Legislature(2003 - 2004)
05/09/2004 03:35 PM House JUD
| Audio | Topic |
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* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
ALASKA STATE LEGISLATURE
HOUSE JUDICIARY STANDING COMMITTEE
May 9, 2004
3:35 p.m.
MEMBERS PRESENT
Representative Lesil McGuire, Chair
Representative Tom Anderson, Vice Chair
Representative Dan Ogg
Representative Ralph Samuels
Representative Les Gara
Representative Max Gruenberg
MEMBERS ABSENT
Representative Jim Holm
COMMITTEE CALENDAR
CS FOR SENATE BILL NO. 306(FIN) am
"An Act relating to the practice of naturopathic medicine; and
providing for an effective date."
- HEARD AND HELD
CS FOR SENATE BILL NO. 97(JUD) am(ct rule fld)(efd fld)
"An Act relating to public interest litigants and to attorney
fees and costs and the posting of bonds or other security."
- SCHEDULED BUT NOT HEARD
CS FOR SENATE BILL NO. 269(CRA)
"An Act relating to access to library records, including access
to the library records of a child by a parent or guardian."
- SCHEDULED BUT NOT HEARD
PREVIOUS COMMITTEE ACTION
BILL: SB 306
SHORT TITLE: NATUROPATHIC MEDICINE
SPONSOR(S): SENATOR(S) SEEKINS
02/06/04 (S) READ THE FIRST TIME - REFERRALS
02/06/04 (S) L&C, FIN
02/19/04 (S) L&C AT 1:30 PM BELTZ 211
02/19/04 (S) Heard & Held
02/19/04 (S) MINUTE(L&C)
02/26/04 (S) L&C AT 1:30 PM BELTZ 211
02/26/04 (S) Moved SB 306 Out of Committee
02/26/04 (S) MINUTE(L&C)
02/27/04 (S) L&C RPT 1DP 3NR
02/27/04 (S) NR: BUNDE, FRENCH, STEVENS G;
02/27/04 (S) DP: SEEKINS
03/11/04 (S) FIN AT 9:00 AM SENATE FINANCE 532
03/11/04 (S) -- Meeting Canceled --
03/25/04 (S) FIN AT 9:00 AM SENATE FINANCE 532
03/25/04 (S) Heard & Held
03/25/04 (S) MINUTE(FIN)
03/30/04 (S) FIN AT 9:00 AM SENATE FINANCE 532
03/30/04 (S) Heard & Held
03/30/04 (S) MINUTE(FIN)
04/27/04 (S) FIN AT 9:00 AM SENATE FINANCE 532
04/27/04 (S) Moved CSSB 306(FIN) Out of Committee
04/27/04 (S) MINUTE(FIN)
04/28/04 (S) FIN RPT CS 4DP 2NR 1AM SAME TITLE
04/28/04 (S) DP: GREEN, WILKEN, DYSON, STEVENS B;
04/28/04 (S) NR: HOFFMAN, OLSON; AM: BUNDE
05/05/04 (S) TRANSMITTED TO (H)
05/05/04 (S) VERSION: CSSB 306(FIN) AM
05/06/04 (H) HES AT 3:00 PM CAPITOL 106
05/06/04 (H) <Pending Referral>
05/07/04 (H) READ THE FIRST TIME - REFERRALS
05/07/04 (H) JUD
05/08/04 (H) JUD AT 11:00 AM CAPITOL 120
05/08/04 (H) Scheduled But Not Heard
05/09/04 (H) JUD AT 3:00 PM CAPITOL 120
WITNESS REGISTER
BRIAN HOVE, Staff
to Senator Ralph Seekins
Alaska State Legislature
Juneau, Alaska
POSITION STATEMENT: Presented SB 306 on behalf of the sponsor,
Senator Seekins.
SENATOR RALPH SEEKINS
Alaska State Legislature
Juneau, Alaska
POSITION STATEMENT: Sponsor of SB 306.
REPRESENTATIVE PEGGY WILSON
Alaska State Legislature
Juneau, Alaska
POSITION STATEMENT: During discussion of SB 306, as chair of
the House Health, Education and Social Services Standing
Committee, responded to questions regarding a proposed committee
substitute for HB 434, Version W, and provided comments.
SCOTT LUPER, N.D.
Alaska Association of Naturopathic Physicians (AKANP)
Fairbanks, Alaska
POSITION STATEMENT: Provided comments and responded to
questions during discussion of SB 306.
KAYCIE ROSEN, N.D.
Anchorage, Alaska
POSITION STATEMENT: Provided comments and responded to
questions during discussion of SB 306.
ALEX MALTER, M.D., President
Alaska State Medical Association (ASMA)
Juneau, Alaska
POSITION STATEMENT: During discussion of SB 306, provided
comments and urged members not to support the bill.
DON LEHMAN, M.D.
Sitka, Alaska
POSITION STATEMENT: Responded to a question during discussion
of SB 306.
DAVID M. HEAD, M.D., Chair
Alaska State Medical Board (ASMB)
Nome, Alaska
POSITION STATEMENT: During discussion of SB 306, provided
comments, urged a "No" vote, and responded to questions.
ACTION NARRATIVE
TAPE 04-82, SIDE A
Number 0001
CHAIR LESIL McGUIRE called the House Judiciary Standing
Committee meeting to order at 3:37 p.m. Representatives
McGuire, Samuels, Gara, and Gruenberg were present at the call
to order. Representatives Anderson and Ogg arrived as the
meeting was in progress.
SB 306 - NATUROPATHIC MEDICINE
[Contains discussion of HB 434.]
Number 0044
CHAIR McGUIRE announced that the committee would consider CS FOR
SENATE BILL NO. 306(FIN) am, "An Act relating to the practice of
naturopathic medicine; and providing for an effective date."
CHAIR McGUIRE asked what the differences are between the Senate
and the House versions of the bill.
Number 0249
BRIAN HOVE, Staff to Senator Ralph Seekins, Alaska State
Legislature, sponsor, on behalf of Senator Seekins, noted that
the committee has before it [CSSB 306(FIN) am], which, he
opined, has been greatly improved from the original version via
the committee process. He relayed that the sponsor has listened
to and read extensive testimony on both sides of the issue. As
a result, [CSSB 306(FIN) am] now contains some sideboards to
accommodate naturopaths, particularly with regard to
prescription schedules IIIA, IVA, and VA drugs. This was
accomplished by providing for a process whereby a naturopath
would collaborate with a doctor to develop a formulary and work
together on certain issues. He expressed the hope that [CSSB
306(FIN) am] will satisfy most, though perhaps not all, of the
concerns raised by the bill, and posited that most of the bases
have been covered.
