Legislature(1999 - 2000)
05/03/1999 03:23 PM L&C
* first hearing in first committee of referral
= bill was previously heard/scheduled
= bill was previously heard/scheduled
CSSB 88(FIN) - DIETITIANS AND NUTRITIONISTS Number 0137 CHAIRMAN ROKEBERG announced the committee's first order of business is CSSB 88(FIN), "An Act relating to licensure of dietitians and nutritionists; and providing for an effective date." Chairman Rokeberg acknowledged the bill sponsor. Number 0150 SENATOR DAVE DONLEY, Alaska State Legislature, came forward as the sponsor of SB 88. Senator Donley stated that SB 88 would adopt title licensure in Alaska for dieticians and nutritionists. Other states currently have licensure for these individuals; some Alaskans are going to other states for licensure so they can have legitimate use of the title. The legislation has been requested by these professionals who would be regulated. As is mandatory under Alaska's occupational licensing rules, the program would pay for itself. Additionally, this licensure would allow possible access by Alaskans to federal funding at a future time. Senator Donley noted there is legislation pending in Congress which would allow reimbursement for nutrition services within the Medicare program. However, this reimbursement would only be allowed to those recognized by a state as nutrition professionals. If Alaska does not have some minimum licensure, which is what title licensure is, Alaskans would be denied this opportunity if the federal legislation is passed. Senate Bill 88 would allow people to know, when using the services of someone professing to be a dietician or nutritionist, that person has at least the minimum standards required by this legislation for licensure. Number 0282 REPRESENTATIVE HARRIS questioned if any of Alaska's universities offer the courses or degrees necessary to qualify for either of the two portions. SENATOR DONLEY noted a couple of the witnesses present have degrees in these areas and are indicating the answer is yes. He commented these witnesses might able to provide more detail in their testimony. REPRESENTATIVE HARRIS questioned if it is Senator Donley's knowledge through his research that this is fairly standard for other states. SENATOR DONLEY indicated there is an accepted national standard for the dietician license which is adopted by the legislation. The nutritionists' licensure is a little more complicated; there is no one accepted national standard. Therefore, the equivalent of a three-part test is being adopted. Senator Donley referred to the language regarding nutritionist licensure on page 2 of CSSB 88(FIN). [This language read: Sec. 08.38.030. Nutritionist licensure. The department shall issue a nutritionist license to an individual who pays the required fee, applies on a form provided by the department, and submits evidence satisfactory to the department that the individual either (1) has qualified as a diplomate of the American Board of Nutrition or as a Certified Nutrition Specialist with the Certification Board for Nutrition Specialists; or (2) meets the following qualifications: (A) has received a master's or doctoral degree from an accredited college or university with a major in human nutrition, public health nutrition, clinical nutrition, nutrition education, community nutrition, or food and nutrition; and (B) has completed a documented work experience in human nutrition or human nutrition research of at least 900 hours.] CHAIRMAN ROKEBERG commented there are five witnesses signed up to testify. He invited Senator Donley to remain with the committee at the table. Number 0435 DEBRA MESTAS, registered dietician (RD), testified next via teleconference from Anchorage in support of the legislation. Ms. Mestas informed the committee she has lived in Anchorage since 1980, has worked as the renal dietician for the Alaska Kidney Center for those 13 years, and also worked at the WIC [Special Supplemental Nutrition Program for Women, Infants, and Children] clinic at the Anchorage health department for 12 years. In addition to being a registered dietician, she is a certified breast-feeding consultant and is looking forward to becoming a certified diabetes educator. Ms. Mestas feels that registered dieticians, and nutritionists with the qualifications listed on page 2 [of CSSB 88(FIN)], are consumer advocates. She feels these professionals are very serious about promoting education, usually not charging for those services in many of their job situations. These professionals are the prime source of information for patients who need specialized care. Ms. Mestas said her patients, in particular, have kidney failure. She indicated many of her patients have diabetes which causes their renal failure, or cancer along with their renal failure. Ms. Mestas further indicated her patients have many other medical problems or diseases, mentioning high blood pressure and lupus as two examples. She is very concerned that people who go out into the community for services know what they are getting. With this legislation, she feels these people will be assured that the qualified dietician or nutritionist has the schooling behind him/her and resources available from the physicians, nurses, and other parts of the medical team. Number 0551 MS. MESTAS indicated dieticians have been part of the medical team for years but have not been recognized as licensed professionals. She is particularly concerned about the Alaska Native population. Ms. Mestas indicated she is seeing a rapidly expanding number of diabetic Native patients in line to begin dialysis. She further indicated that if the committee is unfamiliar with the national cost of dialysis, it would want to discover those costs. Diabetes is a very expensive disease and diabetics are now living long enough to lose their kidneys and require dialysis. Alaska Natives are very prone to diabetes. Ms. Mestas noted there are approximately 1,750 diabetics currently registered at the Alaska Native Medical Center ["Native hospital"]; this number includes both insulin and non-insulin dependent diabetics. In 1989 there were only 700 diabetics registered there. Ms. Mestas commented this number is only increasing. She is very concerned that this population is not going to be able to receive services from qualified professionals. She stated, "And we need to ensure that that is available to the Native population and that these people out in villages and other smaller communities are assured they're getting the right information from the right folks at the right time, and I think Senate Bill 88 can ensure