HB 103-OPTOMETRY & OPTOMETRISTS  3:49:32 PM CHAIR SPOHNHOLZ announced that the final order of business would be HOUSE BILL NO. 103, "An Act relating to the practice of optometry." [In front of the committee was the proposed committee substitute for HB 103, Version D.] 3:49:57 PM BERNICE NISBETT, Staff, Representative Ivy Spohnholz, Alaska State Legislature, paraphrased from the sponsor statement [Included in members' packets] which read: HB 103 modernizes and updates the Alaska Optometry Statute, as many parts are over 50 years old. It allows the optometry board the authority to regulate its practice the same as other prescribing health professions such as dentistry, medicine and nursing. This bill also allows the board to continue to adopt regulations, updated to current practice and moves the continuing education (CE) requirements back into regulations. Continuing education is still required by current statute, but the hours and subjects will be determined by the board as with other professions. This change allows the board flexibility to control CE requirements and is recommended by the Department of Commerce, Community and Economic Development. The current regulations require more CE hours than the statute subsection deleted by this bill. HB 103 allows the optometry board to determine prescribed drug schedules, including standards and limitations on practice determined by the board. The bill ensures that no licensee may perform any procedure beyond the scope of the licensee's education, training, and experience as established by the board. This allows for future new and improved diagnostic and therapeutic procedures as determined by the board, while not having to return to the legislature for every new technological advance, which is currently the case and unnecessarily burdensome. The optometry definition in this bill is updated to reflect current and modern-day practice. MS. NISBETT paraphrased from the Sectional Analysis [Included in members' packets], which read: Section 1 AS.08.72.050 (4)(6) updates very old statutes to indicate that regulations shall be adopted to govern the current prescription and use of pharmaceutical agents; and develop uniform standards for the practice of optometry. Section 2 AS.08.72.060 (c)(4) the board shall publish advisory opinions regarding standards for the practice of optometry. Section 3 AS 08.72.181(d) moves the continuing education (CE) requirements back into regulation, as desired by the Department of Commerce, Community and Economic Development. Continuing education is still required by current statute, but the hours and subjects will be determined by the board. Section 4 AS 08.72.272(a) clarifies the current statute for the board to regulate pharmaceutical agent prescription including standards and limitations on practice determined by the board. Section 5 AS 08.72.278 Limitation on practice adds a new section that sets limitations on services, ensuring that the board may not authorize any procedure beyond the scope of the licensee's education and experience. Section 6 AS 08.72.300(3) updates the optometry definition to reflect current practice. Section 7 Effective date for Section 2. This is because (3) of Section 2 was added to statute in 2016 via Senate Bill 74, the Medicaid Reform bill, and it had the effective date of July 2017, so (4) is written to comply with that date as well. (per Legislative Drafting) 3:52:17 PM CHAIR SPOHNHOLZ opened public testimony. 3:52:44 PM JILL GEERING MATHESON, OD, reported that she was a practicing doctor of optometry and that she had testified numerous times before legislative committees in support of changes to the optometry statute over the last 25 years. She explained that those statutes had allowed doctors of optometry to safely practice to the level of their training and education. She asked for support to proposed HB 103, explaining that the state boards and commissions were appointed and confirmed by the Alaska State Legislature to represent the people of Alaska in these areas of expertise. She explained that the state chose to set up separate boards for each medical profession because each profession was unique and the oversight needed to be handled by the members of that profession. She noted that the approved statutes were very broad for the medical board, the dentistry board, and the Board of Advanced Practice Nurses, and that these boards could autonomously manage their respective professions within the law in an honest, safe and responsible manner. She pointed out that the optometry statute, however, was too complicated and restrictive. Proposed HB 103 would allow the State Board of Examiners in Optometry to have the same autonomy as the other boards. She assured the committee that, as a past president of the state optometry board, the board acted with the same level of professionalism and safety as the aforementioned boards. She reiterated that the proposed bill was not about eye surgery, even though doctors of optometry had performed minor eye surgery for many years. They were trained in depth for these procedures, which were routine within the scope of practice. She declared that she would no more perform an eye surgery that she was not trained for than any other profession. She offered her belief that all professions, including optometry, must evolve and there was no way to predict what tools and options a doctor of optometry would need in 20 years to protect or cure the vision of a patient. She stated that the proposed bill allowed the profession to evolve and make the necessary changes. HB 103 allowed doctors of optometry in Alaska to operate with the same autonomy, respect, efficiency, and oversight as the other professional health care practitioners were granted. REPRESENTATIVE SULLIVAN-LEONARD asked about the minor surgeries performed by