Legislature(2005 - 2006)CAPITOL 106
04/12/2005 03:00 PM House HEALTH, EDUCATION & SOCIAL SERVICES
| Audio | Topic |
|---|---|
| Start | |
| HB231 | |
| HB161 | |
| HB204 | |
| Adjourn |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
| + | HB 29 | TELECONFERENCED | |
| + | HB 231 | TELECONFERENCED | |
| *+ | HB 112 | TELECONFERENCED | |
| + | HB 161 | TELECONFERENCED | |
| *+ | HB 204 | TELECONFERENCED | |
HB 204-OPTOMETRISTS' USE OF PHARMACEUTICALS CHAIR WILSON announced that the last order of business was HOUSE BILL NO. 204, "An Act relating to the prescription and use of pharmaceutical agents, including controlled substances, by optometrists." 4:38:45 PM REPRESENTATIVE BILL THOMAS, Alaska State Legislature, as sponsor of HB 204, said that he represents 28 communities, which together have one optometrist and no ophthalmologists. He said the bill is critical for the needs of those communities. He said it is important to note that the unemployment rate in those communities ranges from 35 to 85 percent. The chance of many of the citizens in these communities having insurance is "nil." REPRESENTATIVE THOMAS stated that HB 204 would change statutes to allow optometrists to administer oral pharmaceuticals to provide better and more complete eye care to Alaskans. Currently, he noted, optometrists are limited in the treatment of eye disease that is seen on a routine basis and would benefit from oral medication, including acute allergic reactions, ocular herpes, ocular herpes zoster, and chronic lid diseases. Currently 100 optometrists in 17 locations serve the state, spanning from Barrow to Juneau. There are 26 eye care specialists in 6 locations that can prescribe oral pharmaceuticals in Alaska. REPRESENTATIVE THOMAS recounted a time when he was visiting a rural community and was suffering from diverticulitis. He was surprised that the physician's assistant could prescribe medication for him, while an optometrist could not. The proposed legislation would enable the optometrists to practice at the level at which they are trained. Representative Thomas reminded the committee that the legislature had recently voted in favor of a bill that would allow doctors trained in Asia to come to the Alaska and practice. He said HB 204 is simply asking that optometrists be allowed to use their background and education to the full extent. He also noted that another bill was recently supported that would allow a student to carry his/her own syringe and self treat in the case of anaphylaxis, while an optometrist is not allowed to treat for emergency anaphylaxis. REPRESENTATIVE THOMAS said, without question, vision is an important aspect of a person's life and should be treated by a trained eye care professional. Currently, optometrists must refer outpatients to a general physician, physician's assistant, or a nurse practitioner for oral treatment of ocular disease. He said the proposed legislation would remove an extra step by having the ocular treatment done by an eye care professional, thereby saving the patient from undue complications and financial costs. He said, for example, that a person coming to Juneau from Kake for eye care would spend $200 roundtrip by plane, or would have to take a circuitous route by ferry, which is only offered twice a month. REPRESENTATIVE THOMAS said ophthalmologists are specialists, and he indicated that he is not trying to take anything away from them. He said he just wants people from the Bush to get good and timely eye care. 4:47:10 PM CHAIR WILSON stated her intention to hold the bill because it is "different than the one last year." 4:47:35 PM REPRESENTATIVE GARDNER referred to Representative Thomas' asking that optometrists be allowed to use their training. She stated her understanding that ophthalmologists are doctors, whereas optometrists are not, and she asked if that is correct. REPRESENTATIVE THOMAS offered his understanding that optometrists have been trained in the area of giving oral medicine for eye care. He added that if that were not the case, 44 states would not have already allowed optometrists to [prescribe oral eye medication]. He suggested that the experts could enlighten the committee further. REPRESENTATIVE GARDNER suggested that a person in the Bush could get a prescription from a nurse practitioner. REPRESENTATIVE THOMAS said the concern is that a person not trained specifically in the care of eyes could make a misdiagnosis. 