04/11/2007 03:00 PM House LABOR & COMMERCE
| Audio | Topic |
|---|---|
| Start | |
| HB113 | |
| Adjourn |
+ teleconferenced
= bill was previously heard/scheduled
| += | HB 162 | TELECONFERENCED | |
| += | HB 113 | TELECONFERENCED | |
| += | HB 195 | TELECONFERENCED | |
| + | TELECONFERENCED |
ALASKA STATE LEGISLATURE
HOUSE LABOR AND COMMERCE STANDING COMMITTEE
April 11, 2007
3:07 p.m.
MEMBERS PRESENT
Representative Kurt Olson, Chair
Representative Mark Neuman, Vice Chair
Representative Carl Gatto
Representative Gabrielle LeDoux
Representative Jay Ramras
Representative Robert L. "Bob" Buch
Representative Berta Gardner
MEMBERS ABSENT
All members present
COMMITTEE CALENDAR
HOUSE BILL NO. 113
"An Act relating to the prescription and use of pharmaceutical
agents, including controlled substances, by optometrists."
- MOVED CSHB 113(HES) OUT OF COMMITTEE
HOUSE BILL NO. 162
"An Act relating to mortgage lenders, mortgage brokers, mortgage
originators, state agents who collect program administration
fees, and other persons who engage in activities relating to
mortgage lending; relating to mortgage loan activities; relating
to an originator fund; relating to fees for mortgage loan
transactions; and providing for an effective date."
- SCHEDULED BUT NOT HEARD
HOUSE BILL NO. 195
"An Act relating to limited liability companies."
- SCHEDULED BUT NOT HEARD
PREVIOUS COMMITTEE ACTION
BILL: HB 113
SHORT TITLE: OPTOMETRISTS' USE OF PHARMACEUTICALS
SPONSOR(s): REPRESENTATIVE(s) SAMUELS
01/30/07 (H) READ THE FIRST TIME - REFERRALS
01/30/07 (H) HES, L&C
03/20/07 (H) HES AT 3:00 PM CAPITOL 106
03/20/07 (H) Heard & Held
03/20/07 (H) MINUTE(HES)
03/31/07 (H) HES AT 12:30 AM CAPITOL 106
03/31/07 (H) Moved CSHB 113(HES) Out of Committee
03/31/07 (H) MINUTE(HES)
04/02/07 (H) HES RPT CS(HES) 4DP 1NR 2AM
04/02/07 (H) DP: CISSNA, SEATON, NEUMAN, FAIRCLOUGH
04/02/07 (H) NR: GARDNER
04/02/07 (H) AM: ROSES, WILSON
04/11/07 (H) L&C AT 3:00 PM CAPITOL 17
WITNESS REGISTER
REPRESENTATIVE RALPH SAMUELS
Alaska State Legislature
Juneau, Alaska
POSITION STATEMENT: Presented HB 113.
REPRESENTATIVE BILL THOMAS
Alaska State Legislature
Juneau, Alaska
POSITION STATEMENT: Spoke as a joint prime sponsor of HB 113.
CYNTHIA BRADFORD, M.D.
American Academy of Ophthalmology (AAO)
Edmond, Oklahoma
POSITION STATEMENT: Testified during hearing on HB 113.
ERIC COULTER, M.D.
Anchorage, Alaska
POSITION STATEMENT: Testified during hearing on HB 113.
CARL E. ROSEN, M.D., President
Alaska State Ophthalmological Society
Anchorage, Alaska
POSITION STATEMENT: Testified during hearing on HB 113.
DANIEL BRICELAND, M.D.
American Academy of Ophthalmology (AAO)
Sun City West, Arizona
POSITION STATEMENT: Testified during hearing on HB 113.
MICHAEL BENNETT, O.D., President
Alaska Optometric Association (AKOA)
Juneau, Alaska
POSITION STATEMENT: Testified in support of HB 113.
ACTION NARRATIVE
CHAIR KURT OLSON called the House Labor and Commerce Standing
Committee meeting to order at 3:07:46 PM. Representatives Buch,
Gardner, Neuman, and Olson were present at the call to order.