CHAIR McGUIRE noted that a sectional analysis has been provided
to members. In response to a question, she relayed that copies
of the original version and latest version of HB 434 would be
provided to members as well.
MR. HOVE explained that the sectional analysis pertains to CSSB
306(FIN) and so does not reflect the amendment adopted on the
Senate floor, and offered his understanding of what that Senate
floor amendment entailed. He suggested that this change will
ensure that just one or two doctors aren't collaborating with
all the naturopaths, since this might not be good public policy.
MR. HOVE went on to explain that Section 1 of [CSSB 306(FIN) am]
changes "naturopathy" to "naturopathic medicine", and is
basically a housekeeping provision. He characterized Sections 2
and 3 as similar, and said Section 4 repeals and reenacts AS
08.45.030, which pertains to the issuance of a license. He
noted that the original law [regarding naturopaths] is 17 years
old, and so much of what [CSSB 306(FIN) am] does is update
existing statute with what he described as much-needed
revisions. Section 5 speaks to restrictions on the practice of
naturopathic medicine, he relayed.
CHAIR McGUIRE noted that the sectional analysis indicates that
Section 4 removes a reciprocity provision previously available
to naturopaths licensed in other states. She asked why [the
sponsor] would want to do that.
MR. HOVE said doing so will give the state more control over who
it wishes to license versus just allowing for automatic
reciprocity.
CHAIR McGUIRE directed attention to Section 5 and offered her
understanding that the language therein had been removed from
some version of one of the bills though she couldn't recall
which one.
MR. HOVE offered his belief that that language had not been
removed from any of the Senate versions of the bill, the latest
of which is currently before the committee.
CHAIR McGUIRE noted that Section 5 allows for the performing of
minor surgery.
MR. HOVE offered his understanding that that provision covers
only very minor types of [surgeries], not anything that would be
considered invasive surgery.
CHAIR McGUIRE offered the adage that "surgery is only major when
it's on you - it's minor when it's on others."
Number 0890
REPRESENTATIVE GARA asked about AS 08.45.120(a)(6), which is
referenced in Section 5.
CHAIR McGUIRE posited that perhaps it is referencing a proposed
new provision of statute that can be found further on in the
bill. She suggested that perhaps the naturopaths that will be
testifying could provide a description of what constitutes
"minor surgery". She noted that Section 6 addresses the grounds
for suspension, revocation, or refusal to issue a license.
MR. HOVE said the important part of the bill is Section 9 - new
statutory language that addresses collaborative agreements,
continuing education, and a peer review process. Directing
attention to Section 10, starting on page 5, regarding
"Authorized activities; use of titles", he noted that it says in
part, "A person licensed under this chapter may ... (4) if
authorized under regulations of the department, prescribe
schedules IIIA, IVA, and VA controlled substances ...". He
characterized these controlled substances as the heart of the
addictive drugs, offered his belief that [CSSB 306(FIN) am] now
contains "something that will be acceptable in terms of
arranging for these collaborative agreements," and again
mentioned putting together a formulary between the naturopath
and the doctor such that there will be a pretty good one-on-one
understanding between them regarding what is allowed.
MR. HOVE said: "So the sideboard we built in here is the
collaborative agreements, ... specifically with respect to
developing that formulary; then it goes through ... the
regulatory process - so the sideboards that are here will be
fleshed out in that process; and then it comes down to how it
works in practice." He described the latter as being a one-on-
one situation such that "individuals will have a pretty good
idea of who they're working with, what they're capabilities are
and level of experience, and so on and so forth."
CHAIR McGUIRE posited that much of the controversy over this
bill probably centers on the issue of schedules IIIA, IVA, and
VA controlled substances as described under AS 11.71.160,
11.71.170, and 11.71.180. She noted that phenobarbital is
included in [schedule IVA], and asked why a naturopath would be
[prescribing/using] such a drug.
MR. HOVE suggested that the naturopaths who will be testifying
could better address that issue.
CHAIR McGUIRE, noting that the sponsor had joined them via
teleconference, mentioned that the bill seems somewhat circular
with regard to the reference to "minor surgery".
Number 1267
SENATOR RALPH SEEKINS, Alaska State Legislature, sponsor,
offered his belief that "minor surgery" would include simple
things like treating abrasions, removing a piece of class or
gravel, or sewing a couple of stitches; "it's nothing invasive."
He also offered his belief that naturopaths have had training in
minor surgery "before they could get there." With regard to
schedules IIIA, IVA, and VA controlled substances, he said that
under the bill, the naturopath will have to review a particular
drug with the collaborative physician, and have an individual,
written protocol - which they must both agree on - regarding how
to use that drug. Additionally, before a naturopath may
prescribe a schedule IIIA controlled substance, the protocol
that's developed and agreed to must be patient specific.
SENATOR SEEKINS said he feels that of any other state's law,
[CSSB 306(FIN) am] contains the best sideboards that exist with
regard to allowing naturopaths to service their patients. He
predicted that California and Alaska will be vying to see which
state has the best collaborative agreements. He, too, suggested
that the naturopaths that will be testifying can better address
some of the committee's questions.
CHAIR McGUIRE noted that "minor surgery" is defined on page 8,
lines 18-29:
(6) "minor surgery"
(A) means the use of
(i) operative, electrical, or other methods
for surgical repair and care incidental to superficial
lacerations and abrasions or superficial lesions, and
the removal of foreign bodies located in superficial
tissues; and
(ii) antiseptics and local anesthetics in
connection with methods authorized under (i) of this
subparagraph;
(B) does not include use of general or spinal
anesthetics, major surgery, surgery of the body
cavities, or specialized surgery, such as plastic
surgery, surgery involving the eyes, or surgery
involving tendons, ligaments, nerves, or blood
vessels.
