Legislature(2011 - 2012)
02/28/2011 03:28 PM House L&C
| Audio | Topic |
|---|---|
| Start | |
| HB122 | |
| HB155 | |
| Adjourn |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
HB 122-NATUROPATHS
3:28:26 PM
CHAIR OLSON announced that the first order of business would be
HOUSE BILL NO. 122, "An Act relating to naturopaths and to the
practice of naturopathy; establishing an Alaska Naturopathic
Medical Board; authorizing medical assistance program coverage
of naturopathic services; amending the definition of 'practice
of medicine'; and providing for an effective date."
3:29:08 PM
KENDRA KLOSTER, Staff, Representative Cathy Munoz, Alaska State
Legislature, on behalf of the prime sponsor, explained that HB
122 would establish a Naturopathic Medical Board consisting of
three naturopaths, one pharmacist, and one public member, who
may also be a licensed physician. This bill would authorize a
prescription endorsement for naturopaths (ND) who have five
years of experience as an ND, 60 hours of pharmacology
education, and who have met the criteria relating to the
administration of prescription drugs. This bill would also
provide NDs with a limited prescription authority for non-
controlled substances. These drugs would include drugs such as
blood pressure medication or antibiotics, but not controlled
substances which are addictive in nature. This bill would
update the definition for Naturopathic Doctor (ND) to align with
the current federal definition and would add NDs to the Medicaid
roster. This bill would allow NDs to treat patients under the
Denali Kid Care and for those NDs who want to be able to provide
service to Medicaid patients.
3:30:53 PM
MS. KLOSTER related that about 40 Naturopathic Doctors (NDs)
currently practice in Alaska. The prescription authority would
give the NDs the flexibility to provide necessary medical
treatment. In order for NDs to practice in Alaska they must
attend a graduate program with doctorate level training from a
U.S. Department of Education accredited school of Naturopathic
medicine, possess a four-year undergraduate degree in current
basic science, and complete the minimum prerequisites. The NDs
must pass 14 national licensing exams, which includes five basic
sciences and nine diagnostic therapeutic exams. Additionally,
NDs must obtain state licensure and be of good moral standing.
She stated that NDs have been licensed in Alaska since 1986.
3:31:45 PM
MS. KLOSTER related that NDs' primary focus is on preventative
care through traditional healing, which is holistic, and
comprehensive in nature. Dr. Emily Kane and Dr. Kristin Cox are
available for questions.
3:32:19 PM
REPRESENTATIVE MILLER asked anyone who could describe an ND's
current training and experience. He related his understanding
that HB 122 would create an ND board and provide for limited
prescription authority, but that the ND's duties would remain
the same.
MS. KLOSTER recapped the changes she previously mentioned, plus
she added that the definition would allow NDs to use the title
of Naturopathic Doctor and Naturopathic Physician. These terms
are ones used by the U.S. Department of Labor, she said. She
added that the NDs would also need to submit to continuing
education (CE) requirements, which the proposed board would
monitor. The NDs would also specifically be required to meet CE
in pharmaceuticals, as well.
3:34:06 PM
EMILY KANE, Naturopathic Doctor, stated that she is also the
President of the Alaska Association of Naturopathic Physicians.
She related that NDs are interested in bringing their scope of
practice into alignment with their training. The NDs have
comprehensive medical training. She explained that the
naturopathic law in Alaska has not been modified since 1986 so
it has fallen behind most other states that license NDs. Thus,
as a Naturopath (ND) she feels underutilized as a resource for
wellness, prevention, and disease management. She pointed out
that the NDs focus is on disease prevention and to promote
patient wellness. Additionally, NDs diagnose illnesses in their
practices. She recalled a press release issued by Commissioner
Streur, Department of Health and Social Services (DHSS), that
indicated by 2014, 32,000 more Alaska will be Medicaid eligible.
She asked who would provide the care since currently many
Medicaid patients wait months to see physicians. Some diseases
can be prevented through preventive care and nutritional
guidance, such as preventing obesity, alcoholism, and diabetes.
She offered her belief that NDs are well positioned to help
reduce the burden of these diseases. The bill addresses the
formation of a board. All other health care professionals in
Alaska have boards and it is time for NDs to also have a board,
she said.