Representatives Gatto, LeDoux, and Ramras arrived as the meeting
was in progress.
HB 113-OPTOMETRISTS' USE OF PHARMACEUTICALS
CHAIR OLSON announced that the only order of business would be
HOUSE BILL NO. 113, "An Act relating to the prescription and use
of pharmaceutical agents, including controlled substances, by
optometrists."
3:08:19 PM
REPRESENTATIVE RALPH SAMUELS, Alaska State Legislature, stated
that in 45 other states, optometrists are allowed to perform
more functions than those in Alaska. He said that Alaska has
many remote communities, and the legislature should strive for
anything that will increase access to healthcare. He stated
that allowing optometrists to have a larger scope of practice
has not caused problems in the aforementioned states. He noted
that there would be testimony both for and against the bill. He
then gave a detailed comparison of the education requirements
for optometrists, dentists, physician's assistants, and nurse
practitioners. He pointed out that while the education
requirements are similar, only optometrists are limited to
prescribing topical agents. He opined that because Alaska has
many rural areas, the legislature needs to do what it can to
provide better access to healthcare. He shared his belief that
this is "extremely reasonable."
3:10:57 PM
The committee took an at-ease from 3:12 PM to 3:24 PM.
3:23:46 PM
REPRESENTATIVE BILL THOMAS, Alaska State Legislature, joint
prime sponsor, pointed out that during a hearing in the House
Health, Education and Social Services Standing Committee (HHES),
the ophthalmologists admitted that Haines is the only community
in his district that is visited. He shared his belief that it
is important to allow optometrists to provide treatment for
certain eye diseases. He stated that some communities have
Southeast Alaska Regional Health Consortium (SEARHC) clinics,
although the cost to transport a patient to a clinic can be
high. He said that if an optometrist could work with the nurse
practitioner or a physicians assistant, this would be beneficial
to remote communities.
3:26:06 PM
CINDY BRADFORD, M.D., American Academy of Ophthalmology (AAO),
said that she is a practicing Ophthalmologist. She stated that
she is not opposed to optometry, and works with optometrists.
She expressed concern that the bill allows optometrists to use
medications that effect the entire body. She opined that the
committee needs to consider what measuring stick is being used
to decide whether the education of an optometrist is adequate to
prescribe systemic medications. She questioned whether the
hours of education are enough to do this, or whether other
authorities have been examined. She opined that the question of
whether the hours of education are enough has yet to be
answered, noting that the training given to optometrists is
different than medical school. She questioned whether the 45
states actually allow this scope of practice. She suggested
that members take a closer look at what these states actually
allow. She understands that Alaska has remote areas, and said
"We certainly want everybody to be ... taken care of." However,
she stated that "the eye is not the tooth," and is one of the
most complex organs of the body. She opined that vision is "the
most precious sense that the body has," and said that the
diagnosis and treatment of an eye disease is not simple. She
said that if a patient needs specialty care he or she will need
to see an ophthalmologist, regardless of location. She stated
that the training cannot be replaced simply because of location.
She said that this might result in a delayed diagnosis.
3:31:10 PM
REPRESENTATIVE RAMRAS asked when Dr. Bradford visited Alaska.
DR. BRADFORD replied that she has never been to Alaska. She
said that she was raised in Texas, and is aware that there are
significant differences. She said "I do know that people
deserve treatment that allows them to be cared for." She shared
her belief that allowing someone without the training to treat
patients "is not getting us anywhere."
REPRESENTATIVE RAMRAS asked whether Dr. Bradford feels that
Oklahoma and Texas have extensively developed road systems.
DR. BRADFORD replied that while many people complain about the
roads, there are no mountains. She acknowledged that this makes
travel easier. In response to an additional question, she said
that in Oklahoma, most places can be reached by road.
3:32:28 PM
REPRESENTATIVE LEDOUX noted Dr. Bradford's concern with regard
to the statement that 45 states give optometrists a broader
scope of practice. She asked which states allow this and which
states do not.
