Legislature(2017 - 2018)CAPITOL 106
03/18/2017 03:00 PM House HEALTH & SOCIAL SERVICES
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| Audio | Topic |
|---|---|
| Start | |
| HB159 | |
| SB91 | |
| HB103 | |
| Adjourn |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
| *+ | HB 159 | TELECONFERENCED | |
| + | TELECONFERENCED | ||
| + | SB 91 | TELECONFERENCED | |
| += | HB 103 | TELECONFERENCED | |
ALASKA STATE LEGISLATURE
HOUSE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE
March 18, 2017
3:03 p.m.
MEMBERS PRESENT
Representative Ivy Spohnholz, Chair
Representative Sam Kito
Representative Geran Tarr
Representative David Eastman
Representative Jennifer Johnston
Representative Colleen Sullivan-Leonard
MEMBERS ABSENT
Representative Bryce Edgmon, Vice Chair
Representative Matt Claman (alternate)
Representative Dan Saddler (alternate)
COMMITTEE CALENDAR
HOUSE BILL NO. 159
"An Act relating to the prescription of opioids; establishing
the Voluntary Nonopioid Directive Act; relating to the
controlled substance prescription database; relating to the
practice of dentistry; relating to the practice of medicine;
relating to the practice of podiatry; relating to the practice
of osteopathy; relating to the practice of nursing; relating to
the practice of optometry; relating to the practice of
veterinary medicine; related to the duties of the Board of
Pharmacy; and providing for an effective date."
- HEARD & HELD
CS FOR SENATE BILL NO. 91(HSS)
"An Act relating to the opioid epidemic; authorizing the chief
medical officer of the Department of Health and Social Services
to issue a standing order for the prescription of an opioid
overdose drug; and providing for an effective date."
- MOVED CSSB 91(HSS) OUT OF COMMITTEE
HOUSE BILL NO. 103
"An Act relating to the practice of optometry."
- MOVED CSHB 103(HSS) OUT OF COMMITTEE
PREVIOUS COMMITTEE ACTION
BILL: HB 159
SHORT TITLE: OPIOIDS;PRESCRIPTIONS;DATABASE;LICENSES
SPONSOR(s): RULES BY REQUEST OF THE GOVERNOR
03/06/17 (H) READ THE FIRST TIME - REFERRALS
03/06/17 (H) HSS, FIN
03/18/17 (H) HSS AT 3:00 PM CAPITOL 106
BILL: SB 91
SHORT TITLE: DISASTER EMERGENCY: OPIOID EPIDEMIC
SPONSOR(s): RULES BY REQUEST OF THE GOVERNOR
03/10/17 (S) READ THE FIRST TIME - REFERRALS
03/10/17 (S) HSS
03/13/17 (S) HSS AT 1:30 PM BUTROVICH 205
03/13/17 (S) Heard & Held
03/13/17 (S) MINUTE(HSS)
03/15/17 (S) HSS AT 1:30 PM BUTROVICH 205
03/15/17 (S) Moved CSSB 91(HSS) Out of Committee
03/15/17 (S) MINUTE(HSS)
03/16/17 (S) HSS RPT CS 5DP NEW TITLE
03/16/17 (S) DP: WILSON, VON IMHOF, BEGICH, GIESSEL,
MICCICHE
03/16/17 (S) TRANSMITTED TO (H)
03/16/17 (S) VERSION: CSSB 91(HSS)
03/17/17 (H) READ THE FIRST TIME - REFERRALS
03/17/17 (H) HSS
03/17/17 (H) HSS WAIVED PUBLIC HEARING NOTICE, RULE
23
03/18/17 (H) HSS AT 3:00 PM CAPITOL 106
BILL: HB 103
SHORT TITLE: OPTOMETRY & OPTOMETRISTS
SPONSOR(s): SPOHNHOLZ
02/03/17 (H) READ THE FIRST TIME - REFERRALS
02/03/17 (H) HSS, L&C
03/14/17 (H) HSS AT 3:00 PM CAPITOL 106
03/14/17 (H) Heard & Held
03/14/17 (H) MINUTE(HSS)
03/16/17 (H) HSS AT 3:00 PM CAPITOL 106
03/16/17 (H) Scheduled but Not Heard
03/18/17 (H) HSS AT 3:00 PM CAPITOL 106
WITNESS REGISTER
JAY BUTLER, MD, Chief Medical Officer/ DPH Director
Central Office
Division of Public Health
Department of Health and Social Services
Anchorage, Alaska
POSITION STATEMENT: Answered questions during discussions of HB
159 and SB 91.
BERNICE NISBETT, Staff
Representative Ivy Spohnholz
Alaska State Legislature
Juneau, Alaska
POSITION STATEMENT: Answered questions about HB 103 on behalf
of the bill sponsor, Representative Spohnholz.
JILL GEERING MATHESON, OD
Juneau, Alaska
POSITION STATEMENT: Testified in support of HB 103.
HARRIET MILKS, Assistant Attorney General
Commercial and Fair Business Section
Civil Division (Juneau)
Department of Law
Juneau, Alaska
POSITION STATEMENT: Answered questions during discussion of HB
103.
RACHEL REINHARDT, MD
American Academy of Ophthalmology
Seattle, WA
POSITION STATEMENT: Testified in opposition to HB 103.
VICTORIA BLOWER, OD
Optometrist
Anchorage, Alaska
POSITION STATEMENT: Testified in support of HB 103.
KARL ROSEN, MD
Ophthalmologist
Anchorage, Alaska
POSITION STATEMENT: Testified in opposition to HB 103.
ALFRED DERAMUS, MD
Ophthalmologist
Fairbanks, Alaska
POSITION STATEMENT: Testified in opposition to HB 103.
DAVID ZUMBRO, MD
Ophthalmologist
Anchorage, Alaska
POSITION STATEMENT: Testified in opposition to HB 103.
PAUL BARNEY, OD
Chair
Board of Optometry
Anchorage, Alaska
POSITION STATEMENT: Testified in support of HB 103.
ELIZABETH MORGAN, MD
Ophthalmologist
Anchorage, Alaska
POSITION STATEMENT: Testified during discussion of HB 103.
DAVID KARPIK, OD
Kenai, Alaska
POSITION STATEMENT: Testified in support of HB 103.
ERIC COULTER, MD
Ophthalmologist
Anchorage, Alaska
POSITION STATEMENT: Testified in opposition to HB 103.