optometrists. DR. MATHESON explained that the most common surgery was for removal of a foreign body, and that these had been approved and authorized for almost 25 years. REPRESENTATIVE TARR offered her belief that practitioners should be authorized to practice to their full scope and be regulated by peer professionals. She stated her support for the proposed bill. She said that regulations would be drafted, which would be followed by a public comment period when professionals could speak out, and if there was anything questionable, the process would reveal any problems. DR. MATHESON expressed her agreement that any complaint brought to the board would be investigated, and there could be a vote to see if there should be a sanction on an optometrist. She said that the legal process would also be started. She stated that there had not been any sanctions against optometrists during her 8 years on the board. REPRESENTATIVE TARR asked if the regulations were available for public comment. DR. MATHESON expressed her agreement, and explained that after the regulations were set, they went to Department of Law to ensure they met the law, went out for public comment, and were again voted on by the board. REPRESENTATIVE EASTMAN stated that the investigation process could be very costly, even if they did not result in sanctions. He asked if there was any hesitation due to the potential of an increase to liability cost. DR. MATHESON replied that she was not aware of any opposition from optometrists for that reason, and she explained that this could lead to an increase in licensing fees at a later time. She offered her belief that optometrists and the board were all "a pretty conservative bunch." CHAIR SPOHNHOLZ pointed out that Dr. Matheson was a practicing optometrist and not necessarily an expert on the operations of the board. REPRESENTATIVE EASTMAN asked why the optometry board was not currently treated like the other boards. DR. MATHESON offered her belief that this had just been a matter of time, and, as other parts of the statute had been cleaned up, this was now the final stage. 4:04:01 PM HARRIET MILKS, Assistant Attorney General, Commercial and Fair Business Section, Civil Division (Juneau), Department of Law, said that she represented professional licensing boards. REPRESENTATIVE TARR asked about the process. MS. MILKS, in response, said that the board typically drafted the proposed regulation, and it often took time to determine the language which represented the inclination of the board. Then, the proposed regulation went out for public comment. It could go out more than once for public comment and for more than 30 days. She noted that, based on public comment, the board could revisit the regulation, and if there were substantial changes, it would again go out for public comment. She acknowledged that the transparency of this process could sometimes frustrate the public for the amount of time necessary to adopt a regulation. She added that the board did discuss the scope of practice. She said that typically the health care related boards met at least two or three times each year, and that the public was always advised. 4:08:09 PM RACHEL REINHARDT, MD, American Academy of Ophthalmology, reported that she was a board-certified ophthalmologist. She stated her opposition to proposed HB 103. She said that the primary goal of any legislation involving medical care was for patient safety. She stated that HB 103 removed the existing surgery restrictions, and would redefine the field. She asked that it be clearly specified in the law that surgery was outside the scope of practice for optometry. She said that without specific language to restrict surgery, Alaska would be the first state to adopt such broad unprecedented legislation. She suggested that the definition of surgery be added to the proposed bill, and that surgery be expressly prohibited. She noted that the Board of Optometry could still govern its own profession, even though surgery was prohibited. She offered an example of the lack of restrictions under the Oklahoma law. She said that a major study released in July 2016 had data which concluded that optometrists doing laser surgery in Oklahoma were causing patient harm and increasing health care costs. She stated that the proposed bill would result in unprecedented sweeping change in the practice of optometry, with profound implications for patient safety. She said that, at the very least the proposed bill needed a definition of surgery to ensure public safety. She made the distinction that optometry school was not a medical education or a surgical education, as the students received approximately one tenth of the clinical hours. She concluded by stating that prescription narcotic death was the leading cause of unintended death in the country, and that HB 103 would allow optometrists to prescribe these narcotics. She declared that this was not the time to expand who could prescribe these medications. REPRESENTATIVE TARR said that there was a challenge from a shortage of providers in every area of health care in Alaska. She suggested that the proposed bill offered an opportunity for trained professionals to meet this need for health care. She relayed that the optometrists wanted to continue with the things they had already done for the past decade. DR. REINHARDT relayed that there were 26 ophthalmologists in the State of Alaska and that the State of Washington had a similar ratio of ophthalmologists to the population. She acknowledged that the Alaska population was spread over remote areas, though she stated that the State of Washington had patients in remote areas, as well. She said that it was important to note that ophthalmologists had a responsibility for patient safety. She suggested that there was a nationwide trend of optometrists introducing vague bills with the intention of expanding the scope to include surgery. REPRESENTATIVE JOHNSTON asked about the committee substitute which had removed the reference to surgery. DR. REINHARDT explained that the committee substitute did not change Sections 5 and 6, which offered new definitions for optometry, which inserted language for treatment or performance of preventive procedures. She stated that the inclusion of treatment opened the door for any treatment modality to treat any and all eye diseases, and it included surgery. She deemed that the crux of the issue was that the new definition of optometry could be interpreted to include all surgeries. 