Legislature(2001 - 2002)
02/22/2002 03:30 PM House L&C
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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 LABOR AND COMMERCE STANDING COMMITTEE
February 22, 2002
3:30 p.m.
MEMBERS PRESENT
Representative Lisa Murkowski, Chair
Representative Kevin Meyer
Representative Pete Kott
Representative Norman Rokeberg
Representative Harry Crawford
MEMBERS ABSENT
Representative Andrew Halcro, Vice Chair
Representative Joe Hayes
COMMITTEE CALENDAR
HOUSE BILL NO. 215
"An Act relating to the use of pharmaceutical agents in the
practice of optometry; and providing for an effective date."
- HEARD AND HELD
PREVIOUS ACTION
BILL: HB 215
SHORT TITLE:OPTOMETRISTS AND PHARMACEUTICALS
SPONSOR(S): LABOR & COMMERCE BY REQUEST
Jrn-Date Jrn-Page Action
03/26/01 0730 (H) READ THE FIRST TIME -
REFERRALS
03/26/01 0730 (H) HES, L&C
04/24/01 (H) HES AT 3:00 PM CAPITOL 106
04/24/01 (H) Moved Out of Committee
04/24/01 (H) MINUTE(HES)
04/25/01 1197 (H) HES RPT 3DNP 4NR
04/25/01 1197 (H) DNP: COGHILL, WILSON, CISSNA;
04/25/01 1197 (H) NR: KOHRING, JOULE, STEVENS,
DYSON
04/25/01 1197 (H) FN1: ZERO(CED)
02/22/02 (H) L&C AT 3:15 PM CAPITOL 17
WITNESS REGISTER
AMY ERICKSON, Staff
to Representative Lisa Murkowski
Alaska State Legislature
Capitol Building, Room 408
Juneau, Alaska 99801
POSITION STATEMENT: Presented HB 215 on behalf of the House
Labor and Commerce Standing Committee, sponsor.
JEFF GONNASON, O.D.;
Chair, Alaska Optometric Association Legislative Committee
2211 East Northern Lights Boulevard
Anchorage, Alaska 99508
POSITION STATEMENT: Testified in support of HB 215.
ROBERT A. BREFFEILH, M.D.
9590 Whitewater Court
Juneau, Alaska
POSITION STATEMENT: Testified as a licensed ophthalmologist.
JILL GEERING, O.D.
PO Box 240227
Douglas, Alaska 99824
POSITION STATEMENT: Testified on HB 215.
DAVID KATZEEK, Alaska Native Brotherhood Camp 2
6590 Glacier Highway, Number 179
Juneau, Alaska
POSITION STATEMENT: Testfied in opposition to HB 215.
CATHERINE REARDON, Director
Division of Occupational Licensing
Department of Community & Economic Development
PO Box 110806
Juneau, Alaska 99811-0806
POSITION STATEMENT: Answered questions related to HB 215.
GORDON PREECS, M.D.
3268 Hospital Drive
Juneau, Alaska
POSITION STATEMENT: Testified as a licensed ophthalmologist.
LINDA CASSER, O.D.;
President, National Board of Examiners in Optometry
Associate Dean for Programs, Pacific University of Optometry;
(No address provided)
Forest Grove, Oregon
POSITION STATEMENT: Testified in support of HB 215.
CARL ROSEN, [M.D.]; President
Alaska Ophthalmologic Society
(No address provided)
POSITION STATEMENT: Testified as an ophthalmologist.
DENISE THANEPOHN, O.D.
(No address provided)
POSITION STATEMENT: Testified in support of HB 215.
OLIVER KORSHIN, M.D.
(No address provided)
POSITION STATEMENT: Testified as an ophthalmologist in
opposition to HB 215.
JIM SWARTLEY, M.D.;
Member, American Academy of Ophthalmology State Affairs
Committee
(No address provided)
POSITION STATEMENT: Testified as an ophthalmologist.
ACTION NARRATIVE
TAPE 02-22, SIDE A
Number 001
CHAIR LISA MURKOWSKI called the House Labor and Commerce
Standing Committee meeting to order at 3:30 p.m.
Representatives Murkowski, Meyer, Kott, and Crawford were
present at the call to order. Representative Rokeberg arrived
as the meeting was in progress.
HB 215-OPTOMETRISTS AND PHARMACEUTICALS
Number 012
CHAIR MURKOWSKI announced that the only item on the agenda is
HOUSE BILL NO. 215, "An Act relating to the use of
pharmaceutical agents in the practice of optometry; and
providing for an effective date."
Number 024
AMY ERICKSON, Staff to Representative Lisa Murkowski, Alaska
State Legislature, presented HB 215 to the committee. She said
that HB 215 was introduced at the request of the Alaska
Optometric Physicians Association and would authorize
optometrists to prescribe medications to treat allergy
conditions, infections of the eye and eyelids, glaucoma, and eye
abrasions and allergies. Thirty-eight states already allow
optometrists to prescribe [the aforementioned medications]. She
stated that optometrists have extensive training and are
required to complete a pre-professional undergraduate program
followed by four additional years of professional education at a
college of optometry, which would earn them a doctorate in
optometry. Then an optometrist has to pass a national board
exam. She pointed out that an optometrist's education and
training requirements in many areas match or exceed that of
other health care providers who are currently able to prescribe
oral medications to their patients. She noted that the training
of physician assistants, advanced nurse practitioners, and
dentists mirrors that of optometrists.
MS. ERICKSON said that in many cases optometrists are the only
eye care practitioners available in outlaying communities;
having the ability to prescribe would give optometrists the
ability to provide optimum care for their patients and allow
them to practice to the fullest extent of their education.
Currently, all 50 states authorize optometrists to prescribe,
and 38 states and Washington, D.C., allow [optometrists to
prescribe] oral or systemic drugs. In those 38 states there
have been no reported cases of harm. Only 12 states restrict
prescriptive privilege to topical drugs only. She mentioned
that there is a proposed committee substitute (CS), Version L.
