Legislature(2001 - 2002)
04/24/2001 03:08 PM House HES
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* first hearing in first committee of referral
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+ teleconferenced
= bill was previously heard/scheduled
HB 215-OPTOMETRISTS AND PHARMACEUTICALS CHAIR DYSON announced that the next order of business would be HOUSE BILL NO. 215, "An Act relating to the use of pharmaceutical agents in the practice of optometry; and providing for an effective date." Number 2070 JEFF GONNASON, O.D., Chair, Alaska Optometric Association Legislative Committee, came forth and stated: Optometry is a primary health care profession [that] examines, diagnoses, and treats disorders of the human eye. [It] uses diagnostic and therapeutic medications, methods, and procedures. Education consists of a bachelor's degree, followed by a four- year professional program of didactic and clinical training to receive a doctorate of optometry degree, known as an O.D. Many graduates also take an additional one-year residency specialty. This is identical to the training in dentistry. The course of instruction and pharmacology and the use of medication are equivalent, in scope and hours, [to what is] taught in medical school, dentistry school, and podiatry school, with many more hours of emphasis on treating the eye. ... In 1988, after 12 years of effort testifying here, Alaska's statutes were updated to allow optometrists, [who] were qualified, to use diagnostic drugs. ... We were the 49th state out of 50 to enact that. In 1992 the prescribing of therapeutic drugs to treat eye diseases was authorized, and Alaska was the 32nd state. However, due to a compromise in that original bill, the oral medications were dropped, so drugs prescribable were just limited to topical only: eye drops and salves. ... Currently in the United States, all 50 states authorize optometrists to prescribe drugs - 37 of those states allowing oral drugs to be prescribed, including controlled substances, and 21 states allowing some form of injectable drugs. House Bill 215 before you will bring Alaska up to where North Carolina started back in 1976, 25 years ago. ... This is not new ground. One state, Oklahoma, authorizes optometrists to perform laser surgery. Five years ago, a bill was introduced and heard that would allow the state board to determine the scope of practice of optometry, as is the case for nurse practitioners. This bill would have not only included all medications for the eye, but also advanced use of lasers and some minor surgical procedures for qualified optometrists. That bill did not pass. Three years ago, Senate Bill [SB] 78 was introduced. ... It was highly compromised, and it did not contain any expanded scope of practice such as lasers or minor surgery, even though those are currently taught in the schools. The SB 78 simply removed the topical restriction on our drug allowance, allowing optometry to use the necessary tools of treatment. ... There was no testimony opposing the bill other than a couple of written letters in two years of hearings. The bill passed the House 37 to 2 last year and concurred in the Senate 19 to 0 last May. The governor vetoed the bill, citing possible inadequate board oversight of training and testing and concern regarding eye injections. Number 2230 DR. GONNASON continued, stating: For 2001 ... this current bill is similar to SB 78, but with further limitations and board authority for ensuring competency. It will change the scope of board-endorsed optometrists to prescribe the additional medications beyond topical for treatment related only to the eye - they can't do stomach or gout medicine, ... unlike our nurse practitioner friends, who can treat anything within their level with one year less training. And this bill also has Section 3 added, which prohibits injections into the globe of the eye. ... Malpractice carriers report no difference in premiums or claims between states with or without pharmaceutical authority. And optometrists are considered physicians under federal Medicare law. Now, the state audit committee reported that eye care was improved in Alaska by allowing optometrists [to] prescribe drugs, and [have] saved money on travel and double visits. House Bill 215 will allow Alaska optometrists to practice at the currently accepted level of care. The rural optometrist often has to get the PA (physician's assistant) or the health aid to authorize the needed medication. Alaska's 90-plus optometrists are located in over 18 towns and travel to many villages, while the ophthalmologists are located mostly in Anchorage - 18 of them - with a few in Fairbanks - 4, Juneau - 2, and the Kenai Peninsula - 2. ... Now we're faced with the difficulty of getting new graduates to come back to Alaska to practice because we're so far behind the times. And also, ironically, Alaska Statute 08.72.240 requires that