3:36:33 PM
DR. KANE offered that while the Department of Commerce,
Community & Economic Development (DCCED) has been helpful the
NDs and will continue to manage NDs, the agency's staff is not
qualified to handle the NDs once they receive prescription
ability. She assured members that NDs simply want to practice
their profession per their training. Historically, objection to
the proposed changes in Alaska's statutes governing NDs have
come from the NDs professional allies, which is disappointing to
her since "in real life" she works closely with the medical
community. She provided an example, such as if she has a
patient with a complicated tonsil or abscess ailment that she
would refer the patient to Dr. Raster, the local Ear, Nose, and
Throat specialist. She has no interest in going beyond the
scope of her own skill set, she said. Often other health care
professionals will allege that NDS are untrained and pose a
danger to the public. However, there has never been a
malpractice suit against an ND during the 26 years NDs have
practiced in Alaska since NDs know their training and skills and
do not go beyond the scope of their ability. The NDs inherently
practice safe natural remedies and never use pharmaceuticals
first. One of the main reasons she wants access to
pharmaceuticals is that many of her patients are on drugs and
are unwell. She assists her patients by assisting them to get
well. This may include incorporating a regimen to reduce their
drugs and to review drug incompatibilities that have created
adverse drug interaction cross effects. Often, her patients use
natural drugs or herbs they have purchased from the natural food
store, which can create side effects. She stressed that NDs are
the only health care providers who are trained in drug nutrient,
drug herbal medicine interaction.
3:39:15 PM
DR. KANE related a scenario in which one of her patients
suffered from a urinary tract infection that needed immediate
attention so she referred her patient to the local Urgent Care.
However, this meant her patient had to incur the additional
medical costs just to obtain an antibiotic that Dr. Kane could
have provided if only she had the authority to write
prescriptions. She related that pharmacists are very familiar
with NDs. She suggested several options she could have taken,
including that she could have called a pharmacist in Oregon and
had the medication sent to Alaska. Another option would have
been to call one of her colleagues in the Lower 48, and a local
pharmacist could have filled the prescription, she said. In
fact, local pharmacists can fill prescriptions written by other
NDs who possess the same training she has, yet she cannot have
local pharmacists fill her prescriptions since she does not have
the authority to prescribe.
3:40:26 PM
DR. KANE reiterated her training is the same as her colleagues
in Washington, Oregon, and California. She related that she
attended a four-year undergraduate college, obtained a degree in
an unrelated subject, and then attended graduate school in
Naturopathic medicine. She related she spent six years in
school with a one year residency. She carries malpractice
insurance, has hospital privileges, and uses the full set of
diagnostic tools available to any health care professional, such
as lab work and radiology. She explained that how she differs
from medical doctors is that she spends more time with her
patients to educate them and help them modify their wellness
with good food choices and exercise. She said it may not sound
"all that jazzy" but it is hugely important. She suggested that
curing someone by modifying his/her food and exercise is a
better place to start than prescribing drugs. She stressed that
she needs access to drugs because she sometimes helps diabetics
and as these patients begin to lose weight, they need to have
their insulin reduced. She has had several patients who have
been able to completely stop using insulin. However, she cannot
help them "dial down" their medication since she cannot
prescribe.
3:42:32 PM
REPRESENTATIVE MILLER related his understanding that HB 122
would provide limited prescription ability.
DR. KANE agreed. She explained that drugs are listed by
schedule and some drugs have the potential for addiction, such
as narcotics used for pain medication. Schedule 1 drugs are
highly addictive drugs. The other drugs are legend drugs, which
include antibiotics, and antihypertensive drugs such as beta
blockers. Drugs used to treat urinary tract infections and
anti-viral medications fall under legend drugs and do not have a
great potential for harm or addiction, she said.
DR. KANE advised members when she has patients with intractable
pain that she refers them to a pain specialist or a neurologist.
Additionally, she indicated that the likeliness of these
patients becoming addicted is fairly high so the pain specialist
must develop a skill set to wean the patient off the scheduled
drugs. She stressed that all 40 of the NDs in Alaska would be
comfortable having restrictions and limits on prescription drugs
they could prescribe. The NDs would continue to refer patients
who need Schedule I drugs to medical doctors, she said.