Number 067
REPRESENTATIVE KOTT moved that the committee adopt CS for HB
215, Version 22-LS0538\L, Lauterbach, 1/31/02, as the working
document. There being no objection, Version L was before the
committee.
Number 082
JEFF GONNASON, O.D.; Chair, Alaska Optometric Association
Legislative Committee, testified on HB 215. He noted that he
has been a licensed optometrist in Alaska since 1976, and was
Past Chair of the Alaska State Optometry Board. He noted that
he had provided the committee with his written testimony. He
testified as follows:
The education and training of optometrists in
pharmacology and clinical medicine, the eye, since
about 1969 has been on a par with medical and dental
schools with a bachelor's degree and then followed by
four years of professional school for a doctors
degree. Optometry education includes extensive
clinical training in treating eye diseases.
It has taken 30 years for all 50 states to finally
authorize optometry to prescribe therapeutic drugs.
Thirty-eight of the states go beyond the topical
restrictions that Alaska has, so [HB 215] is not new
ground. Alaska currently has a shortage of
optometrists, as many are unwilling to practice here
because of outdated statutes. The State of Washington
has basically the same [type of legislation] in the
hopper as we speak. They're on a 60-day short cycle,
so we'll know how they do within the next month-and-a-
half. I might point out that the states that don't
have this, like Mississippi, Florida, and Michigan,
have almost as many ophthalmologists as optometrists.
In fact, New York State has more ophthalmologists
[than optometrists]; they tend to congregate in urban
areas. In Alaska, we have approximately 90-some
optometrists and about 22 ophthalmologists.
Optometrists are scattered pretty much over the state,
and the ophthalmologists are basically all in
Anchorage, except three in Fairbanks, two in Juneau,
and a couple in the Kenai Peninsula.
DR. GONNASON said that many Alaskans, particularly in the rural
areas, currently rely on the local optometrists to treat their
eye disease, and are referred to specialists when necessary. He
stated that the current regulations that have been in place for
ten years require demonstrated education and competence, and
only those drugs that treat the eye are authorized. He said,
"Our state law defines optometry as diagnosis and treatment of
the eyes", yet the tools are restricted for no valid reason. My
Tlingit-Haida traditional cures are unfortunately not the most
effective for the eyes, he said.
DR. GONNASON continued:
Optometrists are considered physicians under federal
Medicare law, as are dentists and podiatrists, who
also prescribe similar drugs but are not "M.D.s".
Optometrists have far more education and training in
the treatment of eye diseases than taught in medical
school, just as dentists are taught more about tooth
disease. We are "primary care" eye doctors. We treat
many eye diseases. However, we often refer the
patients to the surgical or the specialist
ophthalmologists when a patient requires such advanced
care, just as family doctors refer to a specialist
like a cardiologist or a neurologist, for example. We
would never claim to be at the level of the
ophthalmology specialists, we respect them and we need
their expertise, but qualified optometrists should be
allowed to practice at the full level of their
training.
Number 147
DR. GONNASON stated:
In 1988, Alaska was 49 out of 50 states to enact a
statute to allow optometrists to use diagnostic drugs.
And then in 1992 we became state number 32 as this
legislature, ten years ago, authorized us to prescribe
therapeutic prescription drugs, but the bill ... [was]
compromised so that we could only prescribe topical
drugs. The two most recent state audits of optometry
report improved access to eye care and there have been
no reports of any harm in these past ten years through
the board. A major malpractice insurance carrier in
the nation states that they have found no difference
in claims between states with various levels of drug
authority. And the rates are extremely low at about
$400 per year for $2 million in coverage. Optometry
has a great track record, and no states have ever
repealed any of the many drug expansion laws.
Four years ago in the '97-'98 [legislative] session,
we had a hearing on a new bill that would expand the
scope of optometry to not only include the rest of our
needed drugs, but to also allow the use of lasers and
additional surgery by qualified optometrists, as is
now being taught in the school. Currently, we're
limited to a minor surgical procedure where we remove
embedded foreign bodies, like pieces of metal in the
eye. One state, Oklahoma, currently, has for four or
five years authorized laser surgery by optometrists.
Now our bill in the legislature here was opposed by
the ophthalmologists, but we heard they wouldn't
object if lasers and surgery were removed. So two
years ago in the '99-'00 session, we removed the
lasers and additional surgery from the bill; identical
to the Tennessee bill and that became the famous SB 78
from two years ago. I have a memo from the state of
Tennessee stating the fact that since their origin in
1987, 14-15 years ago, they've never had any
litigation against an optometrist and no discipline
action for misuse of medication. So they have a clean
track record, Tennessee. The medical board was
opposed after the legislature adjourned in May of
2000. The governor vetoed SB 78; he cited the medical
board's opposition. The medical board was opposed
after hearing from ophthalmology, but without hearing
from optometry.
Number 189
DR. GONNASON stated:
[House Bill 215] has been redrafted from the vetoed
bill ... [and] incorporated two changes to answer the
concerns of the governor and medical board. Change
one was that a section was put in for board authority
for limiting drugs so that there is no grand
fathering. The board has the authority to limit
certain medications that certain doctors might
prescribe to give the board more control there to
require more education and to ensure competence. The
second thing it changed was it prohibited injections
into the eye globe because someone had commented that
they thought we might do that, and I can assure you
that no optometrist injects the globe.
The governor asked the medical board to meet with the
optometry board, which they did. And they've had a
formal meeting and they had discussions. So after
this recent meeting and discussions between the
medical and optometry boards a committee substitute
bill has been drafted and incorporates several more
changes that were suggested to try to gain support
from the medical board and the governor, which is the
CS before you.
Number 203
DR. GONNASON continued:
The four additional changes are, one, there is a more
precise definition of the scope of treatment for
ocular tissues only. The former bill said "related to
the eye" and some of the doctors thought that because
we diagnose diabetes we would then treat diabetes, and
that isn't the case, so this specifically states that
we can just treat eye tissues only. Secondly, there's
a restriction that there's no more than a 7-day supply
of analgesic drugs (schedule II-V, which is the same
as nurse practitioners and physician assistants have).