ERIK CHRISTIANSON, OD
Optometrist
Ketchikan, Alaska
POSITION STATEMENT: Testified in support of HB 103.
ACTION NARRATIVE
3:03:19 PM
CHAIR IVY SPOHNHOLZ called the House Health and Social Services
Standing Committee meeting to order at 3:03 p.m. Representatives
Spohnholz, Sullivan-Leonard, Eastman, Kito, and Tarr were
present at the call to order. Representative Johnston arrived
as the meeting was in progress.
HB 159-OPIOIDS;PRESCRIPTIONS;DATABASE;LICENSES
3:03:59 PM
CHAIR SPOHNHOLZ announced that the first order of business would
be HOUSE BILL NO. 159, "An Act relating to the prescription of
opioids; establishing the Voluntary Nonopioid Directive Act;
relating to the controlled substance prescription database;
relating to the practice of dentistry; relating to the practice
of medicine; relating to the practice of podiatry; relating to
the practice of osteopathy; relating to the practice of nursing;
relating to the practice of optometry; relating to the practice
of veterinary medicine; related to the duties of the Board of
Pharmacy; and providing for an effective date."
3:04:59 PM
JAY BUTLER, MD, Chief Medical Officer/ DPH Director, Central
Office, Division of Public Health, Department of Health and
Social Services, stated that there had been a fourfold increase
in the number of opioid associated deaths in the past 20 years.
He declared that this was an opioid epidemic, pointing out that
no other cause of death had increased so remarkably over such a
short period of time. He reported that there was also an
increase in the rates of Hepatitis C, as well as other burdens
on the health care system associated with increased use of
opioids, both legal and illicit. He said that there were many
things that had to be done, which would require a multi-faceted
approach. He declared that it was necessary to address the
needs of people who were currently struggling with addiction,
and to prevent addiction through more evidence based prescribing
practices, control the flood of prescription opioids in the
community, and address the access to treatment and the de-
stigmatization by improving provider knowledge. He reported
that there had been an increase in illicit opioid use, beginning
with heroin in the past five years, and more recently with
fentanyl and other synthetic opioids. He noted that 80 percent
of heroin users started opioid use with prescription
painkillers. He said that HB [159] aligned with many
prescribing guidelines delivered to the legislature from the
health care boards through Senate Bill 74 in 2016, as well as
the Centers for Disease Control and Prevention pain management
guidelines, and the Surgeon General's report on alcohol, drugs,
and health. He added that recent statements from the American
Medical Association and the American Dental Association, as well
as recommendations for evidence based improvement and
prescription drug monitoring from the PEW Charitable Trust also
supported these guidelines.
DR. BUTLER offered to outline the proposed bill for three
particular areas: patients, providers, and the prescription drug
monitoring program. He said that proposed HB [159] empowered
patients in two ways, it provided an option for those who did
not wish to be prescribed opioids to communicate that preference
to the providers by way of a voluntary revocable opioid advanced
directive which could be placed on the medical record. He
shared that this had been a request from the recovery community,
describing the challenges they faced in interactions with the
health care system when a provider was unaware that the patient
was in recovery. He shared that the second way was that it
allowed patients to request that the pharmacist dispense less
than the total prescribed amount. He said that a partial fill
was authorized under federal law, with a goal to affirm the
rights of the patient and the authority of the pharmacist. He
said that a portion of the continuing professional education
that health care providers must receive would include a section
of at least two hours designated on pain management and the
basics of addiction medicine. He explained that the renewal of
a medical license required at least 40 hours of continuing
medical education credit. He said that the second component for
providers was a setting of dispensing limits for the initial
opioid prescription to no more than 7 days. He added that the
proposed bill did allow exceptions, when in the professional
judgment of the provider, a longer supply was necessary due to
chronic pain, severe acute pain, cancer pain, or palliative
care, or when a longer supply was necessary due to travel or
other logistical barriers. The third component was for changes
to the prescription drug monitoring program, a data base
accessible to prescribers and dispensers, in order to share
information about controlled substances. He declared that the
data base was secure and confidential, and met the requirements
of the Health Insurance Portability and Accountability Act
(HIPAA). He added that this database was not openly available
to law enforcement without appropriate search warrant authority.
DR. BUTLER said that the proposed bill authorized the pharmacy
board to issue routine periodic confidential reports to
prescribers to provide feedback on their prescribing practices
relative to those of their peers. These "report cards" were a
good way to provide feedback for providers for their own
prescribing habits. He said that this had been proven effective
in other states for reducing the number of excessive
prescriptions with other substances. He stated that the second
component of the changes to the prescription drug monitoring
program (PDMP) was for clarification to include veterinarians
who prescribe opioids to register and use the monitoring
program. He referenced recent media reports regarding attempts
to get opioid medications from veterinarians. He explained that
the third component was to make the PDMP a more useful tool by
providing that pharmacists update the data on a daily, rather
than weekly, basis. He stated that the proposed bill had a
zero-fiscal note from the Department of Health and Social
Services and the Department of Corrections, and a one-time cost
of $27,500 from the Department of Commerce, Community & Economic
Development to cover legal costs to amend the regulations and
for printing. He directed attention to a letter of support from
the Alaska Dental Society.
REPRESENTATIVE TARR asked if there had been a response from
pharmacists regarding the more frequent updating of PDMP.
DR. BUTLER said that there had been this discussion with the
pharmacists and that DHSS shared concern for any increased
burden on the smaller pharmacies. He explained that there could
be a delay for this requirement to take effect. He pointed out
that some of the larger, more automated pharmacies already
updated more frequently than currently required by law.
3:16:58 PM
CHAIR SPOHNHOLZ asked about the option for patients to decline
the full prescription amount, as it seemed counter intuitive to
ask permission to accept less medicine than prescribed. She
asked if that was not currently possible.
DR. BUTLER offered his belief that "it depends on who you ask"
and that federal law had recently changed, which clarified that
pharmacists could do a partial fill at the request of the
patient.
REPRESENTATIVE KITO pointed out that there were certain
medications which required the full regimen to be effective,
which could lead to some confusion.
DR. BUTLER acknowledged and stated that the law specified for
federally designated Schedule 2 controlled substances. He said
that this use for full regimen may have inadvertently lead to
patient confusion with opioid prescriptions.
