Legislature(2001 - 2002)
02/22/2002 03:30 PM House L&C
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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 Number 012 CHAIR MURKOWSKI announced that the only item on the agenda is 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 024 AMY ERICKSON, Staff to Representative Lisa Murkowski, Alaska State Legislature, presented HB 215 to the committee. She said that HB 215 was introduced at the request of the Alaska Optometric Physicians Association and would authorize optometrists to prescribe medications to treat allergy conditions, infections of the eye and eyelids, glaucoma, and eye abrasions and allergies. Thirty-eight states already allow optometrists to prescribe [the aforementioned medications]. She stated that optometrists have extensive training and are required to complete a pre-professional undergraduate program followed by four additional years of professional education at a college of optometry, which would earn them a doctorate in optometry. Then an optometrist has to pass a national board exam. She pointed out that an optometrist's education and training requirements in many areas match or exceed that of other health care providers who are currently able to prescribe oral medications to their patients. She noted that the training of physician assistants, advanced nurse practitioners, and dentists mirrors that of optometrists. MS. ERICKSON said that in many cases optometrists are the only eye care practitioners available in outlaying communities; having the ability to prescribe would give optometrists the ability to provide optimum care for their patients and allow them to practice to the fullest extent of their education. Currently, all 50 states authorize optometrists to prescribe, and 38 states and Washington, D.C., allow [optometrists to prescribe] oral or systemic drugs. In those 38 states there have been no reported cases of harm. Only 12 states restrict prescriptive privilege to topical drugs only. She mentioned that there is a proposed committee substitute (CS), Version L. Number 067 REPRESENTATIVE KOTT moved that the committee adopt CS for HB 215, Version 22-LS0538\L, Lauterbach, 1/31/02, as the working document. There being no objection, Version L was before the committee. Number 082 JEFF GONNASON, O.D.; Chair, Alaska Optometric Association Legislative Committee, testified on HB 215. He noted that he has been a licensed optometrist in Alaska since 1976, and was Past Chair of the Alaska State Optometry Board. He noted that he had provided the committee with his written testimony. He testified as follows: The education and training of optometrists in pharmacology and clinical medicine, the eye, since about 1969 has been on a par with medical and dental schools with a bachelor's degree and then followed by four years of professional school for a doctors degree. Optometry education includes extensive clinical training in treating eye diseases. It has taken 30 years for all 50 states to finally authorize optometry to prescribe therapeutic drugs. Thirty-eight of the states go beyond the topical restrictions that Alaska has, so [HB 215] is not new ground. Alaska currently has a shortage of optometrists, as many are unwilling to practice here because of outdated statutes. The State of Washington has basically the same [type of legislation] in the hopper as we speak. They're on a 60-day short cycle, so we'll know how they do within the next month-and-a- half. I might point out that the states that don't have this, like Mississippi, Florida, and Michigan, have almost as many ophthalmologists as optometrists. In fact, New York State has more ophthalmologists [than optometrists]; they tend to congregate in urban areas. In Alaska, we have approximately 90-some optometrists and about 22 ophthalmologists. Optometrists are scattered pretty much over the state, and the ophthalmologists are basically all in Anchorage, except three in Fairbanks, two in Juneau, and a couple in the Kenai Peninsula. DR. GONNASON said that many Alaskans, particularly in the rural areas, currently rely on the local optometrists to treat their eye disease, and are referred to specialists when necessary. He stated that the current regulations that have been in place for ten years require demonstrated education and competence, and only those drugs that treat the eye are authorized. He said, "Our state law defines optometry as diagnosis and treatment of the eyes", yet the tools are restricted for no valid reason. My Tlingit-Haida traditional cures are unfortunately not the most effective for the eyes, he said. DR. GONNASON continued: Optometrists are considered physicians under federal Medicare law, as are dentists and podiatrists, who also prescribe similar drugs but are not "M.D.s". Optometrists have far more education and training in the treatment of eye diseases than taught in medical school, just as dentists are taught more about tooth disease. We are "primary care" eye doctors. We treat many eye diseases. However, we often refer the patients to the surgical or the specialist ophthalmologists when a patient requires such advanced care, just as family doctors refer to a specialist like a cardiologist or a neurologist, for example. We would never claim to be at the level of the ophthalmology specialists, we respect them and we need their expertise, but qualified optometrists should be allowed to practice at the full level of their training. Number 147 DR. GONNASON stated: In 1988, Alaska was 49 out of 50 states to enact a statute to allow optometrists to use diagnostic drugs. And then in 1992 we became state number 32 as this legislature, ten years ago, authorized us to prescribe therapeutic prescription drugs, but the bill ... [was] compromised so that we could only prescribe topical drugs. The two most recent state audits of optometry report improved access to eye care and there have been no reports of any harm in these past ten years through the board. A major malpractice insurance carrier in the nation states that they have found no difference in claims between states with various levels of drug authority. And the rates are extremely low at about $400 per year for $2 million in coverage. Optometry has a great track record, and no states have ever repealed any of the many drug expansion laws. Four years ago in the '97-'98 [legislative] session, we had a hearing on a new bill that would expand the scope of optometry to not only include the rest of our needed drugs, but to also allow the use