that." Ms. Mestas indicated dieticians spend a lot of their own money to become qualified and licensed, and to pay dues for professional organizations and additional certifications, because they believe in what they do and think education is the way to go. She feels this does protect the consumers and she urges the committee's support. CHAIRMAN ROKEBERG asked Ms. Mestas if she had a college degree. MS. MESTAS answered that her bachelor's of science is in dietetics from Colorado State, Fort Collins. She received her internship from Washington University's Barnes-Jewish Hospital in St. Louis, Missouri. CHAIRMAN ROKEBERG questioned if she had any other nursing credentials or anything. MS. MESTAS answered in the negative, but pointed out that dieticians are basically in school with the physicians. Their education track is the medical track; they take four years of chemistry and are right along with the pre-med students. Number 0770 JOHN WRAY, Registered Dietician, Bartlett Regional Hospital; Alaska Dietetic Association, came forward in Juneau to testify in support of the legislation, representing the Alaska Dietetic Association (AKDA). He thanked the committee for considering the bill and thanked Senator Donley for his sponsorship. Mr. Wray based his comments on a prepared statement and provided the following testimony: "I represent the Alaska Dietetic Association, which is a group which Debra's [Ms. Mestas] a member of. ... This group represents dietitians and nutritionists in Alaska. We strongly support this piece of legislation. Currently 39 states, the District of Columbia and Puerto Rico have some form of licensing for dietitians and nutritionists. "In Alaska there are over 120 dieticians and nutritionists working in a wide variety of settings: in hospitals, continuing care facilities, outpatient clinics, school districts, the WIC Program like Debra mentioned, ... the University of Alaska system, ... the state Department of Education, Health and Social Services, and we also have dieticians who ... are out in private practice trying to make a go of it. These individuals have at least a bachelor's degree, many of them have master's, some of them have Ph.D.'s. "There are 2 main reasons why we would like to have the state of Alaska license dieticians and nutritionists. First, as Senator Donley mentioned, there is proposed legislation within Congress that would provide coverage for Part B portion of Medicare, which is outpatient services, which would pay for nutrition therapy services being furnished by dieticians or qualified nutritional professionals. Currently, only a portion of these services are covered." Number 0872 "The legislation provides that the services will only be reimbursed to those professionals who that state legally recognizes as the expert in the specific health care field, in this case nutrition therapy. "Being able to provide covered nutrition services will be a cost savings to Alaskans and to the health care facilities where these people are staying. Speaking from experience and also backed by many studies, proper nutrition therapy reduces the length of stay for people in hospitals, ... they recover from surgery, they recover from trauma quicker, and more importantly, as Debra was taking about, in the area of chronic diseases like diabetes, proper nutrition therapy can reduce and/or prevent the complications that many of these patients have - just not in diabetes, but also in heart disease, strokes, and some forms of cancer. "The second reason ... we support licensure is again similar to what Senator Donley said: professional recognition. I have a degree in dietetics from UC Berkeley [University of California at Berkeley], I have a master's degree, I went through a year of internship, ... I passed an exam to get my RD license, very similar to what an RN [registered nurse] does. ... Deborah's comment ... was also very appropriate; ... a lot of my training was medically-oriented. I teach - I teach nutrition. I teach nutrition [and] I also end up teaching some disease-state education because doctors are so busy that they many times don't have the time to spend the time with their patients that they would like to. I'm part of a health care team at the hospital. Every person in that health care team is licensed by the state of Alaska except my profession. That includes pharmacists, RNs, respiratory therapists, occupational therapists, physical therapists, along with the doctors, obviously." Number 0986 "The bill before you, as someone mentioned, is for title licensure or title protection. It simply says that the person may not hold ... herself or himself out to be dietician or nutritionist unless so licensed. We wish to make it clear that this title licensure does not limit others from engaging in nutritional care practices as long as they do not call themselves dieticians or nutritionists. There are number of other professions who ... currently can provide nutrition services in the course of their work within the occupational licensing in Alaska. There is no effect upon them with this legislation. It's business as usual for them. Nor does this bill affect people who work in the health food store or diet centers, as long as they don't hold themselves out to be dieticians or nutritionists unless they are so licensed." MR WRAY indicated he also wished to respond to Representative Harris' question about the University of Alaska. The University of Alaska Anchorage (UAA) offers a program called "AP4." A person can come in through the nutrition program at UAA, overseen by Dr. Nancy Overpeck, to attain a degree and receive his/her internship to qualify to take the registered dietician examination. UAA is currently the only school in the state which has a degree. Number 1069 REPRESENTATIVE MURKOWSKI asked Mr. Wray to explain the meaning of "registered dietician." MR WRAY answered there is the American Dietetic Association in Chicago. If a person wants to become registered, the association requires that person to have a degree from an accredited university, complete an internship, and pass the association's day-long examination. The person receives the designation of "registered dietician." Mr. Wray noted this is very similar to the American Nurses Association's requirements for RNs. Registry does not mean that a dietician is recognized by any individual state as a nutrition expert. REPRESENTATIVE MURKOWSKI questioned what the internship requires in terms of the work experience. She noted the language in the bill requiring 900 hours for licensure [of nutritionists] and asked how that