Legislature(2003 - 2004)

02/03/2004 03:04 PM HES

Audio Topic
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
                    ALASKA STATE LEGISLATURE                                                                                  
          HOUSE HEALTH, EDUCATION AND SOCIAL SERVICES                                                                         
                       STANDING COMMITTEE                                                                                     
                        February 3, 2004                                                                                        
                           3:04 p.m.                                                                                            
                                                                                                                                
MEMBERS PRESENT                                                                                                               
                                                                                                                                
Representative Peggy Wilson, Chair                                                                                              
Representative Carl Gatto, Vice Chair                                                                                           
Representative John Coghill                                                                                                     
Representative Paul Seaton                                                                                                      
Representative Kelly Wolf                                                                                                       
Representative Sharon Cissna                                                                                                    
                                                                                                                                
MEMBERS ABSENT                                                                                                                
                                                                                                                                
Representative Mary Kapsner                                                                                                     
                                                                                                                                
COMMITTEE CALENDAR                                                                                                            
                                                                                                                                
HOUSE BILL NO. 337                                                                                                              
"An Act relating to anatomical donor registries, to an                                                                          
anatomical gift awareness fund, to an anatomical gift awareness                                                                 
program, and to motor vehicle licenses and registrations."                                                                      
                                                                                                                                
     - HEARD AND HELD                                                                                                           
                                                                                                                                
HOUSE BILL NO. 306                                                                                                              
"An Act relating to the use of pharmaceutical agents by                                                                         
optometrists."                                                                                                                  
                                                                                                                                
     - HEARD AND HELD                                                                                                           
                                                                                                                                
PREVIOUS COMMITTEE ACTION                                                                                                     
                                                                                                                                
BILL: HB 337                                                                                                                  
SHORT TITLE: ANATOMICAL GIFTS REGISTRY                                                                                          
SPONSOR(s): REPRESENTATIVE(s) MCGUIRE                                                                                           
                                                                                                                                
01/12/04       (H)       PREFILE RELEASED 1/2/04                                                                                

01/12/04 (H) READ THE FIRST TIME - REFERRALS

01/12/04 (H) STA, HES, FIN

01/20/04 (H) STA AT 8:00 AM CAPITOL 102

01/20/04 (H) Heard & Held

01/20/04 (H) MINUTE(STA)

01/27/04 (H) STA AT 8:00 AM CAPITOL 102

01/27/04 (H) Moved CSHB 337(STA) Out of Committee

01/27/04 (H) MINUTE(STA)