4:50:40 PM CARL ROSEN, M.D., President, Alaska Eye Physicians and Surgeons, testified in opposition to HB 204. He told the committee that he is an ophthalmologist who practices in Anchorage. He stated that ophthalmologists attend college for four years, go through four years of medical school into which only 1 in 200 get accepted, serve a one-year internship in medicine or surgery, and complete a three-year intensive residency, at which point the ophthalmologist learns to diagnose, treat, and operate. The residency is typically done in a large university or city hospital where the ophthalmologist conditions him/herself to deal with very sick people. The system filters out those who can't handle the surgical anxiety that comes with the job. Dr. Rosen said he completed a fellowship in addition to the three years of residency to further train himself in orbital surgery and neuro-opthomology. DR. ROSEN said the issue of the rarity of finding an ophthalmologist in a rural community is "yes and no." He explained that the Native hospital travels frequently to various Native communities and has its own patient population. He noted that the U.S. Air Force also does that. His own practice has doctors who travel to Kodiak, Cordova, and Sitka. He added that there are [ophthalmologists] in both Juneau and Fairbanks. DR. ROSEN confirmed that nurse practitioners have the ability to prescribe medications, but they are specifically trained to "be the first line." They treat with medication and also are knowledgeable regarding the pharmacology of medicines. He said anyone trained as an optometrist beyond five years ago did not have the intensive training to understand the pharmacokinetics and interaction of medicines. Optometrists also do not have hospital-based privileges or interact with the medical community on a regular basis. Dr. Rosen said he frequently consults other medical specialists when multiple drugs are involved. DR. ROSEN stated that HB 204 does not differentiate treating an infant versus a ninety-nine-year-old. He said there is a danger in "just allowing this to go forward." He said the subject of the bill has been seen in the past and has consistently been thwarted. He said, "If you read the bill, it's under the jurisdiction of the optometric community, which is outside the purview of the medical board and the medical community." He said he thinks that's a dangerous problem. DR. ROSEN said ophthalmologists in Alaska do take phone calls as a courtesy to the people of the state. He said he is available 24 hours a day, 7 days a week. He said: Some states do have this bill, but if you look at the overall number of optometrists who use it, it's very small .... Let's say there's 100 optometrists in New Mexico who have this privilege; roughly 10-15 will actually use medications on a consistent basis to be considered familiar with medications. So, the vast majority don't have the numbers. And in medical school and in residency training, you're only allowed to graduate if you can prove that you have the ... capability to do this procedure or understand this disease. That's how medical school training [works]. And optometric training will not have that, because now they're outside of school and they're relying on the optometric board to give them a go or a no-go on this. So, I think that's also a problem. 4:57:53 PM REPRESENTATIVE ANDERSON indicated that he would like to know if there would be trouble if the bill is not passed. DR. ROSEN answered no. He stated: As long as you're able to communicate the clinical symptoms and describe the ophthalmic condition to an ophthalmologist, or even [to] the emergency room which can transfer [that information] to the ophthalmologist ..., we're able to intervene and appropriately manage and assess the patient and then prescribe any medication, if any is necessary. ... There is no public outcry for this, and I have not heard or [do not] know of a problem where an optometrist has had a dire condition and has not been able to contact an ophthalmologist when needed. I just don't know of one. 5:00:30 PM REPRESENTATIVE CISSNA asked if "telemedicine" is involved. DR. ROSEN said he not only supports telemedicine, but it's been a hobby and avocation of his for the past seven years. He said efforts are being made to get more of the medical community to accept [telemedicine]. He listed some of the cases that he has treated by telemedicine. 5:01:53 PM DONALD J. CINOTTI, M.D., said that he is from the American Academy of Ophthalmology and is "on the state affairs committee" in New Jersey. He said he monitors similar bills across the country and considers the ramifications of them. Dr. Cinotti stated that the proposed legislation is by far the most expansive of any bill he has seen in a long time, because of its vague language. For example, the bill mentions pharmaceutical agents, but does not specify oral pharmaceutical agents, which he said would lead a person to believe that injectable medications could be used, which he said is very troublesome. He said another concern is in regard to the use of "off-label medication." The treatments for ophthalmic disorders are becoming very complex. He offered an example of medicine that can be dangerous in the wrong hands, and he said some complications can lead to death. He stated, "Certainly we don't believe that the optometrists have the expertise or the knowledge to recognize the complications