equates to the internship requirements for a registered dietician. [The language in CSSB 88(FIN) regarding requirements for licensure of dieticians read: Sec. 08.38.020. Dietitian licensure. The department shall issue a dietitian license to an individual who pays the required fee, applies on a form provided by the department, and submits evidence satisfactory to the department of being certified as a Registered Dietician by the Commission on Dietetic Registration.] Number 1131 MR WRAY replied they are exactly the same; it is basically slave labor for a year for a hospital. REPRESENTATIVE MURKOWSKI noted the packet contains some federal guidelines, either for licensure or registration, with a requirement that the work experience be under the supervision of a registered dietician or a nutrition professional. Representative Murkowski commented the legislation does not require this supervision for the work experience. She asked if Mr. Wray feels that is an issue, having gone through the registered dietician process himself. MR WRAY answered that any internship program available for a person to complete has to be scrutinized very greatly by the American Dietetic Association. The association does not bestow its accreditation on just any program; it is very similar to the internship a nurse would do. Therefore, their feeling is that if it is a program which has been approved by the American Dietetic Association, it fills the bill and all those other requirements, such as who oversees it, the hours, and so forth, will be met. REPRESENTATIVE MURKOWSKI commented she had one final question regarding the educational requirements for a licensed dietician. She referred to the definitions section on page 4 of CSSB 88(FIN), specifically subsection (3) of Sec. 08.38.100, the definition of "dietetics or nutrition practice". [This subsection (3) read: (3) "dietetics or nutrition practice" means the integration and application of scientific principles of food, nutrition, biochemistry, physiology, food management, and behavioral and social sciences to achieve and maintain human health through the provision of nutrition care services.] REPRESENTATIVE MURKOWSKI questioned what "behavioral and social sciences" have to do with the food end of things. Number 1255 MR. WRAY responded that a large part of his education efforts with patients is changing someone's behavior. He said, "You have, for yourself, adapted certain nutritional habits since a very early age. If you are referred to me by a physician that you have now ... liver disease or even diabetes, I'm gonna be asking you to make changes in your behavior. I need to have a basic understanding of the human psyche and how to go about facilitating that change in behavior, because that actually is the biggest problem most people have. ... We can give them the information. How to put that into action, into place, is the ongoing efforts that we have." REPRESENTATIVE MURKOWSKI remarked that makes perfect sense. REPRESENTATIVE HALCRO asked how this affects what could be called retail weight centers like "Jenny Craig" or "Weight Watchers," where they basically sell food products. Representative Halcro questioned if the people selling those food products would have to be registered. MR. WRAY indicated that if these people are holding themselves out as nutritionists and they meet the qualifications of a nutritionist, under this legislation, they would have to be licensed. In reality, he noted, most of the people who work for diet centers or for health food stores don't call themselves nutritionists but they dispense nutrition information. It would be business as usual for these people. Mr. Wray indicated the use of the title is the issue; there is no intent to dictate to anyone what kind of information someone can provide. Number 1353 REPRESENTATIVE BRICE questioned if there are a large number of people passing themselves off as trained dieticians or nutritionists. He asked what the consequences are. MR. WRAY answered he could not provide exact numbers, indicating he has heard stories. Currently, there is no mechanism - if someone wants to call themselves a nutritionist and has no qualifications, this person is free to do so. If someone wants to call himself/herself a dietician, he/she can do that. The difficult thing to document is that specific information supplied by an individual to another person was bogus and caused the other person a specific health problem. He commented it is impossible to prove. Mr. Wray indicated other states with licensure don't even attempt to show that. He summarized that within the health care setting the dieticians' and nutritionists' work is cost effective. His boss at Bartlett Regional Hospital knows it: Mr. Wray saves people money by getting them out of the hospital faster. Number 1452 CINDY SALMON, registered dietician and certified personal trainer, testified next via teleconference from Fairbanks in support of the legislation. Ms. Salmon based her remarks on a prepared statement and provided the following testimony: "Hello, members of the House Labor and Commerce Committee. My name's Cindy Salmon. ... I am a registered dietitian, a certified personal trainer, and a lifelong Alaskan. I'm in private practice here in Fairbanks. ... I am also an adjunct lecturer at the University of Alaska in Fairbanks [UAF]. My bachelor of science degrees include nutrition science with a chemistry minor. I obtained it at Northern Arizona University in Flagstaff, Arizona because there is nowhere to get a degree in nutrition in Alaska. However, I was able to be accepted to and complete the requirements of the first AP4 program in Anchorage, which lasted nine months. My services are presently available at the University of Alaska student rec [recreation] center, Fairbanks Athletic Club, and at our outpatient facility, as well as in the client's home. Clients come, or [are] referred, for medical nutrition therapy from many walks of life. There's UAF students, senior citizens, local professionals, children and families, for conditions such as low growth/failure to thrive, eating disorders, anemia, osteoporosis, hyperlipidemia, heart disease, hypertension, and of course diabetes, as well as [for] sound nutritional guidance. I am a member of their health care team and I'm working with other licensed practitioners, closely with physical therapists, occupational therapists, speech therapists, dentists, physicians, nurses, nurse practitioners, social workers and physician's assistants, all in an effort to decrease medical cost and increase the client's quality of