Legislature(2017 - 2018)BARNES 124
03/29/2017 03:15 PM House LABOR & COMMERCE
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| Audio | Topic |
|---|---|
| Start | |
| Confirmation Hearing(s) | |
| HB126 | |
| HB142 | |
| HB103 | |
| Adjourn |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
| *+ | HB 142 | TELECONFERENCED | |
| + | HB 126 | TELECONFERENCED | |
| + | TELECONFERENCED | ||
| + | TELECONFERENCED | ||
| += | HB 103 | TELECONFERENCED | |
HB 103-OPTOMETRY & OPTOMETRISTS
4:34:22 PM
CHAIR KITO announced that the final order of business would be
HOUSE BILL NO. 103 "An Act relating to the practice of
optometry."
4:35:03 PM
REPRESENTATIVE IVY SPOHNHOLZ provided a brief reintroduction of
HB 103. She said the bill would give authority to the Board of
Optometry to regulate the practice of optometrists. It would
ensure that the Board of Optometrists would have the opportunity
to update the current and continuing education standards and
scope of practice based on best available evidence. The bill
would not allow optometrists to perform outside of their scope
of practice, for example as in performing surgeries. It would
allow the board to utilize the regulatory process to manage
itself, just as doctors, chiropractors, nurses, and dentists are
regulated.
REPRESENTATIVE SPOHNHOLZ pointed out that current statute, AS
08.72.273, does not allow optometrists to provide invasive
surgeries. She further noted that licensees must submit the
necessary credentials, including the proper experience,
education, and training, to perform procedures that require
approval from the board. Lastly, she pointed out that Assistant
Attorney General Harriet Milks had testified that a robust
process for adopting new regulations already exists and includes
board meetings that are open to the public, a 30-day public
comment period, a Department of Law review period, and a review
from the governor's office. She said that this final point gets
at Representative Josephson's question about "where the buck
stops"; it stops with the governor when it relates to the
adoption of any new regulations.
REPRESENTATIVE SPOHNHOLZ acknowledged that it was the
legislature that developed the statute in question. She stated
that it was her hope that this bill will remove the legislature
from the business of managing optometrists, so they can focus on
other issues they need to resolve, rather than the "eye wars."
She said that the intent of HB 103 is to delegate the "eye wars"
to the Board of Optometry, which is where it belongs. She
pointed out further that the legislature is not a group of
medical professionals, and yet they have been discussing medical
procedures. Such discussions should be held at the Board of
Optometry, just as dental and chiropractic issues are discussed
at their respective boards.
4:39:12 PM
REPRESENTATIVE WOOL asked if there was perhaps an analogy to
this issue in the world of dentists and oral surgeons; such that
there might be one board for dentists and one for oral surgeons.
4:41:28 PM
BERNICE NESBITT, Staff, Representative Ivy Spohnholz, Alaska
State Legislature, on behalf of Representative Spohnholz, prime
sponsor of HB 103, said that she thought Representative Wool was
correct: because oral surgeons are medical doctors, they would
be regulated by a medical board, whereas dentists, she believed,
would be regulated by a board of dentistry.
REPRESENTATIVE WOOL said that if that is the case, then the
situation with optometrists and ophthalmologists is very
similar. He said that he would assume that a dentist would not
have to come and ask the legislature if say he/she wanted to
pull a tooth.
4:42:22 PM
REPRESENTATIVE SPOHNHOLZ said that Representative Wool provided
a good analogy; if dentists wanted to introduce a regulation
that would expand their scope, then the process would occur at a
board of dentistry. She also said that in that process, oral
surgeons, like any member of the public, would have the
opportunity to provide testimony and feedback. Similarly, oral
surgeons could attend any board of dentistry meetings to stay
apprised of new developments.
4:43:10 PM
CHAIR KITO stated that they would now return to public
testimony.
4:43:55 PM
RACHEL REINHARDT, MD, stated that she was testifying on behalf
of The American Academy of Ophthalmologists and its world-wide
membership of 32,000 eye physicians and surgeons. She said that
she was a board-certified ophthalmologist from Washington state.