optometrists, "keep informed of and use current professional theories [or] practices." ... The Academy of Ophthalmology argues that an ophthalmologist is more qualified to treat diseases of the eye. This is partly true, in that they are trained in specialty, tertiary care and surgery of the eye as a specialist, just as a heart surgeon is specialized. But the optometrist is specialty-trained for primary and secondary care and limited surgery. One of the things we currently do is remove foreign bodies from the eye; that's in our statute. ... Included in our training is prescribing pharmaceuticals. ... The question is not who is more qualified, but rather should qualified optometrists be allowed to practice at their highest level of training with the current standard of care? After carefully examining the facts, we're confident that you can trust a board-endorsed Alaskan optometrist to provide confident, primary and secondary care for their patients, and refer to the ophthalmologist when needed for their advanced specialty care. [This is] no different [from] when family doctors refer to heart or cancer specialists. The legislature offers full authority to M.D.s to perform anything they wish, by trusting they will not practice above the level of their training and refer to specialists. The same applies to dentists and nurse practitioners in Alaska, where their scope of practice is determined ... TAPE 01-50, SIDE B DR. GONNASON continued, stating: ... by their own state board and the Alaska legislature trusting them to practice only as qualified. Why, then, are optometrists so untrustworthy and untrainable, when we actually have more education in applying the same standards to these health professions? Number 2284 LINDA CASSER, Optometric Physician, Associate Dean for Academic Programs, Pacific University College of Optometry, testified via teleconference in support of HB 215. She explained the following seven key points to the committee: The doctor of optometry degree program is a four-year graduate level program. It is comprised of 180 credit hours, which equate to 4,315 contact hours of education. Secondly, the prerequisite course of study is rigorous and comprehensive. It is comparable to that completed by premedical and predental students. Thirdly, preoptometry students are required to pass the optometry admissions testing examination, which is comparable to the MCAT [medical college admission test] examination required of medical students. The OAT [optometry admission test] examination is actually administered by the American Dental Association. Fourthly, students in the doctor of optometry program are thoroughly educated in the basic sciences so that diseases and disorders of the eye are understood and treated in their proper context. (Indisc.) In several institutions, optometry students sit side-by- side with medical and dental students in these basic science courses. Fifthly, 255 classroom hours within the curriculum are assigned to the area of pharmacology, including the use of topical, oral, and ingestible medications in the treatment of the eye and the study of its structure. This cited figure does not include the additional 165 classroom hours pertaining to the diagnosis, treatment, and management of ocular disease as well as the extensive patient care clinical experience in which these pharmacological concepts are actively applied. My sixth point is that studies indicate that optometry isn't receiving comparable course hours and pharmacology as is medical and dental students. Students in the doctor of optometry program receive added training and education in ocular pharmacology. And finally, our students begin their clinical activity in their first year. Patient care experience increases in complexity and (indisc.) throughout the program. The fourth year is spent in full-time patient care activity. Two of the three semesters are spent at off-campus clinical preceptorships in a variety of health care settings. In total, our students spend at least 2,000 contact hours examining diverse patient populations who have (indisc.) and systemic diseases. In closing, doctors of optometry are thoroughly prepared to provide safe and effective eye and vision care services for the patients they serve, including the use of systemic medication. Number 2100 CHAIR DYSON remarked that it has been represented to him that one of the reasons optometrists should not to be able to dispense drugs is that if a patient is taking a second drug for another condition, the optometrist is untrained to be able to determine any possible negative interactions of the two medications. DR. CASSER responded that that could not be farther from the truth. She said [optometric] students receive general pharmacology training, which includes a full understanding and education of the side effects from the interaction of drugs. CHAIR DYSON asked Dr. Casser if what she listed as part