Legislature(2003 - 2004)
03/30/2004 09:04 AM Senate FIN
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* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
SENATE BILL NO. 306
"An Act relating to the practice of naturopathic medicine; and
providing for an effective date."
This was the second hearing for this bill in the Senate Finance
Committee.
Co-Chair Wilken explained that this bill, which is sponsored by
Senator Ralph Seekins, would enact an Act relating to the practice
of naturopathic medicine. Initially, consideration was given to
implementing a Board to oversee naturopathic medicine; however,
that is not now being considered. The Department of Community and
Economic Development was asked to explain the Department's Division
of Occupational Licensing flow chart, titled "Implementation of
CSSB306(FIN)" [copy on file] that depicts how licensed Naturopathic
Physicians would be monitored.
RICK URION, Director, Division of Occupational Licensing,
Department of Community and Economic Development, clarified that
the Governor Frank Murkowski Administration has no position in
regards to this legislation. Were the Legislature to adopt
regulations in regards to Naturopathic medicine, the Department
would implement supporting rules and regulations. However, the
Department has been regulating this profession and numerous others
without assistance from a Board, for approximately seventeen years
and could continue to do so absent any new legislation.
Co-Chair Wilken asked the current process through which a complaint
against a Naturopath might be reviewed.
Mr. Urion responded that the Department's investigative staff would
address the complaint, and, were it deemed necessary, it might be
forwarded to a hearing officer. A multitude of different processes,
including such things as memorandums of agreement, have been
established through which issues regarding each profession are
addressed.
Co-Chair Wilken asked whether the flow chart provided by the
Department [copy on file] would depict the process involving
naturopaths.
Mr. Urion affirmed.
Co-Chair Wilken asked that the flow chart be explained.
Mr. Urion explained that currently when a complaint is filed, the
Division's investigative staff who, based on a priority list that
heavily ranks Life/Safety issues, would determine whether charges
should be filed addresses it. Were that the case, a hearing officer
would be assigned, a trial might ensue, and the hearing officer
would render a decision including the level of punishment. This
could include such things as license removal, suspension and fines.
Were the defendant to reject the decision of the hearing officer,
they have the right to appeal to a higher court.
Mr. Urion shared that in situations in which there is a Board, the
Board would have the authority to act on the complaint.
Co-Chair Wilken asked whether the Department, in conjunction with
Naturopaths, developed the chart.
Mr. Urion concurred.
Co-Chair Wilken asked whether the Division's investigators are
trained professionals.
Mr. Urion responded that while none of the Division's investigators
are trained in any of the fields that they investigate, they are
trained investigators. He noted however, that they do consult with
the appropriate medical professional pertinent to each situation.
He noted that the Medical Board recently adopted a procedure that
specifies that complaints dealing with such things as sexual abuse,
alcohol, or drug misuse be immediately forwarded to the Division's
investigators. However, determinations regarding standards of care
complaints are determined by the Board and then forwarded to the
investigators, who could independently make a determination if they
so chose.
Co-Chair Wilken asked for confirmation that this is the current
practice relating to Medical Board.
Mr. Urion affirmed.
Co-Chair Wilken opined therefore that a procedure akin to a triage
occurs at the investigative level in that the investigator consults
with a medical professional. The investigator would receive a
complaint from a patient, and then the triage would occur in which
it would be determined whether the complaint is serious enough to
advance immediately to a hearing officer.
Mr. Urion clarified that in serious cases, the state investigator
would have the authority to make the determination. Complaints
regarding standards of care might require an investigative review
that might include a medical professional.
Co-Chair Wilken understood that an investigator would be expected
to consult with the appropriate medical professional.
Mr. Urion agreed. He stated that this is the current procedure
utilized when reviewing complaints against naturopaths.
SENATOR RALPH SEEKINS, the bill's sponsor, noted that language on
the bottom of the flow chart specifies that in the case of non-
threatening public safety issue or a Standards of Care complaint,
investigators could consult with the Qualified Trade Association of
Naturopathic Physicians (NP/QTA), which would consist of volunteers
from the field.
Co-Chair Wilken asked whether this organization exists today or
would be established by this legislation.
Senator Seekins responded that while this organization does not
currently exist, its establishment would be clearly defined in a
forthcoming committee substitute.