She stated, "We are asking for your opposition to HB 103." She
stated that the bill was "without a shred of doubt" a "surgery
bill" that would make two very concerning changes to existing
law: removing from existing law the surgery restrictions that
currently exist; and inserting a new definition of the word
optometry in Section 6 that includes the words "treatment" and
"procedures". She said the addition of the word "treatment"
would leave "absolutely no limitations" on the type of
treatment; therefore, any surgeries on the eye would be allowed
under this new law if the Board of Optometry deemed them within
its scope. She said the new definition would allow the Board of
Optometry to redefine itself into a surgical field. She also
said that if proponents of the bill continue to insist that it
is not a surgery bill, then she thinks the bill either cannot
pass or "it needs to be put in writing," because without
specific language Alaska would be the first state in the country
to adopt such broad unprecedented legislation.
DR. REINHARDT said that a number of years ago a similar bill
proposed in Washington state added a definition of surgery that
cleared up the issue, specifically prohibiting an optometrist
from performing surgery. She stated that there are only three
states in the United States that have allowed bills similar [to
HB 103] to pass. In Oklahoma, language in a bill did not
specifically allow surgery, including laser surgery, but it was
never specifically restricted. As such, the Board of Optometry
in Oklahoma interpreted the law to redefine its scope to include
surgery. A study now shows that optometrists in Oklahoma are
causing people harm and increasing healthcare costs.
DR. REINHARDT stated that [the American Academy of
Ophthalmologists] respectfully but strongly disagrees that [the
board addressed under HB 103] is similar to other professional
boards, such as those for nursing, dentistry, and even
engineers. She said that unlike nursing, dentistry, and even
pharmacy, optometry education is not medical education, and it's
not surgical education, yet this bill would allow the Board of
Optometry, which is made up of nonmedical nonsurgical doctors,
to regulate a profession that is nonmedical and nonsurgical.
She said, "This says everything." The statutes and regulations
for the boards of pharmacy, nursing, dentistry, and even
engineering comprise 45-65 pages of Alaska Statutes, yet the
optometry statutes and regulations comprise 12 pages.
DR. REINHARDT said two days ago, an optometrist was heard
stating that insurance companies understand risk. She said that
while she agrees with that 100 percent, committee members should
bear in mind that the Ophthalmic Mutual Insurance Company
(OMIC), the largest insurance company for ophthalmologists in
the country, has essentially come out with a policy stating it
will refuse to insure any ophthalmologist that hires an
optometrist to perform surgery, including laser surgery. She
said that this is the third consecutive year this surgery bill
has been heard, the first time being under Senate Bill 55,
during the Twenty-Ninth Alaska State Legislature. During that
time, she noted, the legislature heard the concerns of scores of
MDs, who were not all ophthalmologists. She implored the
committee to listen to the experts in eye care and "not to leave
the safety of your constituents up to a public comment period or
the assistant attorney general after the fact." Those are not
people that are trained medically. If MDs are having a
difficult time voicing their concerns now, she proffered,
imagine how futile their efforts will be to protect their
patients after HB 103 is passed. She stated there are four
states in the country that don't even allow optometrists to
prescribe oral medication, yet here we are debating (indisc.)
surgery in Alaska. She said HB 103 would be unprecedented, and
it would change the scope for the practice of optometry. She
said that she respectfully asks the committee to vote no;
however, she stated that if the proposed legislation must pass,
then at the very least the definition of surgery should be
added, as it was in other states like Washington, to ensure
public safety. She said that the committee member's
constituents are counting on them.
DR. REINHARDT concluded by mentioning amendment language
regarding the practice and procedures of optometry complying
with acceptable standards, and she said such language would not
resolve the core concern regarding board authority.
4:49:19 PM
REPRESENTATIVE JOSEPHSON asked Dr. Reinhardt whether she had an
opinion on what he described as the apparent conflict between
the two following conditions: passage of a bill with language
stating an optometrist cannot perform any invasive surgery other
than removal of a foreign body; and the elimination of existing
language that says [optometrists] can do assorted things but not
surgery.