Number 1472
SENATOR SEEKINS, in conclusion, said he introduced SB 306 at the
request of the naturopaths, who were seeking to better serve
their patients in a safe and consistent manner through the use
of pharmaceuticals and minor surgery. The goal of the
naturopaths, he surmised, was to provide the same high level of
care as physicians with regard to pharmaceutical protocols, and
the collaborative agreement provisions of [CSSB 306(FIN) am]
should help them achieve that goal. Noting that a lot of people
have done a lot of hard work on this issue, he offered his
belief that [CSSB 306(FIN) am] is a good bill.
CHAIR McGUIRE, referring to a House version of the bill [which
failed to move out of the House Health, Education and Social
Services Standing Committee] - committee substitute (CS) for HB
434, Version 23-LS1574\W, Mischel, 5/4/04 - noted that it
doesn't contain reference to "minor surgery". She also noted
that "the liability is different."
Number 1572
REPRESENTATIVE PEGGY WILSON, Alaska State Legislature, speaking
as chair of the House Health, Education and Social Services
Standing Committee, remarked, "The liability is there now, it
wasn't [before].
CHAIR McGUIRE clarified that she is speaking about liability
with regard to the collaborative agreements.
Number 1601
SCOTT LUPER, N.D., Alaska Association of Naturopathic Physicians
(AKANP), said he would be speaking on behalf SB 306, and noted
that he has three main points to make. He elaborated:
The first one is about education, the second one is
about safety, and the third one is about cooperation.
... In terms of education, in order to become a
naturopathic physician, one needs to graduate with
good grades from an "undergrad degree," then get
accepted into naturopathic medical school, which is
not an easy thing to do, and then go through four
years of naturopathic medical school. The first two
[of those four] years being lecture and didactic, and
the second two years being an emphasis on outpatient
clinical training: basically working with doctors -
mostly naturopathic doctors but also some "M.D.s and
D.O.s" - treating patients, working in their offices,
... working in the college clinic, and [working] some
rotations in hospitals, especially in Arizona.
After that, you need to pass the national board exams,
which makes sure that you're safe, and then after that
you can qualify for a license. Now, the degree of
education of naturopathic physicians does exceed other
health care providers here in Alaska that do have
prescription rights, including nurse practitioners
[N.P.s], and way exceeds the education of physician's
assistants [P.A.s]. And the level of prescription
rights that we've negotiated ... with this compromise
bill is actually less than the nurse practitioners and
[physician's] assistants, though the collaboration
agreement really is modeled on that of the physician's
assistants - since it's already in statute we just
basically adopted it as best we could. So ... the
point I'm making is that we're well trained.
Number 1696
DR. LUPER continued:
The next point is safety. And the fact of the matter
is, ... this isn't new - prescription rights aren't
new for naturopathic physicians. Of the ... 14 states
that license naturopathic physicians, 12 of them have
some level of prescription rights. And we
investigated the rate of disciplinary actions taken
against naturopathic physicians with prescription
rights, and the fact of the matter is, ... in every
state that we got results back from, the complaints
and the disciplinary actions taken against
naturopathic physicians was less than that of other
doctors, M.D.s in particular. For example, in Oregon,
where the ... right for prescriptions has been the
longest, the rate for M.D.s is about [.5] percent
[and] the rate for naturopathic physicians is about
[.33] percent. In Arizona, where the prescription
rights are the broadest, the rate against M.D.s is
about 1 percent and the rate for naturopathic
physicians is about [.5] percent. Nationwide, the
rate is about [.33] percent for naturopathic
physicians.
CHAIR McGUIRE noted, however, that there are probably more
physicians practicing than there are [naturopathic physicians].
DR. LUPER pointed out, though, that the statistics he is
relaying involve "rate." In other words, if there are 1,000
physicians and one looked at 100 of them, it would be the same
as having 100 naturopathic physicians and looking at 10 of them.
REPRESENTATIVE GRUENBERG surmised, though, that the difference
in percentages between the two groups could be because
physicians are probably performing more difficult and more risky
procedures.
DR. LUPER acknowledged that point. He mentioned, though, that
he is merely attempting to illustrate that there is a track
record of naturopathic physicians safely using prescription
medications.
REPRESENTATIVE GARA said: "I take it there's a statute that
comes up with a formulary system with a physician collaborator
for physician's assistants."
Number 1787
DR. LUPER said "No, that's not correct." The prescription
authority for physician's assistants is broader that what is
being proposed via the bill for naturopathic physicians, he
reiterated.
REPRESENTATIVE GARA surmised, then, that if "we're going to
provide prescription authority, what we're going to want to do
is allow a naturopath to administer [a] prescription without
getting approval every single time."
DR. LUPER concurred.
REPRESENTATIVE GARA asked whether physician's assistants can
prescribe drugs without approval for that prescription every
single time.
DR. LUPER said they can. In fact, they can practice without
having a M.D. in their clinic, and many do, often because they
are in communities that don't have M.D.s. Also, physician's
assistants don't have to clear a plan of treatment with an M.D.
on a case-by-case basis before treating a patient. He remarked
that the intention of the [proposed] law is to have oversight,
to have M.D.s oversee protocols.
DR. LUPER went on to say:
The way we see this working is, when the bill passes
and becomes law, we'll go out and find M.D.s that can
supervise us, and we'll create a list of drugs that we
want to use in our particular practice. Now, our
practices are not identical. Some of us [who]
emphasize pain control, for example, may have certain
medications that they want to use. Most of us just
emphasize ... family medicine, and there's certain
things that we want to use. We'll take this list to
our M.D. ... collaborator, and we'll discuss these
medications with them and get their approval, to say,
"Yes, these are appropriate ... to use in these
situations," so that there is a high degree of safety,
[a] high degree of oversight - more than [in] any
other state in the United States that licenses
naturopathic physicians.
And when we create these protocols, ... my hope ... is
that we'll create relationships with these M.D.s, so
that not only will we learn from them, but it's my
conjecture that they're going to learn from us as
well. ... In the treatment of hypertension [for
example] I've had some success; I think I'll be able
to teach them a thing or two. And I think it'll be a
great advantage for the general public to have us
working together hand in hand. In fact, what this
bill does is it really forces that cooperation.
That's how I sold [the concept of the bill] to my
colleagues, and they bought it.
Number 1921
CHAIR McGUIRE asked how a pharmacist would know whether a
particular naturopathic physician has a collaborative agreement
with a physician or whether a naturopathic physician is staying
within the bounds of a collaborative agreement.