of lasers and additional surgery by qualified optometrists, as is now being taught in the school. Currently, we're limited to a minor surgical procedure where we remove embedded foreign bodies, like pieces of metal in the eye. One state, Oklahoma, currently, has for four or five years authorized laser surgery by optometrists. Now our bill in the legislature here was opposed by the ophthalmologists, but we heard they wouldn't object if lasers and surgery were removed. So two years ago in the '99-'00 session, we removed the lasers and additional surgery from the bill; identical to the Tennessee bill and that became the famous SB 78 from two years ago. I have a memo from the state of Tennessee stating the fact that since their origin in 1987, 14-15 years ago, they've never had any litigation against an optometrist and no discipline action for misuse of medication. So they have a clean track record, Tennessee. The medical board was opposed after the legislature adjourned in May of 2000. The governor vetoed SB 78; he cited the medical board's opposition. The medical board was opposed after hearing from ophthalmology, but without hearing from optometry. Number 189 DR. GONNASON stated: [House Bill 215] has been redrafted from the vetoed bill ... [and] incorporated two changes to answer the concerns of the governor and medical board. Change one was that a section was put in for board authority for limiting drugs so that there is no grand fathering. The board has the authority to limit certain medications that certain doctors might prescribe to give the board more control there to require more education and to ensure competence. The second thing it changed was it prohibited injections into the eye globe because someone had commented that they thought we might do that, and I can assure you that no optometrist injects the globe. The governor asked the medical board to meet with the optometry board, which they did. And they've had a formal meeting and they had discussions. So after this recent meeting and discussions between the medical and optometry boards a committee substitute bill has been drafted and incorporates several more changes that were suggested to try to gain support from the medical board and the governor, which is the CS before you. Number 203 DR. GONNASON continued: The four additional changes are, one, there is a more precise definition of the scope of treatment for ocular tissues only. The former bill said "related to the eye" and some of the doctors thought that because we diagnose diabetes we would then treat diabetes, and that isn't the case, so this specifically states that we can just treat eye tissues only. Secondly, there's a restriction that there's no more than a 7-day supply of analgesic drugs (schedule II-V, which is the same as nurse practitioners and physician assistants have). Third, systemic drugs are limited to six specific categories plus over-the-counter, and there is well over 100 categories of drugs, maybe 150, and we've limited it to just six that optometry uses. And fourth, there's a mandatory course and passing an examination in systemic drug administration from an accredited college of optometry, approved by the board. DR. GONNASON said: I personally do not agree that more restrictions are needed, but they are compromises to try to make the medical board and everyone else involved more comfortable. In Alaska, in addition to dentists and podiatrists, [and] advanced nurse practitioners (ANP), who have with less years of training at the masters degree level than optometrists do, can prescribe almost any drugs unsupervised for the entire body, as determined independently by the nursing board. Optometry really should have this same statute. There are no outcries of public harm or "non-M.D.s" practicing medicine, as these fine nurse practitioners offer excellent care for Alaskans. The same with the dentists. A practitioner of any type does not need a license authority to harm patients, but does need it to properly treat patients. Number 232 REPRESENTATIVE MEYER asked Dr. Gonnason if optometrists are common in rural Alaska. He asked, for example, if there would be an optometrist in Bethel. DR. GONNASON replied, "Yes." He said that there are two or three optometrists in Bethel, two in Nome, one in Kotzebue, two in Kodiak, one in Glennallen, and one in Sitka; they're basically in around 22 different communities. He offered that it is often difficult to get recent graduates to come to Alaska because they can't practice at the full level of their training. He noted that the Indian Health Service also has a few optometrists that are stationed at Indian Health Hospitals. Number 248 REPRESENTATIVE MEYER asked if it is safe to say that there are optometrists in cities, towns, and villages of 1,000 people or more. DR. GONNASON answered, "Absolutely." REPRESENTATIVE MEYER asked if currently an optometrist would have to send a patient to Anchorage or Fairbanks [to visit an ophthalmologist]. DR. GONNASON said, for example, in Nome the optometrist is on call and if someone has a sore eye in the middle of the night the optometrist would be called in to examine the patient. If the optometrist, using his/her professional judgment, is comfortable handling the situation, then the patient would receive treatment from the optometrist. If the case is out of the optometrist's scope then he/she would call the Native Medical Center and talk to an ophthalmologist to make a decision whether or not to fly the patient in for treatment. If the optometrist at the Indian Health Service needs to prescribe an oral antibiotic for infection then a physician assistant needs to write the prescription. REPRESENTATIVE MEYER inquired as to the differences in education between a physician assistant and an optometrist. DR. GONNASON described that there are different levels of physician assistants, and range from 2-5 years of education. A nurse practitioner's education, at the masters degree level, ranges from 5-7 years, and an optometrist's education ranges from 7-9 years at the doctorate level. He said that he believes for one to become a physician assistant that one must attain a bachelors degree. He mentioned that often times through emergency medical and clinical training one can become a physician assistant. Number 272 REPRESENTATIVE KOTT said that it seems to him that this particular issue has been recirculating for about ten years. He said, "If my memory serves me correct, the bill passed fairly unanimously in both the House and the