life." Number 1537 "My practice is based on sound, scientific principles and focuses on matching a client's nutritional status, readiness to change, with the appropriate medical nutritional therapy and lifestyle intervention. In short, we teach people to separate fact from fallacy in order to make informed choices about their present and future health. At present, it's pretty easy for the public to take a wrong turn when seeking nutritional care. For example, if using the local phone directory, there is a 50/50 chance a person looking under the heading of Nutritionists would find six separate listings - only three of which meet the proposed definition. So state licensure of dieticians and nutritionists would guide the public and reinforce the importance of utilizing providers who have met the professional standard and are qualified to provide nutritional care. I hope this description of my practice helps increase your insight of the present environment and the need to pass this bill. If you have any questions, please feel free to ask. Thanks for your consideration." REPRESENTATIVE BRICE asked Ms. Salmon what type of work she does with social workers: What is her interaction with them? MS. SALMON replied her interaction with a social worker is a cross reference. Social workers often work with clients who may be experiencing, for example, depression or eating disorders; the social worker has a "handle" on what may be happening in the client's environment. Ms. Salmon referred to Mr. Wray's comments, noting that nutrition therapy is all-encompassing; it is a person's life. The many factors going on in a person's life have to be dealt with, what the person has grown up with and where the person is going. By working with a social worker, she can gain insight on what is occurring in a client's life, what that client might be working on, and how that influences the client's food and health choices. Ms. Salmon indicated this back and forth interface results in reinforcement to the client and a consistent message. She noted this is really important - with nutrition it is very easy to get inconsistent messages. Number 1660 LINDA WILD, nutritionist, came forward to testify in Juneau in support of SB 88. Ms. Wild informed the committee she is representing herself and is also a member of the Alaska Dietetic Association. She is a nutritionist, has a master's degree in nutrition, and is currently certified in Washington State where she received her master's degree. Ms. Wild noted certification is Washington's equivalent of licensing and she pays annual fees to the state of Washington to maintain that certification. She took that step because Alaska does not license nutritionists and she wanted the professional recognition that licensure/certification brings. She indicated anyone could use that title if they wished, there is no real meaning to it. If there isn't licensure, there is no way of knowing if someone has had the appropriate training in the field. MS. WILD commented on all the letters someone looking in the phone book for nutritional counseling might see after people's names. She thinks most people don't really know what those letters mean but "licensed by the state of Alaska" gives someone a high degree of comfort. The public knows that person has met at least the minimum qualifications for licensure in the state; that comfort and security is important for the public. Ms. Wild continued that it is important for the dietitians and nutritionists to be on the same playing field as the other licensed health care professionals. She noted dieticians and nutritionists are very passionate about their field - about the benefits of healthy eating. To her, sound nutrition is really the key to the establishment and maintenance of good health. Additionally, to aging baby boomers like herself, sound nutrition is really key to the prevention of many of the chronic diseases which come with aging. Number 1751 CHAIRMAN ROKEBERG asked what letters would follow Ms. Wild's name as a nutritionist. MS. WILD answered she could use "MSN" for master of science in nutrition and "CN," certified nutritionist, in Washington State. CHAIRMAN ROKEBERG asked what she would have if this legislation passes. MS. WILD answered she would be a licensed nutritionist. CHAIRMAN ROKEBERG indicated the bill allows for letters or titles that appear on all signs, stationery, et cetera. He noted they are almost required to have initials. MS. WILD replied she would say "LN." She added that she is close to becoming a registered dietician. In response to the chairman's comment, she noted would be able to have more initials. CHAIRMAN ROKEBERG mentioned the bill requirements to become a licensed nutritionist. He noted there is also a reciprocity provision which would apply in Ms. Wild's case because she is already certified ["registered"] in Washington. Number 1808 REPRESENTATIVE MURKOWSKI commented she assumes Ms. Wild had to do an internship-type work experience under the supervision of another licensed or certified dietician or nutritionist, within the process of her Washington State certification. MS. WILD explained that to become certified in Washington, she is required to have a master's degree, as opposed to a bachelor's degree which is the minimum to be a dietician. Washington also requires completion of a special training course in HIV/AIDS [human immunodeficiency virus/acquired immunodeficiency virus]. She is currently undergoing an 1,020-hour internship program. REPRESENTATIVE MURKOWSKI noted that was the direction she was going. She mentioned the 900 hours in the legislation, questioning whether that is reasonable, in Ms. Wild's opinion, based on her Washington experience. MS. WILD replied she thinks it is. It is equivalent to the registered dietician internship program. She noted there are a variety of ways that experience can be obtained: in a community setting, possibly working for WIC, a school district, the state Department of Education, individual counseling, teaching classes, et cetera. Ms Wild indicated she has experience with her own business doing individual counseling. REPRESENTATIVE HALCRO questioned where some of Ms. Wild's individual clients came from, noting the phone book example and also mentioning referrals. MS. WILD responded that a lot come from word-of-mouth referrals, or referrals from other health care professionals in the community. She noted a lot of people do say, because she always asks how they heard of her, that they found her name in the phone book. Number 1908 CATHERINE REARDON, Director, Division of Occupational