
     antibiotics  to dangerous heart  medications, to chemotherapy.                                                             
     Allopathic  M.D.  would most  likely not  prescribe  medication                                                            
     outside of  their specialty, as it would be considered  outside                                                            
     of the  "standard of care". If  a bill were passed a  formulary                                                            
     would be much more acceptable and safe.                                                                                    
     3). Response:  Mr. Wilson suggests that an ND  might be tempted                                                            
     to prescribe  outside of their  training/education and  that an                                                            
     MD "would  most likely not" prescribe inappropriately.  This is                                                            
     not  realistic.  A good  "DOC" is  a good  "DOC".  NDs will  be                                                            
     liable for malpractice  on par with MD's and under the auspices                                                            
     of the Div. of Occupational Licensing.                                                                                     
DR. SCOTT LUPER,  Naturopathic Doctor, testified via  teleconference                                                            
from  Fairbanks   and  clarified  that  NDs  are  able   to  acquire                                                            
malpractice  insurance  and that ND  malpractice  insurance is  less                                                            
costly  that MD  malpractice  insurance  due to  the  fact that  the                                                            
complaints  against them are  fewer. He stated  that, while  he pays                                                            
$3,000 a year,  the majority of his  ND colleagues pay between  $600                                                            
and $2,000 annually.                                                                                                            
Co-Chair  Wilken surmised  that NDs carry  malpractice insurance  in                                                            
line with their standards of care.                                                                                              
Dr.  Luper  affirmed.   He  noted  that  the  standard   ND  medical                                                            
malpractice   coverage  would  provide   one  million  dollars   per                                                            
occurrence and three million dollars total.                                                                                     
Senator  Bunde surmised  that  MDs pay  higher  medical malpractice                                                             
insurance due to the fact  that they write prescriptions and perform                                                            
surgeries. Therefore, he  opined that ND's rates might increase were                                                            
this legislation adopted.                                                                                                       
Dr. Luper responded that  this has been investigated and it has been                                                            
determined that the rates  would not increase. He further noted that                                                            
the  Alaskan ND  rates  are comparable  to  those being  charged  in                                                            
states that  provide NDs prescriptive  and minor surgery  authority.                                                            
Dr.  Luper  disclosed that  in  order  to address  the  question  of                                                            
safety, he  had conducted  a survey of states  that license  NDs. He                                                            
had  acquired the  number  of ND disciplinary  actions  in  Arizona,                                                            
Oregon, Hawaii  and Connecticut. ND  disciplinary actions  including                                                            
such things as  license suspensions and other punishing  actions are                                                            
approximately  half of  the amount  pertaining to  allopathic  or MD                                                            
disciplinary  actions. In  Arizona, for  instance, the disciplinary                                                             
rate for MDs is about one  percent of those licensed, and about half                                                            
a percent for  NDs. Nationwide the  rate for NDs is .34 percent.  No                                                            
disciplinary  action has occurred  against NDs in Alaska  during the                                                            
seventeen years in which  they have been licensed in the State. This                                                            
is a reason why the rates  are low and is a testament to the quality                                                            
and care provided by the  profession. He clarified that there are 39                                                            
licensed NDs in the State.                                                                                                      
BARRY CHRISTENSEN,  Practicing Community Pharmacist  and Legislative                                                            
Chair, Alaska Pharmacists  Association, testified via teleconference                                                            
from an offnet site to  voice concern on behalf of the Association's                                                            
200 plus  members  in regards to  the prescriptive  authority  being                                                            
proposed in the  bill for NDs. He informed the Committee  that while                                                            
he heard reference  to Amendment #1, he is unaware  of its contents.                                                            
Co-Chair  Wilken informed  the testifier that  Amendment #1  removed                                                            
the  requirement  regarding  Prescriptive  Schedules  I and  II  and                                                            
retained Schedules  III, IV, and V  in the authority being  proposed                                                            
for NDs.                                                                                                                        
Mr.  Christensen  addressed  the  position  that  NDs  education  is                                                            
"equivalent  or  nearly  equivalent"  to  that  of  an  MD  because,                                                            
similarly,  they also have  a four-year degree.  "While this  may be                                                            
true in  an academic  sense, our  membership has  had little  if any                                                            
interaction with  naturopaths during our professional  training" but                                                            
have  had extensive  training  with  PAs,  NPs,  and MDs  "and  have                                                            
developed  good  working   professional  relationships   with  these                                                            
professionals.  This  relationship is  very important  when  working                                                            
with  patients   and  recognizing   "problems   with  dosing,   drug                                                            
