Legislature(2007 - 2008)SENATE FINANCE 532
05/12/2007 09:00 AM Senate FINANCE
| Audio | Topic |
|---|---|
| Start | |
| HCR6 | |
| HB113 | |
| HB162 | |
| HB90 | |
| HB166 | |
| HB90 | |
| SB178 | |
| Adjourn |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
| += | HB 177 | TELECONFERENCED | |
| + | HCR 6 | TELECONFERENCED | |
| + | HB 113 | TELECONFERENCED | |
| + | HB 90 | TELECONFERENCED | |
| += | HB 162 | TELECONFERENCED | |
| + | HB 166 | TELECONFERENCED | |
| + | TELECONFERENCED |
SENATE CS FOR CS FOR HOUSE BILL NO. 113(L&C)
"An Act relating to the prescription and use of
pharmaceutical agents, including controlled substances, by
optometrists; and providing for an effective date."
This was the first hearing for this bill in the Senate Finance
Committee.
9:22:08 AM
REPRESENTATIVE RALPH SAMUELS, the bill's sponsor, identified the
State's geography and small population base as factors that
limit access to health care in the State. This bill would
enhance health care services by extending prescriptive authority
to optometrists. Alaska would join 45 other states that allow
similar practice.
Representative Samuels declared that expanding the ability of
optometrists, who far outnumber ophthalmologists in the State,
"to do more" would benefit Alaskans.
Representative Samuels stated that the experience of states that
allow optometrists to have prescriptive authority has been
positive.
9:24:02 AM
Senator Thomas understood that college level optometry training
programs include instruction on the use of needles as a matter
of routine. Thus, the seven hours of training identified in this
legislation would be in addition to that training.
9:25:07 AM
Representative Samuels could not speak to that matter, but was
confident it could be addressed by one of the medical
professionals who would be testifying on the bill.
9:25:15 AM
Senator Olson asked how the bill before the Committee differed
from the original bill.
9:25:44 AM
Representative Samuels stated that changes were made to the
education requirements.
9:25:57 AM
In response to a follow-up question from Senator Olson, Co-Chair
Stedman and Representative Samuels advised that the seven hour
training requirement for injecting nontopical therapeutic
pharmaceutical agents, specified in Section 2 subsection (d)(2)
on page 2 lines 16 and 17, was added to the bill.
Representative Samuels also noted that language pertaining to
the use of Botox was added as specified in Section 3 subsection
(a)(1)(E) page 3 lines 2 through 4.
9:26:14 AM
SIDNEY MORGAN, Staff to Representative Ralph Samuels, further
discussed the various provisions that had been added to the bill
to address concerns about injectibles including the provision
that would specify a January 1, 2009 effective date for their
use.
Ms. Morgan also noted that numerous changes had been made by the
House Health, Education & Social Services (HES) Committee, so
much so that the bill increased from two to four pages. The HES
amendments addressed such things as the types of types of
narcotics that could be prescribed and limited the duration of a
prescribed medication to four days.
9:28:37 AM
Co-Chair Stedman asked whether the bill's sponsor was confident
that the zero fiscal note from the Department of Commerce,
Community and Economic Development was a true reflection of the
costs associated with the bill.
9:28:58 AM
Representative Samuels affirmed the accuracy of the fiscal note.
In response to a question from Senator Olson, Co-Chair Stedman
disclosed that numerous ophthalmologists and optometrists had
signed up to testify on the bill.
9:29:48 AM
DR. DAVID CHAMBERLAIN, Ophthalmologist, testified via
teleconference from an offnet location and informed the
Committee that he has practiced in the State for more than ten
years.
Dr. Chamberlain sought to correct misstatements made by a
[unspecified] testifier before another committee of referral
regarding access to health care. Contrary to that testimony,
ophthalmologists do travel to small communities in the State
such as Klawock and Craig.
Dr. Chamberlain stressed that this correction is important as
supporters of the bill tout lack of access as "a big problem"
and thus, reason to support this bill. This is not true. For
example, either he or his practice partner conducts eye clinics
in Klawock once or twice a year. Furthermore, he also regularly
conducts clinics through his job with the Alaska Native Medical
Center, in other small communities including Barrow, Nome,
Kotzebue, Bethel, Dillingham, and Kodiak, and Sitka. The clinics
are conducted in a cooperative effect with optometrists in those
areas.