of the training at Pacific University College of Optometry is comparable to other schools in the country. DR. CASSER answered yes. She said there are 17 schools and colleges throughout North America, and the training is comparable at all of those institutions. Number 2020 REPRESENTATIVE WILSON asked Dr. Casser how far back these educational requirements go. DR. CASSER responded that it would be difficult for her to answer specifically without taking each of the curricula and putting them side-by-side through the varying years. She noted that she graduated from Indiana University in 1978 and she took an oncology course in 1975, which was the same course offered to the medical students. She stated that she would venture to say that 20 years would be a safe [estimation]. REPRESENTATIVE STEVENS asked what the difference is between an optometrist and an ophthalmologist. DR. GONNASON responded that the ophthalmologist goes to undergraduate [school], four years of medical school, and then takes a three-year residency, just like a person would for family practice or gynecology. He explained that a three-year residency is basically on-the-job training. Some ophthalmologists, he said, will go on to an advanced specialty - a fourth year - and be a retina surgeon or a glaucoma specialist. Optometry is the same as for dentistry; it's a four-year undergraduate degree and a four-year professional program. The basic sciences are the same. The problem that comes in is that people are told that optometrists are lumped in with naturopaths and chiropractors, who are some sort of alternative [medical providers]. He stated that they are not. [Optometrists] take the same basic sciences, use the same medical and pharmacology books, and study under the same professors [as ophthalmologists]. He added that the majority of what he knows was taught to him by ophthalmologists. Basically, he said, [optometrists] are generalists in eyes, and [ophthalmologists] are specialists in eyes. DR. GONNASON stated that the optometrists and the ophthalmologists have had a turf battle for 30 years as the education moved into a more advanced training. Around 1968, [optometry] went to a full four-year program, and in some states have been prescribing drugs for 25 years. REPRESENTATIVE STEVENS asked if an ophthalmologist has necessarily been trained as an optometrist. DR. GONNASON responded that a person is required to have a M.D. (medical doctorate) degree to take a residency in ophthalmology. Number 1772 REPRESENTATIVE JOULE stated that in the hub communities in rural areas there are eye doctors. He asked if they would more likely be optometrists or ophthalmologists. DR. GONNASON replied that they are all optometrists. CHAIR DYSON stated that often it is the optometrist who realizes that the patient needs some medication. He asked if [the optometrist] would have to go to a PA or [advanced nurse practitioner] to get [the prescription]. DR. GONNASON answered that he was correct. CHAIR DYSON asked if [PAs and advanced nurse practitioners] have had less training [than an optometrist]. DR. GONNASON answered yes, that a health aid with three weeks of training [can prescribe medications under federal authority with the Public Health Service]. REPRESENTATIVE WILSON added that a health aid can only prescribe under certain conditions. Number 1684 BOB PALMER, Director, State Governmental Affairs, American Academy of Ophthalmology, testified via teleconference. He stated: Although HB 215 is short, the policy ramifications that it can have on [the] Alaska health policy care system, specifically regarding eye health care, is very complex. And due to the time constraints that you are now facing, you may find it necessary to complete this review during the interim. From our perspective, HB 215 gives the optometry profession a ... blank check for prescribing oral drugs, with little supervision and pharmaceutical training. Last year, this type of legislation was rejected in such states [as] Florida, Georgia, Hawaii, Maryland, Mississippi, New York, Pennsylvania, and South Dakota, and Washington state. ... This year, the same provisions were again rejected in Washington state and several other states. ... I think you would agree that ... you and legislators all across the United States are seriously questioning the wisdom of enacting additional legislation that would further expand optometric drug- prescribing authority. The question that you really must address from a policy standpoint is, "What is the bill and why is it before you?" The citizens of Alaska, to our knowledge, are not calling for the [enactment] of this type of broad drug-prescribing authority, only [the] optometry profession. To our knowledge there's been no claims or [delays] getting appointments with ophthalmologists when symptoms of disease are present. And if there are such problems, the ophthalmologists would want to know and would