3:46:00 PM
REPRESENTATIVE MILLER asked whether NDs currently have a
requirement for ongoing pharmacological training.
DR. KANE responded that currently NDs are not required to have
mandated CE. She asserted that the first thing she would do as
after establishing the ND board would be to require mandatory
CE. She related that every ND undergoes CE just to maintain
their standing with the national and state professional
organizations. However, the state does not have any requirement
to do so. She reiterated pharmacological training would be
necessary, especially since new drugs are developed that require
continual knowledge and education.
3:47:27 PM
REPRESENTATIVE JOHNSON asked whether the NDs' insurance costs
are the same as medical physicians and if NDs are concerned that
medical malpractice costs will increase if NDs assume the
liability of prescribing drugs.
DR. KANE responded that she pays $1,600 per year for malpractice
insurance since NDs are a good risk. Nationwide, very few
lawsuits happen even though NDs have been licensed since 1940s.
She reported that there have not been any malpractice lawsuits
in Alaska against NDs since their initial licensure in 1986.
NDs practice safe medicine. "That's our mandate. That's our
shtick, if you will. We do safe medicine. We do prevention,"
she said. Insurers are a good assessor of risk, she added. She
highlighted that she contacted her insurer, who is the largest
insurer nationwide, who related that her insurance rates will
not go up if HB 122 were to pass. The cost of the risk has been
amortized across all NDs. She pointed out only 5,000 NDs
practice nationwide so it is a small profession, but the demand
is growing. Most NDs practicing have access to legend drugs and
some also prescribe scheduled drugs, she said.
REPRESENTATIVE CHENAULT pointed out that 40 naturopaths practice
in Alaska and the proposed board is a five person board. He
said he did not see a fiscal note in members' packets. He asked
for clarification on the costs to administer the proposed board.
3:50:35 PM
The committee took an at-ease from 3:50 p.m. to 3:53 p.m.
3:53:07 PM
REPRESENTATIVE CHENAULT referred to the fiscal note and related
that one Department of Commerce, Community & Economic
Development (DCCED) would require receipt support services of
$48,000, which is nearly $50,000. He related his understanding
that the cost would be passed on to the NDs.
DR. KANE agreed that NDs' fees would increase.
REPRESENTATIVE CHENAULT offered that the fees would increase by
about $1,000.
DR. KANE agreed the fees would increase substantially.
REPRESENTATIVE CHENAULT referred to the Department of Health and
Social Services (DHSS) fiscal note identifies the cost as
$150,000 in services, $75,000 for federal funds, and $75,000
general fund (GF) matching funds for the Medicaid program. He
asked for clarification from the department on the fiscal note.
3:54:35 PM
JON SHERWOOD, Medicaid Special Projects, Office of the
Commissioner, Department of Health and Social Services (DHSS),
stated that the department submitted a fiscal note for a onetime
cost $150,000. The DHSS estimates half would be federal funds,
and half would be state general funds to make changes to the
data system to add another provider type in order to pay claims
for Medicaid services. The department does not expect an
ongoing cost, but it would incur costs to change the system to
add a new provider.
3:56:06 PM
REPRESENTATIVE CHENAULT asked whether NDs are not currently
accepted by Medicaid.
MR. SHERWOOD answered no, that currently NDs are not listed as
an optional service for Medicaid.
REPRESENTATIVE CHENAULT related his understanding that HB 122
would allow NDs to seek compensations for services they render
on behalf of Alaskans.
MR. SHERWOOD answered yes, that under the bill NDs would be able
to seek payment for Medicaid eligible individuals.
3:57:12 PM
CHAIR OLSON asked for another example of optional services for
Medicaid services.
MR. SHERWOOD answered that the basic services covered by
Medicaid include physician, hospital, and lab services, and
nursing facilities. Additionally, many other types of services
are optional, including services performed by advanced nurse
practitioners, direct-entry midwives, and mental health
providers. Medicaid does not cover family and marital
counselors or podiatrists, he said.
CHAIR OLSON recalled Alaska has a board for Certified Direct-
Entry Midwives.
3:58:28 PM
REPRESENTATIVE CHENAULT asked for an explanation of the $150,000
cost in order to change the system to allow NDs to participate
in Medicaid.