of use of these medications, nor the ability to treat them properly." DR. CINOTTI said it's often mentioned that there are not enough ophthalmologists around to take care of patients, but in reality, there are, he said. He explained that when a patient goes to an emergency room there is usually an arrangement between that emergency room and an ophthalmologist on call who can determine the proper treatment. He said the bill has no oversight by physicians of optometrists; there would be no phone call to an ophthalmologist to see if the medication or the diagnosis is correct. He reiterated that the bill is a "very, very dangerous" one. 5:05:58 PM REPRESENTATIVE SEATON asked if the language in the bill that Dr. Cinotti would like tightened is that on page 1, lines 9-10, which read as follows: (2) the pharmaceutical agent is prescribed and used for the treatment of ocular disease or conditions, ocular adnexal disease or conditions, or emergency anaphylaxis; DR. CINOTTI, in response, said many treatments for diseases are progressing, and he offered examples. He reiterated that the language does not specify oral versus injected medicine, but only lists "pharmaceutical agent". 5:07:38 PM DR. CINOTTI, in response to a follow-up question from Representative Seaton, said adding "oral" before "pharmaceutical agent" would help, but there would still be the need to consider what is necessary for an optometrist to treat patients in a rural area. For example, if the concern is that optometrists should be able to use antibiotics, then the bill should specifically list what antibiotics they may use. He stated that an ophthalmologist, in practice, does not, in general, use controlled substances. He said he has worked as a director of ocular trauma in a major hospital for 22 years and has not written a subscription for a narcotic in at least three years. He added, "So, what is the point of giving the optometrist the right to subscribe narcotics?" 5:09:08 PM BOYD WALKER, O.D., testified in support of HB 204. In response to remarks from the previous speakers, he said he believes it is up to the individual practitioner to make the decision as to whether something is within their scope of practice or not. He said a family practice doctor may well be capable of delivering a baby, but an obstetrician may think otherwise. Dr. Walker said he is not arguing that an ophthalmologist's level of training is [not] higher than that of an optometrist; however, he stated that in routine practice, there are times when individual optometrists - especially those in rural areas of Alaska - need to have the ability to prescribe oral medications and occasionally even inject medicine. He continued: I recall back in the 70s, when optometrists were not allowed to use any medications, whatever - not for the purpose of diagnosing eye disease, nor for the purpose of treating eye disease. And ophthalmology said, "Gosh, people die from eye drops that dilate your eyes." Well, I believe today that after 15 years of experience that even our ophthalmology colleagues would agree that optometry has served a great function in terms of diagnosing eye disease that they would not have been able to find had not pharmaceuticals been allowed to optometry. DR. WALKER said Dr. Rosen alluded to the fact that "even in states like New Mexico that have the drugs, not everyone uses them." He stated his belief that that proves that optometrists are judicious in the use of the drugs; they only use them when necessary and they probably do make a lot of referrals to ophthalmologists who are readily available. In rural Alaska, he said, there certainly are cases where individuals might need immediate treatment and be unable to get it. DR. WALKER said the education of an optometrist is similar to that of a family practice physician and dentist, and in most cases above that of a nurse practitioner and physician's assistant. In conclusion, Dr. Walker stated his belief that optometrists have the education and the credentials to use "these medications" and will be careful in using them to the best interest of their patients. He said he believes that rural Alaskans would really benefit from [the proposed legislation], in terms of not having to wait for treatment or having to take the time to travel to a larger center where an ophthalmologist may be available. He urged the committee to support HB 204. 5:13:35 PM DR. WALKER, in response to a question from Chair Wilson, outlined the training necessary to become an optometrist: four years of undergraduate work, pre-optometry, or pre-medicine, followed by an additional four years of post graduate training in optometry school. Many optometrist elect to subsequently complete either an internship or residency, although he said that is not all that common. 