01/27/04 (H) HES AT 3:00 PM CAPITOL 106

01/27/04 (H) -- Meeting Canceled --

01/28/04 (H) STA RPT CS(STA) NT 6DP 1NR

01/28/04 (H) DP: GRUENBERG, SEATON, HOLM, LYNN,

01/28/04 (H) BERKOWITZ, WEYHRAUCH; NR: COGHILL 02/03/04 (H) HES AT 3:00 PM CAPITOL 106 BILL: HB 306 SHORT TITLE: OPTOMETRISTS' USE OF PHARMACEUTICALS SPONSOR(s): REPRESENTATIVE(s) SAMUELS BY REQUEST 05/07/03 (H) READ THE FIRST TIME - REFERRALS 05/07/03 (H) HES 05/15/03 (H) HES AT 3:00 PM CAPITOL 106 05/15/03 (H) <Bill Hearing Postponed> 02/03/04 (H) HES AT 3:00 PM CAPITOL 106 WITNESS REGISTER REPRESENTATIVE LESIL McGUIRE Alaska State Legislature Juneau, Alaska POSITION STATEMENT: Spoke as sponsor of HB 337. JILL STEINHAUS, Director of Development LifeCenter Northwest Bellevue, Washington POSITION STATEMENT: Testified in support of HB 337 and answered questions from the members. HEATH HILYARD, Staff to Representative Lesil McGuire Alaska State Legislature Juneau, Alaska POSITION STATEMENT: Testified on HB 337 and answered questions from the members. DUANE BANNOCK, Director Division of Motor Vehicles Department of Administration Juneau, Alaska POSITION STATEMENT: Testified in support of HB 337. REPRESENTATIVE RALPH SAMUELS Alaska State Legislature Juneau, Alaska POSITION STATEMENT: Spoke as sponsor of HB 306. MICHAEL BENNETT, O.D. Juneau, Alaska POSITION STATEMENT: Testified in support of HB 306 and answered questions from the members. SHERYL LENTFER, O.D. Anchorage, Alaska POSITION STATEMENT: Testified in support of HB 306 and answered questions from the committee. CYNTHIA BRADFORD, M.D. Secretary for State Affairs American Academy of Ophthalmology Oklahoma City, Oklahoma POSITION STATEMENT: Testified in opposition to HB 306. MICHAEL LEVITT, Staff American Academy of Ophthalmology Stanford, California POSITION STATEMENT: During discussion of HB 306, offered some clarification with regard to oxycodone. CARL ROSEN, President Alaska Academy of Ophthalmology Anchorage, Alaska POSITION STATEMENT: Testified in opposition to HB 306 and answered questions from the members. ACTION NARRATIVE TAPE 04-7, SIDE A Number 0001 CHAIR PEGGY WILSON called the House Health, Education and Social Services Standing Committee meeting to order at 3:04 p.m. Representative Wilson, Gatto, Wolf, Coghill, Seaton, and Cissna were present at the call to order. HB 337-ANATOMICAL GIFTS REGISTRY [Contains discussion of SB 78] CHAIR WILSON announced that first order of business would be HOUSE BILL NO. 337, "An Act relating to anatomical donor registries, to an anatomical gift awareness fund, to an anatomical gift awareness program, and to motor vehicle licenses and registrations." Number 0100 CHAIR WILSON stated that CSHB 337(STA) was before the committee. She told the members that this legislation will create a donor registry program in which a donor's Alaska driver's license/identification information can be transferred to Life Alaska Donor Services, the state's donor tissue program. She noted that several committee members had cosponsored this bill. Number 0152 REPRESENTATIVE LESIL McGUIRE, Alaska State Legislature, speaking as sponsor of HB 337, called attention to page 2, line 19, of CSHB 337(STA), and explained that subsection (b) simply restates language from subsection (c) of the original bill and also deletes subsection (b) of the original bill. She thanked Representative Seaton for his help during a previous meeting in clarifying that language in the bill was unnecessary and possibly confusing. Representative McGuire stated that this bill is going to save lives. She told the members that the bill was brought about by a lot of hard work by Life Alaska Donor Services, LifeCenter Northwest, and many physicians and nurses across Alaska. REPRESENTATIVE McGUIRE explained that Life Alaska Donor Services created the first organ and tissue donor registry in 2001; however, the only problem is that most people in Alaska don't know how to get their information to that registry; it's not a well-known fact. She said the Division of Motor Vehicles asks residents if they want to be an organ and tissue donor and many people agree to do it. An organ and tissue donor is provided with a sticker to put on his/her driver's license or is given a card, but unless that donor transfers that information to the Life Alaska Donor Services registry, it will not become part of the database. She said unless the donor's driver's license is on that person at the time of an accident, there is no way for [emergency] responders to know that person is an organ and tissue donor. She remarked, "What a travesty, because if you really are and that's your intent, you could have saved a life." Number 0375 REPRESENTATIVE McGUIRE explained that the bill authorizes the Division of Motor Vehicles to transfer information from a person who voluntarily decides to be a member of the organ and tissue donor registry. She clarified that three options are offered. The first option is to decline being a donor of organs and tissues. The second option is to agree to be a donor, but not to be part of the registry. There would be a sticker on the individual's driver's license, she added. The third option is the one Representative McGuire said she hopes Alaskans will choose, which is to agree to be a donor and participate in the registry. REPRESENTATIVE McGUIRE told the members that a similar bill passed in Washington State and there was an 86 percent increase in the registry. Representative McGuire said she hopes to see the same thing happen in Alaska. She explained that there are provisions in the bill to ensure that privacy is protected and that any misuse of the registry will result in a criminal penalty. Jill Steinhaus, Director of Development from LifeCenter Northwest, and testifiers from Life Alaska Donor Services will tell the committee that [misuse of the registry] has never occurred. Number 0504 REPRESENTATIVE McGUIRE pointed to one other provision in the bill called the "Donate a Dollar Program." She thanked Duane Bannock, who is the director of the Division of Motor Vehicles, for his work with the interim working group [in developing this legislation]. The way the program works is that donors may donate $1 toward the Organ and Tissue Donation Awareness Fund. These donations help to fund the brochures that are printed that inform people about organ and tissue donation. Representative McGuire said, for example, that she received a brochure in her recent utility bill that provided information about the donor program, how it saves lives, and how to register. Both Washington and Montana have passed similar bills, and it has been quite successful, she added. Number 0600 REPRESENTATIVE McGUIRE told the members that the final thing to note is that the State of Alaska is changing to a new license system. She explained that when individuals get their new digital driver's license, it will not be in the plastic coating as it is now; it will be similar to a credit card. If an individual agrees to be a donor, there will be a heart on the driver's license itself, rather than a sticker that could be rubbed off. On a legal note, she stated, this is the best possible way for an individual to convey his/her wishes to family in a final and legal way. Representative McGuire explained that in the past there were problems created when an individual wanted to be a donor, got a sticker, but was not listed in the registry. There was a potential for problems with family members who might contest whether it was really the individual's will or not; since the person was not in the registry, maybe the person had changed his/her mind. Number 0670 JILL STEINHAUS, Director of Development, LifeCenter Northwest, testified in support of HB 337 and answered questions from the members. She explained that LifeCenter Northwest works in cooperation with Life Alaska Donor Services to provide organ services in Alaska. This legislation will help to ensure that more Alaskans are able to make their wishes of donations known and ensures that more lives are able to be saved. She told the members that last year similar legislation passed both in Washington and Montana. In the last six months of 2003 there were 135 organ donors; 106 of them were a direct result of the donor designation or registry system. If this legislation passes this year, she stated, there will be a significant increase in the number of lives saved. Number 0783 REPRESENTATIVE COGHILL asked Representative McGuire about the Department of Health and Social Services' comments on the fiscal