Mr. Urion declared that this would be an opportunity in which
government and private enterprise could work together to regulate
an industry. No professional entity would benefit from "condoning
bad behavior" within its profession.
Co-Chair Wilken summarized that the complaint process would be that
a wronged patient would go to the State, It would then be directed
to an investigator. The investigator could consult with the three-
member NP/QTA panel.
Senator Olson questioned "the wisdom" of allowing naturopaths to
have their own board, as currently the process provides an
investigator the ability to consult with professionals. In
addition, he asked whether there could be the option of having
naturopathic complaints heard by the eight-member Medical Board.
Mr. Urion voiced concern to the appropriateness of having these
complaints heard before the Medical Board due to the negative
comments the medical field has made in regard to naturopaths.
Continuing, he noted that at this point, the Division could monitor
the Naturopathic profession without implementation of a Board.
Senator Bunde countered that currently the Board of Medicine has
oversight over a wide range of medical professions including
Physician Assistants (PAs), Nurse Practitioners (NPs), Registered
Nurses (RNs), Oseopathics, dentists, and paramedics. All these
professions are included under the term "physician" and, since this
bill would expand that term to include Naturopaths, it would be
logical that they be included in those professions monitored by the
Board.
Senator Seekins responded that he would not object to the inclusion
of a naturopath on the Medical Board, were it suggested. Inclusion
of a naturopath on the Board would provide some insight to the
Board regarding Standards of Care for the profession. However, due
to the fact that naturopathic medicine presents competition,
naturopaths "have a fear that there may be some objection "from the
more recognized medical professions.
Co-Chair Wilken recalled that, until a few years ago when they were
granted voting rights, Physician Assistants were ex officio members
of the Medical Board. Perhaps this might be an option with
naturopaths.
AT EASE 10:28 AM / 10:28 AM
Senator Olson clarified earlier information regarding which
professions the State Medical Boards oversees. While it does govern
paramedics, physicians, and physician assistants, it does not have
direct regulatory oversight in regards to dentists, nurses, and
nurse practitioners.
Senator Olson also noted that when he, a medical doctor, was on the
State Medical Board, its seven-person membership consisted of five
physicians and two lay people. He subsequently supported the
representation of a PA on the Board due to their increasing numbers
in the State. He noted that the number of naturopaths in the State
is limited.
Co-Chair Wilken noted that there are currently 27 Naturopaths in
the State.
Senator Seekins countered that any board that regulates a
profession should have, as part of its membership, a representative
of each profession in order to negate such things as "hostility"
against that profession.
Co-Chair Wilken asked for confirmation that PAs were, at one time,
ex officio members of the Board.
Senator Olson specified that PAs were diligent in attending every
meeting even before they had representation on the Board. In that
regard, once they were admitted to the Board, they became voting
members. He agreed with Senator Seekins that representation at the
Board level is important.
Co-Chair Wilken pointed out that the definition of minor surgery is
included in the bill in Section 13, subsection (6), page six, line
19 and reads as follows.
(6) "minor surgery"
(A) means the use of
(i) operative, electrical, or other methods for
surgical repair and care incidental to superficial lacerations
and abrasions or superficial lesions, and the removal of
foreign bodies located in superficial tissues; and
(ii) antiseptics and local anesthetics in connection
with methods authorized under (i) of this subparagraph;
definition;
(B) does not include use of general or spinal
anesthetics, major surgery, surgery of the body cavities, or
specialized surgery, such as plastic surgery, surgery
involving the eyes, or surgery involving tendons, ligaments,
nerves, or blood vessels.
Co-Chair Wilken asked Senator Olson to address his concern
regarding allowing naturopaths to conduct "further tests."
Senator Olson voiced the understanding that one of the reasons that
naturopaths are requesting prescriptive authority is because their
position is that they have similar education and training levels to
that of medical doctors. However, while many of the initial
educational courses were the same, there was a "divergence later
on" as the foundation of the naturopathic delivery system was one
of being "basically drug free."