gladly work with you to remedy any such delay. This can be easily accomplished without the change in the law. For example, right now ophthalmologists from the Alaska State Society are examining rural health care delivery. ... The objective is further to improve the quality of rural health care services at less cost to Alaska's system. In conclusion, we believe the far-reaching health policy implication may not be in the best interest of the citizens of Alaska. House Bill 215 does not improve the access to health care, does not open up new (indisc.), it does not provide new services to the citizens of Alaska, and finally, this bill does not cover the health care cost for Alaska. CHAIR DYSON remarked that there are about 217 or 218 communities in the state that don't have an ophthalmologist, and maybe a third of them have an optometrist. He asked Mr. Palmer how he can make the claim that doing this wouldn't expand the care to those villages that have an optometrist. MR. PALMER responded that from his information, there is a strong telemedicine presence in Alaska. The Alaska State Society is working on improving it so that if there is something that happens in the Bush where there is not an ophthalmologist, the clinician can immediately call an ophthalmologist to get information on what needs to be done. He added that that system seems to be working very well. CHAIR DYSON asked Mr. Palmer if he is recommending that ophthalmologists serve as supervisors to the optometrists in the prescription of these drugs. MR. PALMER stated that that would fall upon the board of medicine, which is the governing board for the state of Alaska. Number 1424 CHAIR DYSON asked Mr. Palmer if he knows of anything that Dr. Casser told the committee about the training of [optometrists] that is untrue. MR. PALMER responded no. REPRESENTATIVE JOULE remarked that while telemedicine is an "exciting" thing, there are many villages that are still without it. Number 1307 CARL ROSEN, Ophthalmologist, testified via teleconference. He stated that 2,000 hours of training is certainly commendable, but he probably has 24,000 hours of training. He said he went to Amherst College, obtained a graduate degree at Harvard University, and went to medical school at Boston University. After that he did an internship for a year, being on call every second and third night at Albert Einstein College of Medicine in New York. He explained that he not only rotated through medicine, oncology, neurology, and the cardiac care unit, but also took care of very sick patients. He added that although the training may sound similar, it is very different. DR. ROSEN stated that Dr. Ford wrote a letter in support of this bill; however, he explained that Dr. Ford is an ophthalmologist who lives in another state and comes to [Alaska] to operate. He then co-manages with optometrists to care for his patients. Dr. Ford is not part of the ophthalmology community in Anchorage because he does not take calls with the other ophthalmologists. DR. ROSEN remarked that as far as reaching the outlying area where there aren't ophthalmologists, [the ophthalmologists] are working hard to allow for patient information collection, data collection including images and sound files, and server storage allowing Internet connections so that [ophthalmologists] can see that information and respond quickly. He added that he was in Washington, D.C., and met with (U.S.) Senator Stevens' aid and the Native group at the Alaska Native Hospital, and they are trying to develop these systems to forge ahead and create a working, functional telemedicine system. Number 1215 CHAIR DYSON stated that [HB 215] even further restricts the range of drugs and the method of delivering them. He asked Dr. Rosen if that is his understanding. DR. ROSEN answered no. He said that it is under the jurisdiction of the optometric board, which is not the medical board. He offered his opinion that petitioning for the granting of individuals' rights, skills, and talents that aren't truly earned could be representative of bad judgment. CHAIR DYSON stated that it doesn't seem to him that optometrists are doing nearly as profound a medical service as ophthalmologists are. He asked Dr. Rosen to respond to the fact that optometrists in the more rural areas have to go to a PA or an advanced nurse practitioner who have the authority to make prescriptions, while the optometrists can't. DR. ROSEN responded that he has not heard of a problem with a patient in that situation. He said the telephone is being used and the plan is to extend telemedicine. Number 0911 MICHAEL LEAVITT, Manager, State Governmental Affairs, American Academy of Ophthalmology, testified via teleconference. He stated that he read in an optometry trade magazine that on average optometrists prescribe one drug script per week, while ophthalmologists prescribe 61 per week. From a public policy perspective, that