note. He said he surmises that the Division of Motor Vehicles would handle the information as it comes in; however, the Department of Health and Social Services was not sure if the department would be [the responsible agency for the donor registry]. Representative Coghill asked who would be responsible for the management of the registry and donation program. REPRESENTATIVE McGUIRE responded that the Division of Motor Vehicles would be the collector [of the funds] and would forward the money on to Life Alaska Donor Services. She told the members that the only role the Department of Health and Social Services will have in this program is certifying those organ and tissue donation centers that would be eligible to participate in the registry and be classified as such. An earlier version of the bill referred to a procurement organization, and it was decided that the Department of Health and Social Services would be the best department to make the delineation. REPRESENTATIVE COGHILL asked if there would be a cost in using the registry. For instance, would doctors or hospitals be charged a fee to access the registry, he asked. REPRESENTATIVE McGUIRE responded that there will be no cost to access the registry for those who are qualified to do so. She pointed out that the reason for the Donate a Dollar Program was to help offset the cost of maintaining the registry. REPRESENTATIVE COGHILL pointed to page 2, lines 27 and 28, where it says in part, "A procurement organization that has requested registry information from the department shall pay the reasonable costs associated with the creation by the organization of a registry". Who is this language referring to, he asked. Number 1069 HEATH HILYARD, Staff to Representative Lesil McGuire, Alaska State Legislature, testified on HB 337 and answered questions from the members. In response to Representative Coghill's inquiry, he said that he understands there will be a certain administrative cost associated with the setup of the registry. He added that this is distinctly different from the Donate a Dollar [Program] fund and the Anatomical Gift Awareness Fund, which is primarily designed to cover the costs associated with marketing materials. Mr. Hilyard explained that there was some discussion about the possibility of appropriating some funds coming from the Anatomical Gift Awareness Fund to help offset some of the costs in establishing the registry. There is no definitive answer on that yet. The Donate a Dollar Program is primarily used for the production of marketing materials, he said. REPRESENTATIVE COGHILL asked for clarification on who will be responsible for paying for the creation of the registry. Number 1080 MS. STEINHAUS said in response to Representative Coghill's question that the language he referred to is in place to ensure that the Alaska state government is not responsible for the funding [of the creation and maintenance] of the registry. The procurement organizations that provides services in Alaska will be responsible for this funding. Ms. Steinhaus explained that the organization she represents, LifeCenter Northwest, will pay 100 percent of the development cost of getting the registry up and running, and of maintaining the system in Alaska. Number 1134 MS. STEINHAUS said in response to a further question that there will be a billing process established that does not impact the [Division of Motor Vehicles]. Number 1159 DUANE BANNOCK, Director, Division of Motor Vehicles, Department of Administration, testified in support of HB 337. He commented that the Division of Motor Vehicles will be responsible for the creation of the data transmission and has estimated the approximate cost to be $7,000. Mr. Bannock summarized that there will be no net cost to the State of Alaska as a result of this [registry]. Number 1204 REPRESENTATIVE CISSNA asked for clarification of the roles of the Department of Transportation and Public Facilities, the Department of Health and Social Services, and the Department of Administration. She referred to page 2, line 12 through the end of the page. Representative Cissna commented that she would like to know that state employees will not be overburdened. Number 1283 REPRESENTATIVE McGUIRE responded that this is not as complicated as it appears. She explained that the reason the Department of Administration is mentioned is due to the fact that the Division of Motor Vehicles is under the umbrella of that department. She reiterated that it is the Division of Motor Vehicles that will be the collector of the money and that will maintain the registry. She went on to explain that it is not the state Department of Health and Social Services, but the U.S. Department of Health and Human Services that will be making the determination as to whether or not an organization qualifies to be a procurement organization for tissue and organ donors. It is very important that these centers apply through the [U.S.] [Department of] Health and Human Services. She summarized that there is no state Department of Health and Social Services impact, only the Department of Administration, Division of Motor Vehicles. REPRESENTATIVE McGUIRE responded to Representative Cissna concern for staffing by saying that Duane Bannock has been involved in the development of this bill for that very reason. She told the members that he'd thought this through and determined that he and the staff were willing to do this as long as the costs associated with establishing the registry were paid for by the procurement organizations. Representative McGuire explained that when a person goes into the Division of Motor Vehicles [to get a driver's license] there is already a list of questions that must be answered, so that is an action that already occurs. What this [legislation] would do is add an additional question. The additional effort that will be required to do this is negligible, she added. Number 1445 CHAIR WILSON referred to page 4, line 16, where it says "approved under the laws of the state". She asked for clarification that the state is not the accrediting authority, but that the U.S. Department of Health and Human Services is. REPRESENTATIVE McGUIRE responded that the original version had language which gave the authority for accreditation [through the U.S. Department of Health and Human Services]; this version does not. The committee took an at-ease from 3:29 p.m. to 3:36 p.m. CHAIR WILSON announced that HB 337 will be held over. HB 306-OPTOMETRISTS' USE OF PHARMACEUTICALS Number 1513 CHAIR WILSON announced that the final order of business would be HOUSE BILL NO. 306, "An Act relating to the use of pharmaceutical agents by optometrists." She commented that this bill has been in the legislature in some version for many years. Number 1589 REPRESENTATIVE RALPH SAMUELS, Alaska State Legislature, speaking as sponsor of HB 306, told the committee that the bill would allow optometrists to prescribe non-topical medications to treat a patient's eyes or for an allergic shock reaction. There is a list of dangerous drugs that optometrists would not be allowed to prescribe. He shared that 40 other states and 85 percent of the population in the United States are currently covered under this type of system. There have been no reported problems over the past 32 years, he added. All the western states currently have this system in place. The only state [besides Alaska] West of the Mississippi [River] that is not covered under this system is Hawaii. The states that have not implemented this system are states that have high-density populations where there are higher numbers of ophthalmologists. Alaska has a unique problem with such a huge land mass and so few doctors and little accessibility to the health care system. In 1992 Alaska was the 32nd state to authorize prescriptions of therapeutic drugs to treat eye diseases, and the compromise at the time was topicals only, he said. He added that there have been no complaints to the [Alaska Board of Examiners in Optometry] in the past 12 years [on optometrists' use of topical prescription drugs]. Number 1712 REPRESENTATIVE SAMUELS told the members that there would be arguments about the differences in educational [background] between optometrists and ophthalmologists. He pointed to the chart in the members' packet which demonstrates the importance of this legislation. For example, if an individual were to go to a dentist to have a filling done, but first had to go to an oral surgeon to administer the Novocain, it would not be good public