DR. LUPER explained that the naturopathic physicians will send
their pharmacists the list of the medications they have approval
for. In that way, a relationship will develop between the
naturopathic physician and the pharmacist, and the pharmacist
will come to know what the naturopathic physician can and cannot
prescribe.
CHAIR McGUIRE, noting that Alaska is a big state, asked whether
Dr. Luper is saying that naturopathic physicians will provide
every pharmacy in the state with a copy of his/her collaborative
agreement. Or would it be part of a collaborative agreement
that a naturopathic physician can only use certain pharmacies?
DR. LUPER replied, "Only certain pharmacies." For example, if a
patient from Barrow came to see him with the end result being
that he wanted to prescribe a particular medication, he would
send/fax a copy of his collaborative agreement to a pharmacist
in Barrow. This sort of thing would happen on a case-by-case
basis. For the most part, though, with regard to his practice,
there are a few pharmacists that he already knows and respects,
and so he would be working with those pharmacists, he relayed.
CHAIR McGUIRE told Dr. Luper that she is not worried about how
he will conduct himself; rather, she is concerned with what
effects the bill will have on the population at large. She said
she wants something in place that will minimize the possibility
that someone might die as a result of allowing naturopathic
physician to prescribe medication.
Number 2088
DR. LUPER, in response to questions, offered his belief that
physician's assistants have prescription rights for schedules
IIA-VA controlled substances as well as "legend" drugs, and that
M.D.s do provide some oversight, though not on a case-by-case
basis. He noted that nurse practitioners have the same
prescription rights as physician's assistants, but are not
subject to any supervision from a doctor; they are completely
independent.
DR. LUPER concluded:
I think I did make my third point, which is
cooperation; I think I spoke to that in answering your
questions. ... Just to summarize, ... I think the
education is very good for naturopathic physicians,
... that we are well educated. We do go to school.
In fact, a point I forgot to mention is pharmacology
specifically. The level of [classroom] pharmacology
that we get is comparable to that of M.D.s ... and
D.O.s. ... The safety record of naturopathic
physicians with prescription rights, and that's
unsupervised prescription rights, ... is safe, is
good. And finally, ... this bill creates a vehicle,
or a discipline if you will, for naturopathic
physicians and allopathic physicians or M.D.s to work
together for the betterment of Alaskans.
CHAIR McGUIRE directed attention to page 2, lines 10-11, which
says in part, "is a graduate of an approved naturopathic medical
college or program". She asked what "approved" in this context
means.
DR. LUPER replied:
That is spelled out later on in the bill. ... What
that approval is, [is it] comes from the Council on
Naturopathic Medical Education [CNME]; that's an
accrediting body that's ... empowered by the federal
government, and every naturopathic college in North
America has accreditation, or at least candidacy for
accreditation, from the CNME. Now, most of the
colleges also have accreditation from local
accrediting bodies. For example, Northwest
Accrediting Agency accredits its Northwest schools,
"central" for Arizona schools, and so on and so forth.
That's the list of schools; it's basically schools
recognized by the federal government.
Number 2291
CHAIR McGUIRE, mentioning a recent scandal involving masters
degrees in teaching that were available on the Internet, asked
whether the CNME regularly polices the entrance and approval of
schools.
DR. LUPER replied:
I can speak to that from personal experience. I was
chairman of diagnostics at the Southwest College of
Naturopathic Medicine, and ... one of my jobs was to
have us go through the self-study for the CNME. And
it was very rigorous, extremely rigorous. We had to
look at every aspect of operations, and it was a
years-long process to get accreditation. We worked
very hard and we were very proud when we received
accreditation.
Now, there are naturopathic colleges, quote,
"colleges," or schools that do generate correspondence
degrees; those do exist in the United States. But in
states that license naturopathic physicians, you can't
practice as a naturopathic physician or a naturopathic
doctor with one of those degrees because they're not
accredited by the CNME. In fact, there's some
misconception about this, that the passage of this
bill will allow uneducated pseudo-naturopaths to [have
prescription rights, but that's not true.] [The
previously bracketed portion was not on tape, but was
taken from the Gavel to Gavel recording on the
Internet.]
TAPE 04-82, SIDE B
Number 2346
DR. LUPER continued:
And in fact, it's no more true than someone who got
their M.D. degree from the Internet being able to
practice allopathic medicine in this state. That
can't happen; that's against the law, and likewise for
the naturopathic physician.
CHAIR McGUIRE asked Dr. Luper whether he would be amenable to an
amendment that specifies that in order to be licensed, a
naturopath must graduate from a naturopathic medical college
certified by the CNME.
DR. LUPER said he would not object to such an amendment. He
mentioned, however, that the name "naturopath" isn't a protected
name, so anybody with any kind of education can say, "I'm a
naturopath," and hang up a shingle. So one of the possible
benefits of [CSSB 306(FIN) am] is that it will protect that name
because it says that one must have gone through a certain level
of education in order to call oneself a naturopath. In response
to further questions, he offered his understanding that
currently, there are five naturopathic schools that have CNME
accreditation and one that has a candidacy for CNME
accreditation. He indicated that the intent of the bill is that
only graduates of CNME accredited schools should have
prescription rights as proposed in the bill.
DR. LUPER opined that naturopathic schools that are not
accredited do not offer the same level of education as those
that are accredited. He noted, for example, that the "Clayton
School of Natural Healing" has a nine-month-long program,
completion of which results in a certificate being issued that
says a person is a naturopath. "Those are the folks that would
not be licensable here in Alaska," he added. In response to
further questions, he reiterated his comments regarding the
amount of education required to graduate from an accredited
naturopathic school, specifically that a person must have a
four-year degree with good grades before being permitted to
enroll in an accredited naturopathic degree program.
Number 2199
KAYCIE ROSEN, N.D., said she fully supports Dr. Luper's
comments. She went on to say:
The main point that I want to make today is that our
intention with this bill and as naturopathic
physicians is to [be] absolutely committed to the
safest, most comprehensive primary care for our
patients. And so by creating this bill, what we're
really hoping for is just to increase our ability to
be as safe and as effective as possible, to make sure
that our patients, when they come in, are able to
receive exactly what they need at that time within the
context of ambulatory outpatient care. And so by
doing this, our patients aren't necessarily going to
receive different care in the sense of whether it is
appropriate at the time to receive some sort of a
prescription medication; it's a question of whether
they will be able to do it within ... adequate cost
and within an adequate time period.