Third, systemic drugs are limited to six specific
categories plus over-the-counter, and there is well
over 100 categories of drugs, maybe 150, and we've
limited it to just six that optometry uses. And
fourth, there's a mandatory course and passing an
examination in systemic drug administration from an
accredited college of optometry, approved by the
board.
DR. GONNASON said:
I personally do not agree that more restrictions are
needed, but they are compromises to try to make the
medical board and everyone else involved more
comfortable. In Alaska, in addition to dentists and
podiatrists, [and] advanced nurse practitioners (ANP),
who have with less years of training at the masters
degree level than optometrists do, can prescribe
almost any drugs unsupervised for the entire body, as
determined independently by the nursing board.
Optometry really should have this same statute. There
are no outcries of public harm or "non-M.D.s"
practicing medicine, as these fine nurse practitioners
offer excellent care for Alaskans. The same with the
dentists. A practitioner of any type does not need a
license authority to harm patients, but does need it
to properly treat patients.
Number 232
REPRESENTATIVE MEYER asked Dr. Gonnason if optometrists are
common in rural Alaska. He asked, for example, if there would
be an optometrist in Bethel.
DR. GONNASON replied, "Yes." He said that there are two or
three optometrists in Bethel, two in Nome, one in Kotzebue, two
in Kodiak, one in Glennallen, and one in Sitka; they're
basically in around 22 different communities. He offered that
it is often difficult to get recent graduates to come to Alaska
because they can't practice at the full level of their training.
He noted that the Indian Health Service also has a few
optometrists that are stationed at Indian Health Hospitals.
Number 248
REPRESENTATIVE MEYER asked if it is safe to say that there are
optometrists in cities, towns, and villages of 1,000 people or
more.
DR. GONNASON answered, "Absolutely."
REPRESENTATIVE MEYER asked if currently an optometrist would
have to send a patient to Anchorage or Fairbanks [to visit an
ophthalmologist].
DR. GONNASON said, for example, in Nome the optometrist is on
call and if someone has a sore eye in the middle of the night
the optometrist would be called in to examine the patient. If
the optometrist, using his/her professional judgment, is
comfortable handling the situation, then the patient would
receive treatment from the optometrist. If the case is out of
the optometrist's scope then he/she would call the Native
Medical Center and talk to an ophthalmologist to make a decision
whether or not to fly the patient in for treatment. If the
optometrist at the Indian Health Service needs to prescribe an
oral antibiotic for infection then a physician assistant needs
to write the prescription.
REPRESENTATIVE MEYER inquired as to the differences in education
between a physician assistant and an optometrist.
DR. GONNASON described that there are different levels of
physician assistants, and range from 2-5 years of education. A
nurse practitioner's education, at the masters degree level,
ranges from 5-7 years, and an optometrist's education ranges
from 7-9 years at the doctorate level. He said that he believes
for one to become a physician assistant that one must attain a
bachelors degree. He mentioned that often times through
emergency medical and clinical training one can become a
physician assistant.
Number 272
REPRESENTATIVE KOTT said that it seems to him that this
particular issue has been recirculating for about ten years. He
said, "If my memory serves me correct, the bill passed fairly
unanimously in both the House and the Senate."
DR. GONNASON said, "37:2 House, and 18 to nothing Senate."
REPRESENTATIVE KOTT stated that there were only two opposition
votes out of 60 [legislators] and then it was sent to the
governor, who vetoed it. He asked what the governor's position
was when he vetoed that piece of legislation.
DR. GONNASON pointed out that no one testified orally against
the bill in two years of hearings. He said that the governor
asked the Alaska State Medical Board (ASMB) for its opinion and
the medical board had a meeting with an ophthalmologist from
Seattle and an ophthalmologist from Fairbanks. He said that the
two ophthalmologists told the "medical board what they thought
about optometry, which we all know what they said." The medical
board reported to the governor that it was unanimously opposed
to the bill because of concerns with the possibility of an
optometrist using needles on patient's eyes. A second concern
that the governor expressed was the level of training and
whether new training would be required. Dr. Gonnason mentioned
that although the governor said he'd be happy to work with
optometry to come up with something, a discussion has not taken
place yet. "I've made six major changes to try to assuage the
governor to sign this legislation," he said.
Number 310
REPRESENTATIVE KOTT recalled that the veto letter "hammered" on
the legislature for not seeking the opinion of the ASMB.
However, the sponsor of the previous legislation on this issue
has indicated that the medical board was approached [for an
opinion]. "The medical board basically said 'no' we're not
responding to the legislature, but if the governor asks us we'll
respond to the governor," explained. Representative Kott asked
whether ASMB's opinion has been sought, or have substantive
changes been made to this piece of legislation such that the
medical board isn't concerned anymore.
CHAIR MURKOWSKI informed the committee that the committee packet
includes a letter from the Alaska State Medical Association
(ASMA) in opposition to HB 215. The letter relates that ASMA
doesn't believe that HB 215 is good medicine. Chair Murkowski
inquired as to the status with the medical board.
DR. GONNASON related his belief that the ASMB hasn't seen
Version L. He explained that ASMB and the Board of Optometry
[took testimony] and the general discussion indicated that if
there were categories of drugs and more restrictions, the board
would be more comfortable. [The ASMB] felt that the legislation
was broad and didn't require more education and thus the changes
[incorporated in Version L] address those concerns.
Furthermore, the Board of Optometry has had further discussions
with ASMB during which the notion of a subcommittee was
mentioned. Meanwhile, Version L has been developed and is
moving through the process. The ASMB hasn't yet responded to
the CS. Dr. Gonnason pointed out that no state medical boards
will support the optometrists, the nurses, or anyone who isn't a
medical doctor. He characterized it as a turf issue.
Furthermore, the American Medical Association (AMA) recently
passed a resolution in opposition to any scope of practice
enhancement by any profession in any state. Dr. Gonnason
informed the committee that ASMB asked all 50 state medical
boards whether they have had problems with their optometrists.