policy. He pointed out that dentists and optometrists have exactly the same amount of education. Other examples he noted were the ability of physician assistants [PAs] to prescribe medications, and these individuals are not even required to have an undergraduate degree; an advanced nurse practitioner can also prescribe, and these individuals have two years of postgraduate work. Representative Samuels noted that podiatrists and dentists have the same four years of medical school, and both of those doctors can prescribe. He summarized that all physicians who have the same education are allowed to prescribe medication, except optometrists. REPRESENTATIVE SAMEULS told the members that this legislation was passed [by] the [last] legislature with only two votes against it, but it was vetoed by the then-Governor Knowles. The previous legislature passed it though the House, but it did not make it through the Senate. In areas of the state outside of the road system the accessibility to good health care is marginal at best, [and this legislation would help to address that issue], he said. Number 1874 MICHAEL BENNETT, O.D., testified in support of HB 306 and answered questions from the members. He commented that optometrists have been trained in prescribing oral medications in [medical] school for about 20 years. He told the members that optometrists see the vast majority of [eye care] patients in Alaska. If there is a need for medical care that can be dealt by using topical pharmaceuticals, then optometrists can treat that. If the patient needs surgical care, then he/she is referred to a surgeon. He explained that there is a small minority of patients that require oral pharmaceuticals and there are real inconveniences for those patients because there are only a couple of choices in Juneau. One is to call an eye surgeon but, of course, the patient would not be able to get in that day, or a call could be made to his/her primary care physician to see if the doctor would be willing to prescribe the medication. He added this is awkward for the physician who is not seeing the patient for the condition he/she is being asked to prescribe treatment for and does not have the training to make that judgment on his/her own. Number 1958 DR. BENNETT told the members that the situation in rural Alaska is much worse. Many communities in rural Alaska have optometrists, but none have eye surgeons. He said his partner for three years, who lives in Kotzebue, was the only eye care practitioner in Northwest Alaska, and had to go to the physician assistant to write the prescription. Aside from being awkward, it is a needless delay for the patient, which is not good care, he commented. If this treatment results in the patient's having to do another office visit to a different practitioner, that adds to the expense to the patient and delay in treatment. Dr. Bennett said he feels strongly that this legislation will add to better patient care. DR. BENNETT offered a brief history on this issue and explained that optometrists have prescribed topical treatments for over 12 years, and there has not been a single complaint brought to the [Alaska Board of Examiners in Optometry] regarding prescription of topical medications. When the topical prescription legislation [came before the legislature] there were the same scare scenarios then that are before the committee today about oral prescription drugs. He noted that malpractice rates have not changed in any states that have enacted this legislation. These fees are extremely low, which he said speaks to the fact that this is not a reckless profession that is trying to go beyond its licensure and knowledge. Number 2072 REPRESENTATIVE COGHILL asked Dr. Bennett to define some terms that are in the bill [on page 1, lines 9 and 10] including: ocular, adnexal, and anaphylaxis. Number 2111 DR. BENNETT explained that ocular disease refers to the eye itself. Adnexal disease refers to the tissues directly surrounding the eye. Emergency anaphylaxis refers to a severe hypersensitivity reaction to [something]. In response to Representative Coghill's request for an example, Dr. Bennett used the example of an individual who is allergic to bee stings. If he/she knows of the condition in advance, it would be advisable to carry an epinephrine injection, which [could be] administers [in the case of an emergency]. Dr. Bennett pointed out that currently a doctor of optometry is not allowed to do that. He summarized by saying that optometrists can administer topical treatments that could conceivably trigger an anaphylactic reaction, but not treat [that reaction] if it occurred in the doctor's office. CHAIR WILSON pointed to [page 1], lines 5 where it says "including a controlled substance, as defined in AS 11.71.900," and also language on [page 1], line 6 where it says "not a schedule IA controlled substance". She asked Dr. Bennett to explain this language. DR. BENNETT responded that this language would allow for optometrists to prescribe controlled substances other than those that are illegal, such as heroin and the opiate-derived controlled substances. CHAIR WILSON asked what drugs an optometrist would be able to prescribe. DR. BENNETT responded that [optometrists would be able to prescribe] any other drug that does not fall under [the IA controlled substance] category. Number 2193 REPRESENTATIVE GATTO posed a hypothetical example of an individual who is stung in the eye by a bee. He is taken to Dr. Bennett's office because it is believed there is something wrong with the individual's eyes. Representative Gatto asked if Dr. Bennett would be allowed to treat the emergency anaphylactic [condition]. Number 2208 DR. BENNETT responded that he would not be able to treat that patient. He added that it is unlikely that he would see someone with a bee sting who is [experiencing an anaphylactic reaction], and had only used that example as one that everyone would be familiar with. It is more likely to be a situation in which a patient has received a topically administered drop that would be administered in the office that could cause an anaphylactic reaction, he said. Dr. Bennett clarified his comments by saying that optometrists are allowed to prescribe the drop, but not allowed to treat an anaphylactic reaction. REPRESENTATIVE GATTO commented that it is hard to believe [optometrists] are not allowed to treat that. Number 2224 REPRESENTATIVE CISSNA asked how often that happens and if anyone has [died as a result of that]. DR. BENNETT responded that it has never happened to him; however, he has one patient that he is aware of who has had an anaphylactic reaction to common dilating agents. It occurred in another office; she spent time in the hospital for it, and she refuses politely to be dilated, he said. It is rare, but it happens. Number 2249 REPRESENTATIVE WOLF asked if oxycodone is a drug that would be one that optometrists could prescribe [under this bill]. DR. BENNETT responded that it is a schedule IA controlled substance [and not one an optometrists could prescribe]. REPRESENTATIVE COGHILL commented that one of the assertions he has heard over and over again is that this legislation jeopardizes eye safety in Alaska. He said he believes it is important to determine what is good public policy. Representative Coghill told the members that he has voted on both sides of the issue and has asked for the Alaska State Medical Board to come to the committee and [address this issue]; however, that has never happened. He noted that Dr. Carl Rosen's letter says that the Alaska State Medical Board unanimously opposes SB 78, which is a companion [bill] to HB 306. However, there may be some differences because SB 78 talks about injections; however, that [language] is not in HB 306. He asked if Dr. Bennett can provide some explanation to the Alaska State Medical Board's opposition to this bill. Number 2345 DR. BENNETT responded that he is not privy to the thoughts [of the Alaska State Medical Board] and is not aware of how in-depth the issue was reviewed. He told the members that he knows primary care physicians who were surprised that [doctors of optometry] do not already have these capabilities. He added that while he cannot speak to the Alaska State Medical Board's proceedings, it is important to note that there is the Alaska Board of Examiners in Optometry. He noted that in most states the optometry board does not involve itself in regulating physicians, and said he cannot understand why the medical board should have the authority