[Chair McGuire turned the gavel over to Representative Samuels.]
And so [if] my patients ... come in [and] need, for
[example], an antimicrobial, an antibiotic, blood
pressure regulating medication, ... blood glucose
regulating medication, ... or hormones - which are the
things that we would most likely [be] dealing with
here in terms of what we'd like to be prescribing -
we're saving our patients the money [they'd spend] to
go see another provider and also the time: ... [it]
is very, very challenging to get patients in to see
... other family practitioners, ... endocrinologists,
et cetera. And so I just want to really underline
that my commitment and our commitment as a profession
is to safe, quality, comprehensive care, and that ...
having this collaboration as part of the medical
community is absolutely our intention.
REPRESENTATIVE OGG - noting that over the course of the
legislative session, the committee has heard much about
malpractice insurance costs and the alleged diminishing numbers
of doctors that can provide care in Alaska - asked how the bill
will help that situation and whether it will help lower the cost
of medicine in Alaska.
Number 2064
DR. ROSEN relayed her belief that it would do the later, and
offered an example wherein a patient, after consulting many
providers, came to her and she, through a basic "workup,"
determined that the patient had very high blood sugar - in the
high-200s - which is a potentially dangerous high number. As
naturopathic doctors, she remarked, they are familiar with a lot
of therapies that are really good at helping to bring down blood
sugar levels. The patient, however, was at a place -
physically, financially, and emotionally - where it was very
difficult for him to be regulating his diet and to be taking a
lot of different types of supplements. When he called to get an
appointment with an endocrinologist, the patient found he would
have to wait six weeks.
DR. ROSEN indicated that had she been able to prescribe
glucophage to regulate his blood sugar while she and her patient
worked out other aspects of a treatment plan, it would have
saved the patient a lot of money because he was left with the
choice of going to either a walk-in family clinic or the
emergency room in order to get that medication. This situation
was not efficient, either for the patient or for the people who
saw him; the patient spent a lot of time and money out of pocket
that he wouldn't have had to spend had she been able to
prescribe the medication. This sort of thing happens all time,
she remarked. As another example, if a patient has
hypothyroidism, under the bill a naturopath would be able to
give the person thyroid supplementation without sending the
patient on to someone else and thereby engendering an extra
doctor bill and an extra wait while being in a potentially
dangerous situation.
DR. ROSEN, in response to questions, relayed that she has been
in practice for less than a year, and that on average, she has
to refer people out for prescription medication one to two times
per week - usually for some type of antibiotic.
[Representative Samuels returned the gavel to Chair McGuire.]
REPRESENTATIVE WILSON asked for a description of the surgical
training naturopathic physicians receive.
Number 1918
DR. LUPER replied:
We have two courses in minor surgery, ... and in those
courses we learn the various techniques involved in
minor surgery. We learn sterile technique, we learn
to do anesthesia appropriately - with epinephrine,
without epinephrine - so on and so forth, those kinds
of things. And then at the end of those two courses,
we go into the clinic with a list of check-offs,
things that we need to: we need to sew up a
laceration, we need to remove a mole, we need to
remove a sebaceous cyst, ... we need to lance an
infection - a boil, ... abscess, and those kinds of
things.
There's check-offs - and several of them - and what we
do is we look hard for those things as they come in
the door, and enthusiastically jump on the people who
have those and practice with them; of course, it's a
teaching clinic. ... We practice those things; then,
at the end of that process, we take a test. ... One of
the tests in the national board exam is on minor
surgery. And if you can pass the courses [and] you
can do the procedure successfully - under supervision
- and then finally pass the ... national board exam,
then you get the right to do minor surgery in states
that allow you to do minor surgery.
REPRESENTATIVE WILSON asked how many procedures must be done, at
a minimum, for each item on the check-off list.
DR. LUPER replied:
I can't answer ... for all the schools, I only can
answer it for the one school that I went through. And
I do want to say, too, that not all the schools
actually practice minor surgery; some of those schools
are located in states that don't allow minor surgery.
So [with regard to] those states that don't allow
minor surgery, ... the students that graduate from
[the schools in] those states would not be able to
perform minor surgery here in Alaska without getting
additional training. Now, that's the kind of stuff
that goes into regulations and not into [statutory]
law, and that'll be addressed in those regulations.
Number 1832
[In speaking] for myself, though, what I ended up
having to do [was] three sebaceous cysts, one lipoma,
any number of lacerations - I couldn't count how many
lacerations, ten, maybe - and then ten moles as well.
Boy, I was scrambling for those moles; I traded moles,
I've lost moles, myself, trading back and forth with
people - ... we had to work hard to get that number of
them. But at the end of that I certainly felt
competent in doing minor surgery. In fact, it turns
out that I had some skill at it - I was pretty good at
it - and went on to write questions for the national
board exam. ...
CHAIR McGUIRE said she wants to see naturopathic physicians and
allopathic physicians working together, and noted that this is
already happening to some degree, both in Alaska and nationally.
A concern, however, is how the surgical provisions of the bill
will interplay with various licensing requirements as they
pertain to allopathic physicians.
DR. LUPER indicated that that aspect has not yet been
researched. He added:
I'm not overambitious with minor surgery; ... if it's
simple and straightforward, I'm going to do it, [but]
if it is at all complicated - and I can speak, really,
for my whole profession - we're going to refer to the
people who do it best, as we do now. ... Stuff that
we're not qualified [to do], or not experienced enough
to be able to treat, ... we're very quick to refer.
That's ... one of the major tenets of naturopathic
medicine, is ... to first do no harm; ... that's the
last thing I want to do, is send somebody with a
botched minor surgery to the emergency room. Heaven
forbid! So I'll [be] very quick to refer those. And
Dr. Rosen, we had this discussion yesterday, she
agrees - the same thing.
REPRESENTATIVE WILSON asked about the training that naturopathic
physicians receive with regard to internal medicine.