MR. SHERWOOD stated that the claims processing system is an old
Medicaid Management Information System (MMIS) legacy system from
the 80s. It is not a modern system with relational structure so
programming is required for reporting. Although he acknowledged
that he is not a computer expert, he related his understanding
that the basic logic in the system would requirement substantial
programming to make the system recognize the new provider type,
to report, process, adjudicate claims and report the claims into
the state's accounting system and into the right formats for the
federal partners. He said he hoped the new system would be in
place by the spring 2012 to make it easier and less costly to
make these changes. The changes would necessary to implement
the bill timely.
4:00:28 PM
REPRESENTATIVE CHENAULT asked whether the funding has been
allocated for the new system.
MR. SHERWOOD offered his belief that most of the money has been
appropriated. He said he was unaware of any outstanding request
for funding.
REPRESENTATIVE CHENAULT how long the process has taken.
MR. SHERWOOD recalled the current attempt was initiated in 2007,
but the department has worked since 1995 to replace the system.
He related that in once instance the bid was unsuccessful and in
another the department had to wait for Y2K changes to occur, as
well as changes to the federal electronic claims transmission.
Additionally, the department had an unsuccessful vendor in the
mid 90s.
4:01:46 PM
CHAIR OLSON has heard legacy brought up several times in the
budget subcommittee meetings. He asked whether that meant it
was no longer the "state of the art" system.
MR. SHERWOOD responded that would be an understatement.
REPRESENTATIVE MILLER referred to the narrative description in
the DCCED's fiscal note that indicates NDs would be allowed
prescriptive authority and could perform minor surgery. He
asked for the definition of minor surgery.
MR. SHERWOOD deferred to the DCCED.
4:03:06 PM
DON HABEGER, Director, Division of Business & Professional
Licensing, Department of Commerce, Community & Economic
Development (DCCED), stated that the reference to medical
procedures in the fiscal note were in error. He explained that
the fiscal note referred to an older version of a naturopathic
bill and should be stricken.
4:04:04 PM
MARY MINER, Naturopathic Doctor (ND), stated that she has been
interested in changes to the naturopathic statutes since 1994.
The crux of the issue for her relates to patient care. Patients
come to see her for routine naturopathic care, but the need
arises for patient referral, that would not be necessary if NDs
had prescription authority. She expressed concern that costs
are prohibitive, especially if patients do not have health
insurance and must pay costs out of pocket. In those instances,
the patient may not make the appointment and may not get
adequate care. This issue arises more frequently as people
become careful about health care dollars. She offered her belief
that this is not novel legislation, that many states have
enacted legislation, such as Oregon, Washington, and Arizona
with little consequence and no harm to the public.
4:06:56 PM
DR. KRISTEN COX, Naturopathic Doctor (ND), offered to speak to
the Medicaid portion of the bill. She related that adding NDs
to the Medicaid roster would save the state money. She said she
often receives calls from patients who want to bring their
children to see her, but Alaska's Denali Kid Care does not cover
her services. She stressed that NDs are willing, able, and
available to see patients. Most of the Medicaid patients are
children, who could benefit from naturopathic medicine since it
preventative medicine that focuses on diet, nutrition and
lifestyle counseling. She and other NDs could potentially save
hundreds of thousands of dollars by educating children. She
stated that by treating children the physician also has access
to the family and have an opportunity to educate their parents
and the benefits get spread. The ND spends significantly more
time, an hour or longer, with each patient gaining trust and
educating patients, which many patients need.
DR. COX asked to speak to prescriptive authority. Many of her
patients want to feel better and when they come to see her they
are often tired, overweight, depressed, with high cholesterol
and high blood pressure. Some patients are interested in
hormone balancing but she cannot prescribe natural hormone
replacement therapy even though she is well trained and could do
so. She screens patients for thyroid problems and encounters
many thyroid problems, which are easy to treat, yet she cannot
prescribe thyroid treatment. If all thyroid problems were
adequately treated it could save money over time. She related
that many NDs are attracted to rural areas and rural areas have
a shortage of doctors. However, an ND cannot practice in rural
Alaska without the ability to prescribe nor can they act as
primary care physicians without the ability to prescribe
antibiotics or other medications. She noted that she practiced
naturopathic medicine in Fairbanks for a year.