Senate." DR. GONNASON said, "37:2 House, and 18 to nothing Senate." REPRESENTATIVE KOTT stated that there were only two opposition votes out of 60 [legislators] and then it was sent to the governor, who vetoed it. He asked what the governor's position was when he vetoed that piece of legislation. DR. GONNASON pointed out that no one testified orally against the bill in two years of hearings. He said that the governor asked the Alaska State Medical Board (ASMB) for its opinion and the medical board had a meeting with an ophthalmologist from Seattle and an ophthalmologist from Fairbanks. He said that the two ophthalmologists told the "medical board what they thought about optometry, which we all know what they said." The medical board reported to the governor that it was unanimously opposed to the bill because of concerns with the possibility of an optometrist using needles on patient's eyes. A second concern that the governor expressed was the level of training and whether new training would be required. Dr. Gonnason mentioned that although the governor said he'd be happy to work with optometry to come up with something, a discussion has not taken place yet. "I've made six major changes to try to assuage the governor to sign this legislation," he said. Number 310 REPRESENTATIVE KOTT recalled that the veto letter "hammered" on the legislature for not seeking the opinion of the ASMB. However, the sponsor of the previous legislation on this issue has indicated that the medical board was approached [for an opinion]. "The medical board basically said 'no' we're not responding to the legislature, but if the governor asks us we'll respond to the governor," explained. Representative Kott asked whether ASMB's opinion has been sought, or have substantive changes been made to this piece of legislation such that the medical board isn't concerned anymore. CHAIR MURKOWSKI informed the committee that the committee packet includes a letter from the Alaska State Medical Association (ASMA) in opposition to HB 215. The letter relates that ASMA doesn't believe that HB 215 is good medicine. Chair Murkowski inquired as to the status with the medical board. DR. GONNASON related his belief that the ASMB hasn't seen Version L. He explained that ASMB and the Board of Optometry [took testimony] and the general discussion indicated that if there were categories of drugs and more restrictions, the board would be more comfortable. [The ASMB] felt that the legislation was broad and didn't require more education and thus the changes [incorporated in Version L] address those concerns. Furthermore, the Board of Optometry has had further discussions with ASMB during which the notion of a subcommittee was mentioned. Meanwhile, Version L has been developed and is moving through the process. The ASMB hasn't yet responded to the CS. Dr. Gonnason pointed out that no state medical boards will support the optometrists, the nurses, or anyone who isn't a medical doctor. He characterized it as a turf issue. Furthermore, the American Medical Association (AMA) recently passed a resolution in opposition to any scope of practice enhancement by any profession in any state. Dr. Gonnason informed the committee that ASMB asked all 50 state medical boards whether they have had problems with their optometrists. Quite a few responded and not one had any trouble with their optometry association or their optometrists' prescription of medications. Dr. Gonnason highlighted that ASMB has nothing to do with the Board of Dentistry or the Board of Optometry; it was a mistake to ask their opinion, which is always going to be in opposition. He didn't believe there was any legislation he could produce that ASMB would support. However, he hoped that ASMB wouldn't be unanimously opposed [to Version L]. CHAIR MURKOWSKI asked if there is a subcommittee working on this issue. DR. GONNASON deferred to Dr. Christianson, who is a member of the Board of Optometry. Number 0381 REPRESENTATIVE KOTT referred to the second paragraph of the governor's veto letter, and read the following: "I also recognize that a few states have recently rejected this proposed expansion of optometrist privileges, citing concern for enlarging the scope of practice without adequate training and education." If HB 215 were to pass and the governor vetoed it, would that concern be part of his veto message, he asked. DR. GONNASON turned to the "recently rejected" language of the veto message. He explained that no state has ever repealed a law, but a new tactic has been to allow legislation to make it to the governor, who is then bombarded [with opposition]. This was the tactic used in Alaska. Dr. Gonnason emphasized that he could prove "beyond a shadow and doubt" that optometrists have adequate training and education. REPRESENTATIVE KOTT related his understanding then that HB 215 would enlarge the scope of practice for optometrists. However, Dr. Gonnason believes that optometrists have adequate training and education to do so. DR. GONNASON noted that older optometrists didn't have the training, but those optometrists aren't grandfathered in. The current law specified that in order to [prescribe] these drugs, the person has to have an endorsement on his/her license and take additional training. Version L would require additional training for systemic drugs. There are three to four optometrists in the state who didn't have [a prescribing] endorsement and thus aren't allowed to prescribe the drugs. REPRESENTATIVE KOTT referred to the CS prior to Version L, and asked if that CS was similar to what was passed in the prior legislation. Also, did the prior legislation allow for needles to be injected into one's eye, he asked. DR. GONNASON answered that SB 78, the legislation vetoed by the governor, allowed optometrists to use any medications, by any means, that are related to treating the eye. Therefore, optometrists would've been allowed to use topical medications, injectible medications, or oral medications. The medications that are injected in the eye are done by surgical specialists, and no optometrists in Alaska would do that. He pointed out that [Version L] includes language specifying that optometrists won't inject into the globe of the eye. He viewed this matter as a scare tactic. Number 0441 ROBERT A. BREFFEILH, M.D., informed the committee that he has practiced ophthalmology since graduation from Walter Reed Medical Army Center in 1987. He reviewed his history prior to 1987. He said that during his nine years in the U.S. Army he had very