Dr. Chamberlain pointed out that the Alaska Native Medical
Center also employs optometrists throughout the State. They
serve both their community and its surrounding area.
Dr. Chamberlain continued. When a person with an eye problem "is
sick enough to require an oral or an injectible medicine", the
community's optometrists or village health aide or physician or
nurse practitioner call an ophthalmologist. The State typically
has two ophthalmologists or medical doctors on call at all
times. The point was that this bill "does not increase access to
an optometrist, and actually it may decrease access to an
ophthalmologist, accidentally."
Dr. Chamberlain professed that this bill would reduce training
requirements pertaining to injecting and prescribing medicines.
It would also force a redefinition of the role between
ophthalmologists and optometrists.
9:33:34 AM
Dr. Chamberlain declared that he has a good working relationship
with optometrists throughout that State and that a good system
is in place to address the State's eye care needs.
Dr. Chamberlain advised that medical issues concerning eye-care
are complex. Oftentimes, an eye problem is associated with
another medical issue such as diabetes; few medicines "treat
just the eye". A topical medication applied by an optometrist in
a remote area would allow for sufficient eye examination.
Dr. Chamberlain declared that safeguards must be in place to
protect patients from eye injuries due to "inadvertent intra-
ocular injections". This "accidental perforation of the eyeball"
can occur even when the procedure is conducted by
ophthalmologists and anesthesiologists. However, the highest
percent of this incidence occurs when an injection is
administered by someone other than an ophthalmologist.
9:35:17 AM
Dr. Chamberlain contended that access to quality medical "care
would be reduced" under this bill. Furthermore, "the complexity
of the human organism is such that we need to listen to the
best" medical advice including that of the Controlled Substance
Advisory Committee and the State Medical Board.
"Ophthalmologists are uniquely qualified to provide medical
information, particularly in regards to when it would be
acceptable for a non-ophthalmologist to perform a medical
procedure.
9:36:10 AM
DR. ERIC COULTER, Ophthalmologist, testified via teleconference
from an offnet location to voice concern about the legislation.
He rebuffed the argument that this legislation would assist in
addressing the "lack of care" in the State. He also thought that
adopting this legislation would reduce the quality of eye care
in the State as allowing optometrists "to delve into greater
therapeutic options without proper training" would likely delay
referral to an ophthalmologist.
Dr. Coulter pointed out that topical eye drops and other
therapeutic medicines currently utilized by optometrists are the
standard medical response to eye problems even by
ophthalmologists. The need for injectibles is relatively ""rare"
and, when administered, is typically in the form of an
intravenous antibiotic. A person requiring that level of care is
likely receiving in-patient hospital care.
Dr. Coulter contended that a medical situation occurring in a
remote area that required more than topical treatment would
likely require more extensive medical care than an optometrist
could provide.
Dr. Coulter advised the Committee that he had submitted written
remarks [copy on file] which outlined many of his concerns. It
also overviewed the optometry field's attempt to broaden their
scope of practice nationwide. One of their arguments is that
Alaska is behind the times because it has not passed similar
legislation. To that point, he thought that each state should
address its needs independently.
Dr. Coulter shared that the American Academy of Ophthalmology's
research department considered this legislation to be "a more
loosely written" and broader bill than any but five of the 45
States that have adopted legislation on this issue.
Dr. Coulter urged the Committee to conduct a thorough review of
the bill before taking action on it; specifically in that
passage of the bill in its current form might have" unintended
consequences". The argument that "a lack of care in the State
warrants expanded pharmacologic privileges, in my mind, is just
misleading". He urged the Committee to seek supporting evidence
to that claim, particularly in respect to rural areas of the
State.
Dr. Coulter argued that many communities experience regular eye
care service and referrals to ophthalmologists are readily
available.
Dr. Coulter shared that an ophthalmologist who practiced on the
Kenai Peninsula for more than 30 years found very little use for
injectibles and even let his narcotics license expire.
9:41:38 AM
Dr. Coulter urged the Committee to respect "the historical
validity of our medical system and try not to rewrite what
constitutes competent medical care in our communities." He
reminded the Committee that the Alaska State Medical Board, the
Alaska State Medical Association, the Alaska Ophthalmology
Society, and the American Academy of Ophthalmology did not
support this bill.
9:42:14 AM
Senator Thomas would have expected the American Academy of
Ophthalmology to be against the bill. Continuing, he asked
whether the concern is that "some obscure eye diseases would not
be diagnosed properly based on" a patient being treated solely
by an optometrist and that the patient would not seek further
care because they had been treated by an eye doctor,
irrespective of the fact the eye doctor was not an
ophthalmologist.