explains three things. First, this bill is not going to materially improve the delivery of better eye care in Alaska. Second, optometrists cannot get the experience they need to safely prescribe systemic drugs safely and appropriately. To put this in perspective, he stated that during a hospital internship a medical doctor personally writes 30,000 prescriptions. Some of these people being treating may be taking 10 or 15 other drugs concurrently. This is where the doctor learns the fundamental drug interactions and the interplay of diseases. MR. LEAVITT stated that during a three-year residency for ophthalmology, the ophthalmologists will write another 30,000 prescriptions in learning the intricacy of ocular disease. He asked, "Where is the optometrist going to get that experience? By whom is the optometrist going to be taught? And who's going to supervise their training?" Third, he said the statistic that he cited [earlier] has led him to the conclusion that [HB 215] is really for a few optometrists with the best of intentions who want to dabble in the treatment of complex eye disease. However, this is unfair to the citizens of Alaska. Last year, Public Opinions Strategy, a public relations firm, conducted a survey of 400 people that showed 50 percent of the public believes that optometrists went to medical school. However, once the public was given specific knowledge of the fact that ophthalmologists went to medical school and optometrists did not, 84 percent said it was important to go to an ophthalmologist for the treatment of an eye infection with medication, and 96 percent thought it was important to go to an ophthalmologist for emergency care for severe eye pain or vision loss. MR. LEAVITT concluded by saying no ophthalmologist is going to go out of business because of this bill, but diseases and degeneration of the visual system [require a person with] medical training. Number 0704 DR. GONNASON, in response, stated: I send Dr. Rosen all of my orbital and lid surgeries, because I certainly don't do orbital lid surgery. ... As far as taking [calls], we've offered to help with the [calls] in Anchorage, but we're optometrists [and] they don't want to let us take the call, even though what happens is we operate at the primary and secondary level; therefore, if there's something that needs ophthalmological care, [the patient is] flown to Anchorage from Bethel and Nome and Kotzebue; [he or she is] ambulanced to the hospital for that specialty care. But for eyelid infections, we handle them just fine. [With] 90 percent of the emergency room things coming in - you got something in your eye or you got a scratch on your eye - that's what's going on. ... We could easily take the call, and the right instruments are right there. ... Of telemedicine, that's great, but you need the microscope to be there. ... No laws have been repealed in the 30 years that these have been going on. All those states [Mr. Palmer] cites as being rejected, that just simply means the bill didn't move through the committees and pass. ... The locations of the ophthalmologists, like I say, they're in Anchorage, [a] couple [are] in Fairbanks, Juneau, and the Kenai Peninsula; they aren't out there and available. The optometrist is the one on call in Nome, the one called at two in the morning. If they can't handle it, [the patient is] shipped to town. ... There's been two studies done [in] California and Kansas [that] looked at the effectivity of treatment and the cost-effectiveness with ophthalmologists, optometrists, and nurse practitioners, and they found that ... the public was indeed safe and well treated. I write one to six prescriptions a day in my office, depending on what comes in. I take a thorough medical history. I know if they are diabetic, whether they're controlled, uncontrolled, and what they're on and all their medicines, and I treat at my comfort level. Number 0518 CHAIR DYSON asked what level of prescription Dr. Gonnason is allowed to do under existing law. DR. GONNASON responded that since 1992 he has been able to prescribe topical [drugs] such as eye drops or ointments. CHAIR DYSON stated that [optometrists] are now trying to expand that to oral [drugs]. He asked if there are any limits [in HB 215] on the oral prescription [optometrists] will be able to give. DR. GONNASON answered, yes, that this bill will not allow for schedule one and two narcotics. Schedule one includes the most dangerous and abused drugs such as heroine and morphine. Schedule two includes narcotic painkillers. He stated that he would rather that schedule one only be excluded, because the nurse practitioners, in their regulations, are authorized to prescribe schedules one through five. CHAIR DYSON asked Dr. Gonnason how many times a day in his practice he has to get another medical professional to write a prescription for him. Number 0376 DR. GONNASON responded, probably twice a week. CHAIR