4:17:41 PM VICTORIA BLOWER, OD, Optometrist, shared that she had been in optometric practice in Anchorage for 32 years. She stated her support for HB 103. She reported that technology and best practices had advanced to allow for superior medical care, which included eye care. She pointed out that the statute governing the optometry board was more than 40 years old and did not allow for reaction to the rapidly changing environment without repeatedly going to the Alaska State Legislature for action. She noted that the protocols had been extended to protect the public. She shared her respect for the Board of Optometry. She said it was unfair and a waste of resources to prevent optometrists from providing care at the highest level of their education and training, as this did include knowledge about the entire body. She pointed out that, as so much of Alaska was rural, most of the eye care was administered by the more than 150 optometrists serving in 80 communities. She directed attention to a letter of support from the CEO of the Southcentral Foundation. She expressed her objection to the argument that optometrists could not be trusted to have sound judgement about their skills and training, thereby not acting in the public's best interest. She offered examples about other medical professions working within their education and training. She stated that HB 103 would modernize the statute and allow detailed legislation to be determined by the optometry board, as was the current standard in all other prescribing professions in Alaska. It would also streamline the legislative governing process and bring the best practices to the residents of the state in a cost-effective manner. 4:21:43 PM KARL ROSEN, MD, Ophthalmologist, voiced his strong opposition to the proposed bill. He reported that he had been in practice for 23 years in Anchorage. He shared his educational background. He declared that the proposed bill was the most expansive scope of practice bill in the country. He said that the bill dismissed the rigorous training of an ophthalmologist. He offered his belief that the optometry board, a group of non- surgeons, was going to decide which potential surgical privileges would be allowed. He suggested to correct the proposed bill by providing an amendment with a definition of surgery. He declared that the optometry board already had the ability to regulate its profession. He shared an article which refuted the statement that more optometrists doing procedures would cut costs, and he directed attention to a study which determined that more than twice the number of eyes were re- treated after laser surgery by optometrists versus ophthalmologists. He stated that health policy makers should be cautious about approving laser privileges for optometrists. He pointed out that optometrists did not take hospital calls and did not have hospital privileges, and if a complication occurred, there would be the need to transfer patients to a hospital. He declared "you can't get good doing a couple of procedures a year." He said that insurance carriers would not accept CPT codes by optometrists. He declared that, should all privileges be made similar, then there needed to be an equally strong legislative effort to ensure that all aspects of school, training, and continued competency were also similar, or it would become a two-tiered system for patients. He declared that the proposed bill would make it difficult to recruit new ophthalmologists to Alaska. REPRESENTATIVE KITO asked how much of his educational study and experience provided for vision and eye, or was most of it just medical. DR. ROSEN explained his education and background, which included three years of ophthalmology residency of more than 110 hours each week. He stated that it was not a job, it was a lifestyle, a culture. He shared that studying at a major medical center included interaction with the other colleges and allowed for better communication with the other areas of medicine. REPRESENTATIVE TARR said that she shared the concern for surgeries by properly trained individuals. She mused that, if the Board of Optometry wanted to propose regulations allowing performance of Lasik surgery, those regulations would be opened for a public comment period. She offered her belief that those with views similar to Dr. Rosen would speak out in opposition. She said that she did not see the circumstance to which he was worried actually happening, as it would not make its way through the public process. DR. ROSEN replied that this was an ideological question and he asked if optometry was being redefined. He said that there had been a change in the past 10 years, and that optometry wanted to be something else. He stated that there had been a process for standardization in the American Medical System since 1910. REPRESENTATIVE TARR reiterated that she could not see a circumstance where this would happen. DR. ROSEN said most providers followed their oath, although he was there to protect the public from the outliers. He reminded that there was method in place for licensing. 