collegial relations with optometrists. There wasn't a financial incentive [that would lead] to the adversarial relationship that exists today. Dr. Breffeilh related his shock [to the situation] when he arrived in Juneau. The referral patterns in Alaska from the optometrists to the ophthalmologists are very weak. Most patients are sent to Seattle, Washington, because the optometrists don't want their patients to have any interaction with the specialists, ophthalmologists, in the community. Dr. Breffeilh said that on a number of occasions he has seen delays in diagnoses from optometrists, which have lead to problems for the patients. He said that he has also seen problems with diagnoses and medications [from optometrists]. He noted that he is now aware that there is a mechanism to report those to the Board of Optometry. Dr. Breffeilh characterized this as a public safety issue. CHAIR MURKOWSKI asked whether this is an issue of turf or training. DR. BREFFEILH said he feels it's an issue of money. Number 0479 JILL GEERING, O.D., informed the committee that she has been an optometrist in Juneau for ten years. She noted that the committee packet should include a letter from her. She also informed the committee that she is a graduate from the Illinois College of Optometry where she had training in oral and topical medications. One of her job offers was from Juneau. However, she didn't accept the job in Juneau until she learned that the legislation allowing her to prescribe topical medication had passed. With regard to referral patterns, Dr. Geering specified that her first concern with a patient needing further surgical care is in regard to who has the best ability to obtain a good surgical outcome for the patient. She stated that her decision doesn't involve money but rather what's best for the patient. In many cases, Dr. Geering felt that what's best for her patients is to be seen elsewhere. However, she pointed out that she does refer her patients in town as well. CHAIR MURKOWSKI posed a situation in which a patient would require an oral medication. She asked Dr. Geering what she would do in such a situation. DR. GEERING answered that she would either refer the patient to the local ophthalmologist or their general practitioner, depending upon the situation. CHAIR MURKOWSKI continued with the above situation and asked if Dr. Geering would consult with the general practitioner when the patient is referred to the general practitioner. DR. GEERING replied that in some cases she would consult with the general practitioner and in others she would leave decisions to the general practitioner. Number 0520 REPRESENTATIVE KOTT inquired as to an example of an acute eye disease that would require immediate attention. He expressed concern with regard to the rural areas of the state where there is no ophthalmologist. DR. GEERING specified her opinion that the immediate need for oral medication would be related to pain management when a foreign body is removed from the eye. She characterized that as an emergency situation. REPRESENTATIVE CRAWFORD inquired as to why these two professions diverged. He related his view that these two professions have a large amount of overlap. He recalled Dr. Gonnason's testimony that [optometrists in Alaska] would never use a needle in the globe of the eye, although 20 states allow optometrists to do that. DR. GONNASON clarified that [optometrists] rarely use injections, but he mentioned the injections used for anaphylactic shock. The point is, he said, that "drugs are drugs" and are administered in different ways. Optometrists are trained with drugs in the same way as dentists and physicians, but with a specific emphasis on the eye. Optometrists are also trained with regard to drug interactions. DR. GONNASON turned to the question as to why the two professions diverged and likened it to the [divergence] of cardiologists from [general] practitioners. He referred members to a letter from Lesley Walls, O.D., M.D. Dr. Gonnason explained that ophthalmologists go to school and become a general physician, after which they receive specialty training with the eye. Most of that training is with surgical and advanced tertiary care. However, optometrists traditionally examined the eye for glasses and contact lenses. Over a hundred years, the profession has advanced such that school for optometrists rose to a level equivalent to that for dentists. Dr. Gonnason remarked that the reason there is no problem with dentists [prescribing] is that dentists, who have the same or a little less training in drugs than optometrists, don't have any financial competition. In some communities there are too many optometrists and ophthalmologists and thus they compete for the same patients. He pointed out that Alaska doesn't have many older people who tend to receive eye surgery. Furthermore, some ophthalmologists don't perform surgery and only provide general medical eye care. Dr. Gonnason agreed that both professions overlap. However, optometrists provide primary care and ophthalmologists provide specialty care. REPRESENTATIVE MEYER recalled that one of the concerns is in regard to optometrists injecting needles in the globe of the eye. Although he understood that injections in the eye are rare, he pointed out that lasers are being used in eyes, which he viewed as bad as injecting a needle in the eye. DR. GONNASON said that optometrists are prohibited from using lasers on the eye, per Alaska law. He noted that in Oklahoma optometrists are able to perform certain laser surgery procedures. He informed the committee that almost all optometrists now days are trained in laser procedures. Dr. Gonnason related his belief that ophthalmologists are really concerned with regard to the line between laser and surgery, the so-called "laser burn and earn." TAPE 02-22, SIDE B DR. GONNASON specified that HB 215 merely replaces what was compromised out of the bill ten years ago. Ten years ago the compromise was to not include the oral and injectible drugs, although the training was occurring. Therefore, optometrists are merely asking for the rest of their tool box. In further response to Representative Meyer, Dr. Gonnason confirmed that [optometrists] would not be able to perform laser [surgery]. He emphasized that optometrists are already trained in prescribing drugs, but [Alaska] limits optometrists to prescribing only drops. Although people seem to view the drops as safer, drops can be very dangerous. The drops are the most powerful way in which the drug is put