interactions and drug abuse."  He questioned the fact that while the                                                            
definition  of naturopathy  that is  included in  the bill does  not                                                            
include  medicine,   the  bill  would   provide  full  prescriptive                                                             
authority  to  NDs.  He  noted  that  most   states  that  allow  ND                                                            
prescribing  provide  NDs with  limited prescriptive  authority.  He                                                            
stated  that  pharmacists  would   be more  comfortable   with  this                                                            
legislation  were NDs required  to work  collaboratively with  other                                                            
licensed  prescriptors.  Lastly,  he raised  concern  regarding  the                                                            
prescriptive authority  of controlled substances,  or narcotics, and                                                            
stated that  control of such substances  should be closely  guarded.                                                            
Absent  a presciptor-based   narcotic tracking  system,  this  issue                                                            
would continue  to be "the  number one" concern  of pharmacists.  He                                                            
assured  that while there  is no  reason to believe  that NDs  would                                                            
abuse this prescriptive  authority, increasing their availability by                                                            
expanding   the  number  of  prescriptors   would  provide   another                                                            
potential avenue for narcotic abusing patients.                                                                                 
Mr.  Christensen stated  that  while the  amendment  would limit  ND                                                            
prescriptive  authority  to  Schedule  III,  IV,  and V  drugs,  the                                                            
majority  of  narcotic  drugs  are  included  in  those categories.                                                             
Therefore, the Membership would continue to voice concerns.                                                                     
Senator Olson  asked, for clarification, the Association's  position                                                            
on Amendment #1.                                                                                                                
Mr. Christensen  responded that a  majority of the Membership  would                                                            
continue  to  have  problems  primarily  due  to  the  inclusion  of                                                            
Schedule III, which encompasses  narcotic painkillers. He noted that                                                            
since he was unaware of  the amendment prior to this, the membership                                                            
has not been conferred with in its regard.                                                                                      
Senator Olson  asked the percent of patients who might  be receiving                                                            
prescriptive  relief  from  either  Schedule  II  through V  or  III                                                            
through V.                                                                                                                      
Mr. Christensen responded  that the majority of people who take pain                                                            
relievers are utilizing  Schedule III drugs, as it is the outpatient                                                            
pain drug  of choice.  A written  prescription is  not required  for                                                            
Schedule  III drugs  whereas  one is required  for  Class II  drugs.                                                            
Therefore,   he  estimated   that   approximately   70  percent   of                                                            
individuals  who  are taking  painkillers  are taking  Schedule  III                                                            
drugs. Schedule  IV drugs  are anti-anxiety  rather than  painkiller                                                            
types of drugs.                                                                                                                 
Senator Bunde voiced that  it would be an inconvenience were someone                                                            
to seek  naturopathic  care and  then discover  that  they would  be                                                            
required to go  to another medical professional were  a prescription                                                            
drug required  to treat,  for instance,  high blood  pressure  or an                                                            
antibiotic  such as penicillin. He  asked what which schedule  these                                                            
types of prescriptions are included.                                                                                            
Mr. Christensen  responded  that antibiotics  are  "not a  scheduled                                                            
narcotic" and  therefore are not regulated  by the Drug Enforcement                                                             
Administration.  They are  instead classified  as a prescription  by                                                            
the  Food  and  Drug  Administration   (FDA)  and  would  require  a                                                            
prescription.  A narcotic-based  pain  reliever such  as Tylenol  #3                                                            
would be a Schedule III drug.                                                                                                   
Senator  Olson clarified  that the  drugs included  in "Schedules  I                                                            
through V are  those that are directly related to  the potential for                                                            
abuse by either  a patient or a patient prescriptor."  An antibiotic                                                            
would not fall in this category.                                                                                                
Senator Seekins understood  that as part of a pharmacist's training,                                                            
they are taught how to recognize signs of abuse or mistakes.                                                                    
Mr. Christensen affirmed.                                                                                                       
Senator Seekins understood  therefore that "even now" in the medical                                                            
profession, abuse does occur.                                                                                                   
Mr. Christensen agreed.                                                                                                         
Co-Chair Wilken  stated that the bill would be HELD  in Committee in                                                            
order  to  develop   a  committee  substitute  that  would   include                                                            
Amendment  #1 and clarify  language regarding  the voluntary  review                                                            

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