Quite a few responded and not one had any trouble with their
optometry association or their optometrists' prescription of
medications. Dr. Gonnason highlighted that ASMB has nothing to
do with the Board of Dentistry or the Board of Optometry; it was
a mistake to ask their opinion, which is always going to be in
opposition. He didn't believe there was any legislation he
could produce that ASMB would support. However, he hoped that
ASMB wouldn't be unanimously opposed [to Version L].
CHAIR MURKOWSKI asked if there is a subcommittee working on this
issue.
DR. GONNASON deferred to Dr. Christianson, who is a member of
the Board of Optometry.
Number 0381
REPRESENTATIVE KOTT referred to the second paragraph of the
governor's veto letter, and read the following: "I also
recognize that a few states have recently rejected this proposed
expansion of optometrist privileges, citing concern for
enlarging the scope of practice without adequate training and
education." If HB 215 were to pass and the governor vetoed it,
would that concern be part of his veto message, he asked.
DR. GONNASON turned to the "recently rejected" language of the
veto message. He explained that no state has ever repealed a
law, but a new tactic has been to allow legislation to make it
to the governor, who is then bombarded [with opposition]. This
was the tactic used in Alaska. Dr. Gonnason emphasized that he
could prove "beyond a shadow and doubt" that optometrists have
adequate training and education.
REPRESENTATIVE KOTT related his understanding then that HB 215
would enlarge the scope of practice for optometrists. However,
Dr. Gonnason believes that optometrists have adequate training
and education to do so.
DR. GONNASON noted that older optometrists didn't have the
training, but those optometrists aren't grandfathered in. The
current law specified that in order to [prescribe] these drugs,
the person has to have an endorsement on his/her license and
take additional training. Version L would require additional
training for systemic drugs. There are three to four
optometrists in the state who didn't have [a prescribing]
endorsement and thus aren't allowed to prescribe the drugs.
REPRESENTATIVE KOTT referred to the CS prior to Version L, and
asked if that CS was similar to what was passed in the prior
legislation. Also, did the prior legislation allow for needles
to be injected into one's eye, he asked.
DR. GONNASON answered that SB 78, the legislation vetoed by the
governor, allowed optometrists to use any medications, by any
means, that are related to treating the eye. Therefore,
optometrists would've been allowed to use topical medications,
injectible medications, or oral medications. The medications
that are injected in the eye are done by surgical specialists,
and no optometrists in Alaska would do that. He pointed out
that [Version L] includes language specifying that optometrists
won't inject into the globe of the eye. He viewed this matter
as a scare tactic.
Number 0441
ROBERT A. BREFFEILH, M.D., informed the committee that he has
practiced ophthalmology since graduation from Walter Reed
Medical Army Center in 1987. He reviewed his history prior to
1987. He said that during his nine years in the U.S. Army he
had very collegial relations with optometrists. There wasn't a
financial incentive [that would lead] to the adversarial
relationship that exists today. Dr. Breffeilh related his shock
[to the situation]
when he arrived in Juneau. The referral patterns in Alaska from
the optometrists to the ophthalmologists are very weak. Most
patients are sent to Seattle, Washington, because the
optometrists don't want their patients to have any interaction
with the specialists, ophthalmologists, in the community. Dr.
Breffeilh said that on a number of occasions he has seen delays
in diagnoses from optometrists, which have lead to problems for
the patients. He said that he has also seen problems with
diagnoses and medications [from optometrists]. He noted that he
is now aware that there is a mechanism to report those to the
Board of Optometry. Dr. Breffeilh characterized this as a
public safety issue.
CHAIR MURKOWSKI asked whether this is an issue of turf or
training.
DR. BREFFEILH said he feels it's an issue of money.
Number 0479
JILL GEERING, O.D., informed the committee that she has been an
optometrist in Juneau for ten years. She noted that the
committee packet should include a letter from her. She also
informed the committee that she is a graduate from the Illinois
College of Optometry where she had training in oral and topical
medications. One of her job offers was from Juneau. However,
she didn't accept the job in Juneau until she learned that the
legislation allowing her to prescribe topical medication had
passed. With regard to referral patterns, Dr. Geering specified
that her first concern with a patient needing further surgical
care is in regard to who has the best ability to obtain a good
surgical outcome for the patient. She stated that her decision
doesn't involve money but rather what's best for the patient.
In many cases, Dr. Geering felt that what's best for her
patients is to be seen elsewhere. However, she pointed out that
she does refer her patients in town as well.
CHAIR MURKOWSKI posed a situation in which a patient would
require an oral medication. She asked Dr. Geering what she
would do in such a situation.
DR. GEERING answered that she would either refer the patient to
the local ophthalmologist or their general practitioner,
depending upon the situation.
CHAIR MURKOWSKI continued with the above situation and asked if
Dr. Geering would consult with the general practitioner when the
patient is referred to the general practitioner.
DR. GEERING replied that in some cases she would consult with
the general practitioner and in others she would leave decisions
to the general practitioner.
Number 0520
REPRESENTATIVE KOTT inquired as to an example of an acute eye
disease that would require immediate attention. He expressed
concern with regard to the rural areas of the state where there
is no ophthalmologist.
DR. GEERING specified her opinion that the immediate need for
oral medication would be related to pain management when a
foreign body is removed from the eye. She characterized that as
an emergency situation.
REPRESENTATIVE CRAWFORD inquired as to why these two professions
diverged. He related his view that these two professions have a
large amount of overlap. He recalled Dr. Gonnason's testimony
that [optometrists in Alaska] would never use a needle in the
globe of the eye, although 20 states allow optometrists to do
that.
DR. GONNASON clarified that [optometrists] rarely use
injections, but he mentioned the injections used for
anaphylactic shock. The point is, he said, that "drugs are
drugs" and are administered in different ways. Optometrists are
trained with drugs in the same way as dentists and physicians,
but with a specific emphasis on the eye. Optometrists are also
trained with regard to drug interactions.