in the eye. Pills generally don't effect the eye that much, and therefore [optometrists] treat patients with drops about 90 percent of the time. However, there are situations that require pills such as with glaucoma, pain, and allergy. Dr. Gonnason explained that in his office, if he's comfortable with "it," the general practitioner across the hall calls in [the prescription] for him. He noted that every day he refers a patient to an ophthalmologist. "We all really work together in the state, with ophthalmologists and optometrists, and then we come and fight at the table over the political issue," he said. Number 0577 REPRESENTATIVE CRAWFORD inquired as to what would keep [optometrists] trained in laser surgery from coming back to the legislature and requesting that part of their tool box. DR. GONNASON identified that as the fear. He reiterated that one state allows [optometrists to perform laser surgery]. Two other states allowed such, but through a court decision optometrists were stopped from doing laser [surgery]. He stressed that every profession grows and advances. He pointed to dentistry, which was performed in a barber shop a hundred years ago, as an example. As a profession advances, it should be able to do the new things that it learns. However, medicine has a blank check; that is M.D.s can do anything they want. For example, an M.D. can perform eye procedures that the physician may not be trained to do, but there is no law against it. Dr. Gonnason said that what keeps medical doctors from doing such procedures is professional judgment, which overlooks monetary gain for good care. He remarked that his ability to prescribe oral medications doesn't impact his income, although he acknowledged that if he [could use] lasers it might. However, he said that there is enough competition with [laser surgery] in Alaska. Furthermore, Alaskan optometrists are far from being interested in laser [surgery]. The legislation [allowing optometrists to use laser surgery was proposed] because if optometrists are trained in such, they should be allowed to use it. REPRESENTATIVE CRAWFORD related his understanding then that there isn't a fine line between the two professions, and there isn't a place where [optometrists] would stop seeking advancement of their profession. DR. GONNASON pointed to the nurse practitioners in Alaska, who have a Masters degree. Although in most states, nurse practitioners have to practice under a doctor's supervision, in Alaska nurse practitioners can practice the same as an M.D. and even establish a clinic. These nurse practitioners also use their professional judgment in regard to prescriptions and referrals. Therefore, he feels that when opponents to HB 215 express concern with regard to injections in the eye, it is a scare tactic. Number 0531 DAVID KATZEEK, Alaska Native Brotherhood Camp 2, began by thanking the committee, in his Native tongue, for the opportunity to provide testimony today. Mr. Katzeek read a letter from the Alaska Native Brotherhood Camp 2 as follows: Dear Members: We at the Alaska Native Brotherhood Camp 2 believe that ... HB 215 is a dangerous bill and one that requires our attention. The bill contains far- reaching negative health policies which are implicated for Alaska. This bill does not improve access to health care and they do not open new clinics. House Bill 215 does not make new services available to residents in rural Alaska; in fact it really is putting rural Alaska at great risk. A second opinion will not be available to the optometrists or to the patients. Without medical training, optometrists are not qualified to thoroughly and properly [assess] medical risks. No matter how well intentioned, optometrists do not have the training to know how a drug might affect the cardiovascular system. Optometrists do not possess a medical degree, and they do not receive training in prescribing medical drugs. With the desire to increase their own medical field of expertise and the monetary benefits, which would follow an expanded medical field, it is our concern that these optometrists will perform procedures that are maybe not necessary. In short, the enactment of HB 215 will not improve the health care services available to Alaskan citizens, but ... may increase the health care risks for ... Alaskan citizens and for these reasons the bill should be defeated. MR. KATZEEK turned to his own comments, and said that he has received services from optometrists as well as ophthalmologists. "Just because you have a tool box and you put a pipe wrench in it doesn't mean you know how to use a pipe wrench," he said. He expressed his concern that serious problems could be caused [with the passage of HB 215]. Mr. Katzeek said that this issue isn't just about money and who can do and should do what, but rather what happens to people as human beings. Mr. Katzeek related a Tlingit story in which Raven picks berries and took his eyeball out in order that the eye could [warn] him when people came. Although Raven's eye began yelling at him that the people were coming, Raven was so busy [picking berries], which would be beneficial to him, he forgot about his eye. Raven lost his eye. Mr. Katzeek stressed the importance of the eye as one of the valuable senses. Therefore, Mr. Katzeek urged the committee to take care when making a decision [regarding HB 215]. "It's not just money, it's the eyes of the people that you represent," he stressed. CHAIR MURKOWSKI commented that she believes the committee does appreciate the relative seriousness of this issue. REPRESENTATIVE KOTT recalled when the legislature asked the ASMB's opinion of SB 78, and ASMB's response was that it didn't respond to the legislature because the board is made up of appointees of the governor and thus respond to him. Representative Kott asked if that is how such boards work, or was it taken out of context. Number 0443 CATHERINE REARDON, Director, Division of Occupational Licensing, Department of Community & Economic Development (DCED), answered that there isn't an established policy to that effect. Ms. Reardon said that she didn't know the exact words of the exchange referenced by Representative Kott, but would like to believe that the response wasn't "so back-in-your-face." She related her sense that ASMB generally isn't a board that relishes getting involved with the legislative process. The ASMB spends much of its time addressing licensing and disciplinary actions, which ASMB views as its primary role. Ms. Reardon related that at couple years