Senator Olson voiced that, with the care of the patient in mind,
there is concern that in the continuance of their care, limiting
prescriptive treatment to medical doctors would be appropriate to
the balance. He noted that there has been an abiding identification
within the medical profession that medical doctors prescribe
medication. In order to expand rather than restrict naturopath
prescriptive authority, it could be suggested that naturopaths
should be required to qualify for Part One, Two, and Three of the
National Medical Board examination rather than being required to
pass only Parts One and Two. Part Three is the section that tests
prescriptive knowledge. Therefore, their ability to pass all three
sections of the examination would indicate that their training was
comparable to that of a medical doctor and would allow them to have
prescriptive authority.
Senator Seekins, being respectful of Senator Olson, clarified that
rather than seeking to be recognized as medical doctors,
naturopaths are seeking to have prescriptive rights that are less
than a PA and NP. This was clarified in Amendment #1 which the
Committee during its first hearing on the bill. That amendment
inserted a new subsection into Section 11, subsection Sec.
08.45.120 on page five, line 16 that reads as follows.
(4) after becoming registered with the federal Drug
Enforcement Administration, prescribe only those controlled
substances allowed under Schedules III, IV, and V.
Senator Olson clarified that a PA could only practice medicine
under a collaborative agreement and direct oversight by a medical
doctor (MD). Were something to go wrong, the MD would also be held
liable.
Senator Bunde asked how an NP's training would differ from that of
a PA in this regard.
Senator Olson stated that while he is familiar with PA requirements
and the associated prescriptive limitations, he is unfamiliar with
the requirements for a NP.
Senator Seekins shared that he is familiar with the NP requirements
as his wife is a nurse and a close friend is a NP.
SFC 04 # 63, Side B 10:40 AM
Senator Seekins noted therefore, that NPs could prescribe all
levels of prescriptive medications as they have a higher level of
training than PAs. "It would be inconceivable" that any
practitioner … would not seek assistance from other caregivers when
encountering serious situations.
Co-Chair Wilken noted that concerns have been raised due to the
understanding that Naturopathic Doctors (ND) would not have medical
malpractice insurance. He referred the Committee to Item #3 on page
two of a letter [copy on file] dated February 24, 2004 from Dr.
Scott Luper, ND that Co-Chair Wilken had received in response to
comments in a letter [copy on file] dated February 9, 2004 that Co-
Chair Wilken had received from Tom Wilson, PA-C. The comment and
response, as written in Dr. Luper's letter are as follow.
#3. The bill is too broad. Currently one could prescribe
antibiotics to dangerous heart medications, to chemotherapy.
Allopathic M.D. would most likely not prescribe medication
outside of their specialty, as it would be considered outside
of the "standard of care". If a bill were passed a formulary
would be much more acceptable and safe.
3). Response: Mr. Wilson suggests that an ND might be tempted
to prescribe outside of their training/education and that an
MD "would most likely not" prescribe inappropriately. This is
not realistic. A good "DOC" is a good "DOC". NDs will be
liable for malpractice on par with MD's and under the auspices
of the Div. of Occupational Licensing.
DR. SCOTT LUPER, Naturopathic Doctor, testified via teleconference
from Fairbanks and clarified that NDs are able to acquire
malpractice insurance and that ND malpractice insurance is less
costly that MD malpractice insurance due to the fact that the
complaints against them are fewer. He stated that, while he pays
$3,000 a year, the majority of his ND colleagues pay between $600
and $2,000 annually.
Co-Chair Wilken surmised that NDs carry malpractice insurance in
line with their standards of care.
Dr. Luper affirmed. He noted that the standard ND medical
malpractice coverage would provide one million dollars per
occurrence and three million dollars total.
Senator Bunde surmised that MDs pay higher medical malpractice
insurance due to the fact that they write prescriptions and perform
surgeries. Therefore, he opined that ND's rates might increase were
this legislation adopted.
Dr. Luper responded that this has been investigated and it has been
determined that the rates would not increase. He further noted that
the Alaskan ND rates are comparable to those being charged in
states that provide NDs prescriptive and minor surgery authority.
Dr. Luper disclosed that in order to address the question of
safety, he had conducted a survey of states that license NDs. He
had acquired the number of ND disciplinary actions in Arizona,
Oregon, Hawaii and Connecticut. ND disciplinary actions including
such things as license suspensions and other punishing actions are
approximately half of the amount pertaining to allopathic or MD
disciplinary actions. In Arizona, for instance, the disciplinary
rate for MDs is about one percent of those licensed, and about half
a percent for NDs. Nationwide the rate for NDs is .34 percent. No
disciplinary action has occurred against NDs in Alaska during the
seventeen years in which they have been licensed in the State. This
is a reason why the rates are low and is a testament to the quality
and care provided by the profession. He clarified that there are 39
licensed NDs in the State.