DR. GONNASON turned to the question as to why the two
professions diverged and likened it to the [divergence] of
cardiologists from [general] practitioners. He referred members
to a letter from Lesley Walls, O.D., M.D. Dr. Gonnason
explained that ophthalmologists go to school and become a
general physician, after which they receive specialty training
with the eye. Most of that training is with surgical and
advanced tertiary care. However, optometrists traditionally
examined the eye for glasses and contact lenses. Over a hundred
years, the profession has advanced such that school for
optometrists rose to a level equivalent to that for dentists.
Dr. Gonnason remarked that the reason there is no problem with
dentists [prescribing] is that dentists, who have the same or a
little less training in drugs than optometrists, don't have any
financial competition. In some communities there are too many
optometrists and ophthalmologists and thus they compete for the
same patients. He pointed out that Alaska doesn't have many
older people who tend to receive eye surgery. Furthermore, some
ophthalmologists don't perform surgery and only provide general
medical eye care. Dr. Gonnason agreed that both professions
overlap. However, optometrists provide primary care and
ophthalmologists provide specialty care.
REPRESENTATIVE MEYER recalled that one of the concerns is in
regard to optometrists injecting needles in the globe of the
eye. Although he understood that injections in the eye are
rare, he pointed out that lasers are being used in eyes, which
he viewed as bad as injecting a needle in the eye.
DR. GONNASON said that optometrists are prohibited from using
lasers on the eye, per Alaska law. He noted that in Oklahoma
optometrists are able to perform certain laser surgery
procedures. He informed the committee that almost all
optometrists now days are trained in laser procedures. Dr.
Gonnason related his belief that ophthalmologists are really
concerned with regard to the line between laser and surgery, the
so-called "laser burn and earn."
TAPE 02-22, SIDE B
DR. GONNASON specified that HB 215 merely replaces what was
compromised out of the bill ten years ago. Ten years ago the
compromise was to not include the oral and injectible drugs,
although the training was occurring. Therefore, optometrists
are merely asking for the rest of their tool box. In further
response to Representative Meyer, Dr. Gonnason confirmed that
[optometrists] would not be able to perform laser [surgery]. He
emphasized that optometrists are already trained in prescribing
drugs, but [Alaska] limits optometrists to prescribing only
drops. Although people seem to view the drops as safer, drops
can be very dangerous. The drops are the most powerful way in
which the drug is put in the eye. Pills generally don't effect
the eye that much, and therefore [optometrists] treat patients
with drops about 90 percent of the time. However, there are
situations that require pills such as with glaucoma, pain, and
allergy. Dr. Gonnason explained that in his office, if he's
comfortable with "it," the general practitioner across the hall
calls in [the prescription] for him. He noted that every day he
refers a patient to an ophthalmologist. "We all really work
together in the state, with ophthalmologists and optometrists,
and then we come and fight at the table over the political
issue," he said.
Number 0577
REPRESENTATIVE CRAWFORD inquired as to what would keep
[optometrists] trained in laser surgery from coming back to the
legislature and requesting that part of their tool box.
DR. GONNASON identified that as the fear. He reiterated that
one state allows [optometrists to perform laser surgery]. Two
other states allowed such, but through a court decision
optometrists were stopped from doing laser [surgery]. He
stressed that every profession grows and advances. He pointed
to dentistry, which was performed in a barber shop a hundred
years ago, as an example. As a profession advances, it should
be able to do the new things that it learns. However, medicine
has a blank check; that is M.D.s can do anything they want. For
example, an M.D. can perform eye procedures that the physician
may not be trained to do, but there is no law against it. Dr.
Gonnason said that what keeps medical doctors from doing such
procedures is professional judgment, which overlooks monetary
gain for good care. He remarked that his ability to prescribe
oral medications doesn't impact his income, although he
acknowledged that if he [could use] lasers it might. However,
he said that there is enough competition with [laser surgery] in
Alaska. Furthermore, Alaskan optometrists are far from being
interested in laser [surgery]. The legislation [allowing
optometrists to use laser surgery was proposed] because if
optometrists are trained in such, they should be allowed to use
it.
REPRESENTATIVE CRAWFORD related his understanding then that
there isn't a fine line between the two professions, and there
isn't a place where [optometrists] would stop seeking
advancement of their profession.
DR. GONNASON pointed to the nurse practitioners in Alaska, who
have a Masters degree. Although in most states, nurse
practitioners have to practice under a doctor's supervision, in
Alaska nurse practitioners can practice the same as an M.D. and
even establish a clinic. These nurse practitioners also use
their professional judgment in regard to prescriptions and
referrals. Therefore, he feels that when opponents to HB 215
express concern with regard to injections in the eye, it is a
scare tactic.
Number 0531
DAVID KATZEEK, Alaska Native Brotherhood Camp 2, began by
thanking the committee, in his Native tongue, for the
opportunity to provide testimony today. Mr. Katzeek read a
letter from the Alaska Native Brotherhood Camp 2 as follows:
Dear Members:
We at the Alaska Native Brotherhood Camp 2 believe
that ... HB 215 is a dangerous bill and one that
requires our attention. The bill contains far-
reaching negative health policies which are implicated
for Alaska. This bill does not improve access to
health care and they do not open new clinics.
House Bill 215 does not make new services available to
residents in rural Alaska; in fact it really is
putting rural Alaska at great risk. A second opinion
will not be available to the optometrists or to the
patients.
Without medical training, optometrists are not
qualified to thoroughly and properly [assess] medical
risks. No matter how well intentioned, optometrists
do not have the training to know how a drug might
affect the cardiovascular system. Optometrists do not
possess a medical degree, and they do not receive
training in prescribing medical drugs.
With the desire to increase their own medical field of
expertise and the monetary benefits, which would
follow an expanded medical field, it is our concern
that these optometrists will perform procedures that
are maybe not necessary.
In short, the enactment of HB 215 will not improve the
health care services available to Alaskan citizens,
but ... may increase the health care risks for ...
Alaskan citizens and for these reasons the bill should
be defeated.
MR. KATZEEK turned to his own comments, and said that he has
received services from optometrists as well as ophthalmologists.