before [the request related to SB 78] ASMB was asked to take a position on a bill and did so; and subsequently three of the members weren't confirmed the following session. She opined that ASMB was trying to not [become involved] in a field that wasn't in their comfort zone. CHAIR MURKOWSKI restated her earlier question with regard to the status of the discussions between the optometrists and ophthalmologist and ASMB. She asked if a subcommittee was established to discuss this. Is there an ongoing discussion, she asked. MS. REARDON confirmed that the governor's office requested that ASMB and the Board of Optometry discuss the issue. This past fall, a representative from the Board of Optometry attended the [ASMB] meeting and had a fairly full discussion of the issue. Following that meeting there was a Board of Optometry meeting, which was attended by an ASMB representative. The Board of Optometry modified its position and then ASMB discussed the issue again in January when it selected two members to work with a Board of Optometry subcommittee. MS. REARDON related her belief that ASMB is fairly uncomfortable with expanding the prescriptive authority [of optometrists]. Although she did believe that ASMB was willing to [continue discussions], she saw the parties as being far apart. Therefore, the fall meetings didn't result in any resolution. She related ASMB's concern with regard to [an optometrist's ability to prescribe] systemic drugs and [their understanding of the] potential impact on other conditions, diseases, and body parts. One item of discussion [between the two boards] was in regard to the [possibility of] collaborative relationship similar to that between physicians and physician assistants in order to provide some oversight. She predicted that such a situation would be acceptable to the Board of Optometry. CHAIR MURKOWSKI surmised that there is no deadline for a report. MS. REARDON replied no. Number 0369 CHAIR MURKOWSKI inquired as to whether the administration has reviewed HB 215. Has HB 215 been modified such that it would avoid the governor's potential veto, she asked. MS. REARDON responded that she couldn't answer that because the governor evaluates legislation as it reaches him. Therefore, she felt that the best guide would be the governor's veto letter to SB 78. That veto letter seemed to include two particular issues. First, there was concern that there was no guarantee that those optometrists currently holding prescriptive endorsements wouldn't, with the passage of HB 215, automatically be raised to this higher level. Although the Board of Optometry said that wasn't the intent, the language didn't guarantee it wouldn't occur. Second, the legislation doesn't specify a new testing requirement for that higher level. MS. REARDON informed the committee that currently there are two types of endorsements for optometrists. Of the approximately 110 optometrists, 105 hold the highest level of prescriptive endorsement currently allowed, which is the therapeutic endorsement and five have no endorsement at all because they didn't qualify or request such. Five of the 110 optometrists have a diagnostic endorsement, which is the result of a law that only allowed diagnostic drug use. That law was prior to the law allowing therapeutic [drug] use. The five optometrists with the diagnostic endorsement didn't or weren't able to rise to the higher endorsement. Therefore, the governor [wanted to ensure], she surmised, that those optometrists with a diagnostic or therapeutic endorsement didn't [automatically] transfer to the systemic endorsement without [proving] their background. Furthermore, ASMB's concern with health risks probably weighed [on his thoughts]. She noted that she has a list of the optometrists in the state by zip code. Number 0304 GORDON PREECS, M.D., related his background, which included the U.S. Army and specialty training in ophthalmology at Walter Reed Medical Army Center. He noted that he and Dr. Breffeilh have been in Juneau since 1989. Dr. Preecs turned to SB 78 and pointed out that it was [passed] during the crunch at the end of the session. He related his belief that leadership at the time directed [the passage of SB 78 due] to compromises made with regard to SB 78 and other legislation that ASMA had. Dr. Preecs said, "I don't know that this was a thoughtful process of consideration for this legislation." DR. PREECS related the concern of the AMA and the Academy of Ophthalmology that [SB 78] allowed optometrists to practice any form of medicine that was available. "It simply allowed the optometrists to tell themselves what they wanted to have," he charged. Although this bill has a remarkably more stringent listing of what [optometrists] can do, it [still] says that optometrists will decide what optometrists will prescribe. Dr. Preecs said that his main concern is that HB 215 removes the authority of the medical practice and [ASMB] to provide any input with regard to who can and will practice. He pointed out that physician assistants are under [ASMB]. Although nurse practitioners mostly work in supervision, they do have independent authority that is [specifically] delineated. Number 0258 CHAIR MURKOWSKI surmised then that the CS is better due to the added restrictions and guidelines with regard to what can be prescribed. She related her understanding that Dr. Preecs is concerned that there is no oversight of the prescribing by ASMB. DR. PREECS said that over the last 12 years optometrists have moved forward [in attempt] to establish and grant the independence of their profession, separate from ophthalmology and medicine. Optometrists have extended their profession such that in the last legislation, SB 78, optometrists were almost indistinguishable from practicing physicians. "If you can prescribe, you can practice," he specified. Dr. Preecs said that he wasn't worried with what HB 215 allows optometrists to prescribe because optometrists already do most of those things, and do so without great tragedies. However, [the legislation] allows optometrists to have the independent authority to decide what that will be in the future. Dr. Preecs turned to laser surgery, and commented that exposure to such is a wonderful first step. However, it's of concern to allow such [to be done by] those not trained in the medical field. He characterized the inclusion of laser surgery in the legislation as bait that could be taken out as if in compromise. DR. PREECS, in response to Chair Murkowski, said that an optometric practice