to regulate optometry. TAPE 04-7, SIDE B Number 2344 REPRESENTATIVE COGHILL commented that as a legislator who is not in the medical field, he is very uncomfortable getting into a turf battle between one authority and another. He summarized his understanding of the bill in that optometrists are asking for prescription authority that is not dissimilar to a PA [physician assistant], nurse practitioner, or dentist. DR. BENNETT responded that the [prescription authority optometrists are seeking] is most similar to a dentist's because it is restricted to a specific area of expertise, as opposed to the whole body. He pointed out that optometrists are not asking to treat other medical conditions, only those involving the eye. REPRESENTATIVE COGHILL asked, if an optometrist prescribed drugs that are not used specifically for the eye, who the enforcing authority would be in holding an optometrist accountable. DR. BENNETT responded that the Alaska Board of Examiners in Optometry would do that. It is a very conservative group, he added. The procedure is the same as for physicians who stray. There have been a few very highly publicized cases recently where physicians have lost their license to practice by the [medical] board. Number 2282 REPRESENTATIVE COGHILL said that he is looking for good middle ground where it is good public policy. He said when there is one board saying one thing, and another board saying another, it is tempting to make a law that combines the boards and then let the board [make that determination]. This debate has been going on for a long time. He said he is very concerned for eye safety. And when someone claims that this bill will jeopardize eye safety in Alaska, legislators take it seriously. He asked Dr. Bennett if this bill will jeopardize eye safety for Alaskans. DR. BENNETT said it is pretty conclusive that [eye safety is not jeopardized]. He commented that while not all of the 40 states have [had this law in place] for a long time, there have not been issues raised and none of those laws have been rescinded. In the 50 states that allow topical prescriptions, none of those laws have been rescinded. Dr. Bennett commented that he hopes these facts speak to the lack of problems associated with this type of legislation. He pointed out that malpractice rates have not gone up, which would indicate that insurance companies have not seen problems. REPRESENTATIVE COGHILL noted that another assertion by those opposing the bill is that [doctors of] optometry simply lack the education and training necessary to appropriately prescribe these drugs. He said that before he could vote in favor of this bill, he would need to have [inrefutable] facts that that is not true. DR. BENNETT responded that 25 years ago when he was a graduate student, he taught in the dental, optometry, and medical schools. He told the members that all the anatomy courses were the same, the pharmacology requirements and textbooks were the same, and the number of course hours was similar. As far as whole-body treatment, [optometry] is certainly equal to that of the dental profession. Dr. Bennett explained that optometrists have not been through residencies that deal with gall bladders, lungs, and other organs, but neither have dentists. Dentists have demonstrated that they have been very safe and effective over a long period of time. He summarized his comments by saying that optometrists are certainly as equally educated in those areas as those in dentistry [who have the ability to prescribe oral drugs]. REPRESENTATIVE COGHILL asked how the members are to compare this education. He noted that a letter [dated January 29, 2004, from Dr. Allan Jensen and Dr. Cynthia Bradford] to the committee asserts that an ophthalmologist completes [eight years of education and training], which is more significant than the licensing requirements for an optometrist. Number 2113 DR. BENNETT replied that he agrees with that, but pointed out that optometrists are not asking to be ophthalmologists. He added that this bill is not requesting surgical rights [for optometrists]. He commented that a great deal of the training and education [that ophthalmologists receive] is directed toward surgical skills. REPRESENTATIVE COGHILL said he would like to substantiate the level of qualifications of optometrists. He said he would like to know what part of this dispute is based on who gets the market share or "the dollar bill," as opposed to what is good health care in Alaska. He told the members that at this point he is reluctant to move forward on the bill because he does not have a clear understanding [of the issue]. He told the members that he is surprised that as a schoolteacher he had to be prepared to administer a shot for a diabetic student or for someone who is allergic to bee stings, but an optometrist cannot [administer the same thing]. Number 1996 SHERYL LENTFER, O.D., testified in support of HB 306 and answered questions from the committee. She told the members that access to the curriculums of the schools is readily available. She urged the members to take a look at [the curriculums] because she believes that will clarify the education issue. She questioned why, if education is a big issue, PAs and nurse practitioners are prescribing and not prescribing with a doctor right behind them at every moment. They are able to do this pretty much on their own, she commented. Dr. Lentfer asked the members to deal with the education issue factually by comparing [the curriculums] of the optometry schools and medical schools. Dr. Lentfer stated that education should not even be an issue in this debate. She urged the committee to compare the education qualifications with those for dentists or podiatrists. DR. LENTFER told the members that she would like to talk about who currently treats the public with oral prescriptions and the educational relationship to these professionals. She said medical doctors, osteopathic doctors, podiatrists, dentists, nurse practitioners, and PAs all have prescriptive authority to prescribe pharmaceutical agents in Alaska. Medical doctors, osteopathic doctors, podiatrists, dentists, and optometrists all have a four-year doctor degree. DR. LENTFER clarified that after a four-year college undergraduate degree, an optometrist receives a four-year doctorate degree. There is no variation in that education, she stated. Nurse practitioners have two years of master's work after an undergraduate degree, but to her surprise she found that PAs do not have to have a four-year undergraduate degree to be accepted into the [PA] program. Number 1916 DR. LENTFER emphasized that PAs and nurse practitioners have been very beneficial to Alaska and that it is not her intention to [undermine their role in ensuring good public health]. She emphasized that her point is only to demonstrate the correlation between their ability to prescribe drugs and their educational background, compared to that of optometrists. DR. LENTFER pointed out that the pharmacology education for medical doctors, osteopathic doctors, and optometric doctors is the same. She told the members that optometrists provide 70 percent of the eye care in the U.S. Considering that there are many professionals treating eye conditions today including PAs, nurse practitioners, physicians, and eye surgeons, that is a large percentage. In Alaska [the percentage of eye care that is provided by optometrists] is greater. There are 103 optometrists in 17 different locations, and many travel a lot. There are only 28 eye surgeons in six locations, most of which do surgery. She pointed out that with a population of over 500,000, eye surgeons availability and accessibility have been a big challenge for this state. Dr. Lentfer explained that this [fact] has put more demand on optometrists to practice to their fullest training. DR. LENTFER spoke to Representative Coghill's comments about training. She told the members that this is not new or additional training, since she was prescribing [oral medications] in 1996 after graduating from medical school. She told the members that while additional training is not required, there will be additional training for those optometrist who have not had prescriptive authority in the last few years. The [Alaska Board of Examiners in Optometry] will require optometrists to probably have over 200 hours of course work, pass a test, and get a therapeutic endorsement on the license. If the optometrist does not pass the test, he/she cannot prescribe [oral medications], she