DR. COX related a scenario in which a man had been bitten by a
cat and had red streaks running up his arm from the bite. He
needed an antibiotic and she referred him to a medical doctor,
but refused to go. She explained that some patients have an
abnormal fear of traditional medical care. She also referred
him to the emergency room. She later found out he lied to his
veterinarian in order to obtain an antibiotic and took medicine
prescribed for a dog. She offered her belief that she should
have been able to prescribe an antibiotic for her patient, but
could not. She characterized this as an example of routine
situations NDs encounter in their practices as primary care
physicians, which they are licensed to do, but must do with "one
hand tied behind their backs."
4:12:16 PM
REPRESENTATIVE MILLER acknowledged the difficulty to quantify
future cost savings with respect to health care costs, but
related his understanding that the main goal of NDs is disease
prevention. He offered his belief, based on earlier testimony,
that as many as 14,000 new Medicaid patients are anticipated.
The system has already been constrained and putting 40 more
physicians into the system could help reduce the strain on the
system.
DR. COX advised members that it is difficult for patients to get
doctor appointments, particularly since many doctors in Juneau
are not accepting new patients. She asserted the need for more
practitioners, especially those who are skilled in nutrition,
prevention, and lifestyle counseling. She offered her belief
that the NDs are those practitioners. The NDs have been
licensed in the state and are an under-utilized resource.
4:14:11 PM
REPRESENTATIVE SADDLER asked why she pursued this branch of
medicine.
DR. COX answered that she was not interested in prescribing,
conventional medicine. She acknowledged that traditional
medicine has its place, particularly for emergency medical care.
The biggest problem she sees in the U.S. is chronic illness,
which responds to low-tech cheap therapies that have been
neglected. It doesn't cost a lot for people to eat well or to
treat people with herbs as compared to pharmaceuticals. She
said she is fascinated with plants and likes the natural world
and was drawn to that type of practice.
4:16:18 PM
REPRESENTATIVE SADDLER asked her to describe her background.
DR. COX explained her education. She related that she first
obtained a Bachelor of Science degree in pre-medicine. She
originally thought she wanted to become a physical therapist.
However, she learned about ND medicine while in Portland, which
has one of the oldest ND schools. She appreciated the
philosophy of the medicine which focuses on the natural cure,
the healing power of the body and its innate powers to heal.
The goal of the physician is to remove the obstacles to the
cure. She remarked at the simple and beautiful process. She
related that NDs tend to use the gentle therapies first. She
said that NDs also encourage patient responsibility and self
healing, which is a lot of work, much more so than taking a
pill. Patients become empowered and change their lives. She
pointed out there is a great demand for this type of medicine.
Clearly no one would argue that nutrition or exercise is
important. She offered her belief that diet and nutrition could
solve 90 percent of the health problems.
4:18:53 PM
REPRESENTATIVE SADDLER asked how she could reconcile having
prescription authority with her philosophy of naturopathic
holistic care.
DR. COX agreed to the conflict. She asserted that she would not
use prescriptions as the primary treatment, but would reserve
writing prescriptions for emergency situations. She related
that NDs know when people need help, such as when patients have
sky high blood pressure, it needs to be treated to come down.
She explained that naturopathic medicine takes time to work such
as to lose weight, but in the meantime the patient's blood
pressure must be treated or they risk having a stroke. It is
difficult to tell a patient who has chosen ND medicine that they
need to go to the emergency room to obtain medicine. For many,
it represents an added expense. She agreed that sometimes
prescriptions are necessary. Her biggest interest in
naturopathic medicine lies in hormone therapy. She has treated
many thyroid patients, who have ailments that can be prevented.
She offered an example of the type of problem she treats. She
related a scenario in which a 50 year carpenter, without medical
insurance, had severe knee pain and his orthopedic surgeon
recommended a double knee replacement. She screened him for a
thyroid problem, treated him with thyroid medicine and his pain
decreased by 90 percent. She said that treating the
inflammation helped reduce his pain. Low thyroid function can
cause carpel tunnel and pain due to the inflammation. She
related her understanding that she saved her patient thousands
of dollars in surgery with about $7 worth of thyroid medicine
and her patient is now back at work.
4:21:46 PM
CHAIR OLSON, after first determining no one else wished to
testify, kept public testimony open on HB 122.
[HB 122 was held over.]
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