DYSON asked Dr. Gonnason what he thinks it is like for the optometrists in the villages that are not on the road system. DR. GONNASON replied that they are using oral medications quite a bit. He added that [the ophthalmologists'] argument could be said for dentists, and asked, "Why don't they suddenly slap the dentists with restrictions or supervision?" He stated that he thinks he has enough training and education that he doesn't need supervision with these medications. REPRESENTATIVE JOULE asked if there are instances of abuse in states where optometrists are given this latitude. He asked if this is something that has caused the repeal of laws in any states. DR. GONNASON responded that no law has ever been repealed; there has only been expansion and amplification. He said there have been no problems in the 25 years since optometrists first started prescribing drugs. He added that Tennessee has had the exact same law as this bill for nine years, and there hasn't been one complaint to the state board of misuse of drugs by optometrists. Number 0128 DR. CASSER remarked that in response to Mr. Palmer, who referenced the blank check for prescribing authority, HB 215 very clearly states that these drugs would be used to treat the eye and its appendages that are very specific and appropriately limiting for optometry. In response to Mr. Palmer's comment about little training, she stated that optometrists' pharmacology training is comparable to other professions that are using oral and systemic medications. She said she believes it is appropriate for the optometry board to be the overseeing body because optometry is an independent profession and should be regulated by the rules of the state board. In response to Dr. Rosen's comments regarding 2,000 hours of training as being regrettable, she said that the 2,000-hour figure she used referred only to the clinical portion of the program. The total program is in excess of 4,300, which does not include the undergraduate work. She remarked that Mr. Leavitt asked who teaches [the optometry students], and she answered that the systemic disease course series [at Pacific University] is taught by a physician who is a specialist in Portland. It is also instructed by an individual who is a pharmacist, optometrist, and in a PA program. TAPE 01-51, SIDE A Number 0043 MR. PALMER remarked that he does not have any knowledge of the Alaska Medical Board working on any type of language or compromised language dealing with this bill. Regarding the information concerning the patients, he stated that that information is very anecdotal. He said the state of Florida is considering a bill dealing with comanagement between the two professions. Emergency physicians have testified in the Florida legislature that there ends up being a "dumping" of patients from optometry into the emergency room. MR. LEAVITT stated that concerning one of the bill's focuses, on controlled substances, a professor of ophthalmology whom he knows tells her first-year residents, "If you have got to prescribe a controlled substance, you probably missed the diagnosis." Number 0210 CHAIR DYSON called for an at-ease at 4:47 p.m. The meeting was called back to order at 4:50 p.m. CHAIR DYSON declared that Dr. Gonnason is his personal optometrist. REPRESENTATIVE CISSNA remarked that Dr. Gonnason is a constituent of hers. She said she helped him work on this bill last year, and he ran against her. CHAIR DYSON stated that it can be argued that both he and Representative Cissna have a conflict of interest, and that this can be viewed in terms of its ethics. He said he is going to rule, however, that both he and Representative Cissna have to vote. REPRESENTATIVE CISSNA remarked that she did work on the bill last year and voted for it. She then discovered that the piece that was missing was that the medical board had not weighed in. When they weighed in with the governor, it was vetoed. She stated that she did call the [medical board] this year on the basis of last year's rejection, and they said they wanted to work with the optometrists in perfecting this bill so it would actually meet everyone's needs. She added that her understanding is that the governor's office has the same concern. CHAIR DYSON stated that Representative Cissna has told him that the State Medical Board had written to the Board of Optometry to discuss this in the fall. Number 0403 REPRESENTATIVE JOULE moved to report HB 215 out of committee with individual recommendations and the accompanying zero fiscal note. REPRESENTATIVE COGHILL objected. Number 0439 A roll call vote was taken. Representatives Stevens, Joule, Kohring, and Dyson voted in favor of moving the bill. Representatives Wilson, Cissna, and Coghill voted against it. Therefore, HB 215 moved from the House Health, Education and Social Services Standing Committee by a vote of 4-3.
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