said. An OD [doctor of optometry] would have to have graduated [from medical school] in the last two years in order to be qualified to prescribe. When therapeutic eye drops were approved by the legislature, optometrists were not automatically allowed to prescribe because the [Alaska Board of Examiners in Optometry] required that optometrists prove that they were qualified. DR. LENTFER pointed out that the language in this legislation is for the treatment of eye-related conditions, as the language on line 9 and 10 is very specific where it says "ocular disease or conditions, ocular adnexal disease or conditions, or emergency anaphylaxis." She added that [this language] makes it clear that optometrist are not interested in prescribing a broad spectrums of pharmaceuticals like PAs or nurse practitioners. The only interest in prescribing is for the treatment of conditions and diseases for which optometrists are trained and practicing. DR. LENTFER explained that it is difficult physically, as well as financially for patients to be sent from an optometrist's office to another practitioner's office to receive treatment that the optometrist has prescribed. In some instances this requires the patient to travel some distance, she said. Dr. Lentfer told the members of an individual who needed an oral prescription for a drug that would relieve a condition she had diagnosed, but could not find a practitioner to prescribe the medication. In this case the medication is most effective when administered within the first 48 hours. Number 1719 DR. LENTFER told the members that after the then Governor Knowles vetoed the legislation that passed the Alaska House of Representatives and the Alaska State Senate, the Alaska Board of Examiners in Optometry went to the State Medical Board and did everything Governor Knowles requested. She stated that there was no cohesiveness. The "so-called turf war" is not a good reason to make a judgment on this bill. The only reason to support this bill is to provide better health care for Alaskans. Number 1680 CHAIR WILSON explained that she worked in the clinic Tok where she worked with a PA or a nurse practitioner who were under the umbrella of a [physician]. She asked if optometrist would want work under [the umbrella] of a physician in the prescribing of drugs. DR. LENTFER responded that optometrists have already completed a four-year doctorate degree program. She said the same comparison could be made in asking a dentist to work under a medical doctor. CHAIR WILSON clarified that she is not talking about dentists; she is talking about PAs and advanced nurse practitioners. DR. LENTFER responded that going under an umbrella of another physician does not make sense. Whose umbrella would optometrists be under? She said that optometrists are established entities with a regulating board that has an excellent history. If the committee had doubts about optometrists' education, training, and ability to prescribe [oral] medications, she urged them to research the educational background. Optometrists are not [in the same educational category] as PAs or nurse practitioners. The educational background is the same as for dentists and medical doctors in pharmacological education. Dr. Lentfer asked why optometrists' educational qualifications are in question, when those for dentists and medical doctors are not. Number 1587 CHAIR WILSON responded that the [educational qualification] is in question because optometrist have not had the other specialized training. Professionals who have not had that training [such as PAs and nurse practitioners have had to] work under other professionals. DR. LENTFER told the members that she took human anatomy, neuroanatomy, physiology, pathology, ocular biology, and ocular physiology at the same time. She explained that, depending on which medical school a medical student goes to, in the third or fourth year there is a series of rotations. During this time the medical student is trying to decide what kind of doctor he/she chooses to be. For those [students] that know they want to be an eye doctor, in the third year of medical school they begin to see patients. She explained that at the school she attended, the first-year ophthalmology residents were under [fourth-year optometry students] in emergency care. Dr. Lentfer emphasized that optometry students not only learn about the whole body, but also specialize in eye care, while other medical students are learning about the whole body and not specializing. The fourth year of medical school consists entirely of clinical hours. There are as many as 2,000 patient hours before finishing the fourth year of medical school, which is very good for any health care profession. Number 1523 REPRESENTATIVE GATTO pointed out that paramedics in Anchorage, after only a year of sporadic training, give intracardiac drugs during ventricular fibrillation. It is not only allowed, it is essential. He pointed out that there is a precedent for other groups to do what the optometrists are asking to do. Representative Gatto said with that in mind, he'd looked at Dr. Carl Rosen's letter, and asked Dr. Lentfer to comment on a couple of statements in that letter. One statement is that HB 306 jeopardizes patient eye safety. The second statement is that optometrists do not have clinical experience to safely administer eye injections. The third statement is that [an expanded scope of practice for] optometrists still would endanger patients. DR. LENTFER responded [to the second statement by saying] that nothing in this bill talks about eye injections. Optometrists do not want to do eye injections, she stated. CHAIR WILSON interjected that there may be confusion about that issue because the sponsor's statement refers to oral or injectable medications. Number 1439 DR. LENTFER emphasized that optometrists are not interested in [injectable medications] because that is an invasive procedure which should be done by a surgeon. Number 1381 DR. LENTFER responded to the [third statement that an expanded scope of practice for optometrists would still endanger patients] by saying that she would like to hear how Dr. Rosen [would justify that statement]. She said, for example, before optometrists had authorization to use topicals, if she had someone in a chair in her office who had very high pressure in the eye, that person could go blind immediately because [she could not treat that condition]. Dr. Lentfer summarized that this was the same kind of statement being made before authorization was given to prescribe topical treatment. She pointed to the problems associated with finding a physician to prescribe an oral medication to treat conditions and said if contact for prescribing the medication is an hour or two later, the patient will lose sight. That is the danger, she stated. REPRESENTATIVE COGHILL commented that some of the backup material referred to the extended use of steroids and how that might affect the eye or the rest of the body. That was cited as one of the first dangers in allowing this bill to go through. He asked Dr. Lentfer to respond to that statement. DR. LENTFER responded that steroids would not be used. One exception] might be if in a rural area; however they would only be prescribed in conjunction with a physician or ophthalmologist. She told the members that often she will see patients who have been prescribed oral steroids from the physician and the eye pressure is elevated. She pointed out that often physicians will forget to tell patients who are on steroids to get their eye pressure checked. Steroid treatment is something that would always be administered with [the consultation of] another physician, she commented. REPRESENTATIVE COGHILL asked if that is a professional barrier that would always be present. He commented that there is the charge is that this could be a significant problem. DR. LENTFER replied that is a serious drug and when it comes time to cross that bridge, optometrists will either be referring the patient to another doctor or calling another doctor. The drugs that optometrists would use are antibiotics, antivirals, or maybe some low-dose pain medications. Pain medication might be prescribed if, for instance, a foreign body was removed from the eye and it was really needed, she said. Number 1185 REPRESENTATIVE COGHILL noted that there is reference to the problem of over-prescribing of antibiotics. He asked Dr. Lentfer to comment on that. DR. LENTFER responded that she believes those concerns regarding [over-prescribing