Legislature(2007 - 2008)
05/10/2007 01:36 PM Senate L&C
| Audio | Topic |
|---|---|
| Start | |
| SB170 | |
| HB14 | |
| HB113 | |
| Adjourn |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
CSHB 113(HES)-OPTOMETRISTS' USE OF PHARMACEUTICALS
2:22:08 PM
CHAIR ELLIS announced CSHB 113(HES) to be up for consideration.
REPRESENTATIVE RALPH SAMUELS, sponsor of HB 113, said this bill
attempts to open access to health care for more Alaskans. Forty-
five other states let optometrists do more than they do here. If
there is any one state that probably needs it, it's Alaska
because of its geographic size and small population. We have
more problems with access than any other state.
CHAIR ELLIS asked how many states allow exactly what is proposed
in the current version of this bill.
REPRESENTATIVE SAMUELS replied that he didn't have the exact
numbers.
CHAIR ELLIS mentioned that he had drafted some amendments as
options that could be offered later.
SENATOR STEVENS said he thought that ophthalmologists can do
what he is asking optometrists to be able to do. He asked how
many ophthalmologists are in Alaska.
REPRESENTATIVE SAMUELS replied roughly 20 ophthalmologists.
2:27:24 PM
CHAIR ELLIS brought up Amendment 1, labeled 25-LS0411\V.1,
emphasizing that he wasn't moving to adopt any of them at this
time.
AMENDMENT 1
OFFERED IN THE SENATE
TO: SCS CSHB 113(HES)
Page 2, line 30:
Delete "and"
Page 3, line 1, following "eye":
Insert "; and
(E) has been reviewed and approved by the
State Medical Board for prescription and use by
optometrists"
Page 3, line 22:
Delete "and"
Page 3, line 25, following "eye":
Insert "; and
(E) has been reviewed and approved by the
State Medical Board for prescription and use by
optometrists"
CHAIR ELLIS explained this amendment would provide that any
pharmaceutical allowed to be prescribed by an optometrist would
first have to be approved for that use by the State Medical
Board. He said this is a big point of contention from the two
sides of this argument. The argument is made that some people
don't think the State Medical Board would approve of any of
these being prescribed by optometrists because of their
interpretation of the public interest. He said this is one
option. Another option is Amendment 2, labeled 25-LS0411\V.2.
AMENDMENT 2
OFFERED IN THE SENATE
TO: SCS CSHB 113(HES)
Page 2, line 15, following "agents;":
Insert "and"
Page 2, lines 16 - 17:
Delete all material.
Renumber the following paragraph accordingly.
Page 2, line 31, through page 3, line 1:
Delete "injected, unless the injection is for emergency
anaphylaxis and is not injected into the ocular globe of the
eye"
Insert "administered by injection"
Page 3, line 13, through page 4, line 1:
Delete all material.
Renumber the following bill sections accordingly.
Page 4, lines 17 - 18:
Delete "secs. 1 - 3, 5, and 6"
Insert "secs. 1 - 5"
Page 4, line 22:
Delete all material.
He explained that Amendment 3, labeled 25-LS0411\V.3, would
prohibit all injections by optometrists and this also seemed to
be a point of contention. The third option would prohibit the
injection of botox by optometrists.
AMENDMENT 3
OFFERED IN THE SENATE
TO: SCS CSHB 113(HES)
Page 2, line 30:
Delete "and"
Page 3, line 1, following "eye":
Insert "; and
(E) is not a derivative of clostridium
botulinum"
Page 3, line 22:
Delete "and"
Page 3, line 25, following "eye":
Insert "; and
(E) is not a derivative of clostridium
botulinum"
CHAIR ELLIS said he has heard that optometrists don't want to be
in the cosmetic procedure business.
2:29:25 PM
REPRESENTATIVE SAMUELS said he opposed the first amendment.
SENATOR STEVENS asked if he might support giving this authority
to a board other than the State Medical Board.
REPRESENTATIVE SAMUELS replied that the conflict between the two
groups would make it impractical and using the Board of
Optometry would be a good idea.
SENATOR DAVIS asked if they had talked to the Medical Board
because she didn't think they would agree with this.
CHAIR ELLIS said he hadn't talked to them.
SENATOR BUNDE asked if it would be fair to characterize
discussion about this bill as turf battles.