Licensing, Department of Commerce and Economic Development (DCED), came forward. If this legislation passes into law, the division will be administering the program directly; there will not be a licensing board. Ms. Reardon said she does not have a lot to add and is available for questions regarding the fiscal note or any other aspect. Because the division will be administering the program, she has no concerns about the legislation's wording. REPRESENTATIVE MURKOWSKI referred to the grounds for suspension, revocation, or refusal to issue a license [Sec. 08.38.040]. She noted one of the items is basically a determination that someone has become unfit due to either professional incompetency, alcohol or drug addiction, or physical or mental disability. Representative Murkowski questioned how the division, without a board, would make a determination that someone has an alcohol dependency, for example, which renders them unfit. [Sec. 08.38.040 of CSSB 88(FIN) read: Sec. 08.38.040. Grounds for suspension, revocation, or refusal to issue a license. The department may refuse to issue a license or impose a disciplinary sanction authorized under AS 08.01.075 on an individual licensed under this chapter when the department finds that the license applicant or licensee, as applicable, (1) secured or attempted to secure a license through deceit, fraud, or intentional misrepresentation; (2) engaged in deceit, fraud, or intentional misrepresentation in the course of providing professional services or engaging in professional activities; (3) advertised professional services in a false or misleading manner; (4) has been convicted of a felony or of another crime that affects the licensee's ability to continue to practice competently and safely; (5) failed to comply with this chapter, with a regulation adopted under this chapter, or with an order of the department; (6) continued dietetics or nutrition practice after becoming unfit due to (A) professional incompetence; (B) addiction or severe dependency on alcohol or a drug that impairs the licensee's ability to practice safely; (C) physical or mental disability; or (7) engaged in lewd or immoral conduct in connection with the delivery of professional service to patients. MS. REARDON answered that the process is very similar to when there is a board. However, the commissioner of the department serves in the capacity of the board. Even when there are boards, it is division staff who investigate complaints. Ms. Reardon noted generally it is going to be citizen complaint driven, unless the division somehow learns on its own of something troubling. Therefore, a citizen complaint is received, the division investigates it and sees if it has sufficient evidence to prove the grounds for the complaint in a hearing process. The division works with the Department of Law to determine whether it has sufficient evidence. The Department of Law reviews the division's formal accusation documents before the documents are issued under the division's name. Often the division has to hire expert witnesses because division staff asserting someone treated a client improperly would not be that convincing in a hearing. Number 2001 MS. REARDON continued that the division does a formal charging document, and almost always the person decides to defend himself/herself. There is a hearing before the department hearing officer under the Administrative Procedure Act [AS 44.62]; the division is represented by the Department of Law, the accused either represents himself/herself or has an attorney. The hearing officer makes a proposed decision. When there is a board, the decision proposed by the hearing officer goes to the board for adoption or rejection. When there is no board, the hearing officer's proposed decision goes the department's commissioner for adoption or rejection. Ms. Reardon noted there are 15 or 16 programs without boards, two examples are acupuncturists and naturopaths. She commented the other place the department serves in the board's capacity is in the adoption of regulations. This means participation from the professionals and the public will be particularly important when the department public notices proposed regulations, since there won't be a board to provide that necessary input. REPRESENTATIVE MURKOWSKI noted the penalty provision provided on page 1 of CSSB 88(FIN) imposed on those who use the title of nutritionist or licensed dietitian without actually being licensed. She asked, then, if it would be the department that would impose a fine based on a consumer complaint. [This language regarding the penalties in CSSB 88(FIN) read: Sec. 08.38.010. License required. (a) An individual may not, unless licensed as a dietician or nutritionist by the department, use the title of "dietician," "licensed dietician," "nutritionist," "licensed nutritionist," or an occupational title using the word "dietician" or "nutritionist." (b) The only penalty that may be imposed on an individual who engages in conduct that violates (a) of this section is a fine of not more than $1,000 under a citation issued under AS 08.01.102 - 08.01.104. (c) An individual who obtains or attempts to obtain a dietician or nutritionist license by dishonest or fraudulent means or who forges, counterfeits, or fraudulently alters a dietitian or nutritionist license, is punishable by a fine or not more than $1,000 under a citation issued by the department. For a citation under this subsection , the department shall use the citation procedures applicable to citations for unlicensed practice under AS 08.01.102 - 08.01.104, and an individual who receives a citation under this subsection is subject to the same requirements as an individual who receives a citation under AS 08.01.102 - 08.01.104.] MS. REARDON answered in the affirmative, although to enforce the fine the department would probably need to go to the court system. Ms. Reardon explained that this in lieu of the misdemeanor language often seen in the department's statutes for unlicensed activity. Any action would almost always be in response to citizen complaints; the department does not initiate a lot of enforcement actions on its own without a complaint. Number 2106 REPRESENTATIVE HALCRO referred to language in the fiscal note: "The division of occupational licensing anticipates existing staff will perform the licensing and investigative functions; however, like all licensing programs, time spent on this program will be based on positive timekeeping." He questioned what "positive timekeeping" is. MS. REARDON indicated this is somewhat licensing jargon. The