antibiotics] belong with every single health care professional. What this comes down to is the professional judgment of doctors of optometry. There are many things that optometrists do [annually] to stay informed, including reading medical journals and 48 hours of continuing education. Licensing hinges on whether these requirements have been met, she said. REPRESENTATIVE COGHILL asked Dr. Lentfer to help him understand the idea of systemic drugs and their impact on the whole body. DR. LENTFER responded that whenever prescribing oral medications, it is important to be aware of the side effects, drug interactions with other prescriptions the patient might take, and the general health of the patient. It would be important, for example, to be aware of any liver or kidney diseases. If it is determined that a patient has a systemic condition, the optometrist would refer the patient to his/her medical doctor. REPRESENTATIVE COGHILL asked Dr. Lentfer to help him understand the interaction of drugs, particularly with seniors who often have conditions that require multiple prescriptions. DR. LANTFER responded that in medical school the pharmacology program covers the entire mechanism action of every drug, including classification of drugs, offshoots, side effects, contra-indication, and what drugs cannot be taken [together]. She told the members that every exam form that patients complete lists the drugs that the patient is taking and why the patient is taking it. So all of that is taken into consideration before any prescription is written, she said. Dr. Lantfer emphasized that the education of optometrists is the same as for general physicians. Number 0889 CHAIR WILSON said she hears Dr. Lantfer saying over and over again that optometrists have the same training as a medical doctor, but she said she knows that medical doctors study different systems. She said she believes that medical doctors go into greater depth on how everything interconnects, and that is what is causing her [to be reluctant in supporting the bill]. Number 0718 DR. LENTFER asked Chair Wilson if she has been able to compare [the educational training between optometrists and medical doctors]. CHAIR WILSON responded that she has talked with people on this issue, but has not researched it personally. DR. LENTFER asked if Chair Wilson's sources told her where medical doctors get this extra [in-depth training]. CHAIR WILSON said she is not concerned with where [medical doctors] get the extra training, but that they have it. DR. LENTFER agreed that if a doctor plans to be a specialist, such as a surgeon, he/she does receive extra training. She pointed out that optometrists do not do surgery. Optometrists are only asking for primary care, which is what is studied in medical school, she added. She emphasized that the same classes, textbooks, and disease and treatment issues are covered in medical schools for optometrist as for [a general physician]. Number 0645 CYNTHIA BRADFORD, M.D., Secretary for State Affairs, American Academy of Ophthalmology, testified in opposition to HB 306. She told the members that she represents the American Academy of Ophthalmology's 26,000 members. Dr. Bradford said that while the bill is short, it has dramatic ramifications for health care in Alaska. She highlighted her educational background to give the committee a perspective on her comments. She told the members that she is a physician, ophthalmologist, and professor of ophthalmology at the University of Oklahoma. She said she has been active throughout her career to give medical school graduates the skills necessary to become qualified specialists in eye care. Number 0490 DR. BRADFORD told the members that she supports Dr. Rosen's views expressed in his letter to the committee [dated May 8, 2003], and the American Academy of Ophthalmology supports his concerns. Expanding [optometrists'] authority to prescribe drugs is a serious public health issue, she said. She went on to say that while on the surface it may appear appropriate for [optometrists] to prescribe oral drugs, closer scrutiny reveals significant quality care and patient safety issues which need to be considered. Dr. Bradford said it is impossible to divorce the eye and visual system from the rest of the body because it is a part of the body. Many diseases in other systems of the body manifest themselves in the eye. Appropriate diagnosis requires many years of professional training in accredited programs. She said that would include three years beyond medical school and an internship for ophthalmology. DR. BRADFORD clarified that the eye is not a tooth and is one of the most complex and delicate body parts. Optometrists do not have the comparable education and training or experience to use the broad range of drugs that HB 306 would authorize, she said. She talked about various medications and the abuse of those substances. Number 0310 DR. BRADFORD told the members of the complications of inappropriately prescribing antibiotics and controlled substances. She explained that during her internship she received vast experience in prescribing controlled substances. It is very rare to prescribe a narcotic for an eye condition, she said. When it is used, it is normally after eye surgery. Dr. Bradford cautioned that seniors who have serious eye conditions often have [other] chronic illnesses and are often less tolerant to a drug's side effects. In these cases, careful evaluation and close coordination by an ophthalmologist is essential, she stated. Number 0261 DR. BRADFORD told the members that four years of medical school does not equate to eight years of ophthalmology training and education. She said that not only do optometrist not possess a medical degree, they are not required to complete clinical rounds, internships, and residency that focus on patients with serious eye disease. In contrast to optometry training, ophthalmologists complete four years of medical school, a one- year hospital residency, and a three-year ophthalmology residency. She asked the members to oppose HB 306. REPRESENTATIVE COGHILL asked Dr. Bradford to draw a comparison between the optometrist's and ophthalmologist's training in pharmacology. He noted that often when ophthalmologists are in residency, much time is dedicated to surgery. DR. BRADFORD agreed that there is a pharmacology course where the basics in medication are covered. It is important to understand the disease process, which is covered in pathology, and physiology teaches how the body parts work, what can go wrong, and how the drugs interact there. Those are the basic background courses, Dr. Bradford explained. During the clinical years the [medical students] begin to apply the paperwork and see firsthand not only the downside to every medication, but also the justifiable need for the medication. There are two years during which these students have a physician looking over their shoulder and telling them that they cannot use a particular drug, she said. Through that process, the student learns what he/she should or should not be prescribing. TAPE 04-08, SIDE A Number 0027 DR. BRADFORD pointed out that the internship is a difficult year that is an important decision-making and learning process. The internship is followed by the ophthalmology residency [after which] the resident knows how to manage the general medical care. The intern then relates the eye diseases back to the medicine. Dr. Bradford related that due to her background in medical school, she can look at a patient and know diseases the patient doesn't know he or she has. Optometry school does not provide that experience. REPRESENTATIVE COGHILL surmised that there are bases in training that are similar, and as a policymaker, he explained that he's trying to determine where the specialty comes into play. The committee, in reviewing this legislation, must determine whether the expansion in this legislation can be tolerated or not. Representative Coghill related his understanding, then, that during the internship the intern is allowed to prescribe drugs with serious oversight. DR. BRADFORD clarified that the oversight occurs during medical school; the internship has much less oversight. Interns write medical prescriptions, the nurses fill those prescriptions, and the pharmacists dispense the intravenous (IV) medication. REPRESENTATIVE COGHILL remarked that the internship occurs fairly early in the formative years of the doctor. He inquired as to the difference of [that experience] versus that of the optometrist with