3:19:16 PM
DR. BUTLER paraphrased from the Sectional Analysis [Included in
members' packets], which read:
Sec. 1 Adds a new Chapter 55, Voluntary Nonopioid
Directive Act, to AS 13, Decedents' estates,
guardianships, transfers, trusts, and health care
decisions, that provides an option for patients to
execute a Voluntary Nonopioid Directive that would
allow a person in recovery (or for other reasons) to
make clear the person's desire not to be administered
an opioid. A person, guardian, conservator or other
appointed person may revoke a directive at any time.
The person would provide this confidential information
to a health care provider or hospital on a form
provided by the Department of Health of Social
Services. The department would promulgate regulations
on procedures, confidentiality, and exemptions for
emergency or substance misuse treatment. Providers are
not liable for following a directive. Prescriptions
are assumed to be valid; pharmacists are not liable
for dispensing a controlled substance in contradiction
to a directive. The directive does not alter an
advance health care directive, limit opioid overdose
drugs, or limit treatment for substance abuse or
opioid dependence.
Sec. 2-25 Amend AS 08, Business and Professions, for
the Boards of Dentistry, Medicine, Nursing, and
Optometry to
• Require two (2) hours of pain management and opioid
misuse and addiction instruction;
• Disciplinary actions for prescribing or dispensing
an opioid in excess of the maximum dosage allowed by
law or violated a law related to drugs, regardless of
any criminal action;
• Set the maximum dosage for initial opioid
prescriptions at a seven-day supply unless, in the
practitioner's professional judgment, it is necessary
for chronic pain management or a patient is unable to
access a practitioner in time to refill the
prescription; and
• Require, for a minor under 18 years of age, the
practitioner discuss with the parent or guardian why
the prescription is necessary and the risks associated
with opioid use.
Sec. 26-27 Amend AS 08.80 for the Board of Pharmacy to
• Register with the Prescription Drug Monitoring
Database (PDMP) with or without a federal Drug
Enforcement Administration registration number; and
• Allow pharmacists to dispense less than the
prescribed amount of a schedule II or III controlled
substance at a person's request; the pharmacists would
inform the prescribing practitioner and the
Prescription Drug Monitoring Database.
Sec. 28 Amends AS 08.98 for the Board of Veterinary
Medicine to • Register with the Prescription Drug
Monitoring Database if the veterinarian has a federal
Drug Enforcement Administration number; and
• Identify resources and educational materials for
veterinarians to identify clients at risk for opioid
misuse or diversion of prescribed opioids.
Sec. 29-36 Amend AS 17.30, Controlled Substances, to
change the frequency pharmacists report to the
Prescription Drug Monitoring Database from weekly to
daily; remove the prohibition on sharing information
with the federal government. The pharmacy board may
provide a confidential unsolicited notification in
summary form to a practitioner's licensing board which
includes the basis for the notification. The
notification must be provided to the practitioner as
well.
Sec. 37 Directs the Department of Health and Social
Services to draft regulations to implement the
Voluntary Nonopioid Directive Act.
Sec. 38 Repeals sunset dates in sections 52 and 73 of
Ch. 25, SLA 2016 (SB 74).
Sec. 39-40 Set an immediate effective date and provide
an effective date for regulations.
3:28:24 PM
REPRESENTATIVE EASTMAN asked for the type of information on the
report cards and whether the confidentiality was discoverable in
any legal action.
DR. BUTLER explained that the report cards, as used in other
states, would compare the usage over the previous 12 months with
other providers. He replied that he did not know if this was
discoverable in a legal situation.
REPRESENTATIVE EASTMAN directed attention to page 7, [lines 8 -
9] of the proposed bill, and questioned whether there should be
sanctions "regardless of whether there has been a criminal
action or patient harm." He expressed his concern, as there was
the possibility of easily breaking one of many, many laws. He
asked if this was opening up the providers to liability.
Although he was unsure of the implications, he suggested this
might require the hiring of extra staff to deal with potential
technical violations, or the increasing of insurance coverage.
He asked for the reason behind this language.
DR. BUTLER offered his understanding that this language was not
new in this bill.
REPRESENTATIVE TARR directed attention to page 28, Section 36,
of the proposed bill, and stated that she was supportive of the
idea that providers be responsible, benchmark their practice
against others, and adjust their own prescribing practices
accordingly. She pointed out that the language was permissive
and not required, and asked if this should be required. She
declared that providers were part of the solution, as they
recognized that there were alternative options for their
patients to address health care needs.
DR. BUTLER explained that the primary goal of Section 36 of the
proposed bill was to provide authority to the Board of Pharmacy
to issue the report cards, and whether or not it was a mandate
was a matter of ideology. He said that, as the issuance of
these types of report cards was not currently allowed under
Alaska law, the desire was to establish the authority to do so.
REPRESENTATIVE TARR asked if the board had a better
understanding for whether this would be voluntary. She asked if
these were the recommendations from the task force.
DR. BUTLER, in reference to the Alaska Opioid Policy Task Force,
said that a number of its recommendations were used in the bill.
3:35:28 PM
CHAIR SPOHNHOLZ said that the bill would be held over.
SB 91-DISASTER EMERGENCY: OPIOID EPIDEMIC
3:35:50 PM
CHAIR SPOHNHOLZ announced that the next order of business would
be CS FOR SENATE BILL NO. 91(HSS), "An Act relating to the
opioid epidemic; authorizing the chief medical officer of the
Department of Health and Social Services to issue a standing
order for the prescription of an opioid overdose drug; and
providing for an effective date."
JAY BUTLER, MD, Chief Medical Officer/ DPH Director, Central
Office, Division of Public Health, Department of Health and
Social Services, reported that in late 2016, Department of
Health and Social Services was awarded a five-year federal grant
to support an opioid overdose prevention program which included
the distribution of naloxone, a lifesaving drug when
administered during an opioid overdose. He explained that the
grant funds had been used to acquire a nasal spray form of the
drug which was part of the rescue kit, and distributed through
Project HOPE, Harm reduction Overdose Prevention and Education.