5:14:47 PM REPRESENTATIVE CISSNA noted that she has heard the subject of the bill for seven years. She asked if there was some way that the optometrists could augment their education so that the concerns of the medical community could be solved. DR. WALKER responded that optometric education already trains individuals to use "these medications." He said it appears that it is the ophthalmology community who is showing an unwillingness to compromise. He clarified that he does not even categorize that group as being the medical community. Currently, statute requires that optometrists partake in continuing medical education, which is regulated by the state. Those optometrists that utilize pharmaceutical agents have to have specific retraining on a biannual basis in order to renew their licenses. 5:19:02 PM REPRESENTATIVE GARDNER noted that a naturopathic doctor undergoes eight years of training. She asked Dr. Walker if he thinks they should have prescriptive rights. DR. WALKER responded that he knows nothing about the training of a naturopathic doctor and therefore cannot speak to that. He said he thinks every professional who [prescribes] medication or performs procedures should be willing to display his/her curriculum of training. He said, "Those who have an M.D. behind their name, once they've received their training and they have their degree and their board exams behind them, really have no one to answer to other than the medical board. ... All other ... limited license practitioners must come to ... the legislature to develop regulation to delineate their scope of practice." 5:21:01 PM GRIFF STEINER, M.D., offered his medical training history and told the committee that he is an ophthalmologist who has special training in glaucoma and corneal surgery. He said that although he has respect for Dr. Walker and the profession of optometry, he must refute a number of Dr. Walker's assertions. First, regarding Dr. Walker's claim that optometrists have the same amount of training as family medical physicians and dentists, he said that during their entire training period, physicians, dentists, and nurse practitioners administer medications to patients under the supervision of other physicians. At no time during optometrists' training are they prescribing medications under supervision, or at all. Dr. Steiner said in his practice he has rarely had to prescribe oral antibiotics. He continued: The only times I have had to prescribe oral antibiotics is when the patient had a very dire infection, the kind that could kill them - the thing that would have to be referred. If an optometrist saw lid swelling and treated it with oral antibiotics and it was instead a diabetic infection of the sinuses, that patient would die in a matter of days. It cannot be overstated that optometrists have no practical training in prescribing medications, other than eye drops. During their training, they do not prescribe oral antibiotics or pain medications to patients in the hospital; they're not responsible for any patients in the hospital during their entire training. DR. STEINER agreed with the prior testimony of [Dr. Cinotti] that HB 204 is dangerous because of its vagueness. If the bill were to pass, he warned, optometrists would then have precedent to apply to the federal drug enforcement agency to be allowed to prescribe drugs that are "way outside their purview." He said he thinks the bill would also be a stepping-stone in allowing optometrists to do surgical things they are also not trained to do. DR. STEINER said the only way that optometrists are associated with operations is by doing the post-operative care for an itinerate physician who flies to Alaska from out of state, performs surgery, and leaves the patient in the care of the optometrist. He continued: They're not trained to do this either. If we allow them to do these prescriptions, they will keep prescribing medications for patients they're not trying to take care of in the first place, and they're especially not allowed to prescribe the medications to those patients. And they'll be no supervision as this itinerate physician flies immediately back down to Seattle. ... The itinerate physician himself has said that he doesn't feel qualified to treat these medical patients, so, ... as an M.D., he does not take referrals from his optometric network. And the optometrists are too embarrassed or reluctant to refer to us, because of the arrangement with the itinerate physician, which ..., albeit not illegal, ... allows for a $200-400 per eye payment if they refer to the itinerate physicians. They would get no money if they referred to us. And so, ... the only M.D. that they're strongly associated with feels unqualified to treat patients and refers them back to the optometrists, who then refer back and forth between optometry. We've seen patients admitted to hospitals treated by optometrists [with] medications that they're not licensed to prescribe. ... I don't think I can overstate this enough. [HB 204 was heard and held.]
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