9:43:00 AM
Dr. Coulter stated that the concern goes beyond that
circumstance; it includes the complete evaluation of such things
as "whose training is more adequate."
Dr. Coulter affirmed there was a good working relationship
between the two professions as evidenced by the fact that he
refers patients to optometrists and they refer patients to him.
The concern "is not so much a turf battle" as it is the
misconception that expanded pharmacologics is somehow going to
improve the care in rural areas if it is delivered by people
that are more accessible.
Dr. Coulter agreed that there were more optometrists than
ophthalmologists' practicing in the State, but that is true in
every State in the nation "because of the different training
requirements". The concern is not that optometrists are
incapable of utilizing pharmacologics, it is to the "casual
comments about the lack of care in communities because there are
so few ophthalmologists". This is a misguided argument.
Dr. Coulter reiterated that a person who does not respond well
to the topical medications currently available to optometrists
is likely a person with a serious medical condition. Thus, if
the intent is to enhance the quality of care in communities, the
Committee should consider the fact that this legislation might
be "counter-intuitive" to the goal: it might actually delay a
referral to a specialist.
9:45:03 AM
DR. CARL ROSEN, Ophthalmologist and President, Alaska Society of
Ophthalmology, testified via teleconference from an offnet
location. He reviewed his extensive medical background and noted
that as a result of his experience he had "a unique vantage
point" regarding eye injections.
Dr. Rosen stated that the Society considers this a bad bill for
a number of reasons. "One is that it is so extremely difficult
to acquire acceptance into a medical school"; ophthalmology
programs are very selective and once admitted, students are
subjected to six years of rigorous training.
Dr. Rosen also pointed out that, unlike optometrists,
ophthalmologists have hospital privileges and are on-call in
case of an emergency. This has been the practice for more than
30 years.
9:47:15 AM
Dr. Rosen informed the Committee that ophthalmologists typically
undergo 24,000 hours of clinical training; optometrists however
typically undergo 2,000 hours of such training.
Dr. Rosen declared that this bill would expand optometrists'
"scope of practice enormously," specifically their prescriptive
authority. They would be authorized to prescribe Class III, IV,
and V medications, including codeine, pain medications, valium,
cardiac, diabetic, and anti-seizure medications to children,
pregnant women, infants, and the elderly.
Dr. Rosen recommended the formation of a committee to determine
"exactly what is needed". Their task should include a review of
current health care services, timetables, limitations, and even
what diseases should be addressed. He was confident that such a
committee could develop workable solutions to the issues, with
"better limits and boundaries that the ophthalmology and medical
community can live with".
9:49:45 AM
REPRESENTATIVE BILL THOMAS declared that this bill is about the
availability of adequate eye care, specifically for people
living in rural communities. A person living in Haines, for
example, would be required to spend approximately $1,000 dollars
to get their child to Juneau or Anchorage for treatment. Such
costs would be alleviated where there an opportunity to be
treated by an optometrists in their community.
Representative Thomas observed that the Legislature routinely
strives to allow those in the medical field to "maximize their
abilities". Rather than this being "a turf war", the effort
should be on taking care of people.
Representative Thomas discussed a problem a family member had
with treatment provided by an ophthalmologist. It was
exacerbated by the fact that she had to travel from a rural
community to Juneau for treatment.
Representative Thomas respected the services provided by
ophthalmologists and urged them to respect the abilities of
optometrists. The on-going challenge of attracting medical
professionals to the State could be lessened by allowing them to
perform duties they were trained for.
Representative Thomas urged the Committee to pass the bill. "It
is important to small communities."
9:53:05 AM
BOB LOESCHER testified in Juneau and informed the Committee that
as a legally blind man, he has received treatment from both
optometrists and ophthalmologists.
Mr. Loescher, on behalf of health care consumers, questioned the
reason the bill was not accompanied by a fiscal note that
addressed whether this legislation would increase costs or risks
to consumers.
Mr. Loescher provided a list of questions [copy on file] that
should be asked on behalf of consumers. He contended that the
legislation would impact the Department of Commerce, Community
and Economic Development since they administer and assist boards
pertinent to this legislation such as the State Medical Board
and the Board of Optometry Examiners. New regulations, testing
and monitoring pertaining to the expanded scope of practice for
optometrists would be required.