4:50:32 PM
MS. REINHARDT said the concern is that when there is conflicting
language in a bill, it is not abnormal for laws to be
interpreted in different ways. The risk is that not defining
the term "invasive surgery" creates loopholes for performing
surgeries. She said she takes issue with categorizing surgeries
as "invasive" versus "noninvasive," because "surgery is
surgery." She explained that surgery involves cutting,
ablating, or altering tissue somehow. She also said that it's
not hard to define surgery, adding that the American Medical
Association has had a definition for decades. She concluded by
saying that the problem lies in not defining the word surgery
[in the proposed bill].
4:51:37 PM
DAVID S. ZUMBRO, MD, Ophthalmologist, introduced himself as an
eye physician, surgeon, and retina specialist in Anchorage,
Alaska. He said that he is also a partner with Alaska Retina
Consultants and a retired colonel from the U.S. Army, and he has
had the opportunity to participate in a training program for
ophthalmologists for five years in San Antonio, Texas. He
expressed his hope that the committee would consider rejecting
or modifying HB 103. He said that while the bill may seem
"innocent and safe," the vagueness of the language would allow
non-physicians and non-surgeons to determine the medical and
surgical procedures they can perform on the eye, which is a real
patient safety issue. He proposed the question of why he should
still be worried about procedures when it has been said the bill
is not about surgery and optometrists will not perform surgeries
they are not trained to perform. In response to his question,
he stated that an optometrist in Alaska told him that they are
planning to help with eye injections. He said that looking
around the country we see multiple states which have similar and
current legislation, some of which are worded more directly.
All of these are associated with expanding the scope of practice
for optometry into surgery.
DR. ZUMBRO said that the reason he is worried about patient
safety is because the "optometry curriculum" does not provide
the training for optometrists to perform surgery, gives
injections, and operate lasers, let alone regulate such
activity. He stated that with any procedure there is a
difference between knowing what to do and how to do it safely,
and the hardest thing for a surgeon to learn is when to step
back and not do something. As in any profession, where a person
is young and eager to serve, inexperience sometimes interferes
with proper judgement. He said that all one must do is look at
the ophthalmology curriculum to understand the "gold standard"
for training eye physicians and surgeons. He asked for the
evidence optometry has produced to show their curriculum is
equivalent to the gold standard.
DR. ZUMBRO stated that he has no problem with the Board of
Optometry regulating the optometry profession. Notwithstanding
that, he stated that while it has been said that the Board of
Optometry will hold public testimony for any procedure, that is
what is being done now, and he opined that if eye surgery is
being discussed, then it would make sense that the current
board-certified eye surgeons should participate in the
discussion. Dr. Zumbro questioned how it could be logical for
non-physicians and non-surgeons to regulate eye surgery. He
stated that the antidote to this argument is simple: if the
optometrists wish to practice medicine and surgery, then they
should be regulated by the medical board, as it is with
podiatry. If this is unpalatable, then Alaska needs an eye
surgery amendment just like Washington, Arizona, and Florida.
He said HB 103 is not a simple housekeeping bill, as it would
redefine optometry into a surgical profession, and this makes
for legitimate patient safety concerns.
4:54:34 PM
CARL ELI ROSEN, MD, Ophthalmologist, specified that he is an
ocular plastic surgeon and neuro-ophthalmologist. He said that
he interfaces with neurology and neurosurgery with regard to
patient diagnosis and treatment. He said that he "takes care
of" bumps and cysts on eyelids and has performed over 15,000
surgeries on eyelids for folks with eyelid and cornea
abnormalities, cancers, reconstructions, trauma, et cetera. He
said he has been in practice for 23 years with Ophthalmic
Associates in Anchorage and has taken emergency calls
voluntarily. He said he is a past president with the Alaska
State Medical Association.
DR. ROSEN indicated that he had been confused by what he heard
at the committee's previous hearing on HB 103, on Monday, March
27, 2017. He pointed out that at that meeting, Dr. Dobson had
said that the bill was not about surgery and that optometrists
have no business performing surgery and do not want to perform
surgery. He said the prime sponsor of HB 103 and her aide had
stated that the proposed bill is not about surgery, and all
surgery language was removed from the bill. He went on to point
out that during that meeting, Dr. Matheson had testified that
she had been doing surgical procedures for 30 years, removing
eyelashes and foreign bodies from the cornea. He reminded the
committee that Dr. Christianson said that he drains sties.