He added that Project HOPE had prioritized partnerships with
staff of organizations which did not have medical direction, and
whose staff were most likely to be present when an overdose
occurred, including first responders and recover support. In
order to provide the kits statewide under a standing order, with
a prescription that was present, DHSS had explored some options
and decided that the best way to move forward expeditiously was
for the state medical officer to issue a standing order, under a
disaster declaration. He reported that the governor had issued
the disaster declaration on February 14, with an anticipated
legislative resolution to extend this declaration. He pointed
out that no state funds were requested, and that 14 provider
organizations had received over 1200 kits. He reported that
Legislative Legal Services had offered the opinion that a bill
was required to extend the disaster declaration for continued
distribution of the kits. He reported that SB 91 included
further improvements to HB 174, as it authorized the Chief
Medical Officer of DHSS to issue a state wide standing order for
prescription of an opioid overdose drug. This authorization
would mean that the disaster declaration was no longer necessary
to conduct the program, and would be allowed to lapse after 30
days, as prescribed under Alaska statute. He added that, as
stated in AS 44.62.270, emergencies were held to a minimum. He
pointed out that the proposed bill had a zero fiscal note, and
was supported by the federal grant.
3:40:20 PM
DR. BUTLER paraphrased from Senate Bill 91 Sectional Analysis,
version J, [Included in members' packets] which read:
Sec. 1 amends AS 17.20.085, Opioid overdose drugs, to
authorize the Chief Medical Officer to issue a
standing order, including a statewide standing order,
for the prescription of an opioid overdose drug
through June 30, 2021. The department is required to
report annually to the Legislature on the opioid
epidemic's SAMHSA grant activities and expenditures.
Sec. 2 repeals section 1 on June 30, 2021.
Sec. 3 makes the effective date retroactive to March
15, 2017, when the disaster declaration expires.
Sec. 4 provides for an immediate effective date.
REPRESENTATIVE EASTMAN said that the committee substitute was
cleaner than the original and he asked if the emergency
[declaration] had expired and was not being extended.
DR. BUTLER replied, "that is correct."
REPRESENTATIVE EASTMAN voiced his support for not making a habit
of declaring emergencies for one year.
3:42:18 PM
CHAIR SPOHNHOLZ opened public testimony.
3:43:38 PM
CHAIR SPOHNHOLZ closed public testimony.
3:43:45 PM
REPRESENTATIVE TARR moved to report CSSB 91(HSS) out of
committee with individual recommendations and the accompanying
zero fiscal notes. There being no objection, CSSB 91(HSS) was
moved from the House Health and Social Services Standing
Committee.
3:44:10 PM
The committee took an at ease from 3:44 p.m. to 3:49 p.m.
HB 103-OPTOMETRY & OPTOMETRISTS
3:49:32 PM
CHAIR SPOHNHOLZ announced that the final order of business would
be HOUSE BILL NO. 103, "An Act relating to the practice of
optometry."
[In front of the committee was the proposed committee substitute
for HB 103, Version D.]
3:49:57 PM
BERNICE NISBETT, Staff, Representative Ivy Spohnholz, Alaska
State Legislature, paraphrased from the sponsor statement
[Included in members' packets] which read:
HB 103 modernizes and updates the Alaska Optometry
Statute, as many parts are over 50 years old. It
allows the optometry board the authority to regulate
its practice the same as other prescribing health
professions such as dentistry, medicine and nursing.
This bill also allows the board to continue to adopt
regulations, updated to current practice and moves the
continuing education (CE) requirements back into
regulations. Continuing education is still required by
current statute, but the hours and subjects will be
determined by the board as with other professions.
This change allows the board flexibility to control CE
requirements and is recommended by the Department of
Commerce, Community and Economic Development. The
current regulations require more CE hours than the
statute subsection deleted by this bill. HB 103 allows
the optometry board to determine prescribed drug
schedules, including standards and limitations on
practice determined by the board. The bill ensures
that no licensee may perform any procedure beyond the
scope of the licensee's education, training, and
experience as established by the board. This allows
for future new and improved diagnostic and therapeutic
procedures as determined by the board, while not
having to return to the legislature for every new
technological advance, which is currently the case and
unnecessarily burdensome. The optometry definition in
this bill is updated to reflect current and modern-day
practice.
MS. NISBETT paraphrased from the Sectional Analysis [Included in
members' packets], which read:
Section 1 AS.08.72.050 (4)(6) updates very old
statutes to indicate that regulations shall be adopted
to govern the current prescription and use of
pharmaceutical agents; and develop uniform standards
for the practice of optometry.
Section 2 AS.08.72.060 (c)(4) the board shall publish
advisory opinions regarding standards for the practice
of optometry.
Section 3 AS 08.72.181(d) moves the continuing
education (CE) requirements back into regulation, as
desired by the Department of Commerce, Community and
Economic Development. Continuing education is still
required by current statute, but the hours and
subjects will be determined by the board.
Section 4 AS 08.72.272(a) clarifies the current
statute for the board to regulate pharmaceutical agent
prescription including standards and limitations on
practice determined by the board.
Section 5 AS 08.72.278 Limitation on practice adds a
new section that sets limitations on services,
ensuring that the board may not authorize any
procedure beyond the scope of the licensee's education
and experience.
Section 6 AS 08.72.300(3) updates the optometry
definition to reflect current practice.
Section 7 Effective date for Section 2. This is
because (3) of Section 2 was added to statute in 2016
via Senate Bill 74, the Medicaid Reform bill, and it
had the effective date of July 2017, so (4) is written
to comply with that date as well. (per Legislative
Drafting)
3:52:17 PM
CHAIR SPOHNHOLZ opened public testimony.
3:52:44 PM
JILL GEERING MATHESON, OD, reported that she was a practicing
doctor of optometry and that she had testified numerous times
before legislative committees in support of changes to the
optometry statute over the last 25 years. She explained that
those statutes had allowed doctors of optometry to safely
practice to the level of their training and education. She
asked for support to proposed HB 103, explaining that the state
boards and commissions were appointed and confirmed by the
Alaska State Legislature to represent the people of Alaska in
these areas of expertise. She explained that the state chose to
set up separate boards for each medical profession because each
profession was unique and the oversight needed to be handled by
the members of that profession. She noted that the approved
statutes were very broad for the medical board, the dentistry
board, and the Board of Advanced Practice Nurses, and that these
boards could autonomously manage their respective professions
within the law in an honest, safe and responsible manner. She
pointed out that the optometry statute, however, was too
complicated and restrictive. Proposed HB 103 would allow the
State Board of Examiners in Optometry to have the same autonomy
as the other boards. She assured the committee that, as a past
president of the state optometry board, the board acted with the
same level of professionalism and safety as the aforementioned
boards. She reiterated that the proposed bill was not about eye
surgery, even though doctors of optometry had performed minor
eye surgery for many years. They were trained in depth for
these procedures, which were routine within the scope of
practice. She declared that she would no more perform an eye
surgery that she was not trained for than any other profession.