Number 1641
DR. LUPER relayed that naturopathic physicians take courses in
anatomy, physiology, biochemistry, histology, embryology and
many other courses. They learn a lot of vocabulary and concepts
about how the human body works, and pathology - how things go
wrong. "Basically, we learn the same things that M.D.s and
D.O.s learn at the same degree of intensity ... for those first
two years," he added. He emphasized that students learn to
recognize illness in a class called "clinical physical
diagnosis," which enables a naturopathic physician to interview
a patient, get past medical history - family history, habits,
review of systems - do a physical exam, and run appropriate lab
tests to come up with a diagnosis. He remarked that this aspect
[of training] is quite strong in naturopathic medicine.
DR. LUPER explained that after learning these various aspects of
medicine, naturopathic physicians must pass a "clinic entrance
exam" in order to be able to work in a clinical setting;
naturopathic physicians can't get into the clinic unless they
can show that they have a basic level of skill at doing the
interview, doing the physical exam, identifying the appropriate
lab tests, and then coming up with the correct diagnosis.
CHAIR McGUIRE surmised, then, that this applies to all CNME
accredited schools.
REPRESENTATIVE WILSON asked whether the four years at a CNME
accredited college would qualify a person for [allopathic]
medical school.
DR. LUPER replied:
No, it would not because the medical schools don't
recognize the education. Likewise, we wanted to take
the national medical boards and we were told we
couldn't. That's why we came up with the national
naturopathic medical boards, is because we were not
allowed to take the national medical boards. I wish
we could. I think it would answer a lot of questions.
Number 1477
DR. LUPER, in response to another question, reiterated that the
course work naturopathic physicians take doesn't count. He
added:
The education is just thrown out wholesale. If you
want to become an M.D., you have to start from the
beginning. There's no reciprocity at all to my
knowledge. ... The real difference between the ...
three professions [N.D., M.D., D.O.] ... is in the
second two years. In the second two years, what we're
taught are natural methods of treating illness; we're
taught how to use herbs, nutrients, diet, physical
therapy. We're also taught how to use drugs
appropriately in certain situations, but given the
choice between using a drug and using a natural
substance and having the natural substance work, we'll
go for ... [the natural substance] first.
It's in our nature in terms of our hierarchy of
therapeutics to use something that will restore normal
function in somebody as best we can. And there [are]
differences; ... clearly there's a difference in
philosophy, there's a difference in approach. There's
certain ways of thinking about illness that we're
imbibed with as a culture that's different from M.D.s,
and it should be that way - there's some people that
resonate more with natural medicine and there's some
people that resonate more or get better results with
allopathic medicine. And part of our job is to
recognize [that] and to refer our patients to where
they're going to get their [best] care.
DR. LUPER, in response to a comment, remarked that there is much
more in common between N.D.s and M.D.s than there are
differences.
CHAIR McGUIRE relayed that she thinks naturopathic medicine has
a big role to play, and that she has two childhood friends that
are N.D.s. She said that according to her understanding, the
mission of a naturopathic physician is to try to treat patients
holistically, to try to look at alternatives to chemicals,
drugs, and invasive methods of treatment. Many times when one
goes to an allopathic physician, she ventured, dietary and
nutritional aspects are overlooked. One of the issues to
contemplate is where do the two different philosophies/methods
appropriately cross and where do they appropriately stay
separate. She said she is trying to understand why they would
want to move towards granting prescriptive chemical authority,
minor surgery, and other types of things that are associated
with allopathic medicine, to naturopathic physicians. Why
shouldn't the focus of naturopathic physicians remain on
naturopathic methods? Where is this push coming from?
Number 1270
DR. LUPER said the push is coming from his patients. So
although naturopathic physicians are trained to look at a
patient from a naturopathic perspective, from a holistic
perspective, sometimes the patient just needs antibiotics. He
offered an example of a patient with a kidney infection who came
to him while he was practicing in Arizona; in addition to
discussing holistic ways of keeping one's kidneys healthy he was
able to write prescription for that condition, and the patient
improved. But practicing in Alaska, if faced with a similar
case, he would have to refer the patient elsewhere. The same
would occur if he saw a patient who needed thyroid medication -
while practicing in Alaska, he would have to refer that patient
elsewhere. Although the number of cases may not be great, he
relayed, there are just enough that he feels he's got one hand
tied behind his back; "I took the classes, I passed the national
board exam, and I still can't ... [treat the patient].
CHAIR McGUIRE, mentioning a concern that someone might suffer
serious consequences as a result of an N.D. not getting a
diagnosis right and prescribing the wrong medication, asked what
the harm is in having to refer a patient to someone else if
holistic measures are not sufficient.
DR. ROSEN explained that a naturopathic physician's training is
to provide ambulatory family care; therefore, N.D.s will be
using the same diagnostic skills in determining whether it is
appropriate to refer a patient elsewhere that any other family
doctor - whether an M.D. or a D.O. - would use. The bottom
line, she said, is that if a procedure is not appropriate for
outpatient care, naturopathic physicians won't be performing it.
In response to further questions, Dr. Rosen echoed Dr. Luper's
comments regarding surgical training and what might be required
[via statute and regulations] to ensure that a naturopathic
physician has the appropriate training, and mentioned that
students graduating from CNME accredited schools are required to
have had 2,000-plus hours of clinical experience under
supervising physicians, as well as other experience in either
hospitals or similar clinical situations.
Number 0875
DR. LUPER added:
What's happening across the country is [that] M.D.s
and N.D.s are working together more and more, that the
profession is maturing, and that we're getting
friends, frankly, colleagues that we're working with.
And in Arizona, the students now do [an observatory]
rotation through Banner Health emergency rooms, so
that they get to see ... a wider variety of health ...
conditions. And as time goes on, it's my hope and my
... [belief] that it's going to happen more - we're
simply going to see more of this cooperation, more of
this working together.
REPRESENTATIVE GRUENBERG, noting that he is a fan of continuing
education, asked why the continuing education provision of the
bill doesn't take effect until January 1, 2007.
DR. LUPER said it might be because continuing education
requirements are going to be "reported for two-year blocks." In
response to another question, he indicated that he would support
changing the effective date of that provision to January 1,
2006. He noted that currently, there is no statutory
requirement, at all, for continuing education of naturopathic
physicians.