REPRESENTATIVE SAMUELS replied that he would characterize it
that way, but others wouldn't. He said Amendment 3 sounded
pretty reasonable. The debate on Amendment 2 on the House floor
and in the House HESS committee was about injections into an
eyelid and centered around an optometrist could spend his entire
career every day all day dealing with the eyes, but could not do
something that a general practitioner could do. He said the
optometrists and ophthalmologists could clarify the risks and
how often they are taken. The idea is to open access to the
health care system by allowing a larger number of doctors to
provide a little bit more service. So, if he could vote, he
would vote against Amendments 1 and 2.
2:33:17 PM
DR. DONALD CINOTTI, Chairman, State Governmental Relations
Committee, American Academy of Ophthalmology, said his expertise
is in scope of practice and ophthalmology. He said his main
concern is when an optometric degree becomes an ophthalmologist
degree. In every state bills continue to pop up to increase the
scope of practice of optometry and this bill is by far one of
the most liberal. It essentially makes an optometrist an
ophthalmologist who doesn't do surgery.
He went over some of the myths that are heard is that the main
reason for expansion of practice always comes down to access to
care and this is a turf battle. In every state optometrists say
they have to refer some patients to an ophthalmologist to get
care. He said probably the only time they hear from constituents
about access to care is when bills like this are in committee.
DR. CINOTTI stated that rural communities have taken care of
access in all fields of medicine for time immemorial by the
physicians, the optometrists, the emergency rooms having
friendly ophthalmologists who they call and will guide them
through the care of the patient and be told which patients need
to be referred in and for which patients a prescription can be
called in. "So, there really is no access problem in any state
in this country."
2:36:14 PM
Second, he said training is an issue. He has been training for
26 years and small ophthalmology programs have been ended; the
majority of programs are very highly supervised and
standardized. The average three-year ophthalmology residence
program would have five residents per year or 15 residents. The
average residency is about 10 to 15 patients per day. So, taking
the small number, that would be 15 times 10 or 150 patients a
day would have to be seen in the clinic to qualify for the set
standards - plus the patients that are seen on nights and
weekends.
An average optometric program has many more students - 60 per
year for four years and that would result in 240 students times
10 patients or 2,400 patients a day to be equivalent to the
experience that an ophthalmology resident has during his
training.
DR. CINOTTI said that ophthalmology residency programs see a
tremendous amount of pathology every day. They are supervised
from medical school through residency by another ophthalmologist
or someone who has more training. All of their prescriptions are
looked at before they are written.
So, in medicine, we have always learned and been
trained before we were given the right to prescribe.
What this bill and all of the expansion bills around
the country do is they get the right to prescribe and
then we worry about how they are going to be trained -
whether it's going to be a weekend course or how much
training do they need to take.
2:38:21 PM
Specifically, Dr. Cinotti said he was concerned about the oral
medications part of the bill - especially with off-label use. He
said that many diseases now, especially Uvitis, which is an
inflammation inside the eye, are now being treated with anti-
cancer drugs. He asked if an optometrist is trained to be
prescribing anti-cancer drugs and would they know the side
effects. Would they require medical consultations and would all
of their patients be seen by medical doctors.
He was also very concerned about the use of medications in the
pediatric population. There is no equivalent between a child and
a baby and a new born to an adult; the doses are completely
different and the danger is extremely high. This bill allows an
optometrist to treat a baby who is one hour old and up through
adult life.
He was concerned about what he has seen happen in other states
where optometrists were found writing prescriptions for Viagra
and birth control - things they are not entitled to. He was also
concerned that these prescriptions would be given unwittingly to
drug addicts. Ophthalmologist and medical doctor graduates have
training in psychiatry and recognizing when a patient is in the
office complaining about something so they can get drugs. He
asked where the optometrist would get the training to prescribe
the narcotics and would they recognize if a patient is a drug
addict.
He also said that people who prescribe narcotics have a much
higher incidence of addiction to them. The highest addiction
rate in medicine is in anesthesiology. He asked if optometrists
who prescribe narcotics would have an increase in rate of
addictions and said that in general ophthalmologists don't write
narcotics. They manage pain with topical drops. He concluded
saying:
We in medicine feel that these bills and this bill, in
particular, is creating a medical graduate from an
optometrist without the education. We understand the
difficulty that you have in Alaska with the rural
population, but we know that those people have been
taken care of. And I think it's difficult for you to
talk to your constituents and really say to them 'Hey,
today we did a good job. We got you second best.'
2:42:02 PM
BOB LOSHER, Juneau consumer of health care services, said he
opposed this legislation. He said he is legally blind as a
result of diabetes and a kidney transplant. He has spent a lot
of money and has a lot of experience with both ophthalmologists
and optometrists having had nine eye surgeries and many other
treatments.