DR. BRADFORD said that this information was previously made
available. She said that the statutes differ from state to
state, and there are not 45 states that allow this currently.
She offered to provide this information.
REPRESENTATIVE LEDOUX replied that she would like to see this
information. She asked whether Dr. Bradford is aware of any
states that have similar legislation.
DR. BRADFORD replied that Oklahoma has the most liberal practice
act for optometry.
REPRESENTATIVE LEDOUX questioned whether there is evidence that
the quality of eye care has diminished as a result of this.
DR. BRADFORD shared her belief that the majority of optometrists
do not do this, as it is not needed. She shared a story in
which a patient almost went blind as a result of being treated
with the wrong medication. She said that she has seen a delay
in treatment because the optometrist thought he or she had the
ability to manage the condition, adding that some of the cases
were "a block away from an ophthalmologist."
3:35:47 PM
REPRESENTATIVE NEUMAN, in regard to the "measuring stick" that
is being used, referred to the sponsor statement and shared his
belief that the measurement is clearly stated.
DR. BRADFORD replied that the wording is "very impressive,"
however, this simply says that what is being taught in optometry
school is adequate to allow an optometrist to prescribe systemic
medications. She questioned what the "gold standard" is, and
shared her belief that the "gold standard" is attending medical
school to learn how different medications affect the different
systems of the body. She questioned how, if a person does not
take care of patients and learn the lessons taught in medical
school, he or she would know that the education provided by
optometry school is adequate.
3:38:25 PM
REPRESENTATIVE NEUMAN asked if optometrist school is considered
a medical school.
DR. BRADFORD replied that optometrist school is not a medical
school.
CHAIR OLSON stated that New York, Rhode Island, New Jersey, and
Florida do not currently allow an extended scope of practice.
He opined that the aforementioned states have a different level
of expertise than Alaska.
DR. BRADFORD replied that this is the "easy list." She shared
her belief that the remaining 45 states do not allow the same
scope of practice that is allowed by HB 113.
3:39:36 PM
REPRESENTATIVE GARDNER noted that there is a lot of variation
with respect to what is allowed. She said that the handout in
members' packets is "a little inaccurate," as it suggests that
all 45 states allow everything [that is allowed by HB 133]. She
pointed out that the lists shows, state by state, what is
allowed.
CHAIR OLSON shared his understanding that the handout says that
"some level" is allowed.
REPRESENTATIVE LEDOUX, with regard to the "gold standard,"
questioned whether the same argument could be made for different
medical schools. She commented that the credential should
provide a certain amount of comfort, as the human anatomy does
not change.
DR. BRADFORD replied that optometry schools have a different
system for accreditation than medical schools. Graduates of
medical school must pass a national board exam. Additionally,
medical school faculty must have certain credentials. The
process for medical school is different from the process for
optometry school. The education received at a medical school is
the same across the board, as is the testing.
REPRESENTATIVE LEDOUX shared her understanding that doctors with
medical degrees from other countries are allowed to practice
medicine in the United States, although the education received
may not be up to the same standards.
DR. BRADFORD explained that these individuals take a separate
test, which many foreign graduates do not pass. She said that a
person is not board certified in ophthalmology unless an
American residency in ophthalmology is completed.
REPRESENTATIVE LEDOUX shared her understanding that an
ophthalmologist can administer the same drugs and treatments,
regardless of whether or not he or she is board certified.
DR. BRADFORD said that ophthalmologists must take a test to
ensure that he or she is able to prescribe the medication and
provide treatments.
3:44:50 PM
ERIC COULTER, M.D., began by stating that he is a board
certified ophthalmologist, and a member of the American Academy
of Ophthalmology. He stated that there are differences between
an optometrist and an ophthalmologist. He said that throughout
the 50 states, ophthalmologists are considered surgical sub-
specialists, adding that ophthalmologists receive a medical
license, while optometrists do not. Ophthalmologists attend
allopathic medical schools, and optometrists attend optometry
school. He said that the Alaska State Medical Board does not
offer a medical license to optometrists, and hospitals do not
allow optometrists on staff. He said that there are seven
ophthalmologists who take call for the entire state. If a
person is admitted to the emergency room with an eye injury, the
on-call ophthalmologist handles this. He stated that he has
received the same training as an orthopedic surgeon.