4:33:23 PM ALFRED DERAMUS, MD, Ophthalmologist, stated his gentle opposition to the proposed bill. He said that this was the latest legislation on which he had been testifying since 1982. He said that the ophthalmologist purview for the definition of surgery was different than the definition of surgery by optometry. His problem was that the proposed legislation left an opening for interpretation that treatment for all eye disease could include surgery. He declared that "we should be very, very careful about this bill." He emphasized that ophthalmologists were concerned that optometrists would perform ophthalmic surgeries and be protected by the definition. REPRESENTATIVE JOHNSTON asked what type of surgery would be performed by optometrists. DR. DERAMUS replied that the definition was open ended, and he offered an example for the removal of a superficial foreign body versus a deeply imbedded foreign body in the cornea. CHAIR SPOHNHOLZ referenced the earlier testimony regarding the regulatory process for changing regulations around the practice of optometry and asked if he was concerned that there would not be the opportunity to testify and for those concerns to be put on the record. DR. DERAMUS expressed his agreement that he would be allowed to testify, and, in response to Chair Spohnholz, that he was aware that the meetings of the Board of Optometry were all public. He replied that he had only testified on one occasion regarding various optometric bills, and that he had found that, regarding the experience, he had been able to present his point of view and have it weighed by the board. In further response to Chair Spohnholz, he said that he had always been treated respectfully by the board. REPRESENTATIVE TARR reiterated that she could not see the circumstance whereby optometrists were given the authority to perform procedures that offered concern to ophthalmologist. She stated that there were "bad actors that are in the provider community whether it be for dental care or physical therapy or other areas." DR. DERAMUS said that the reality of life goes far beyond the written or spoken word. He said that the pain of experience from a surprise was "where you really find out where you stand." He offered an example for a seemingly minor accident. CHAIR SPOHNHOLZ asked if he was suggesting that an optometrist might try to treat this incident in an emergency room. DR. DERAMUS replied that he did not believe that an optometrist would be in the operating room because they did not have admitting privileges. 4:45:43 PM DAVID ZUMBRO, MD, Ophthalmologist, shared his background as a retina surgeon. He offered his belief that the proposed bill "radically redefines optometry" as optometry did not have any procedural background in its training or practice. He stated that the proposed bill removed the prohibition against lasers in surgery. He declared that there was a difference between optometry and ophthalmology. He offered an example of some co- workers who were optometrists and had gone back to school for ophthalmology. He stated that they were not given any credit by the medical school for their doctor of optometry degree. He offered his belief that the regulations had changed in 2008 when prescriptive authority advanced the scope of the optometry practice. The proposed bill was too vague and open ended, as it removed the specific prohibition against lasers in surgery and allowed non-physicians to regulate the practice of surgery. He declared that the focus of any health care issue should be patient safety. CHAIR SPOHNHOLZ asked where the legislation changed the scope of practice. DR. ZUMBRO explained that the removal of the prohibition against lasers in surgery and the allowance for the treatment of eye conditions were worrisome, as it would allow optometrists to expand the scope of practice. CHAIR SPOHNHOLZ stated that the proposed bill did not remove any limitations, but only added language for the opportunity to use pharmaceutical agents for the treatment of eye disease and develop uniform standards for the practice of optometry. She said that it rescinded the limitations on the amount of education, as the continuing education requirements had already been expanded. DR. ZUMBRO suggested that an amendment defining eye surgery would offer clarity for all the parties. 4:50:30 PM PAUL BARNEY, OD, Chair, Board of Optometry, reassured the committee that the board did not have the authority to write regulations for anything that optometrists did not have the education to do, and that the purpose of the board was to protect the public. In response to Representative Tarr, he said that he supported the bill. 4:52:17 PM ELIZABETH MORGAN, MD, Ophthalmologist, said that she had practiced in Anchorage for almost 14 years, and that she worked closely with optometrists, especially in working with glaucoma patients. She lauded the relationship and stated that the proposed bill created a divisive force between the two practices. She said that ophthalmologists took eye care of individuals very seriously and they were adamant if there was something that threatened the patient's best interest. She offered her belief that the problem with the bill was that the language was "a bit open ended." She suggested that the two groups of providers arrive at a common definition for treatment that was in the best interest of the patient. REPRESENTATIVE JOHNSTON asked for that definition for treatment. DR. MORGAN offered her belief that both sides needed to agree on the definition of surgery. 