division employees' record on their biweekly time sheets which professions they spent time on and how much time per day per profession. This is how the division figures out how much to bill each profession during the year for the division's efforts. REPRESENTATIVE HALCRO mentioned the licensing fees, noting it is being assumed that 100 people will apply for these licenses. Representative Halcro mentioned other boards and commissions, especially with biennial licensing where there is a peak [in funding]. He questioned if any money left over in a licensing program remains credited to that program. MS. REARDON answered in the affirmative, noting this would be dependent on the front section of the state budget language continuing as it has since fiscal year (FY) 1995. Unexpended occupational licensing fee revenue rolls forward to the next year. Program deficits also roll forward. If the division spends more for a program than was brought in for it, the program has to pay that back so that the other professions can be reimbursed. Number 2189 REPRESENTATIVE MURKOWSKI referred to Section 4 of CSSB 88(FIN) which allows individuals until June 30, 2001, to come into compliance with this Act. She commented this would give a person about a year once the legislation became law, although the sectional analysis notes the legislation would give a person approximately 1-1/2 years to get everything in order. Representative Murkowski noted, however, the sectional analysis was probably drafted at the same the legislation was introduced. She asked Ms. Reardon if this time frame is reasonable, given discussions they have had on similar issues this session. MS. REARDON commented she thinks they would be able to get moving somewhat more quickly because there is no board and corresponding appointments. She could conceive that some regulations might need to be written regarding the 900 hours of work experience for nutritionists ["(B) has completed a documented work experience in human nutrition or human nutrition research of at least 900 hours."]. These regulations might entail defining what the work experience is that would count for an internship or something similar; this would cause a small amount of delay. However, Ms. Reardon said she would hope the division would have the application forms and regulations by this January . This scenario is more likely than 1-1/2 years. She said it is unlikely the division would begin processing licenses on July 1, 1999. Ms. Reardon noted she would also defer somewhat to the bill sponsor. Number 2282 SENATOR DONLEY responded a normal workday for 6 months would be approximately 900 hours. A person would not have to get this work experience until July 1, 2001. Therefore, people would have all of the year 2000 and until July 1, 2001, so it is still quite a ways away. MS. REARDON commented she had not done her math correctly. CHAIRMAN ROKEBERG invited Ms. Wild to join the committee at the table and asked her to explain the 900-hour requirement. He mentioned there were two different directions to go for nutritionists. MS. WILD informed the committee that there are possibly two nutritionists in the state of Alaska currently, herself and maybe one other person. She noted the vast majority of the people are already dieticians. Both the people they know of have already completed that [work] experience. She thinks a grandfather clause was included in case there is someone else unknown out there. Ms. Wild indicated the grandfather clause gives a person time, if he/she has the degree, to complete the work experience requirement, and it seems sufficient to them. She commented they think possessing the master's degree is very important. Number 2341 CHAIRMAN ROKEBERG asked for confirmation that bachelor's degrees in the field of nutrition are given. MS. WILD agreed, noting this bachelor of science degree in nutrition is the minimum requirement for a dietician. A dietician must have a bachelor's or above, a nutritionist must have a master's or above. She commented the master's degree takes two to three years to obtain. In addition, in her case at least, there is on-the-job training, practicums in different areas, counseling experience, several quarters in clinic working one-on-one with patients in the hospital or clinical setting. She said, therefore, it is very similar. CHAIRMAN ROKEBERG confirmed the dietician is not required to have a master's degree. However, he indicated it is somewhat ironic that dietician is the highest designation in the profession. MS. WILD explained that the dietician has the bachelor's degree, the 900-hour internship program, and has passed the examination from the American Dietetic Association. The nutritionist has a master's degree, which takes two or three years to obtain, and the 900-hour work experience. Those are equivalent work experiences. She commented it is a different group; for one reason or another there are people called nutritionists who have not gone through the internship program and the registration through the American Dietetic Association. This legislation recognizes that there are other professionals in the nutrition field who have not chosen, for one reason or another, to become registered dieticians. Ms. Wild added that they feel this is quite appropriate. Number 2421 CHAIRMAN ROKEBERG confirmed, then, it is a difference in nomenclature rather than a significant difference in terms of academic backgrounds and requirements. MS. WILD confirmed the educational experiences would be relatively parallel. The dietician would tend to have his/her experience in a hospital setting. The nutritionist would tend to be more likely to have his/her experience in a community or educational sort of setting, rather than a hospital setting per se. CHAIRMAN ROKEBERG confirmed, then, the recommendation that someone shouldn't go to a dietician but instead to a nutritionist because of a difference in knowledge wouldn't necessarily be correct. The chairman continued, "It depends on their own personal knowledge and background and specialties." MS. WILD said, "The - the..." [TESTIMONY INTERRUPTED BY AUTOMATIC TAPE CHANGE] [From tape log notes: 'different initials'] TAPE 51, SIDE B Number 0001 CHAIRMAN ROKEBERG requested Ms. Reardon rejoin the committee. REPRESENTATIVE MURKOWSKI noted she thinks this is a question for everyone - for the sponsor, Ms. Wild and possibly anyone else who wishes to join in. Representative Murkowski commented she had raised the point earlier about the 900-hour work experience being under the supervision of a registered dietitian or nutrition professional, at least for the federal requirements. She questioned if they needed to indicate on page 2, line 23 ["22"] where this work experience is coming from or that it should be under the supervision of a registered dietitian or nutrition professional; or if, in their experience, that is just how it happens [CSSB 88(FIN), page 2, lines 23 and 24,"(B) has completed a documented work experience in human nutrition or human nutrition research of at least 900 hours."]