DR. COULTER stated that he does not have any problem with
optometrists, and feels that they provide a "wonderful service."
However, he shared his belief that this is similar to comparing
an orthopedic surgeon to a paramedical profession such as
chiropractic care. He questioned the point at which the
prescribing authority is limited for [chiropractic care and
optometry]. He opined that it is inappropriate to legislate
laws that determine medical competency. He shared his belief
that this is a task that reaches farther than the legislative
process. He expressed concern that these issues have not been
discussed with the Alaska State Medical Board or medical
schools. He stated that if he had a crisis on his hands, he
would not call an optometrist for assistance, and would contact
the Alaska State Medical Board if he was overwhelmed or
overburdened with call duties. However, this is not the case.
He shared his belief that if optometrists wish to have the
ability to dispense medications, they should be responsible for
tracking down the cause of an eye disease. He said that this
brings up other concerns, and "seems like an oxy-moron." He
opined that a more appropriate course of action would be for the
optometrists to present concerns regarding limitations of
practice to the State Medical Board. He said that the State
Medical Board is really in tune with the pulse of medical care
in Alaska. He shared his belief that it is not possible to
legislate medical competency. In closure, he expressed his hope
that members would understand what the ophthalmologists do for
the state and the rigors gone through to reach their level of
responsibility. He said that this is not a "turf battle," but
an interest in promoting what is best for the patient. He
stated that he is not aware of any ophthalmologists that are
"screaming for assistance." If the Alaska State Medical Board
decides to present optometrists with a medical license as a
result of presentations made by the optometrists, he feels this
is fine. However, he feels that to "open the door a little bit"
is irresponsible.
3:56:22 PM
REPRESENTATIVE NEUMAN referred to a handout in members' packets
from the Alaska Optometric Association titled "Frequently Asked
Questions," and pointed out that the Alaska State Medical Board
surveyed other medical boards throughout the nation to find out
if there were problems in states that passed similar
legislation. He noted that no problems were reported. He asked
if Dr. Coulter is aware of any problems that the Alaska State
Medical Board is not.
DR. COULTER shared his belief that in Alaska, the optometric
community "does a great job" of caring for patients. He said
that the Alaska State Medical Board does not have much authority
over the optometric profession in Alaska. He questioned whether
the medical board is sponsoring the bill, and shared his
understanding that the Alaska State Medical Board, along with
the Alaska State Medical Association, is not interested in
promoting the expansion of a paraprofessionals' scope of
practice.
REPRESENTATIVE NEUMAN reiterated that the Alaska Medical Board
surveyed medical boards across the nation and did not find any
problems.
DR. COULTER said that he can appreciate this, and is not
suggesting that cataclysmic problems have occurred. He stated
that he is simply pointing out the difference between the two
professions, and sharing his belief regarding the legislation.
4:00:09 PM
REPRESENTATIVE LEDOUX asked if general practitioners are allowed
to address eye-related problems or concerns.
DR. COULTER replied that general practitioners are able to
practice based on the standard of care in the community. He
explained that general practitioners can treat and prescribe
medication. For a general practitioner to operate on the eye
depends on the availability of ophthalmologic care. He stated
that when a general practitioner is not seeing results from
efforts to improve a condition, the patient is sent to an
ophthalmologist.
REPRESENTATIVE LEDOUX asked if an optometrist would also send a
patient to an ophthalmologist if the condition was not
improving.
DR. COULTER replied that this happens often. He said that the
difference is that one is a medical doctor and the other is not.
He reiterated that he does not have a problem with optometrists.
He questioned whether the medical knowledge of a general
practitioner is equitable with that of an optometrist. He said
that if it was, optometrists would be given a medical license.
He pointed out that this is not true in any state.