Mr. Loescher agreed that the bill would increase service to
people living in rural Alaska. However, there is concern that
this expanded service might increase the cost of Medicaid for
young people and the elderly. This should be addressed in a
fiscal note.
Mr. Loescher has spent considerable time tracking this bill
during its progression through the Legislature. The questions he
has provided have been well-researched and should be addressed.
For instance, this bill would require optometrists to undergo
continuing education; the question is where and who would
provide that training. This might require the involvement of the
Department of Labor and Workforce Development. Other State
agencies and departments might also be affected by this bill.
9:58:46 AM
Mr. Loescher summarized his goals. One is that adequate consumer
protection be provided. This would require State boards and
agencies to be involved in certifying and monitoring doctors.
The other goal would be to ensure that the State has the
"highest qualify medical care for all Alaska citizens performed
by the most qualified persons." State government is responsible
for insuring these standards.
Mr. Loescher concluded that these responsibilities must be
addressed in a fiscal note and reviewed by the Committee.
9:59:56 AM
Senator Elton informed the Committee he had previously met and
discussed this bill with Mr. Loescher, who is one of his
constituents. During that discussion, Mr. Loescher asked Senator
Elton to read his list of questions to the Committee, however,
Senator Elton did not deem that necessary now as it was part of
the record and each Member of the Committee had received a copy
of it.
Senator Elton stated that the list of questions was quite
extensive and an immediate response was unlikely. Therefore, he
committed to being responsible for getting the appropriate
entities to respond.
Co-Chair Stedman acknowledged. Time would be available to
further address concerns since the intent was to hold the bill
in Committee.
10:00:54 AM
Senator Huggins addressed the concern raised in a May 11, 2007
letter [copy on file] from Mr. Loescher that optometrists would
be allowed to administer Botox: optometrists would not be
allowed to administer that drug under the Senate Labor and
Commerce version of the bill before the Committee.
Mr. Loescher appreciated the clarification. Optometrists had
been allowed to administer Botox in an earlier version of the
bill.
10:02:01 AM
DR. MICHAEL BENNETT, Optometrist and President, Alaska
Optometric Association testified in Juneau on behalf of the
Association's 107 members and their patients.
Dr. Bennett considered the scope of the bill to be "far more
limited" than it was being portrayed. Nine states have approved
legislation allowing optometrists to utilize injectibles with
zero requirements and limitations. At least ten states do not
impose limits on the length of time a drug could be prescribed.
The variety of approaches taken by states on this type of
legislation makes comparisons difficult.
Dr. Bennett expressly clarified that this bill "does not grant
surgical privileges" to optometrists. Such privileges were not
being sought by optometrists. There was no desire "to usurp the
position" of ophthalmologists.
10:04:27 AM
Dr. Bennett reviewed the education received by optometrists. The
"four rigorous years" of training beyond that required for a
bachelors' degree, qualified them as a "doctoral level
profession". The 200 hours of pharmacological training enables
them to be well-qualified for the prescriptive rights provided
in this bill. Other training they receive is closely aligned
with that required of doctors and dentists.
Dr. Bennett stated that the 2,000 hours of "supervised direct
patient contact" optometrists undergo is not limited to healthy
young individuals. A large number of eye care problems "arise in
people who are older or have other debilitating diseases." This
is reflected in the patient contact training. Optometrists also
participate in hospital-based training.
Dr. Bennett informed the Committee that optometrists conduct a
complete medical background, including a review of the patient's
medications, on each patient's initial visit. Optometrists are
also trained to spot signs of such things as high blood pressure
during an eye examination. Optometrists also work closely with
patients' primary care doctors on a variety of health issues.
Dr. Bennett clarified that the course work identified in this
bill, such as the seven hour training requirement pertaining to
the injection of nontopical therapeutic pharmaceutical agents,
should be viewed as "refresher" training, as that training is
conducted in optometry school.
Dr. Bennett stated that the use of these new privileges would be
rather limited and would not be utilized on a day to day basis.
Typical infection treatment would tend to be an oral antibiotic
or a topical medication. Extreme cases would continue to be
referred to another doctor.
10:08:44 AM
Senator Olson asked the Board of Optometry's position on the
bill.
Dr. Bennett deferred to the next testifier, who was the Chair of
that Board.
Senator Olson, a medical doctor, asked regarding the training an
optometrist would have in respect to treating a person who had
an anaphylactic shock response to an injection.