"Just because you have a tool box and you put a pipe wrench in
it doesn't mean you know how to use a pipe wrench," he said. He
expressed his concern that serious problems could be caused
[with the passage of HB 215]. Mr. Katzeek said that this issue
isn't just about money and who can do and should do what, but
rather what happens to people as human beings. Mr. Katzeek
related a Tlingit story in which Raven picks berries and took
his eyeball out in order that the eye could [warn] him when
people came. Although Raven's eye began yelling at him that the
people were coming, Raven was so busy [picking berries], which
would be beneficial to him, he forgot about his eye. Raven lost
his eye. Mr. Katzeek stressed the importance of the eye as one
of the valuable senses. Therefore, Mr. Katzeek urged the
committee to take care when making a decision [regarding HB
215]. "It's not just money, it's the eyes of the people that
you represent," he stressed.
CHAIR MURKOWSKI commented that she believes the committee does
appreciate the relative seriousness of this issue.
REPRESENTATIVE KOTT recalled when the legislature asked the
ASMB's opinion of SB 78, and ASMB's response was that it didn't
respond to the legislature because the board is made up of
appointees of the governor and thus respond to him.
Representative Kott asked if that is how such boards work, or
was it taken out of context.
Number 0443
CATHERINE REARDON, Director, Division of Occupational Licensing,
Department of Community & Economic Development (DCED), answered
that there isn't an established policy to that effect. Ms.
Reardon said that she didn't know the exact words of the
exchange referenced by Representative Kott, but would like to
believe that the response wasn't "so back-in-your-face." She
related her sense that ASMB generally isn't a board that
relishes getting involved with the legislative process. The
ASMB spends much of its time addressing licensing and
disciplinary actions, which ASMB views as its primary role. Ms.
Reardon related that at couple years before [the request related
to SB 78] ASMB was asked to take a position on a bill and did
so; and subsequently three of the members weren't confirmed the
following session. She opined that ASMB was trying to not
[become involved] in a field that wasn't in their comfort zone.
CHAIR MURKOWSKI restated her earlier question with regard to the
status of the discussions between the optometrists and
ophthalmologist and ASMB. She asked if a subcommittee was
established to discuss this. Is there an ongoing discussion,
she asked.
MS. REARDON confirmed that the governor's office requested that
ASMB and the Board of Optometry discuss the issue. This past
fall, a representative from the Board of Optometry attended the
[ASMB] meeting and had a fairly full discussion of the issue.
Following that meeting there was a Board of Optometry meeting,
which was attended by an ASMB representative. The Board of
Optometry modified its position and then ASMB discussed the
issue again in January when it selected two members to work with
a Board of Optometry subcommittee.
MS. REARDON related her belief that ASMB is fairly uncomfortable
with expanding the prescriptive authority [of optometrists].
Although she did believe that ASMB was willing to [continue
discussions], she saw the parties as being far apart.
Therefore, the fall meetings didn't result in any resolution.
She related ASMB's concern with regard to [an optometrist's
ability to prescribe] systemic drugs and [their understanding of
the] potential impact on other conditions, diseases, and body
parts. One item of discussion [between the two boards] was in
regard to the [possibility of] collaborative relationship
similar to that between physicians and physician assistants in
order to provide some oversight. She predicted that such a
situation would be acceptable to the Board of Optometry.
CHAIR MURKOWSKI surmised that there is no deadline for a report.
MS. REARDON replied no.
Number 0369
CHAIR MURKOWSKI inquired as to whether the administration has
reviewed HB 215. Has HB 215 been modified such that it would
avoid the governor's potential veto, she asked.
MS. REARDON responded that she couldn't answer that because the
governor evaluates legislation as it reaches him. Therefore,
she felt that the best guide would be the governor's veto letter
to SB 78. That veto letter seemed to include two particular
issues. First, there was concern that there was no guarantee
that those optometrists currently holding prescriptive
endorsements wouldn't, with the passage of HB 215, automatically
be raised to this higher level. Although the Board of Optometry
said that wasn't the intent, the language didn't guarantee it
wouldn't occur. Second, the legislation doesn't specify a new
testing requirement for that higher level.
MS. REARDON informed the committee that currently there are two
types of endorsements for optometrists. Of the approximately
110 optometrists, 105 hold the highest level of prescriptive
endorsement currently allowed, which is the therapeutic
endorsement and five have no endorsement at all because they
didn't qualify or request such. Five of the 110 optometrists
have a diagnostic endorsement, which is the result of a law that
only allowed diagnostic drug use. That law was prior to the law
allowing therapeutic [drug] use. The five optometrists with the
diagnostic endorsement didn't or weren't able to rise to the
higher endorsement. Therefore, the governor [wanted to ensure],
she surmised, that those optometrists with a diagnostic or
therapeutic endorsement didn't [automatically] transfer to the
systemic endorsement without [proving] their background.
Furthermore, ASMB's concern with health risks probably weighed
[on his thoughts]. She noted that she has a list of the
optometrists in the state by zip code.
Number 0304
GORDON PREECS, M.D., related his background, which included the
U.S. Army and specialty training in ophthalmology at Walter Reed
Medical Army Center. He noted that he and Dr. Breffeilh have
been in Juneau since 1989. Dr. Preecs turned to SB 78 and
pointed out that it was [passed] during the crunch at the end of
the session. He related his belief that leadership at the time
directed [the passage of SB 78 due] to compromises made with
regard to SB 78 and other legislation that ASMA had. Dr. Preecs
said, "I don't know that this was a thoughtful process of
consideration for this legislation."
DR. PREECS related the concern of the AMA and the Academy of
Ophthalmology that [SB 78] allowed optometrists to practice any
form of medicine that was available. "It simply allowed the
optometrists to tell themselves what they wanted to have," he
charged. Although this bill has a remarkably more stringent
listing of what [optometrists] can do, it [still] says that
optometrists will decide what optometrists will prescribe. Dr.
Preecs said that his main concern is that HB 215 removes the
authority of the medical practice and [ASMB] to provide any
input with regard to who can and will practice. He pointed out
that physician assistants are under [ASMB]. Although nurse
practitioners mostly work in supervision, they do have
independent authority that is [specifically] delineated.