Further, he had heard that optometry removes fish hooks from
eyes. He said that he also heard that as times change, scope of
practice must be modernized by the Board of Optometry; should a
surgical procedure be deemed within the scope of practice by the
board, it won't want to come back to the legislature. He also
recollected that the attorney general had stated that public
testimony would help decide if surgery was appropriate for an
optometrist.
DR. ROSEN asked, "Doesn't that bother any of you? Not only
would there be no one with actual surgical experience on this
board, but you're going to double down and ask the public for
help?" He answered his own question by emphasizing that an
expert - someone with actual experience - should be consulted,
because "the stakes are far too high." He said that while it
seems so innocent for someone to say that they'll remove a
foreign body or drain/inject a sty or a cyst, there are serious
situations that might arise under those circumstances,
including: when a foreign body is full thickness and results in
a leaking, open globe; when a drained sty results in lid
retraction, and the patient can't close the eye; or when
infection and necrosis of the eyelid results, requiring a full-
thickness skin graft.
DR. ROSEN stated that (indisc.) boards and nurse practitioner
boards police themselves because of the procedures learned in
graduate school. He said that optometry students do not perform
surgery, operate lasers, or administer injections. He
questioned why [someone without sufficient training] would be
allowed to put a needle into an eye with macular degeneration,
for example. He warned that if something is said enough, it
becomes reality; therefore, he is asking folks to wake up and
think about what is being said here [in this process].
DR. ROSEN said an article, dated July 2016, in the Journal of
American Medical Association (JAMA) states that health policy
making should be cautious with approving laser privileges for
optometrists. He said that optometrists do not take hospital
emergency calls or (indisc. -- overlapping voices). He said
that optometrists cannot transfer or admit patients to the
hospital as bylaws do not allow this. He remarked that people
like to plan for the unknown by buying fire and earthquake
insurance, even though it is unlikely they will ever use it. He
then asked why anyone would be willing to risk patients' safety
based on the words "trust us." He emphasized the need to set
boundaries and consequences. He said, "Let's fix this all with
a definition of surgery and we can all go home." Dr. Rosen
concluded, "At some point in your lives you will need an
ophthalmologist. Do you want to continue to alienate and
marginalize the Alaskan ophthalmology community? As it stands
it is difficult enough to recruit new ophthalmologists to
Alaska. This bill only makes it more so."
4:58:28 PM
ERIC COULTER, MD, Ophthalmologist; Medical Director, Alaska Eye
Surgery and Laser Center, stated that the last testimony in
favor of HB 103 expressed nebulous reasons why [optometrists]
require HB 103, except "to modernize and be more able to manage
themselves." He mentioned the testimony of Dr. Rosen and the
questions of why ophthalmologists should get into a conflict
over a nonsurgical issue. Dr. Coulter stated, "We agree that
they are good and great optometrists, but we disagree that that
group is ready, now or in the future, to be great surgeons, and
despite what they say, this is a surgical bill. ... Unless
self-governance is dependent upon expanded scope of practice and
surgical privileges, this really doesn't have anything to do
with self-governance."
DR. COULTER said there is ample evidence that HB 103 is "a
surgical-oriented bill." He noted that the original bill
version would have, under AS 08.72.050, required the Board [of
Optometry] to adopt regulations "describing the scope of
practice for a licensee to perform ophthalmic surgery and
noninvasive procedures"; however, that language was subsequently
removed from [CSHB 103(HSS), the version that passed out of the
previous committee of referral], as a result the legislature
receiving "overwhelming concern about optometrists performing
surgery." He said this is a moot point, because the current
version would define "optometry" under AS 08.72.300 as "the
examination, evaluation, diagnosis, treatment, or performance of
preventive procedures related to diseases, disorders, or
conditions of the human eyes or adjacent and associated
structures, consistent with this chapter and regulations adopted
by the board". He said this language removes restrictions
related to the use of lasers or performing surgery. He said he
does not see how this change in the definition of optometry is
going to enhance the ability to self-regulate.