can be supported with a service area of 10,000 people while an ordinary demographic population of 30,000 would support an ophthalmologist. He informed the committee that there is a partnership of optometrists in Ketchikan, which is 10,000 people plus a service area. In Sitka, population 7,000, there is a single optometrist practicing full-time. Dr. Preecs said the practice he and Dr. Breffeilh have serves the whole of Southeast, which amounts to about 60,000-70,000 people. Places such as Wrangell are too small [to support an optometrist]. Number 0200 CHAIR MURKOWSKI posed a situation in which an individual needs pain medication. She inquired as to how such a situation would be handled in some of the smaller communities such as Sitka. DR. PREECS answered that he tends to be the point of contact for things that are specifically and directly related to ophthalmologic issues. However, if someone needed pain medication, the local family practitioner [would be accessed]. He said that the local family practitioners are the best level of expertise for their local people when [ophthalmologists] aren't in town. In small towns when there is the need for sophisticated medical care, phone calls are made, questions and answers are exchanged, and advice is given. Number 0159 LINDA CASSER, O.D.; Associate Dean for Programs, Pacific University of Optometry in Forest Grove, Oregon; President, National Board of Examiners in Optometry, announced her support of HB 215. She related the following information regarding the extensive training and education received by "optometric physicians" [optometrists], particularly in the area of pharmacology. She informed the committee that the Doctor of Optometry degree program is a four-year graduate level program; students leave the program with seven to eight years of education and training. The prerequisite course of study is rigorous and comprehensive, and comparable to that completed by pre-medical and pre-dental students. Pre-optometry students are required to pass the Optometry Admission Test (OAT), which is comparable to the MCAT examination required of medical students. The OAT is administered by the American Dental Association. Furthermore, the 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. In several of the institutions of optometry, optometry students sit side-by-side with medical and dental students in the basic science courses. Dr. Casser specified that 255 classroom hours within the curriculum are assigned to the area of pharmacology, including the use of topical, oral, and injectible medications in the treatment of the eye and its associated structure. Additionally, 165 classroom hours pertain to the diagnosis, treatment, and management of ocular disease as well as the extensive patient care clinical experience in which the pharmacological concepts are applied. She highlighted that studies indicate that optometry students receive comparable course hours in pharmacology to that of medical students. Students in the Doctor of Optometry program receive added training and education in ocular pharmacology. She also mentioned that optometric students begin their clinical activity in their first year of professional study; the patient care experience increases in complexity and intensity throughout the program. The fourth and final year of the program is spent in full-time patient care activity; two of the three semesters are spent in off-campus clinical preceptor shifts in a variety of health care settings. In total, these students spend at least 2,000 contact hours examining diverse patient populations with ocular and systemic diseases. DR. CASSER concluded by saying, "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 medications." She related that during her 25 years in the profession [she has] had the opportunity to testify in multiple states and committees. From that experience she has found that the comments regarding the lack of training and education of Doctors of Optometry is based on misinformation or inadequate information. She submitted that the packet she provided the committee documents the excellent training that optometrists receive, especially in the area of pharmacology. She commented that she has found that those who have retained objectivity and an open mind come to the same conclusion. Dr. Casser informed the committee that at Pacific University there is a physician assistant program, which is a Masters level program in which the students receive seven semesters of training. She highlighted that optometry students receive ten years of training, and many faculty train students in both the physician assistant program and the optometry program. DR. CASSER turned to Dr. Preecs' comments regarding board involvement in optometry. She reminded the committee that optometrists are licensed, independent practitioners and thus it's appropriate that the Board of Optometry is the body that makes the decisions with regard to the rules and scope of practice [for the profession]. Everyone in optometry [falls under] the overarching guideline of the optometry practice's statutes, which limits practice to the eye and associated structures. Dr. Casser pointed out that the committee packet should contain her longer testimony as well as a table comparing the training and education of dentists and optometrists, which she believes to be very similar and even identical in some areas. The comparison is the result of her review of the curriculum of the School of Dentistry at the Oregon Health Sciences University. The packet should also include a single- page summary that specifies the pharmacology training of optometrists, a summary of the curriculum, a couple of informational articles that illustrate how the curriculum has evolved, and an article she authored with a pharmacologist in the State of Indiana regarding the pharmacology training an optometrist receives in comparison to other health care professions. CHAIR MURKOWSKI asked if Dr. Casser would say that the Pacific University's curriculum [for optometrists] is standard amongst other schools of optometry. TAPE 02-23, SIDE A DR. CASSER answered that all the schools and colleges [offering training in optometry] have a comparable curriculum. She informed the committee that [schools and colleges offering training in optometry] are all accredited by the Accreditation Council on Education, which is overseen by the U.S. Department of Education. Therefore, she said that any graduate who comes to Alaska as a practitioner would have comparable education