She offered her belief that all professions, including
optometry, must evolve and there was no way to predict what
tools and options a doctor of optometry would need in 20 years
to protect or cure the vision of a patient. She stated that the
proposed bill allowed the profession to evolve and make the
necessary changes. HB 103 allowed doctors of optometry in
Alaska to operate with the same autonomy, respect, efficiency,
and oversight as the other professional health care
practitioners were granted.
REPRESENTATIVE SULLIVAN-LEONARD asked about the minor surgeries
performed by optometrists.
DR. MATHESON explained that the most common surgery was for
removal of a foreign body, and that these had been approved and
authorized for almost 25 years.
REPRESENTATIVE TARR offered her belief that practitioners should
be authorized to practice to their full scope and be regulated
by peer professionals. She stated her support for the proposed
bill. She said that regulations would be drafted, which would
be followed by a public comment period when professionals could
speak out, and if there was anything questionable, the process
would reveal any problems.
DR. MATHESON expressed her agreement that any complaint brought
to the board would be investigated, and there could be a vote to
see if there should be a sanction on an optometrist. She said
that the legal process would also be started. She stated that
there had not been any sanctions against optometrists during her
8 years on the board.
REPRESENTATIVE TARR asked if the regulations were available for
public comment.
DR. MATHESON expressed her agreement, and explained that after
the regulations were set, they went to Department of Law to
ensure they met the law, went out for public comment, and were
again voted on by the board.
REPRESENTATIVE EASTMAN stated that the investigation process
could be very costly, even if they did not result in sanctions.
He asked if there was any hesitation due to the potential of an
increase to liability cost.
DR. MATHESON replied that she was not aware of any opposition
from optometrists for that reason, and she explained that this
could lead to an increase in licensing fees at a later time.
She offered her belief that optometrists and the board were all
"a pretty conservative bunch."
CHAIR SPOHNHOLZ pointed out that Dr. Matheson was a practicing
optometrist and not necessarily an expert on the operations of
the board.
REPRESENTATIVE EASTMAN asked why the optometry board was not
currently treated like the other boards.
DR. MATHESON offered her belief that this had just been a matter
of time, and, as other parts of the statute had been cleaned up,
this was now the final stage.
4:04:01 PM
HARRIET MILKS, Assistant Attorney General, Commercial and Fair
Business Section, Civil Division (Juneau), Department of Law,
said that she represented professional licensing boards.
REPRESENTATIVE TARR asked about the process.
MS. MILKS, in response, said that the board typically drafted
the proposed regulation, and it often took time to determine the
language which represented the inclination of the board. Then,
the proposed regulation went out for public comment. It could
go out more than once for public comment and for more than 30
days. She noted that, based on public comment, the board could
revisit the regulation, and if there were substantial changes,
it would again go out for public comment. She acknowledged that
the transparency of this process could sometimes frustrate the
public for the amount of time necessary to adopt a regulation.
She added that the board did discuss the scope of practice. She
said that typically the health care related boards met at least
two or three times each year, and that the public was always
advised.
4:08:09 PM
RACHEL REINHARDT, MD, American Academy of Ophthalmology,
reported that she was a board-certified ophthalmologist. She
stated her opposition to proposed HB 103. She said that the
primary goal of any legislation involving medical care was for
patient safety. She stated that HB 103 removed the existing
surgery restrictions, and would redefine the field. She asked
that it be clearly specified in the law that surgery was outside
the scope of practice for optometry. She said that without
specific language to restrict surgery, Alaska would be the first
state to adopt such broad unprecedented legislation. She
suggested that the definition of surgery be added to the
proposed bill, and that surgery be expressly prohibited. She
noted that the Board of Optometry could still govern its own
profession, even though surgery was prohibited. She offered an
example of the lack of restrictions under the Oklahoma law. She
said that a major study released in July 2016 had data which
concluded that optometrists doing laser surgery in Oklahoma were
causing patient harm and increasing health care costs. She
stated that the proposed bill would result in unprecedented
sweeping change in the practice of optometry, with profound
implications for patient safety. She said that, at the very
least the proposed bill needed a definition of surgery to ensure
public safety. She made the distinction that optometry school
was not a medical education or a surgical education, as the
students received approximately one tenth of the clinical hours.
She concluded by stating that prescription narcotic death was
the leading cause of unintended death in the country, and that
HB 103 would allow optometrists to prescribe these narcotics.
She declared that this was not the time to expand who could
prescribe these medications.
REPRESENTATIVE TARR said that there was a challenge from a
shortage of providers in every area of health care in Alaska.
She suggested that the proposed bill offered an opportunity for
trained professionals to meet this need for health care. She
relayed that the optometrists wanted to continue with the things
they had already done for the past decade.
DR. REINHARDT relayed that there were 26 ophthalmologists in the
State of Alaska and that the State of Washington had a similar
ratio of ophthalmologists to the population. She acknowledged
that the Alaska population was spread over remote areas, though
she stated that the State of Washington had patients in remote
areas, as well. She said that it was important to note that
ophthalmologists had a responsibility for patient safety. She
suggested that there was a nationwide trend of optometrists
introducing vague bills with the intention of expanding the
scope to include surgery.
REPRESENTATIVE JOHNSTON asked about the committee substitute
which had removed the reference to surgery.
DR. REINHARDT explained that the committee substitute did not
change Sections 5 and 6, which offered new definitions for
optometry, which inserted language for treatment or performance
of preventive procedures. She stated that the inclusion of
treatment opened the door for any treatment modality to treat
any and all eye diseases, and it included surgery. She deemed
that the crux of the issue was that the new definition of
optometry could be interpreted to include all surgeries.
4:17:41 PM
VICTORIA BLOWER, OD, Optometrist, shared that she had been in
optometric practice in Anchorage for 32 years. She stated her
support for HB 103. She reported that technology and best
practices had advanced to allow for superior medical care, which
included eye care. She pointed out that the statute governing
the optometry board was more than 40 years old and did not allow
for reaction to the rapidly changing environment without
repeatedly going to the Alaska State Legislature for action.