. MS. WILD responded she thinks that when the department adopts regulations, the regulations would define what the parameters of that work experience are in the areas of nutrition. She noted it may or may not be under the supervision of a registered dietician, or it may be a combination of things. MS. REARDON added it seems like there is a concern that if the department did not adopt regulations requiring that type of supervision, that possibly the licenses would not achieve the goal in terms of Medicare reimbursement. Therefore, Ms. Reardon indicated it would be pretty essential the department adopt regulations which require that type of supervision, if this is the intention. Number 0075 SENATOR DONLEY indicated, however, the federal law has not passed so it somewhat depends on the final version of that legislation. CHAIRMAN ROKEBERG confirmed this relates to Medicare. SENATOR DONLEY indicated, then, the current language in subsection (B) on page 2 of CSSB 88(FIN) provides the department with some flexibility to address the work experience, depending on what the federal law would consider title licensure. REPRESENTATIVE MURKOWSKI noted, then, it would be the sponsor's preference to leave it as is and address it within the regulations when the regulations come up. SENATOR DONLEY answered in the affirmative. MS. WILD added that the proposed [federal] legislation for Medicare reimbursement says "licensed nutritional professionals in their state". She said the legislation proposed in Alaska is quite similar to the legislation that has gone through the other states. REPRESENTATIVE MURKOWSKI said that satisfies her. Number 0115 REPRESENTATIVE HALCRO mentioned fly-by-night operations and misuse of the titles. He asked Senator Donley where the enforcement is. SENATOR DONLEY answered that there is a provision that the person can be cited for up to $1,000 by the department. He noted this citation could occur if there was a consumer complaint or if the department did its own investigation. Senator Donley said it would not be a crime, it would simply be a citation. REPRESENTATIVE HALCRO asked who would issue the citation. MS. REARDON answered the Department of Commerce and Economic Development, under AS 08.01. She noted the department has an entire section of law that speaks about citations. SENATOR DONLEY commented he thinks citations are a good way to go in a regulatory system because the behavior is not being criminalized; it is a much simpler procedural system to go through. Number 0166 CHAIRMAN ROKEBERG referred to the $31,000 fiscal note, mentioning it looked a bit high. He asked if the licensing examiner would be drafting the regulations or what. MS. REARDON responded the $31,000 is for two years, pointing out that the chairman is looking at the "revenue" line. The division is planning on spending $15,500 a year, but was showing it would probably receive most of the money in one year because of the biennial renewal cycle. The spending breakdown is on the second page of the fiscal note. Ms. Reardon informed the chairman she has asked for a quarter-time range 12 licensing examiner for $8,500; the remaining $7,000 is in contractual services and supplies. These costs would include AG [attorney general] time and phone, postage, printing and advertising costs for regulations and things like that. Ms. Reardon expressed that it is difficult to predict in advance how much time something will take. However, she anticipates that at least for the first two years, a quarter of range 12 is not unreasonable. She indicated there will be others working on this program but extra funds were not requested for their services. There is a range 16 regulation specialist who helps with the writing of regulations, some supervisors will assist the range 12, but this will just be part of everyone's daily job. Therefore, she is estimating about one day a week of a licensing examiner would be appropriate for the first year or two. Ms. Reardon indicated the examiner would be handling the telephone calls, information requests, et cetera, from all of the 100 or so potential licensees. Number 0246 CHAIRMAN ROKEBERG questioned the fiscal note language, "Provides 2.5 months of an Occupational Licensing Examiner I position, Range 12, $8.5 [$8,500]." He noted the 2.5 months and the quarter time, asking if most state employees only worked 10 months a year. MS. REARDON commented she had overestimated - they are asking for a bit less than quarter time. She noted it's not really possible to hire a quarter-time person; she has a half-time employee whose time she would intend to increase by an hour or two per day. CHAIRMAN ROKEBERG commented this is not the House Finance Standing Committee either, but he is concerned by her 50-50 overhead to services. [From the 3/26/99 fiscal note: "REVENUE & FUND SOURCE: Revenue will be generated by the licensing fees sufficient to cover program costs. Approximately 100 licensees are expected to seek licensure and renew licenses biennially. Licensing fees must cover direct costs plus approximately $100 per licensee for division/department overhead for the two-year period. Based on 100 licensees, licensing fees are estimated to be $410.00 for the first biennium , and adjusted to actual costs based on positive timekeeping for the first renewal."] MS. REARDON responded she was probably waving a "red flag" by typing that, but indicated it is included in the interests of honesty. She added "overhead" might not be the most delicate way of putting it. However, it is costing the department about that amount for every licensee. This would be all costs the department does not attribute down to the profession level; for example: her time at this hearing, the receptionists' answering the telephone. Ms. Reardon noted there are a variety of employees who would be providing real services but whose services cannot be tracked efficiently at the profession level. She noted there are real things like receptionists, people who open the mail, photocopier costs, that are billed out as overhead. Number 0322 REPRESENTATIVE MURKOWSKI referred to the exemptions, questioning