Dr. Bennett clarified that the most common cause of an
anaphylactic reaction in an optometrist's office is from
dilating agents. This risk is ever-present to him since he
conducts an average of ten dilations a day in his practice.
Current law prohibits him from even using an EpiPen to address
an anaphylactic situation even though "anyone with a bee string
allergy" can. This could be considered one of "the most critical
aspects" of this bill.
10:10:22 AM
Senator Olson inquired to the number of optometrists who possess
an Advanced Cardiac Life Support (ACLS) certification, as that
would allow them to administer to an anaphylactic individual.
Dr. Bennett did not know.
Senator Olson spoke to the testimony proclaiming that this
legislation would provide optometrists in Alaska the authorities
granted them in other states. Oklahoma, which is considered to
have some of "the most liberal" regulations in this regard, has
experienced some negative repercussions.
Senator Olson asked Dr. Bennett to compare the prescriptive
authority this bill would provide to those of other states. Even
though the sponsor statement indicates that marijuana use would
not be allowed under this legislation, he understood that
marijuana is reportedly effective in treating glaucoma.
Dr. Bennett affirmed that marijuana has been used to treat
glaucoma; however, other medications are more effective.
Senator Olson asked how this legislation compared to legislation
adopted by other states.
Dr. Bennett noted that Alaska currently ranks around 48th of 50
states in the authority granted to optometrists. This
legislation would place Alaska in the fifteenth to twentieth
place range.
Senator Olson asked how the State would rank in terms of the
prescriptive authority granted in this legislation.
Dr. Bennett would provide that information.
10:12:26 AM
DR. JILL MATHESON, Optometrist and Chair, Alaska State Board of
Optometry, addressed a question asked earlier by Senator Olson
by stating that the Board, which consists of four optometrists
and one member of the public, was in unanimous support of the
bill.
Dr. Matheson next addressed some of the fiscal concerns that
have been raised. The Board of Optometry is self-sufficient in
that any expenses incurred to it by this bill or any other
function it undertakes, are covered by optometrists' licensing
fees. Therefore any expense incurred by the Department of Labor
and Workforce Development or the Department of Commerce,
Community and Economic Development as a result of this
legislation would be addressed in that manner.
Dr. Matheson also clarified that no expense would be incurred to
the State for any continuing education programs as optometrists
pay those themselves.
Dr. Matheson informed the Committee that current regulations
mandate that any continuing education program utilized by
optometrists be from an accredited school of optometry. Since no
such school is located in State, the Board would search for a
national program that could provide the continuing education
courses required by this bill.
10:15:09 AM
Dr. Matheson addressed the expense this legislation might incur
to patients, insurance companies, and to Medicaid. Some of those
costs might be reduced. For example, expanding the scope of what
an optometrist could do would negate costs a patient might incur
by having to undergo another exam when referred to another
provider.
10:15:52 AM
Senator Olson asked the level of disciplinary action the Board
has taken during Dr. Matheson's tenure on it.
10:16:08 AM
Dr. Matheson stated that no disciplinary action has occurred in
the two and a half to three years she has been on the Board. The
open cases currently under review primarily deal with failure to
renew a license.
Senator Olson observed that the lone fiscal note accompanying
the bill is a zero fiscal note from the Department of Commerce,
Community and Economic Development. He asked whether expanding
the scope of what optometrists could do might increase the
number of disciplinary actions coming before the Board.
Dr. Matheson expressed that the Board would be billed for any
legal expenses incurred by the Department of Law's involvement
in a disciplinary case.
Senator Olson directed attention to language in Section 4
subsection (a)(2)(B), page 3 lines 9 through 13 of the bill,
which references a licensee's federal Drug Enforcement
Administration registration number for controlled substances. He
asked how many optometrists currently have such a license.
Dr. Matheson responded that no such license is held by any
optometrist in the State because they currently do not have the
authority to prescribe controlled substances.
Senator Olson next directed attention to Section 3 subsection
(a)(1)(E), page 3 line 2, which specifically excludes the
prescription of a certain type of drug. The question was whether
this language could be expanded to also exclude "synthetic
Botox-type drugs".
Dr. Matheson was unsure.
Senator Olson expressed that this could be further investigated
since the bill would be held in Committee.
There being no further questions or testimony to come before the
Committee, Co-Chair Stedman ordered the bill HELD in Committee.
AT EASE 10:18:40 AM / 10:19:02 AM
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