4:05:57 PM
CARL E. ROSEN, M.D., President, Alaska State Ophthalmological
Society, began by giving a brief explanation of his work, and
stated that he is not in favor of HB 113. He said that
clarification is needed with regard to the number of
ophthalmologists versus optometrists in the state. He stated
that there are around 40 ophthalmologists and 87 optometrists.
Additionally, there are two ophthalmologists that serve nine
communities. This is a larger number of communities than was
stated by Representative Samuels during a previous committee
hearing. He stated that there is no public outcry for the
passage of HB 113.
4:09:09 PM
DR. ROSEN went on to say that it is difficult to submit
complaints to the Alaska Optometric Board. He stated that
claims that no complications have occurred are untrue, pointing
out that two letters from patients experiencing problems are in
members' packets. He stated that injecting medication around
the eye can be very complex, and said that steroids are the most
common injection. He said that steroids can cause systemic
complications, adding that he does not do this often. He
questioned why this would be done by someone who does not do it
frequently. He then shared a story involving an experienced
physician that accidentally penetrated a patient's eye, and said
that errors can still occur. With regard to access, he
explained that photo screening and telemedicine are being
adopted by more medical practitioners, and will result in better
access to care. He said that there is no concern with
optometrists giving anaphylactic injections, adding that in
fifteen years, he has not had to do this. Finally, he pointed
out that many states, including California, require that the
optometrist work with an ophthalmologist, prior to working
independently. He stated that oftentimes, optometrists do not
reach the level of experience needed to work independently. He
then shared his personal residency experience, pointing out that
he was required to perform 150 supervised injections prior to
graduating from the program.
REPRESENTATIVE GARDNER asked whether there is a shortage of
care, absent the photo screening and telemedicine technology.
DR. ROSEN replied that this depends on the perspective. While
there are more optometrists than ophthalmologists, the Medical
Board is not being called with concerns or requests for
additional ophthalmologists. He said that more ophthalmologists
are being recruited, although he does not feel that there is a
shortage.
DR. DANIEL BRICELAND, American Academy of Ophthalmology (AAO),
shared his understanding that the Board of Examiners in
Optometry did a survey and said that there were no complaints in
other states where a broader scope of practice is allowed. He
expressed concern with this, and stated that Arizona has had two
cases go to trial based on complaints from the optometric board.
He opined that it is unfair that unrealistic information has
been given. He then said that the education received by an
ophthalmologist and the education received by an optometrist is
not comparable, and detailed the education required before an
individual can practice ophthalmology.
4:31:41 PM
MICHAEL BENNETT, O.D., President, Alaska Optometric Association
(AKOA), stated that HB 113 is "a very narrow bill." He pointed
out that it does not allow prescription of the most abused
substances, and specifically prohibits injections inside the
eye. It does not grant surgical privileges, and mandates
continuing education and competency testing. While he agrees
that ophthalmologists are different than optometrists, he
pointed out that optometry is a "doctor level" profession. He
detailed the education received by an optometrist, which
requires four years of coursework beyond a bachelor's degree.
This includes 200 hours in pharmacology course work, and over
2,000 hours of supervised patient care. He stated that a
medical case history is taken every time a patient is seen, and
drug interactions are considered. He pointed out that for many
years optometrists have been licensed to prescribe beta-blockers
for the treatment of glaucoma, which can run into many systemic
problems. These problems are always considered, and this is
part of the optometric training. He said that all medications
can be absorbed and may have systemic side-effects, whether
topical or in the form of an eye drop. He commented that the
majority of patients seen are middle aged or older, and may be
on multiple medications, adding that part of his training
included clinical rotations in a Veterans Affairs (VA) hospital.
DR. BENNETT went on to say that the entrance requirements and
course load for both optometric and ophthalmology schools are
similar. With regard to entrance difficulty, he stated that the
school he attended was second in the state of Michigan. He said
"The notion that we are bringing in second-rate people who can't
get into medical school is just simply not accurate." He stated
that the scope of practice is a very difficult issue. While the
optometrists would like to have uniform licensure, it is a
legislated profession. He referred to a handout in members'
packets titled "Prohibitions and Restrictions on the Practice of
Optometry Checklist," and explained that Alaska would fall into
the second group, which is not a "leap."