She noted that the protocols had been extended to protect the
public. She shared her respect for the Board of Optometry. She
said it was unfair and a waste of resources to prevent
optometrists from providing care at the highest level of their
education and training, as this did include knowledge about the
entire body. She pointed out that, as so much of Alaska was
rural, most of the eye care was administered by the more than
150 optometrists serving in 80 communities. She directed
attention to a letter of support from the CEO of the
Southcentral Foundation. She expressed her objection to the
argument that optometrists could not be trusted to have sound
judgement about their skills and training, thereby not acting in
the public's best interest. She offered examples about other
medical professions working within their education and training.
She stated that HB 103 would modernize the statute and allow
detailed legislation to be determined by the optometry board, as
was the current standard in all other prescribing professions in
Alaska. It would also streamline the legislative governing
process and bring the best practices to the residents of the
state in a cost-effective manner.
4:21:43 PM
KARL ROSEN, MD, Ophthalmologist, voiced his strong opposition to
the proposed bill. He reported that he had been in practice for
23 years in Anchorage. He shared his educational background.
He declared that the proposed bill was the most expansive scope
of practice bill in the country. He said that the bill
dismissed the rigorous training of an ophthalmologist. He
offered his belief that the optometry board, a group of non-
surgeons, was going to decide which potential surgical
privileges would be allowed. He suggested to correct the
proposed bill by providing an amendment with a definition of
surgery. He declared that the optometry board already had the
ability to regulate its profession. He shared an article which
refuted the statement that more optometrists doing procedures
would cut costs, and he directed attention to a study which
determined that more than twice the number of eyes were re-
treated after laser surgery by optometrists versus
ophthalmologists. He stated that health policy makers should be
cautious about approving laser privileges for optometrists. He
pointed out that optometrists did not take hospital calls and
did not have hospital privileges, and if a complication
occurred, there would be the need to transfer patients to a
hospital. He declared "you can't get good doing a couple of
procedures a year." He said that insurance carriers would not
accept CPT codes by optometrists. He declared that, should all
privileges be made similar, then there needed to be an equally
strong legislative effort to ensure that all aspects of school,
training, and continued competency were also similar, or it
would become a two-tiered system for patients. He declared that
the proposed bill would make it difficult to recruit new
ophthalmologists to Alaska.
REPRESENTATIVE KITO asked how much of his educational study and
experience provided for vision and eye, or was most of it just
medical.
DR. ROSEN explained his education and background, which included
three years of ophthalmology residency of more than 110 hours
each week. He stated that it was not a job, it was a lifestyle,
a culture. He shared that studying at a major medical center
included interaction with the other colleges and allowed for
better communication with the other areas of medicine.
REPRESENTATIVE TARR said that she shared the concern for
surgeries by properly trained individuals. She mused that, if
the Board of Optometry wanted to propose regulations allowing
performance of Lasik surgery, those regulations would be opened
for a public comment period. She offered her belief that those
with views similar to Dr. Rosen would speak out in opposition.
She said that she did not see the circumstance to which he was
worried actually happening, as it would not make its way through
the public process.
DR. ROSEN replied that this was an ideological question and he
asked if optometry was being redefined. He said that there had
been a change in the past 10 years, and that optometry wanted to
be something else. He stated that there had been a process for
standardization in the American Medical System since 1910.
REPRESENTATIVE TARR reiterated that she could not see a
circumstance where this would happen.
DR. ROSEN said most providers followed their oath, although he
was there to protect the public from the outliers. He reminded
that there was method in place for licensing.
4:33:23 PM
ALFRED DERAMUS, MD, Ophthalmologist, stated his gentle
opposition to the proposed bill. He said that this was the
latest legislation on which he had been testifying since 1982.
He said that the ophthalmologist purview for the definition of
surgery was different than the definition of surgery by
optometry. His problem was that the proposed legislation left
an opening for interpretation that treatment for all eye disease
could include surgery. He declared that "we should be very,
very careful about this bill." He emphasized that
ophthalmologists were concerned that optometrists would perform
ophthalmic surgeries and be protected by the definition.
REPRESENTATIVE JOHNSTON asked what type of surgery would be
performed by optometrists.
DR. DERAMUS replied that the definition was open ended, and he
offered an example for the removal of a superficial foreign body
versus a deeply imbedded foreign body in the cornea.
CHAIR SPOHNHOLZ referenced the earlier testimony regarding the
regulatory process for changing regulations around the practice
of optometry and asked if he was concerned that there would not
be the opportunity to testify and for those concerns to be put
on the record.
DR. DERAMUS expressed his agreement that he would be allowed to
testify, and, in response to Chair Spohnholz, that he was aware
that the meetings of the Board of Optometry were all public. He
replied that he had only testified on one occasion regarding
various optometric bills, and that he had found that, regarding
the experience, he had been able to present his point of view
and have it weighed by the board. In further response to Chair
Spohnholz, he said that he had always been treated respectfully
by the board.
REPRESENTATIVE TARR reiterated that she could not see the
circumstance whereby optometrists were given the authority to
perform procedures that offered concern to ophthalmologist. She
stated that there were "bad actors that are in the provider
community whether it be for dental care or physical therapy or
other areas."
DR. DERAMUS said that the reality of life goes far beyond the
written or spoken word. He said that the pain of experience
from a surprise was "where you really find out where you stand."
He offered an example for a seemingly minor accident.
CHAIR SPOHNHOLZ asked if he was suggesting that an optometrist
might try to treat this incident in an emergency room.
DR. DERAMUS replied that he did not believe that an optometrist
would be in the operating room because they did not have
admitting privileges.
4:45:43 PM
DAVID ZUMBRO, MD, Ophthalmologist, shared his background as a
retina surgeon. He offered his belief that the proposed bill
"radically redefines optometry" as optometry did not have any
procedural background in its training or practice. He stated
that the proposed bill removed the prohibition against lasers in
surgery. He declared that there was a difference between
optometry and ophthalmology. He offered an example of some co-
workers who were optometrists and had gone back to school for
ophthalmology. He stated that they were not given any credit by
the medical school for their doctor of optometry degree. He
offered his belief that the regulations had changed in 2008 when
prescriptive authority advanced the scope of the optometry
practice. The proposed bill was too vague and open ended, as it
removed the specific prohibition against lasers in surgery and
allowed non-physicians to regulate the practice of surgery. He
declared that the focus of any health care issue should be
patient safety.
CHAIR SPOHNHOLZ asked where the legislation changed the scope of
practice.
DR. ZUMBRO explained that the removal of the prohibition against
lasers in surgery and the allowance for the treatment of eye
conditions were worrisome, as it would allow optometrists to
expand the scope of practice.