and training such that he/she would be qualified to use these medications. Number 026 CARL ROSEN, [M.D.]; President, Alaska Ophthalmologic Society, testified via teleconference. He explained that he represents the ophthalmologists in Alaska and their patients. "The primary reason that we're here today is the protection and the ... interest of our patients," he said. He pointed out that the optometric community has steadily [worked toward] their profession's expansion. He noted that "we" are present to protect the public from misadventure of even one or two optometrists who may not know what they are doing with medications. For example, this year alone Georgia, Minnesota, Mississippi, South Dakota, and Washington have defeated drug initiative legislation by the optometric community. He then turned to the issue of training, and mentioned that 2,000 hours, the clinical hours that most optometrists acquire as specified by Dr. Casser, is a lot of time. However, Dr. Rosen pointed out that before he was allowed to practice in Alaska he logged 24,000 hours. Furthermore, Dr. Rosen said that the notion that optometrists are more qualified to treat primary eye care is an opinion rather than fact. In regard to pharmacology, he stressed that the bar is medical school and the American medical system. "Using that bar as a reference point, I put it to you: 'How would you want your family or your eye care?' And I think the obvious answer is you'd want the best care possible," he charged. He characterized the "best care possible" to be a [collaboration] between the two professions. He emphasized that pain medications and oral antibiotics can be [prescribed] in a rural community or locally via a phone call or quick referral. "The people of Alaska aren't clambering to have an optometric expansion, and specifically the Native community is not and they're the community most frequently discussed when you're talking about the rural community," he said. He reiterated that the most important issue here is in regard to what is best for the patient. REPRESENTATIVE KOTT asked if Dr. Rosen's remark that the Native community doesn't want [HB 215] is the position of the Alaska Federation of Natives (AFN). DR. ROSEN pointed out that he receives his information from the Alaska Native Brotherhood. REPRESENTATIVE KOTT remarked that he didn't believe the Alaska Native Brotherhood speaks for the entire Native population, whereas AFN seems to be the group responsible for that. Number 120 DENISE THANEPOHN, O.D., testified via teleconference. Dr. Thanepohn testified in support of HB 215. She said that the debate seems to be with regard to whether optometrists have the practical knowledge to do [what HB 215 would allow]. She informed the committee that she is familiar with many medications that she uses on a daily basis. Furthermore, [optometrists] deal with patients that are using a variety of systemic medications and thus [optometrists] have to deal with those medications and their ocular side effects. She pointed out that frequently she performs consults with internists, cardiologists, and endocrinologists before eye care medication is started. Therefore, [what is proposed in HB 215] wouldn't be out of line for optometrists. DR. THANEPOHN related her interpretation that some testimony has indicated that optometrists don't practice prudent and conservative prescribing. However, there have been no complaints to the Alaska Board [of Optometry] for the last ten years. The lack of complaints seems to speak well of the quality of optometrists and their prescribing ability. Furthermore, some folks seem to believe that an M.D. degree magically guarantees intelligent, clinical decision making. Although M.D.s are knowledgeable, they make mistakes as well. REPRESENTATIVE KOTT asked if Dr. Thanepohn has referred patients to ophthalmologists. He also asked if she referred to certain ophthalmologists. DR. THANEPOHN replied yes. Certainly, for certain conditions certain ophthalmologists are more trained than others. REPRESENTATIVE KOTT related his understanding then that there is a good relationship between [Dr. Thanepohn's office] and the ophthalmologist. Number 185 OLIVER KORSHIN, M.D., testified via teleconference. He informed the committee that he received his M.D. degree 35 years ago from Harvard. He noted that he is board certified in preventive medicine as well as ophthalmology. Dr. Korshin announced his opposition to HB 215 due to his experiences as a medical doctor, such as seeing the effects of systemic medication when incorrectly and correctly prescribed or administered. He pointed out that optometrists have basically no hands-on training or experience with serious systemic disease of the level that M.D.s experience. With regard to an optometrists training in pharmacology, Dr. Korshin said that no amount of classroom hours can substitute for the rigorous clinical patient-based training all medical doctors undergo. "If classroom learning were a acceptable substitute, then we should also grant driver's licenses or pilot certificates on the basis of written examinations alone," he charged. DR. KORSHIN pointed out that HB 215 provides the impression that only a narrow range of drugs will be used [by optometrists]. However, the categories include a broad range of very powerful drugs. "Granting optometrists the authority they seek under HB 215 is in reality granting them a blank check to prescribe a broad range of potent drugs, not a limited handful," he said. In conclusion, if HB 215 is passed, Dr. Korshin predicted that optometrists will return next session requesting the authority to perform laser surgery or more. Dr. Korshin urged the committee not to pass HB 215. Number 252 JIM SWARTLEY, M.D.; Member, American Academy of Ophthalmology State Affairs Committee, testified via teleconference. Dr. Swartley noted that the committee should have a letter from Dr. Thomas Weingeist, Ph.D., M.D., which outlines concerns with HB 215. DR. SWARTLEY related the following personal comments. As a general ophthalmologist who is the primary care [physician]. He pointed out that not many ophthalmologists spend all their time in surgery but rather spend more time in the office. With regard to injections in the eye, Dr. Swartley said that often injections into the eye are inadvertent and are probably of more concern. Number 280 CHAIR MURKOWSKI announced that public testimony is closed and HB 215 will be held and heard on the upcoming Monday.
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