MR. LOSHER said he had traveled extensively through Alaska and
helped many people with their health, jobs, energy and other
things including building medical clinics in rural communities.
He was concerned that legislators should not diminish the
quality or safety of health care and delivery to any Alaskan
whether they live in an urban or rural area; and that is one of
the main premises he is hearing. He said this is a consumer
protection issue and he is more concerned that people have
qualified people providing their health care services. He
believed the legislature should protect consumers in these
areas.
2:45:29 PM
Second, Mr. Losher said that the Boards of Optometry and
Ophthalmology say two different things and the Medical Board
didn't even want to deal with this issue at all. As a consumer,
he is concerned that these boards are charged with the
responsibility of making sure that Alaskans get qualified
practitioners and have qualified facilities and treatment
programs. He didn't think they were being well-served by these
boards because they can't come forward with a uniform opinion on
the subject.
2:47:07 PM
Third, he said he was surprised there was no fiscal note and
certainly thought there would be costs to the Department of
Commerce, Community & Economic Development from, at least, more
applications, certifications and testing. This legislation
represents an expansion of service that would impact delivery of
the state medical programs like Medicaid.
2:48:23 PM
He concluded saying that he knows from his own experience with
diabetes and a kidney transplant that your eyes' health can't be
disassociated from health in the rest of your body. "My
experience teaches me that you need a fully qualified medical
doctor to deal with your comprehensive health, including your
eyes."
CHAIR ELLIS thanked him for his testimony and apologized that
the committee could not accommodate Dr. Steiner's surgery
schedule, but that he had submitted written testimony.
2:50:25 PM
DR. MICHAEL BENNETT, President, Alaska Optometric Association,
urged the committee to support HB 113. He said it would
authorize licensed and trained optometrists to prescribe
medications for the treatment of eye and surrounding tissues -
not for birth control or other purposes. This is stipulated
directly in the bill. The pain medications are somewhat limited
and for very brief periods of time - four days. It also provides
for the treatment of anaphylactic shock, which can occur in rare
instances of topical administration of drugs. This is a critical
part of this bill because people can die from anaphylactic
shock. Under current law, he would have to treat the person
illegally or let them die on the floor.
DR. BENNETT reiterated that the bill is quite narrow in scope
and does not allow prescription of the most abused controlled
substances such as oxycodone and specifically prohibits
injections inside the eye. It in no way grants surgical
privileges and it mandates continuing education and competency.
The course work that is mandated is meant as refresher course
work; it is not intended to teach somebody off the street how to
prescribe medication for eye care.
Supported HB 113.
He said the bill stipulates only eye treatment and eye issues,
on other purposes, somewhat limited pain medications for a
limited amount of time - 4 days. It provides for treatment of
anaphylactic shock which is critical. It specifically prohibits
injections into the eye and mandates continuing education and
competency. The course work is refresher work, not to teach
more.
2:53:35 PM
DR. BENNETT said optometrists have been well-qualified for these
rights for a long time; they are a doctoral level profession -
that's four rigorous years beyond a bachelor's degree. Optometry
school provides over 200 hours of classroom pharmacology which
is comparable to pharmacology training in medical and dental
schools. There is greater than 2,000 hours of supervised patient
care. These patients are not limited to the young and the
health. Elderly people and folks with serious illnesses form the
preponderance of most eye care practices. People with
debilitating diseases are far more likely to have serious eye
health problems and they form the bulk of most practices.
DR. BENNETT said that complete medical case history is always
taken on every patient he has ever seen. Medications are looked
at and interactions are considered. New medications, drops or
otherwise, are looked at for interactions. If there are any
questions or concerns, he contacts the patient's primary care
physician before proceeding.
Under current law, when you see a patient who requires an oral
antibiotic or an antiviral, or something that is covered in this
bill, they must be referred to either an eye surgeon or to their
primary care doctor, a nurse practitioner, or a physician's
assistant to get the prescriptions covered. Many times it's the
end of the day and you try to call the patient's primary care
physician and get them to call in the prescription to cover it.
That's an awkward position to put the physician in. Or since
they have almost no specific eye training, it's difficult for
them to make that diagnosis if an eye surgeon is not available.
Generally, it results in the wait of a day or two for the
patient to see them. This results in unnecessary travel and
always results in delayed treatment, additional fees and
additional lost time at work.