4:39:43 PM
DR. BENNETT explained that graduates of optometry school must
complete a series of exams, much like graduates of medical
school. The exams are not widely different from one school to
another, with strict credentials for the minimum number of hours
and required coursework. Additionally, optometrists must take a
series of national board exams prior to receiving licensure. He
said that when he moved to Alaska, the Alaska Board of Examiners
in Optometry required that he have all current portions of the
national board exam, and he took the entire exam over again. He
said "I'm not ... here to tell you that no optometrist ... has
ever made a wrong clinical judgment and had an unfortunate
outcome." He stated that optometrists are very conservative,
and have a "great track record." He pointed out that an
optometrist pays $511 per year, for $1 million worth of
malpractice insurance coverage, while an ophthalmologist pays 38
times this amount. The major optometric malpractice insurance
carrier conducted a study that examined states that have a
limited scope versus those that have allowed a more expansive
scope. This study found that there was no correlation between
the scope of practice and the number of malpractice cases. He
reiterated that optometrists are not "angling to be surgeons."
4:45:40 PM
REPRESENTATIVE RAMRAS expressed concern regarding the amount of
time spent discussing this issue, and stated that he is in
support of this legislation.
4:47:05 PM
REPRESENTATIVE NEUMAN referred to a letter from the Alaska State
Medical Association (ASMA), which states that "No parameters are
provided concerning the educational or post graduate training
criteria that the Board of Optometry would apply." He asked Dr.
Bennett to describe the education and post graduate training
criteria that the [Board of Examiners in Optometry] would apply.
DR. BENNETT replied that this is addressed in the most recent
version of the bill. He surmised, then, that this letter may
refer to the original version of bill.
4:49:05 PM
DR. BENNETT, in response to a question from Representative
Gardner, said that Oklahoma has the "most liberal" scope of
practice, while North Carolina has the "longest standing"
extended scope of practice. He stated that both are among the
states which allow the broadest scope of practice.
REPRESENTATIVE GARDNER, referring to the handout titled
"Prohibitions and Restrictions on the Practice of Optometry
Checklist," pointed out that North Carolina is among the states
that prohibit all drug injections.
DR. BENNETT replied that this information is incorrect. He
offered to contact the board, and shared his understanding that
North Carolina is among the seven states that have very little,
if any restrictions. Injections into the eyeball may be
restricted. He shared his understanding that the information
included in the handout was taken from the internet, and stated
that the information offered by the AOA was gathered from the
various state boards.
4:51:13 PM
REPRESENTATIVE NEUMAN shared his understanding that the House
Health, Education and Social Services Standing Committee added
language regarding the parameters for education and post
graduate training.
DR. BENNETT agreed that this is correct, and reiterated that the
aforementioned concerned individuals must not have seen the
committee substitute that added this language. He then stated
that the survey of state medical boards was done by the Alaska
State Medical Board. Although the ophthalmologists in some
states did not like the expanded scope of practice, no problems
were reported. He commented that the State Medical Board has
nothing to do with optometry.
REPRESENTATIVE GARDNER, referring to Section 3 of the bill,
asked Dr. Bennett to discuss the "physician-patient
relationship."
DR. BENNETT replied that he is "a little puzzled" as to this
language. He surmised that this might be an attempt to restrict
optometrists from selling medication over the internet. He said
that whenever a patient is seen in the office or spoken to over
the phone, this type of a relationship exists.
CHAIR OLSON closed public testimony.
4:54:20 PM
REPRESENTATIVE NEUMAN moved to report CSHB 113(HES) out of
committee with individual recommendations and the accompanying
fiscal notes. There being no objection, CSHB 133(HES) was
reported from the House Labor and Commerce Standing Committee.
4:54:57 PM
ADJOURNMENT
There being no further business before the committee, the House
Labor and Commerce Standing Committee meeting was adjourned at
4:55 PM.
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