5:02:20 PM
DAVID KARPIK, OD, introduced himself as a residency-trained and
board-certified Doctor of Optometry testifying in full support
of HB 103. He said that he and his wife are partners in a four-
doctor, two-location practice that provides the majority of eye
care on the Kenai Peninsula. He said that he is also the
medical director for the Vision Source Network in Alaska,
representing 18 private optometry practice locations scattered
throughout the state, many of which are remote and rural. He
said that some of the opposing testimony has indicated that all
optometrists' training occurs within the statutorily required
continuing education but neglects to mention the thousands of
hours of training on the human body for the diagnosis and
treatment of eye disease that optometrists receive during their
4 years at optometry school, post graduate residency, and
additional maintenance requirements for board certification,
which are well beyond the statutory requirements.
DR. KARPIK said that Doctors of Optometry have a long history of
providing quality, conservative care and practicing within the
limits of what they are highly trained to do. Non-
ophthalmologist medical doctors, osteopaths, and nurse
practitioners are not statutorily restricted from performing any
eye treatment or surgery. The average medical student receives
about two weeks in an ophthalmology rotation, yet they safely
perform eye treatment within their training and comfort level
and refer the balance often to optometrists in their small
communities, like himself.
DR. KARPIK said that a U.S. News & World Report study published
this month ranked Alaska last in access to health care. Today
[the legislature] has an opportunity to change that alarming
statistic by creating a statute that will be durable and allow
incorporation of new technology as it is developed, provided
that training is certified. He said all healthcare providers
need to practice to the extent of their training, which he added
is provided at great cost to tax payers whose tax dollars
support optometry schools at state universities, hospitals, and
VA hospitals.
DR. KARPIK said that he supports the proposed bill because it's
simple and would replace the rigid and aging current optometry
law with one that would match the laws for other prescribing
professions like dentistry and advanced practice nursing, which
are also regulated by state boards. He said that as regulation,
technology, and research continue to change best practices,
regulation by an optometry board appointed by the governor and
confirmed by the legislature ensures protection of the public
with timely updates in practice, and that allows for optimum
access to eye care for Alaskans.
5:05:15 PM
ALFRED DERAMUS, MD, Ophthalmologist, stated, "It is well
understood by both sides that the issue of surgery and the
definition of surgery is the lynchpin for the continued need for
us to go back to the legislature and be very specific about the
definition." He said that both sides have tried to talk about
performing and not performing surgery, but that this does not
ring true to him. He said that the definition of surgery is the
incision and the alteration of tissue. He opined that
optometrists are doing a very good job in optometry, and the
surgeons - the ophthalmologists - are doing a very good job at
what they do. He emphasized the need to provide a clear
definition of surgery in statute, because "... just like water
goes through small cracks, we are very concerned that surgery
will be performed by the optometrists if there's a small crack."
5:07:21 PM
REPRESENTATIVE WOOL recollected that the definition of surgery -
possibly with a laser - that he had heard from other
ophthalmologists that testified is to cut, ablate, or alter
tissue. He asked Dr. Deramus if this is correct.
DR. DERAMUS answered that the definition was "getting close,
yes." He added that if laser energy is applied to tissue, then
there would be no question that tissue would be altered.
REPRESENTATIVE WOOL asked if that would qualify as surgery.
DR. DERAMUS responded that it would qualify as surgery, because
laser trabeculoplasty affects the tissue in a fashion that
causes contraction and movement of the microstructures, which
increases outflow; therefore, that is surgery.
REPRESENTATIVE WOOL asked if having a tattoo removed with a
laser would fall under the same definition.
DR. DERAMUS said, "Yes, I'm sorry, you walked right into that
one, it sure does." He offered further details.
5:09:28 PM
ELIZABETH MORGAN, MD, Ophthalmologist, introduced herself as a
board-certified ophthalmologist who also has a fellowship in
glaucoma. She said that she has heard repeated testimony
regarding how "self-legislation" by optometrists could "easily"
result in increased scope of care for optometrists. She said
that this precedent has been set in Oklahoma. She cited
information from JAMA, dated October 2016, which looks at the
difference in outcomes in the use of lasers for glaucoma
performed by optometrists versus ophthalmologists. She said it
was a very powerful study, as there were 13,084 eyes included in
it. She said the study discovered there were more than two
times the number of repeat laser surgeries performed by
optometrists. She said the potential explanation for this is
ominous, because it indicates that either optometrists are not
performing laser surgery correctly or they are repeating the
laser surgeries as an effort to increase reimbursement, which is
an issue with cost containment in healthcare today. Dr. Morgan
acknowledged that she was repeating a lot of what had already
been said, but as a glaucoma specialist wanted to bring these
details to light. She said she would like to work together with
optometrists and ophthalmologist but thinks it is very important
to "come up with a definition of surgery so that we may continue
to do that for the people of Alaska."