BARRY CHRISTENSEN, Practicing Community Pharmacist and Legislative
Chair, Alaska Pharmacists Association, testified via teleconference
from an offnet site to voice concern on behalf of the Association's
200 plus members in regards to the prescriptive authority being
proposed in the bill for NDs. He informed the Committee that while
he heard reference to Amendment #1, he is unaware of its contents.
Co-Chair Wilken informed the testifier that Amendment #1 removed
the requirement regarding Prescriptive Schedules I and II and
retained Schedules III, IV, and V in the authority being proposed
for NDs.
Mr. Christensen addressed the position that NDs education is
"equivalent or nearly equivalent" to that of an MD because,
similarly, they also have a four-year degree. "While this may be
true in an academic sense, our membership has had little if any
interaction with naturopaths during our professional training" but
have had extensive training with PAs, NPs, and MDs "and have
developed good working professional relationships with these
professionals. This relationship is very important when working
with patients and recognizing "problems with dosing, drug
interactions and drug abuse." He questioned the fact that while the
definition of naturopathy that is included in the bill does not
include medicine, the bill would provide full prescriptive
authority to NDs. He noted that most states that allow ND
prescribing provide NDs with limited prescriptive authority. He
stated that pharmacists would be more comfortable with this
legislation were NDs required to work collaboratively with other
licensed prescriptors. Lastly, he raised concern regarding the
prescriptive authority of controlled substances, or narcotics, and
stated that control of such substances should be closely guarded.
Absent a presciptor-based narcotic tracking system, this issue
would continue to be "the number one" concern of pharmacists. He
assured that while there is no reason to believe that NDs would
abuse this prescriptive authority, increasing their availability by
expanding the number of prescriptors would provide another
potential avenue for narcotic abusing patients.
Mr. Christensen stated that while the amendment would limit ND
prescriptive authority to Schedule III, IV, and V drugs, the
majority of narcotic drugs are included in those categories.
Therefore, the Membership would continue to voice concerns.
Senator Olson asked, for clarification, the Association's position
on Amendment #1.
Mr. Christensen responded that a majority of the Membership would
continue to have problems primarily due to the inclusion of
Schedule III, which encompasses narcotic painkillers. He noted that
since he was unaware of the amendment prior to this, the membership
has not been conferred with in its regard.
Senator Olson asked the percent of patients who might be receiving
prescriptive relief from either Schedule II through V or III
through V.
Mr. Christensen responded that the majority of people who take pain
relievers are utilizing Schedule III drugs, as it is the outpatient
pain drug of choice. A written prescription is not required for
Schedule III drugs whereas one is required for Class II drugs.
Therefore, he estimated that approximately 70 percent of
individuals who are taking painkillers are taking Schedule III
drugs. Schedule IV drugs are anti-anxiety rather than painkiller
types of drugs.
Senator Bunde voiced that it would be an inconvenience were someone
to seek naturopathic care and then discover that they would be
required to go to another medical professional were a prescription
drug required to treat, for instance, high blood pressure or an
antibiotic such as penicillin. He asked what which schedule these
types of prescriptions are included.
Mr. Christensen responded that antibiotics are "not a scheduled
narcotic" and therefore are not regulated by the Drug Enforcement
Administration. They are instead classified as a prescription by
the Food and Drug Administration (FDA) and would require a
prescription. A narcotic-based pain reliever such as Tylenol #3
would be a Schedule III drug.
Senator Olson clarified that the drugs included in "Schedules I
through V are those that are directly related to the potential for
abuse by either a patient or a patient prescriptor." An antibiotic
would not fall in this category.
Senator Seekins understood that as part of a pharmacist's training,
they are taught how to recognize signs of abuse or mistakes.
Mr. Christensen affirmed.
Senator Seekins understood therefore that "even now" in the medical
profession, abuse does occur.
Mr. Christensen agreed.
Co-Chair Wilken stated that the bill would be HELD in Committee in
order to develop a committee substitute that would include
Amendment #1 and clarify language regarding the voluntary review
committee.
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