CHAIR SPOHNHOLZ stated that the proposed bill did not remove any
limitations, but only added language for the opportunity to use
pharmaceutical agents for the treatment of eye disease and
develop uniform standards for the practice of optometry. She
said that it rescinded the limitations on the amount of
education, as the continuing education requirements had already
been expanded.
DR. ZUMBRO suggested that an amendment defining eye surgery
would offer clarity for all the parties.
4:50:30 PM
PAUL BARNEY, OD, Chair, Board of Optometry, reassured the
committee that the board did not have the authority to write
regulations for anything that optometrists did not have the
education to do, and that the purpose of the board was to
protect the public. In response to Representative Tarr, he said
that he supported the bill.
4:52:17 PM
ELIZABETH MORGAN, MD, Ophthalmologist, said that she had
practiced in Anchorage for almost 14 years, and that she worked
closely with optometrists, especially in working with glaucoma
patients. She lauded the relationship and stated that the
proposed bill created a divisive force between the two
practices. She said that ophthalmologists took eye care of
individuals very seriously and they were adamant if there was
something that threatened the patient's best interest. She
offered her belief that the problem with the bill was that the
language was "a bit open ended." She suggested that the two
groups of providers arrive at a common definition for treatment
that was in the best interest of the patient.
REPRESENTATIVE JOHNSTON asked for that definition for treatment.
DR. MORGAN offered her belief that both sides needed to agree on
the definition of surgery.
4:56:01 PM
DAVID KARPIK, OD, stated that he was an optometrist and his
group provided the majority of eye care on the Kenai Peninsula.
He reported that he was also the medical director [indisc], and
that these practices offered similar comprehensive eye care
services and worked in conjunction with other primary care
providers. He declared that this model was cost effective and
in the patient's best interest. He stated that optometrists
practiced in small communities throughout Alaska and had a long
history of compassionate conservative care. He referenced a
recent study which reported that Alaska was last in access to
health care, and that this was an opportunity to help change
that alarming statistic. He said that all health care providers
practiced to the extent of their ever-evolving training. He
declared that optometrists have had full prescribing privileges
for 10 years. He pointed out that optometrists had been safely
performing procedures for decades, noting that they had training
on the entire body. He said that some schools duplicate medical
and dental courses for the first few years of the program.
4:59:26 PM
ERIC COULTER, MD, Ophthalmologist, referenced a letter that he
had sent to the committee, and shared that he had good
relationships with optometrists. He stated that privileges were
delineated through hospitals and surgery centers and were
outlined by law. He expressed his concern that the optometric
community would not let the public know the differences in
medical training. He declared that the proposed bill needed a
definition of surgery.
5:02:17 PM
ERIK CHRISTIANSON, OD, Optometrist, said that he was the only
full-time eye care provider in the community. He suggested that
the proposed bill was modernizing language to allow the
profession to move forward and regulate similar to other health
care providers. He said that the goal was to work as
effectively as possible, and that there were a variety of little
procedures that could be done often enough to be good. He
expressed his concern for the rural communities to get qualified
health care providers, and, unless there was the ability to
practice to the level of training, it would be difficult to
attract them.
5:04:28 PM
CHAIR SPOHNHOLZ closed public testimony.
5:04:51 PM
CHAIR SPOHNHOLZ stated that the proposed bill was introduced to
modernize the way optometry was managed in Alaska, as it was the
only health profession in the state where it was necessary to
visit in statute every time a small change was made to education
or scope of practice. She pointed out that things changed more
rapidly than the legislature could move. She offered her belief
that there were enough tools in the regulatory process to allow
for robust public participation and opportunities for concerns
to be expressed and to ensure that the Board of Optometry would
not "go rogue." She added that the proposed bill would get the
legislature out of the business of micromanaging optometrists.
She shared a personal story of an eye surgery performed by a
local optometrist. She offered her belief that it was best to
not define "surgery" in statute as it was a complex and broad
term. She shared that it was very difficult to arrive at a
definition of "surgery" which met all the criteria. She
suggested that it was best to let the regulatory process work.
She said that best management practices were to delegate
authority to the lowest possible level, and allow those
professionals the opportunity to perform their work. She lauded
the "robust regulatory process as it related to the way that
board regulations were adopted."
REPRESENTATIVE JOHNSTON asked how the board for chiropractors
regulated in Alaska.
MS. MILKS, in response, explained that the Board of Chiropractic
Examiners was managed with the same legal advice from the
Department of Law as the other boards. She stated that an
Assistant Attorney General was assigned to advise in both board
procedure and procedure for constructing and adopting
regulations, and that sometimes the Assistant Attorney General
would attend the board meetings.
REPRESENTATIVE JOHNSTON asked if there was a similar process for
change which required bringing proposed changes to the Alaska
State Legislature.
MS. MILKS replied that all the boards were under the
Administrative Procedure Act (APA). She explained that the APA
set out the procedures for adopting regulations and having
hearings, and that all the boards were under the APA and
followed the same rules with respect to adoption of regulations.
REPRESENTATIVE EASTMAN shared that the board of chiropractors
were very proud of their process, as they had pursued some
unique approaches to their profession. He expressed his hope
that the Board of Optometry would review this example. He asked
whether an expanded scope for optometrists would result in fewer
ophthalmologists.
CHAIR SPOHNHOLZ emphasized that she did not, as the sponsor of
the proposed bill, introduce the bill because of the unique
nature of the state. She said that this was a response to a
comparison of the State of Alaska to the State of Washington by
an earlier testifier. She declared that the intent of the
proposed bill was not to expand the scope of the Board of
Optometry, but instead to delegate discussions regarding the
practice of optometry to the Board of Optometry, rather than
having it done in statute on an annual basis.
REPRESENTATIVE TARR said that she would have concerns if the
regulations allowed for optometrists to perform eye surgery.
She offered her understanding that this was beyond the scope of
practice, and she could not see a circumstance in which this
would be the result. She declared that there were many barriers
to expansion of specialties. She opined that with the limited
number of providers it was necessary to take the opportunity to
allow practice to the full scope of training. She added that
the health care fields were always evolving, and she stated her
support of HB 103.
5:15:41 PM
REPRESENTATIVE TARR moved to report CSHB 103, Version 30-
LS0459\D, Bruce, 2/21/17, out of committee with individual
recommendations and the accompanying fiscal notes. There being
no objection, CSHB 103 (HSS) was moved from the House Health and
Social Services Standing Committee.