Number 0700
ALEX MALTER, M.D., President, Alaska State Medical Association
(ASMA), remarked that according to allopathic teachings, kidney
infections, as was offered as an example by Dr. Luper, are
classified as complicated, and it is during the five-plus years
of clinical education that M.D.s experience as interns and
residents that they learn that kidney infections are never
considered simple. He then paraphrased from his written
testimony, which read in part [original punctuation provided]:
The Alaska State Medical Association (ASMA) represents
physicians statewide and is primarily works to ensure
that Alaskans receive high quality healthcare. ASMA
urges the committee to not support SB 306. The
legislation would not enhance patient care nor would
it improve access to care.
Training for naturopaths is less rigorous than that
for medical doctors, in both length and depth of
study. Its emphasis on natural healing does not allow
students sufficient time to fully learn the in depth
pathology, physiology and pharmacology needed to treat
most medical conditions. A list complied by the
American Association of Naturopaths (Attachment 1)
shows the different treatment modalities studied by
naturopaths. Such a broad curriculum cannot allow the
time needed to master the appropriate use of
prescription drugs.
We are not convinced that the first two years of
naturopath and medical schools are the same. But for
any courses that actually did cover material in the
same detail, medical students might still be expected
to master the content better than naturopaths. This
is because students are only admitted to medical
school if they've excelled in sciences as
undergraduates and then passed rigorous entrance
exams.
By comparison, we are not aware of similar admission
tests for naturopath schools and some don't even
require a college degree for enrollment. (While the
naturopath doctors have argued this isn't true for
programs accredited for the Alaskan licensure, the
HHES committee heard testimony two days ago of a
Bastyr student without a prior college degree enrolled
in a ND program.)
REPRESENTATIVE GARA interjected to point out that one either is
or isn't required to complete four years of college education
before entering a naturopathic program at an accredited school,
and so simply hearing testimony that someone heard from someone
else that someone got into a naturopathic program at an
accredited school without first completing four years of college
education isn't helpful.
Number 0387
DON LEHMAN, M.D., acknowledged that he was the one who had
provided the House Health, Education and Social Services
Standing Committee with the aforementioned testimony, and that
it pertained to his nephew who, he relayed, was accepted in the
naturopathic program as a first-year student at Bastyr
University even though he didn't have a four year degree.
REPRESENTATIVE GRUENBERG suggested that they do some research to
find out whether Bastyr University offers a special program for
exceptional students, one that might allow a few persons to
start in the naturopathic program while still shy of a four-year
degree. He also suggested that they could amend the bill such
that it would require a four-year degree in addition to the
educational requirements already listed in the bill.
Number 0189
DAVID M. HEAD, M.D., Chair, Alaska State Medical Board (ASMB),
predicted that if Alaska becomes one of the few states that
grants prescriptive rights to naturopaths, it will open the
floodgates for an onslaught of naturopathic physicians and
providers all over the country that will be looking for a place
to widen their scope of work far beyond their level of training.
He went on to say:
I have absolutely nothing against naturopaths; I have
consulted them myself regarding nutritional subjects,
regarding my own health, and I think, when it comes to
their own scope of work, that naturopaths can
definitely add something to the healthcare and to the
management of patients. And it's also not [an] issue
of a turf battle. As a provider in Nome, Alaska, I
would welcome the help from any qualified provider
that I could get. But, in my opinion and the opinion
of the [ASMB], naturopaths are not qualified ... to
provide the type of primary care when it comes to
prescribing medication and doing the type of minor
surgery that is described here.
Neither their training nor their philosophy, the
philosophy of their training, meets the standard of
care that ... the Alaska public has come to expect and
... deserve. I'd like to have the members of the
committee ... ask themselves if they want someone
who's just received [pharmacological] training from a
book or from a [CNME] course changing their heart
medications or their hypertensive medications, or
suturing up their son's face [the] next time he comes
to the [emergency room after having some misfortunate
accident.] [The previously bracketed portion was not
on tape, but was taken from the Gavel to Gavel
recording on the Internet.]
TAPE 04-83, SIDE A
Number 0001
DR. HEAD, referring to Dr. Luper's example of a patient with a
kidney infection, offered his opinion that there are no
uncomplicated cases from the viewpoint of the patient; "very few
patients don't consider it an emergency when it is taking place
on their body." He went on to say, "There are many things that
a, quote, 'uncomplicated kidney infection' could actually be,
and its medicine, unfortunately, is not black and white, it's
not well tested on national board exams, and that's where the
fear comes that this may be an area that the public of Alaska
should not be exposed to." He relayed that the ASMB feels that
it would be irresponsible and unconscionable to pass the bill,
that doing so would create a serious threat to the health and
wellbeing of Alaskans; the ASMB strongly recommends a vote of
"No."
REPRESENTATIVE OGG asked whether the ASMB has passed a
resolution outlining its opinion of the bill.
DR. HEAD said the ASMB did not pass a resolution, though it did
send a letter to the governor relaying its opinion of the bill.
REPRESENTATIVE GRUENBERG, referring to Dr. Head's hypothetical
example of a child coming in with a laceration on his/her face,
offered his belief that the bill specifies that minor surgery
can include treating superficial lacerations but does not
include performing specialized surgery such as plastic surgery.
He asked how one would tell whether a laceration fell within the
realm of needing plastic surgery.
DR. HEAD said that such a determination would be hard to make
and would be dependant upon the eye of the beholder and his/her
experience with similar lacerations. So much of what is in the
bill is open to interpretation, he remarked, that he feels it
would be premature to pass it. He suggested that the bill needs
to have more work done on it.
Number 0321
CHAIR McGUIRE noted that members' packets now include the ASMB's
letter to the governor. Addressing Dr. Head, she said:
What do you feel is the appropriate way, over the
interim, ... to have these discussions? Do you feel
like there should be a task force? Do you feel like
you ought to select some folks from the [ASMB] and the
naturopaths ought to select some folks from their
board to begin these dialogs? Because I think what
you have seen this session is a wakeup call that there
[are] folks across the state of Alaska that see
naturopathic physicians, that have a concern about
this bill passing.
And we are just mere policy makers [and] there are
arguments on both sides. But one thing that I think
has become clear is that there does need to be some
communication between the M.D.s and the N.D.s with
respect to these protocols, ... the differences in
defining serious or ... superficial laceration versus
a no-superficial [laceration], how could these
collaborative agreements be worked out, and so on. Do
you have any recommendation or ideas that you would be
willing to make?