why federal government employees and those in the armed services would be exempted. Additionally, she asked if there are really animal nutritionists, and if so, she needs the name of one. MR. WRAY answered that there is an individual who teaches animal nutrition at the University of Alaska Fairbanks and is a Ph.D. Mr. Wray explained all the other 39 states with licensure/certification have the same exemption. REPRESENTATIVE MURKOWSKI asked about the exemptions for the military and the federal government. SENATOR DONLEY responded they just felt it was appropriate for someone who is working for the armed forces or the federal government. The government will be controlling that person; it is not as if the person is out in the open marketplace offering his/her services. REPRESENTATIVE BRICE noted it is a practice commonly used as well with the other professions. The state does exempt federal employees and military employees from licensure. REPRESENTATIVE HALCRO indicated he had posed this question earlier that day to Ms. Wild. If someone is in the military and is using the title dietician or nutritionist, the legislation clearly states the person needs to be licensed if he/she is using the title outside the scope of the person's military service. Representative Halcro noted, however, it does not dictate that for a federal government employee and he asked if there is a reason for that, mentioning the possibility of someone moonlighting. Number 0407 SENATOR DONLEY answered there was no particular reason other than that a specific circumstance was being addressed in subsection (3) [of the exemptions]. He noted it could be made to apply to both and they have language available if that is the committee's will. [The exemptions section of CSSB 88(FIN) read: Sec. 08.38.080. Exemption. The requirements of this chapter do not apply to (1) an animal nutritionist whose activities are limited to the nutritional care of animals; animal nutritionists may use the title "nutritionist" as long as they provide nutrition services only to animals; (2) a person who is serving as an employee of the federal government whose job title includes the term "dietician" or "nutritionist"; or (3) a person who is serving as a dietician or nutritionist in the armed forces of the United States, but the exemption provided under this paragraph does not authorize the person to use the title "dietician," "licensed dietician," "nutritionist," "licensed nutritionist," or an occupational title using the word "dietician" or "nutritionist" outside the scope of the person's military service.] REPRESENTATIVE HALCRO indicated he had simply been curious. MR. WRAY commented, regarding the military exemptions, that Elmendorf Airforce Base hospital has a dietician and there are number of dietitians in active military reserve. These dieticians have all told him the direction received from their superiors, at their commanders' discretion - and he noted this applies to all health professions - is that person should obtain licensure in the state he/she is assigned to if licensure exists for his/her specific health care field. Mr. Wray indicated it had not been the intention to dictate this with the legislation's language, adding, "If it's their call, they make that call themselves ...." CHAIRMAN ROKEBERG asked Mr. Wray if medical schools are now including an integrated degree of nutritional training. He noted they had never done anything in the past. MR. WRAY replied his understanding is that it varies greatly. There is some emphasis, but on the other hand, medical school is "no walk in the park." He noted there is not a lot of free time and trying to throw in electives is probably very difficult for any sort of regular medical school program. His understanding is that most medical school curriculums do offer a basic nutritional program. Mr. Wray referred to Representative Halcro's question about where Ms. Wild receives her patients; Mr. Wray receives all of his from physician referrals. Physicians basically count on him to teach nutrition to the patients, knowing that dieticians have a level of knowledge the physicians didn't have a chance to get in medical school. Number 0505 CHAIRMAN ROKEBERG questioned the sponsor if there is anything in the legislation that would require a payment to a dietician or a nutritionist under an insurance contract that would not otherwise be made without the bill. The chairman asked if there is anything in this legislation which require an insurance company to make payments they would not have to make otherwise. SENATOR DONLEY replied he guesses it would depend on the insurance contract. In response to the chairman's comment, the senator answered that if a company wrote a contract which said the company would pay a person's costs for a licensed dietician, then the company would be obligated to do that if the state licenses dieticians. CHAIRMAN ROKEBERG noted he thinks the answer is correct but doesn't believe it is typically a covered area. The chairman asked for Mr. Wray's assistance. Number 0553 MR. WRAY responded his understanding, from the other 39 states with licensure/certification, is that there has been no additional cost to any insurance companies involved. He said he would echo Senator Donley's comment, stating, "What you find ... in the health care reimbursement is the big player who's dictating the field is HCFA [Health Care Financing Administration, United States Department of Health and Human Services], the people who administer Medicare." He commented HCFA decides the service is going to be covered. Many times years later, the insurance companies may decide to cover those services, but may not. Currently some of his services are covered by insurance companies and some are not; it is the insurance company's prerogative. CHAIRMAN ROKEBERG commented that Alaska has an unusual insurance statute - it has a special section or list. The chairman indicated he did not see "dietician" or "nutritionist" appearing on that list and simply wanted to put it on the record. SENATOR DONLEY said perhaps another way to answer the chairman's question is that nothing in this bill mandates that this is covered by insurance. CHAIRMAN ROKEBERG asked the pleasure of the committee. Number 0605 REPRESENTATIVE HALCRO made a motion to move CSSB 88(FIN) out of committee with individual recommendations and the attached fiscal note. There being no objection, CSSB 88(FIN) moved out of the House Labor and Commerce Standing Committee. Number 0619 CHAIRMAN ROKEBERG called an at-ease at 4:26 p.m. The committee came back to order at 4:47 p.m.