the same level of training. DR. BRADFORD stated that the optometrist hasn't had the same level of training because the optometrist hasn't been through two years of medical school with close oversight. Furthermore, ophthalmologists don't often see a patient who only has the problem of needing glasses, which is often the case for optometrists. Most of the patients seen by ophthalmologists have some sort of eye disease, and therefore these ophthalmologists see a variety of different eye diseases. Therefore, an optometrist would not have the same experience as an ophthalmologist with regard to seeing ocular disease. Number 0329 REPRESENTATIVE COGHILL remarked that it seems that what is being [proposed in this legislation] is minimal prescriptive authority. He said from those describing the legislation, he has ascertained that the drugs [the optometrists would be allowed to prescribe] are on the lower end of the pharmacological ladder. DR. BRADFORD pointed out that when one is prescribing narcotics, one must take care not to miss the diagnosis. She expressed concern with [optometrists'] being allowed to prescribe narcotics to kill pain when it's rare that such is necessary for eye conditions. She expressed further concern that [pain medication] could mask the symptoms of true eye disease. REPRESENTATIVE COGHILL clarified that he is looking at the principle of operation without going into the anecdotal side because one could probably find "bad people" on both sides. He specified that he is trying to determine what's the best medicine and practice. DR. BRADFORD said she agreed, but noted that in eye care she doesn't write many narcotic prescriptions - perhaps one or two a year. In general eye care, [narcotic prescriptions] aren't necessary. Most narcotic prescriptions for eye care are given after surgery. Number 0493 REPRESENTATIVE COGHILL inquired as to the professional peer review discussion between ophthalmology and optometry that could be reviewed to determine the professional barriers in education and practice in order to help the legislature understand how to license the profession. DR. BRADFORD explained that [ophthalmologists] generally say they look at eye diseases and want to treat patients to a certain level. The American Board of Ophthalmology has assigned the educational requirements to do what ophthalmologists do. She explained that the American Board of Ophthalmology looks at different disease processes and make an assessment with regard to what is necessary to train someone to understand and treat eye diseases. Ophthalmologists are tested to ensure that they reach this level. Furthermore, [the American Board of Ophthalmology] determines how much patient experience is necessary in order to be good. She predicted that as the world becomes more complex, if anything, more time would be added. There has never been a time when [ophthalmologists] have said they, as a profession, should cut back and not train as much. CHAIR WILSON recalled earlier testimony that optometrists had the same training and actually trained students who are studying to become ophthalmologists. DR. BRADFORD responded that it isn't common, and noted that there is a great deal of variability with regard to optometry school training. Number 0706 MICHAEL LEVITT, Staff, American Academy of Ophthalmology, returned to the earlier discussion surrounding oxycodone and what schedule drug it is. He informed the committee that a drug intelligence brief from the U.S. Drug Enforcement Agency specifies that oxycodone is a schedule II drug under the Controlled Substances Act because of its high propensity to cause dependence and abuse. Number 0762 CARL ROSEN, President, Alaska Academy of Ophthalmology, informed the committee that he is an ophthalmologist practicing at Ophthalmologic Associates, which is the largest eye practice in Alaska. He also informed the committee that he has taken care of Alaskans, performing orbital reconstruction, eyelid plastics, and neuro-ophthalmology for the past 10 years. He noted that he practices with six ophthalmologists and two optometrists. Dr. Rosen said that he believes there has been a lot of misleading discussion, especially since it's difficult for nonphysicians to understand the vernacular of the [eye care] community and how it works. DR. ROSEN recognized that this legislation isn't new, as there have been multiple versions over the past four years; the most recent legislation was an attempt at "hijacking" SB 270 in 2002. However, SB 270 failed as Democrats and Republicans joined together to take the optometric scope out of the legislation. Dr. Rosen emphasized that [optometrists and ophthalmologists] don't receive the same training. He also emphasized that there is a vast difference between the requirements, the population that takes the tests, and the curves on which one is graded. Dr. Rosen related that he spent at least 24,000 hours of clinical training; one year of medical internship; three years of residency; and a year of fellowship training. He explained that he dealt with sick patients in a cardiac care unit in which he dealt with oncology and neurology. However, Dr. Rosen said that once medical school is complete, one really learns the craft. For further clarification, Dr. Rosen highlighted that the American Academy of Ophthalmology requires board certification, while the American Academy of Optometry does not. Furthermore, there is recertification in the American Academy of Ophthalmology, which he noted he is currently experiencing. During this recertification, medical ethics courses, 300 hours of continuing medical education, chart reviews, and an exam [are required]. DR. ROSEN related that in his opinion and that of the American Academy of Ophthalmology, this legislation is dangerous for patients. This legislation would allow the Alaska Board of Examiners in Optometry, not the [State] Medical Board, to oversee its members, with which he disagreed. He related that [the American Academy of Ophthalmology] believes in legislating medical knowledge and skills that will affect the quality of patient care. Dr. Rosen concluded by saying, "Leave the practice of medicine to medical school graduates." Number 1054 REPRESENTATIVE COGHILL inquired as to why Dr. Rosen doesn't believe the Alaska Board of Examiners in Optometry has the ability to handle the cases that might come before it. DR. ROSEN pointed out that the optometric board can't come to a consensus with regard to testing its own constituents, and therefore there is no national certification. Furthermore, he believes something is wrong if the optometric community says that there have been no complications with anything they've done over the past 12 years because everyone has a complication. The problem is with regard to tracking reported problems because there is no database on such. However, the complicated patient ultimately ends up in [an ophthalmologist's office], where the patient complains. REPRESENTATIVE COGHILL suggested that HB 306 be held. He then turned to his earlier question regarding the peer review in the medical arena with regard to the education level and the practice ability. DR. ROSEN related his belief [that this matter has come about] because [the optometrists] have trained and now want to do more. However, the medical community doesn't recognize that want. He stressed the need for there to be appropriate medical training that is recognized by the medical community. If the aforementioned can be offered, then the medical community would [become involved] and some sort of consensus could be developed. However, the aforementioned hasn't occurred. Furthermore, when there have been discussions, a year later there is something that needs to be added in order to satisfy the patients' requirements and needs. CHAIR WILSON noted that she has spoken with both sides of this issue. One side says that [what HB 306 proposes] is how it's done in almost all the other states, while the other side says that only four states do this. Therefore, she requested an answer to the foregoing by the next hearing on this legislation. Chair Wilson encouraged the [optometrists and ophthalmologists] to come together to work this out. She expressed concern with regard to the optometrists' policing themselves. [HB 306 was held over.] ADJOURNMENT There being no further business before the committee, the House Health, Education and Social Services Standing Committee meeting was adjourned at 5:10 p.m.

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