DR. HEAD replied:
The [ASMB] is always open to any type of
communication. We've had a similar issue going on
with the Board of Pharmacy recently, and we have
actually met with the Board of Pharmacy, we've invited
them to our meetings, and ... we've sent [a]
representative to their meetings. And, like I said
during my statement, I definitely think naturopaths
have a place in the medical care of the patients of
Alaska, and I would be more than happy to meet with
them or to have members of the [ASMB] meet with them
and work the details out, work something out that was
agreeable to us and to them if at all possible. I
think [the] more communication that goes on in the
health field, the better off we are, because I
definitely think that there is a place [for
naturopathic medicine]. I just don't think that this
bill necessarily addresses it.
Number 0457
CHAIR McGUIRE said she wants Dr. Head's ideas about the two
groups working together in writing as soon as possible, perhaps
by tomorrow, including his thoughts about whether there should
be a governmental vehicle to highlight the issues. She
mentioned that she would be asking the same of the naturopathic
physicians who've come to today's meeting. She indicated that
what she would like to see in writing are: "what would be your
expectations, what would be the things that you would hope to
get out of such a working relationship, and whether or not you
believe it takes us to force that issue." It's really easy for
both sides to say, "Well, our doors are open," but then no one
makes an effort to knock on the door and so nothing is ever
accomplished, she remarked.
DR. HEAD said he could not commit the ASMB to such an
enterprise, though he knows the ASMB would be open to
communication. He added that although he could provide
suggestions in writing, it wouldn't be by tomorrow because he
would have to consult with the rest of the ASMB first.
REPRESENTATIVE GRUENBERG, acknowledging that there are probably
those who feel that the bill could still use some more work,
suggested that with only two days left before the end of
session, that it might be better to work on a compromise
solution over the interim in order to allow for thoughtful
legislative drafting. For example, perhaps including a
provision in the bill to form an interim committee, made up of
representatives from the interested professions, that with the
assistance and guidance of the legislature, would take the
language in the bill as a starting point and fine tune it so
that all interested parties are satisfied, and report back to
the legislature early in the upcoming legislative session,
perhaps by February 1, 2005. Such an endeavor might result in
the interested parties arriving at a consensus. He went on to
say:
You people are used to solving problems, problems that
save people's lives; surely you ought to be able to
solve this problem with some help from your friends.
And we in the legislature are used to solving problems
too. And with a little bit of time, what do you folks
think? Would that be worth doing?
DR. MALTER relayed that the ASMA made a similar suggestion when
testifying in the House Health, Education and Social
Services Standing Committee. He said he committed the ASMA
to work on this [legislation] over the interim.
Number 0775
CHAIR McGUIRE characterized the current version of the bill as
creating a profound change in state policy and law. She noted
that although 14 other states are doing something similar to
what the bill proposes, the details all vary. She also noted
that the latest version of HB 434, Version W, failed to be
reported from the House Health, Education and Social Services
Standing Committee. On the issue of [perhaps forming an interim
working group], she said, "I don't want this to be promises that
never come through and ... some way of pushing away the issue
and never coming back to it for the folks that oppose [the
bill], because this is a serious issue that's going to keep
coming up ... until we address it."
REPRESENTATIVE WILSON added:
I don't want the naturopaths to think that this is
just something that we're brushing aside and then we
can let go [of it], because ... we do want something
to happen. And I put that charge to the M.D.s because
we do want to see some honest effort put forth to try
to ... make some progress here, ... and we're very
serious about this.
REPRESENTATIVE GRUENBERG suggested that an interim working group
could meet under the auspices of both committees jointly.
REPRESENTATIVE GARA offered:
I do have one reservation about this whole approach.
... If we think that the two professions are going to
get together and come up with something that they can
agree upon, we have to recognize they take two
completely different approaches to the practice of
medicine. ... Naturopaths are naturopaths because they
believe in that kind of health care; M.D.s are M.D.s
because they believe in that kind of health care.
There's a certain portion of their ethic that is
inconsistent, that causes them to join the profession
that they join. ... It might work out very well that
they can come up with a very good piece of legislation
that they all agree upon, but that shouldn't be a
requirement. Ultimately, ... in many of the pieces of
legislation we work upon, there are interest groups
that have completely different views on them, and we
can't expect that everybody can always come to an
agreement that everybody is happy with.
Number 1017
So, ... the task force idea is good, but ultimately I
don't think we should assume that ... both parties
will agree to the best piece of policy. One party
might and one party might not, so we have to recognize
that. And I hope we can come up with a good piece of
legislation. If we think that it's good, or the task
force thinks it's good, even if one party doesn't ...,
that's ultimately our job when interest groups can't
agree with each other.
REPRESENTATIVE GRUENBERG concurred, adding that via a task force
approach, the legislature can't make people agree - it can only
help by providing a little mediation. "We're here to help, and
if you are at a total impasse, ... we'll make the decision and
maybe neither one of you will be happy, but at least let's take
it as far as it can go," he added.
CHAIR McGUIRE mentioned that the committee must recess for the
purpose of allowing members to attend a caucus meeting and then
a House floor session. She asked the interested parties to
consider the committee's thoughts regarding an interim task
force and present something in writing, if possible, to the
committee as soon as possible. She said that as chair of the
House Judiciary Standing Committee, she would support a bill
that will direct a task force to form and work on the issues
raised, perhaps with legislators present; the membership of the
task force could be made up of members of the legislature,
members of the allopathic medical profession, members of the
naturopathic medical profession, members of the pharmacological
profession, and members of any group as yet unknown to the
committee with an interest in the legislation. She noted that
members have heard concerns from pharmacists regarding the
potential liability that could result from passage of the bill
in its current form. She reiterated that she would like
suggestions from the interested parties in writing, and relayed
that [the committee] would try to synthesize something that will
give all parties some direction over the interim.
DR. MALTER surmised, then, that the bill would become a vehicle
creating an interim task force that would work on the issues
raised.
CHAIR McGUIRE concurred, and indicated that aspects listed in
both the House and Senate versions of the bill would be used as
a starting point for negotiations.
[SB 306 was held over.]
ADJOURNMENT
Number 1258
The House Judiciary Standing Committee meeting was recessed at
5:33 p.m. [The meeting was reconvened May 10, 2004.]
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