5:11:33 PM
JEFF GONNASON, OD, Legislative Chair, Alaska Optometric
Association, stated that he has served under the state optometry
board under two different governors and has been testifying on
this issue for over 40 years in Alaska. He said that every one
of the ophthalmologists and medical organizations that have
testified on this issue for the past 40 years have the same two
demeaning arguments: optometrists are a danger to the public,
and optometrists' education is not adequate. He stated that
both of these statements have been proven patently untrue.
DR. GONNASON, regarding the claim that optometrists are a danger
to the public, stated that public safety has never been an issue
in over 40 years of expanding scope of practice. He said he is
not aware of a single case before the board involving harm from
any optometrist's treatment or drug prescription, and this is a
wonderful record for Alaska. He pointed out that Dr. Lindstrom
commented on the current statute's 4-day supply limit on
narcotics, as described in Sections 4 and 5 of HB 103, and he
stated that this restriction would be kept in regulation by the
board. He said that "optometry" strongly agrees with the new
push to limit narcotics by all providers, and optometry in
Alaska has a 10-year history of prescribing narcotics without
issue; therefore, this part of the bill is not an issue. He
said that optometrists began using eyedrop drugs in the U.S. in
1972, but it was 16 more years before Alaska became the fiftieth
and last legislature to approve this practice. He added that
this was a result of the same arguments of danger and poor
training. He said that he would not be able to give eyedrops to
a child in Yakutat that had pinkeye, even though the health aide
with only a few weeks of training could do this. He said that
Alaskans suffer and pay more when educated providers cannot
utilize their skills.
DR. GONNASON, regarding inadequate education, said that the
education model is identical to dentistry with 8-10 years of
university study. He said that optometrists are not like
technicians; they are real doctors receiving a bachelor's degree
followed by a four-year doctoral program, which first includes
two years of sciences, then two years of clinical experience,
which is followed by the requirement of having to pass state and
national boards. He added that many optometrists take on
additional residencies. He said that optometry and dentistry
schools are similar to medical schools during the first two
years of sciences, stating that optometry and medical students
often train together and have the same professors. He said that
the second two years of clinical are different: Because medical
students must cover the entire range of the body, more clinical
time is spent on the priorities of heart disease, cancer, and
stroke; in comparison, optometry students cover systemic
diseases, diabetes, hypertension, and brain tumors to make the
appropriate referrals.
DR. GONNASON said that his final comment pertains to the scare
tactic regarding surgery. He said optometrists do very little
of the work of ophthalmologists and that optometrists perform
none of the advanced specialty surgeries of the subspecialists,
who have testified. He said that optometrists perform only the
minor procedures for which they are fully competent. He went on
to say that the reason surgery cannot be well defined in statute
is because, technically, anything touching human tissue is
surgery; including clipping fingernails, tattooing of eyelids,
and piercing metal through parts of the body. He said that if
the legislature tries to define surgery in statute, it will end
up with the problem that exists in other states, where they have
long lists of everything that can and cannot be performed. He
stated that having to return to the legislature is the main
problem. He indicated there is always opposition from
"organized medicine." For example, there was opposition to
Alaska's advanced practice nurses, whom Dr. Gonnason opined
provide a "magnificent" service to Alaskans. He asked the
committee to please note the support letters from Southcentral
Foundation, other native health organizations, and Dr.
Castillo's letter, which "aren't, you know, on either side of
this." He said optometrists in Alaska provide the majority of
eye care at lower cost; therefore, he would thank the committee
for [supporting] better eyecare access for Alaskans.
5:15:50 PM
CHAIR KITO, after ascertaining that there was no one else who
wished to testify, closed public testimony on HB 103.
CHAIR KITO announced that HB 103 was held over.