Number 0258
CHAIR MURKOWSKI surmised then that the CS is better due to the
added restrictions and guidelines with regard to what can be
prescribed. She related her understanding that Dr. Preecs is
concerned that there is no oversight of the prescribing by ASMB.
DR. PREECS said that over the last 12 years optometrists have
moved forward [in attempt] to establish and grant the
independence of their profession, separate from ophthalmology
and medicine. Optometrists have extended their profession such
that in the last legislation, SB 78, optometrists were almost
indistinguishable from practicing physicians. "If you can
prescribe, you can practice," he specified. Dr. Preecs said
that he wasn't worried with what HB 215 allows optometrists to
prescribe because optometrists already do most of those things,
and do so without great tragedies. However, [the legislation]
allows optometrists to have the independent authority to decide
what that will be in the future. Dr. Preecs turned to laser
surgery, and commented that exposure to such is a wonderful
first step. However, it's of concern to allow such [to be done
by] those not trained in the medical field. He characterized
the inclusion of laser surgery in the legislation as bait that
could be taken out as if in compromise.
DR. PREECS, in response to Chair Murkowski, said that an
optometric practice can be supported with a service area of
10,000 people while an ordinary demographic population of 30,000
would support an ophthalmologist. He informed the committee
that there is a partnership of optometrists in Ketchikan, which
is 10,000 people plus a service area. In Sitka, population
7,000, there is a single optometrist practicing full-time. Dr.
Preecs said the practice he and Dr. Breffeilh have serves the
whole of Southeast, which amounts to about 60,000-70,000 people.
Places such as Wrangell are too small [to support an
optometrist].
Number 0200
CHAIR MURKOWSKI posed a situation in which an individual needs
pain medication. She inquired as to how such a situation would
be handled in some of the smaller communities such as Sitka.
DR. PREECS answered that he tends to be the point of contact for
things that are specifically and directly related to
ophthalmologic issues. However, if someone needed pain
medication, the local family practitioner [would be accessed].
He said that the local family practitioners are the best level
of expertise for their local people when [ophthalmologists]
aren't in town. In small towns when there is the need for
sophisticated medical care, phone calls are made, questions and
answers are exchanged, and advice is given.
Number 0159
LINDA CASSER, O.D.; Associate Dean for Programs, Pacific
University of Optometry in Forest Grove, Oregon; President,
National Board of Examiners in Optometry, announced her support
of HB 215. She related the following information regarding the
extensive training and education received by "optometric
physicians" [optometrists], particularly in the area of
pharmacology. She informed the committee that the Doctor of
Optometry degree program is a four-year graduate level program;
students leave the program with seven to eight years of
education and training. The prerequisite course of study is
rigorous and comprehensive, and comparable to that completed by
pre-medical and pre-dental students. Pre-optometry students are
required to pass the Optometry Admission Test (OAT), which is
comparable to the MCAT examination required of medical students.
The OAT is administered by the American Dental Association.
Furthermore, the students in the Doctor of Optometry program are
thoroughly educated in the basic sciences so that diseases and
disorders of the eye are understood and treated in their proper
context. In several of the institutions of optometry, optometry
students sit side-by-side with medical and dental students in
the basic science courses. Dr. Casser specified that 255
classroom hours within the curriculum are assigned to the area
of pharmacology, including the use of topical, oral, and
injectible medications in the treatment of the eye and its
associated structure. Additionally, 165 classroom hours pertain
to the diagnosis, treatment, and management of ocular disease as
well as the extensive patient care clinical experience in which
the pharmacological concepts are applied. She highlighted that
studies indicate that optometry students receive comparable
course hours in pharmacology to that of medical students.
Students in the Doctor of Optometry program receive added
training and education in ocular pharmacology. She also
mentioned that optometric students begin their clinical activity
in their first year of professional study; the patient care
experience increases in complexity and intensity throughout the
program. The fourth and final year of the program is spent in
full-time patient care activity; two of the three semesters are
spent in off-campus clinical preceptor shifts in a variety of
health care settings. In total, these students spend at least
2,000 contact hours examining diverse patient populations with
ocular and systemic diseases.
DR. CASSER concluded by saying, "Doctors of Optometry are
thoroughly prepared to provide safe and effective eye and vision
care services for the patients they serve, including the use of
systemic medications." She related that during her 25 years in
the profession [she has] had the opportunity to testify in
multiple states and committees. From that experience she has
found that the comments regarding the lack of training and
education of Doctors of Optometry is based on misinformation or
inadequate information. She submitted that the packet she
provided the committee documents the excellent training that
optometrists receive, especially in the area of pharmacology.
She commented that she has found that those who have retained
objectivity and an open mind come to the same conclusion. Dr.
Casser informed the committee that at Pacific University there
is a physician assistant program, which is a Masters level
program in which the students receive seven semesters of
training. She highlighted that optometry students receive ten
years of training, and many faculty train students in both the
physician assistant program and the optometry program.
DR. CASSER turned to Dr. Preecs' comments regarding board
involvement in optometry. She reminded the committee that
optometrists are licensed, independent practitioners and thus
it's appropriate that the Board of Optometry is the body that
makes the decisions with regard to the rules and scope of
practice [for the profession]. Everyone in optometry [falls
under] the overarching guideline of the optometry practice's
statutes, which limits practice to the eye and associated
structures. Dr. Casser pointed out that the committee packet
should contain her longer testimony as well as a table comparing
the training and education of dentists and optometrists, which
she believes to be very similar and even identical in some
areas. The comparison is the result of her review of the
curriculum of the School of Dentistry at the Oregon Health
Sciences University. The packet should also include a single-
page summary that specifies the pharmacology training of
optometrists, a summary of the curriculum, a couple of
informational articles that illustrate how the curriculum has
evolved, and an article she authored with a pharmacologist in
the State of Indiana regarding the pharmacology training an
optometrist receives in comparison to other health care
professions.
CHAIR MURKOWSKI asked if Dr. Casser would say that the Pacific
University's curriculum [for optometrists] is standard amongst
other schools of optometry.