He said being allowed to write these prescriptions would result
in cost savings; he makes the diagnosis and it doesn't cost any
more to write the prescription form. And the patient doesn't
have to go to another doctor.
SENATOR BUNDE asked if he anticipated getting more patients if
this bill passed.
DR. BENNETT replied no; patients aren't aware that he can treat
their glaucoma and eye infections with topical drops, but that
he can't necessarily treat an infection that has spread a little
further into the eyelid with an oral antibiotic. The patient
comes to his office assuming he can take care of their problem.
He said a lot has been made of the idea that the things they are
talking about are not run-of-the-mill every day occurrences and
that is true. He might not write even one prescription a week
and it's very unusual that one would need to prescribe pain
medication - especially in Juneau or Anchorage. A good example
would be if a battery blows up in someone's face who is in
Kotzebue. That person is going need to get to Anchorage and it
would be nice to provide them some pain relief for a day or two
until they could get there.
2:57:58 PM
SENATOR BUNDE asked if an office visit to an optometrist would
have a different rate than a visit to an ophthalmologist. He
assumed an informed consumer would go the rate is lowest and he
would get more business that way.
2:58:29 PM
SENATOR STEVENS asked Dr. Bennett about an optometrist writing
prescriptions for drugs other than for the eye - specifically
Viagra and narcotics. He asked if this bill encompassed more
than just medication for the eye.
DR. BENNETT replied that this bill specifically states it's for
treatment of eye disorders only.
SENATOR STEVENS said that the comment that he would be supplying
narcotic addicts is not really legitimate.
DR. BENNETT replied that is correct and that you couldn't help
an addict much with a four-day legal supply anyhow.
2:59:55 PM
CHAIR ELLIS said he wanted to turn to the amendment options and
brought up Amendment 1.
SENATOR STEVENS commented that this might be a more appropriate
issue for the Board of Optometry to take up and suggested
amending Amendment 1 to that effect.
CHAIR ELLIS asked Dr. Matheson if it would be redundant to
change to the State Medical Board to the State Optometric Board.
3:01:10 PM
DR. JILL MATHESON, President, Board of Optometry, said the
statute as written is an optometry statute, which is then
automatically regulated by the Optometry Board. So, it would be
unprecedented to give the State Medical Board jurisdiction over
what optometrists do. That doesn't happen anywhere else and it
would be redundant.
It would be unprecedented to have the Medical Board have
jurisdiction over what another profession does. It would open
another can of worms.
CHAIR ELLIS said that amendment would be set aside and brought
up Amendment 2 that would prohibit all injections by
optometrists.
SENATOR STEVENS asked if language on page 3, line 25, didn't
already say that.
CHAIR ELLIS replied that he understands the issue to be the
injecting into the eye or around the eye.
3:03:09 PM
SIDNEY MORGAN, staff to Representative Samuels, said that the
bill specifically says no injections directly into the eyeball.
CHAIR ELLIS remarked that this amendment is more expansive in
prohibiting all injections by optometrists.
MS. MORGAN replied that is correct and that the last committee
made some changes regarding injections. It was going to allow
immediate injections for anaphylactic shock which makes sense.
However, it also took the injections which the original bill
allowed and put in an effective date that allowed the Optometry
Board to insure that everyone was educated and trained properly
for those injections, even though they believe that is already
the case.
CHAIR ELLIS set that amendment aside and moved to Amendment 3
prohibiting the injection of botox by optometrists.
SENATOR DAVIS said that the bill doesn't mention that at all,
but the people who wanted the bill didn't object to it.
3:05:31 PM
CHAIR ELLIS moved to adopt Amendment 1, labeled 25-LS0411\V.3,
[formerly Amendment 3] as follows:
AMENDMENT 1
OFFERED IN THE SENATE
TO: SCS CSHB 113(HES)
Page 2, line 30:
Delete "and"
Page 3, line 1, following "eye":
Insert "; and
(E) is not a derivative of clostridium
botulinum"
Page 3, line 22:
Delete "and"
Page 3, line 25, following "eye":
Insert "; and
(E) is not a derivative of clostridium
botulinum"
There were no objections and Amendment 1 was adopted.
3:06:49 PM
SENATOR DAVIS moved to pass SCS CSHB 113(L&C) from committee
with individual recommendations and a zero fiscal note. CHAIR
ELLIS said he was personally conflicted about this and deferred
to the will of the committee. There were no objections and it
was so ordered.
| Document Name | Date/Time | Subjects |
|---|