4:56:01 PM DAVID KARPIK, OD, stated that he was an optometrist and his group provided the majority of eye care on the Kenai Peninsula. He reported that he was also the medical director [indisc], and that these practices offered similar comprehensive eye care services and worked in conjunction with other primary care providers. He declared that this model was cost effective and in the patient's best interest. He stated that optometrists practiced in small communities throughout Alaska and had a long history of compassionate conservative care. He referenced a recent study which reported that Alaska was last in access to health care, and that this was an opportunity to help change that alarming statistic. He said that all health care providers practiced to the extent of their ever-evolving training. He declared that optometrists have had full prescribing privileges for 10 years. He pointed out that optometrists had been safely performing procedures for decades, noting that they had training on the entire body. He said that some schools duplicate medical and dental courses for the first few years of the program. 4:59:26 PM ERIC COULTER, MD, Ophthalmologist, referenced a letter that he had sent to the committee, and shared that he had good relationships with optometrists. He stated that privileges were delineated through hospitals and surgery centers and were outlined by law. He expressed his concern that the optometric community would not let the public know the differences in medical training. He declared that the proposed bill needed a definition of surgery. 5:02:17 PM ERIK CHRISTIANSON, OD, Optometrist, said that he was the only full-time eye care provider in the community. He suggested that the proposed bill was modernizing language to allow the profession to move forward and regulate similar to other health care providers. He said that the goal was to work as effectively as possible, and that there were a variety of little procedures that could be done often enough to be good. He expressed his concern for the rural communities to get qualified health care providers, and, unless there was the ability to practice to the level of training, it would be difficult to attract them. 5:04:28 PM CHAIR SPOHNHOLZ closed public testimony. 5:04:51 PM CHAIR SPOHNHOLZ stated that the proposed bill was introduced to modernize the way optometry was managed in Alaska, as it was the only health profession in the state where it was necessary to visit in statute every time a small change was made to education or scope of practice. She pointed out that things changed more rapidly than the legislature could move. She offered her belief that there were enough tools in the regulatory process to allow for robust public participation and opportunities for concerns to be expressed and to ensure that the Board of Optometry would not "go rogue." She added that the proposed bill would get the legislature out of the business of micromanaging optometrists. She shared a personal story of an eye surgery performed by a local optometrist. She offered her belief that it was best to not define "surgery" in statute as it was a complex and broad term. She shared that it was very difficult to arrive at a definition of "surgery" which met all the criteria. She suggested that it was best to let the regulatory process work. She said that best management practices were to delegate authority to the lowest possible level, and allow those professionals the opportunity to perform their work. She lauded the "robust regulatory process as it related to the way that board regulations were adopted." REPRESENTATIVE JOHNSTON asked how the board for chiropractors regulated in Alaska. MS. MILKS, in response, explained that the Board of Chiropractic Examiners was managed with the same legal advice from the Department of Law as the other boards. She stated that an Assistant Attorney General was assigned to advise in both board procedure and procedure for constructing and adopting regulations, and that sometimes the Assistant Attorney General would attend the board meetings. REPRESENTATIVE JOHNSTON asked if there was a similar process for change which required bringing proposed changes to the Alaska State Legislature. MS. MILKS replied that all the boards were under the Administrative Procedure Act (APA). She explained that the APA set out the procedures for adopting regulations and having hearings, and that all the boards were under the APA and followed the same rules with respect to adoption of regulations. REPRESENTATIVE EASTMAN shared that the board of chiropractors were very proud of their process, as they had pursued some unique approaches to their profession. He expressed his hope that the Board of Optometry would review this example. He asked whether an expanded scope for optometrists would result in fewer ophthalmologists. CHAIR SPOHNHOLZ emphasized that she did not, as the sponsor of the proposed bill, introduce the bill because of the unique nature of the state. She said that this was a response to a comparison of the State of Alaska to the State of Washington by an earlier testifier. She declared that the intent of the proposed bill was not to expand the scope of the Board of Optometry, but instead to delegate discussions regarding the practice of optometry to the Board of Optometry, rather than having it done in statute on an annual basis. REPRESENTATIVE TARR said that she would have concerns if the regulations allowed for optometrists to perform eye surgery. She offered her understanding that this was beyond the scope of practice, and she could not see a circumstance in which this would be the result. She declared that there were many barriers to expansion of specialties. She opined that with the limited number of providers it was necessary to take the opportunity to allow practice to the full scope of training. She added that the health care fields were always evolving, and she stated her support of HB 103. 5:15:41 PM REPRESENTATIVE TARR moved to report CSHB 103, Version 30- LS0459\D, Bruce, 2/21/17, out of committee with individual recommendations and the accompanying fiscal notes. There being no objection, CSHB 103 (HSS) was moved from the House Health and Social Services Standing Committee.