TAPE 02-23, SIDE A
DR. CASSER answered that all the schools and colleges [offering
training in optometry] have a comparable curriculum. She
informed the committee that [schools and colleges offering
training in optometry] are all accredited by the Accreditation
Council on Education, which is overseen by the U.S. Department
of Education. Therefore, she said that any graduate who comes
to Alaska as a practitioner would have comparable education and
training such that he/she would be qualified to use these
medications.
Number 026
CARL ROSEN, [M.D.]; President, Alaska Ophthalmologic Society,
testified via teleconference. He explained that he represents
the ophthalmologists in Alaska and their patients. "The primary
reason that we're here today is the protection and the ...
interest of our patients," he said. He pointed out that the
optometric community has steadily [worked toward] their
profession's expansion. He noted that "we" are present to
protect the public from misadventure of even one or two
optometrists who may not know what they are doing with
medications. For example, this year alone Georgia, Minnesota,
Mississippi, South Dakota, and Washington have defeated drug
initiative legislation by the optometric community. He then
turned to the issue of training, and mentioned that 2,000 hours,
the clinical hours that most optometrists acquire as specified
by Dr. Casser, is a lot of time. However, Dr. Rosen pointed out
that before he was allowed to practice in Alaska he logged
24,000 hours. Furthermore, Dr. Rosen said that the notion that
optometrists are more qualified to treat primary eye care is an
opinion rather than fact. In regard to pharmacology, he
stressed that the bar is medical school and the American medical
system. "Using that bar as a reference point, I put it to you:
'How would you want your family or your eye care?' And I think
the obvious answer is you'd want the best care possible," he
charged. He characterized the "best care possible" to be a
[collaboration] between the two professions. He emphasized that
pain medications and oral antibiotics can be [prescribed] in a
rural community or locally via a phone call or quick referral.
"The people of Alaska aren't clambering to have an optometric
expansion, and specifically the Native community is not and
they're the community most frequently discussed when you're
talking about the rural community," he said. He reiterated that
the most important issue here is in regard to what is best for
the patient.
REPRESENTATIVE KOTT asked if Dr. Rosen's remark that the Native
community doesn't want [HB 215] is the position of the Alaska
Federation of Natives (AFN).
DR. ROSEN pointed out that he receives his information from the
Alaska Native Brotherhood.
REPRESENTATIVE KOTT remarked that he didn't believe the Alaska
Native Brotherhood speaks for the entire Native population,
whereas AFN seems to be the group responsible for that.
Number 120
DENISE THANEPOHN, O.D., testified via teleconference. Dr.
Thanepohn testified in support of HB 215. She said that the
debate seems to be with regard to whether optometrists have the
practical knowledge to do [what HB 215 would allow]. She
informed the committee that she is familiar with many
medications that she uses on a daily basis. Furthermore,
[optometrists] deal with patients that are using a variety of
systemic medications and thus [optometrists] have to deal with
those medications and their ocular side effects. She pointed
out that frequently she performs consults with internists,
cardiologists, and endocrinologists before eye care medication
is started. Therefore, [what is proposed in HB 215] wouldn't be
out of line for optometrists.
DR. THANEPOHN related her interpretation that some testimony has
indicated that optometrists don't practice prudent and
conservative prescribing. However, there have been no
complaints to the Alaska Board [of Optometry] for the last ten
years. The lack of complaints seems to speak well of the
quality of optometrists and their prescribing ability.
Furthermore, some folks seem to believe that an M.D. degree
magically guarantees intelligent, clinical decision making.
Although M.D.s are knowledgeable, they make mistakes as well.
REPRESENTATIVE KOTT asked if Dr. Thanepohn has referred patients
to ophthalmologists. He also asked if she referred to certain
ophthalmologists.
DR. THANEPOHN replied yes. Certainly, for certain conditions
certain ophthalmologists are more trained than others.
REPRESENTATIVE KOTT related his understanding then that there is
a good relationship between [Dr. Thanepohn's office] and the
ophthalmologist.
Number 185
OLIVER KORSHIN, M.D., testified via teleconference. He informed
the committee that he received his M.D. degree 35 years ago from
Harvard. He noted that he is board certified in preventive
medicine as well as ophthalmology. Dr. Korshin announced his
opposition to HB 215 due to his experiences as a medical doctor,
such as seeing the effects of systemic medication when
incorrectly and correctly prescribed or administered. He
pointed out that optometrists have basically no hands-on
training or experience with serious systemic disease of the
level that M.D.s experience. With regard to an optometrists
training in pharmacology, Dr. Korshin said that no amount of
classroom hours can substitute for the rigorous clinical
patient-based training all medical doctors undergo. "If
classroom learning were a acceptable substitute, then we should
also grant driver's licenses or pilot certificates on the basis
of written examinations alone," he charged.
DR. KORSHIN pointed out that HB 215 provides the impression that
only a narrow range of drugs will be used [by optometrists].
However, the categories include a broad range of very powerful
drugs. "Granting optometrists the authority they seek under HB
215 is in reality granting them a blank check to prescribe a
broad range of potent drugs, not a limited handful," he said.
In conclusion, if HB 215 is passed, Dr. Korshin predicted that
optometrists will return next session requesting the authority
to perform laser surgery or more. Dr. Korshin urged the
committee not to pass HB 215.
Number 252
JIM SWARTLEY, M.D.; Member, American Academy of Ophthalmology
State Affairs Committee, testified via teleconference. Dr.
Swartley noted that the committee should have a letter from Dr.
Thomas Weingeist, Ph.D., M.D., which outlines concerns with HB
215.
DR. SWARTLEY related the following personal comments. As a
general ophthalmologist who is the primary care [physician]. He
pointed out that not many ophthalmologists spend all their time
in surgery but rather spend more time in the office. With
regard to injections in the eye, Dr. Swartley said that often
injections into the eye are inadvertent and are probably of more
concern.
Number 280
CHAIR MURKOWSKI announced that public testimony is closed and HB
215 will be held and heard on the upcoming Monday.
ADJOURNMENT
There being no further business before the committee, the House
Labor and Commerce Standing Committee meeting was adjourned at
5:24 p.m.
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