5:17:04 PM
ADJOURNMENT
There being no further business before the committee, the House
Health and Social Services Standing Committee meeting was
adjourned at 5:17 p.m.
| Document Name | Date/Time | Subjects |
|---|---|---|
| HB0159 ver A 3.6.17.pdf |
HHSS 3/18/2017 3:00:00 PM HHSS 3/25/2017 3:00:00 PM HHSS 3/30/2017 3:00:00 PM HHSS 4/4/2017 3:00:00 PM HHSS 4/11/2017 3:00:00 PM |
HB 159 |
| HB159 Sponsor Statement 3.6.17.pdf |
HHSS 3/18/2017 3:00:00 PM HHSS 3/25/2017 3:00:00 PM HHSS 3/30/2017 3:00:00 PM HHSS 4/4/2017 3:00:00 PM HHSS 4/11/2017 3:00:00 PM |
HB 159 |
| HB 159 Sectional Analysis ver A 3.6.17.pdf |
HHSS 3/18/2017 3:00:00 PM HHSS 3/25/2017 3:00:00 PM HHSS 3/30/2017 3:00:00 PM HHSS 4/4/2017 3:00:00 PM HHSS 4/11/2017 3:00:00 PM |
HB 159 |
| HB159 Fiscal Note DHSS-PHAS 3.6.17.pdf |
HHSS 3/18/2017 3:00:00 PM HHSS 3/25/2017 3:00:00 PM HHSS 3/30/2017 3:00:00 PM HHSS 4/4/2017 3:00:00 PM HHSS 4/11/2017 3:00:00 PM |
HB 159 |
| SB 91 ver A.pdf |
HHSS 3/18/2017 3:00:00 PM |
SB 91 |
| SB091 Sponsor Statement 3.16.17.pdf |
HHSS 3/18/2017 3:00:00 PM |
SB 91 |
| SB091 ver J 3.16.17.pdf |
HHSS 3/18/2017 3:00:00 PM |
SB 91 |
| SB091 Sectional Analysis ver J 3.16.17.pdf |
HHSS 3/18/2017 3:00:00 PM |
SB 91 |
| SB091 Additional Documents-Explanation of Changes, ver J 3.17.17.pdf |
HHSS 3/18/2017 3:00:00 PM |
SB 91 |
| SB091 Fiscal Note DHSS-PHAS ver J 3.16.17.pdf |
HHSS 3/18/2017 3:00:00 PM |
SB 91 |
| SB 36 Opposition Letter Coulter MD vs. SB36 HB103.pdf |
HHSS 3/16/2017 3:00:00 PM HHSS 3/18/2017 3:00:00 PM SFIN 3/14/2017 9:00:00 AM |
HB 103 SB 36 |
| HB 103 Draft Proposed Blank CS ver D 3.13.2017.pdf |
HHSS 3/14/2017 3:00:00 PM HHSS 3/16/2017 3:00:00 PM HHSS 3/18/2017 3:00:00 PM |
HB 103 |
| HB 103 Explanation of Changes (CS) 2.22.17.pdf |
HHSS 3/14/2017 3:00:00 PM HHSS 3/16/2017 3:00:00 PM HHSS 3/18/2017 3:00:00 PM |
HB 103 |
| HB 103 Letters of Support 2.22.17.pdf |
HHSS 3/14/2017 3:00:00 PM HHSS 3/16/2017 3:00:00 PM HHSS 3/18/2017 3:00:00 PM |
HB 103 |
| HB 103 Fiscal Note DCCED--DCBPL 3.13.17.pdf |
HHSS 3/14/2017 3:00:00 PM HHSS 3/16/2017 3:00:00 PM HHSS 3/18/2017 3:00:00 PM |
HB 103 |
| HB 103 Sectional Analysis (CS) 2.22.17.pdf |
HHSS 3/14/2017 3:00:00 PM HHSS 3/16/2017 3:00:00 PM HHSS 3/18/2017 3:00:00 PM |
HB 103 |
| HB 103 Sponsor Statement 2.22.17.pdf |
HHSS 3/14/2017 3:00:00 PM HHSS 3/16/2017 3:00:00 PM HHSS 3/18/2017 3:00:00 PM |
HB 103 |
| HB 103 Supporting Document Ohio State Optometry Curriculum 2.22.17.pdf |
HHSS 3/14/2017 3:00:00 PM HHSS 3/16/2017 3:00:00 PM HHSS 3/18/2017 3:00:00 PM |
HB 103 |
| HB 103 Supporting Document Medical Liability Premiums Fact Sheet 2.22.17.pdf |
HHSS 3/14/2017 3:00:00 PM HHSS 3/16/2017 3:00:00 PM HHSS 3/18/2017 3:00:00 PM |
HB 103 |
| HB 103 Supporting Document Regulation Flow Chart 3-10-17.pdf |
HHSS 3/14/2017 3:00:00 PM HHSS 3/16/2017 3:00:00 PM HHSS 3/18/2017 3:00:00 PM |
HB 103 |
| HB 103 Supporting Document-Board of the Examiners in Optometry.pdf |
HHSS 3/14/2017 3:00:00 PM HHSS 3/16/2017 3:00:00 PM HHSS 3/18/2017 3:00:00 PM |
HB 103 |
| HB 103 Supporting Document-Optometrists Practicing in AK 2.22.17.pdf |
HHSS 3/14/2017 3:00:00 PM HHSS 3/16/2017 3:00:00 PM HHSS 3/18/2017 3:00:00 PM |
HB 103 |
| HB 103 Supporting Documents Optometry Education Flyer 2.22.17.pdf |
HHSS 3/14/2017 3:00:00 PM HHSS 3/16/2017 3:00:00 PM HHSS 3/18/2017 3:00:00 PM |
HB 103 |
| HB103 Career Guide Optometry 2.22.17.pdf |
HHSS 3/14/2017 3:00:00 PM HHSS 3/16/2017 3:00:00 PM HHSS 3/18/2017 3:00:00 PM |
HB 103 |
| HB103 Letters of Opposition-Support.pdf |
HHSS 3/14/2017 3:00:00 PM HHSS 3/16/2017 3:00:00 PM HHSS 3/18/2017 3:00:00 PM |
HB 103 |
| HB 103 Opposing Document--Letters 3.15.17.pdf |
HHSS 3/16/2017 3:00:00 PM HHSS 3/18/2017 3:00:00 PM |
HB 103 |