Legislature(2023 - 2024)BELTZ 105 (TSBldg)
03/15/2024 01:30 PM Senate LABOR & COMMERCE
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| Audio | Topic |
|---|---|
| Start | |
| SB44 | |
| SB225 | |
| SB237 | |
| Adjourn |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
| += | SB 44 | TELECONFERENCED | |
| *+ | SB 225 | TELECONFERENCED | |
| *+ | SB 237 | TELECONFERENCED | |
SB 44-NATUROPATHS: LICENSING; PRACTICE
1:35:10 PM
CHAIR BJORKMAN announced the consideration of SENATE BILL NO.
44, "An Act relating to the practice of naturopathy;
establishing the Naturopathy Advisory Board; relating to the
licensure of naturopaths; relating to disciplinary sanctions for
naturopaths; relating to the Department of Commerce, Community,
and Economic Development; and providing for an effective date."
[Before the committee is CSSB 44 (HSS), work order 33-LS0297\S.]
1:35:30 PM
SENATOR CATHY GIESSEL, District E, Alaska State Legislature,
Juneau, Alaska, sponsor of SB 44, said she is an advanced nurse
practitioner with a national board certification in family
practice. She briefly described her educational experience
obtaining a master's degree at the University of Alaska
Anchorage, which included study of naturopathic medicine. She
explained that after graduation she spent time working in an
alternative medicine clinic alongside a physician, nurse
practitioners, and several naturopathic doctors (ND). She
emphasized the degree of knowledge that she gained as a result
of working alongside naturopaths and briefly described their
method of patient care. She explained that naturopaths are not
able to prescribe medications and would bring patient cases to
her and request prescriptions (typically for thyroid or hormone
replacement medications). She pointed out that naturopaths tend
toward a limited use of prescription medications. She commented
that many Alaskans seek out naturopathic care. She acknowledged
that she has sponsored SB 44 by request; however, she emphasized
that naturopathic doctors are credible healthcare providers.
1:39:56 PM
JANE CONWAY, Staff, Senator Cathy Giessel, Alaska State
Legislature, Juneau, Alaska, offered a presentation on SB 44 and
advanced to slide 2:
[Original punctuation provided.]
WHAT IS A NATUROPATHIC DOCTOR?
• A primary care provider with a four-year post
graduate medical degree who:
• practices evidence-based primary care, with
a patient-centered focus,
• prioritizes disease prevention and
discovering root cause of illness,
• whose treatments focus on lifestyle
modifications, nutrition and low-risk
intervention
MS. CONWAY explained that NDs attempt to answer the question
"why?" and directed attention to recent Health Resources and
Services Administration (HRSA) data indicating that, in the next
decade, Alaska will need 237 primary care doctors. In addition,
HRSA recommended creating interdisciplinary care teams. She
pointed out that Alaska currently has 48-50 NDs who could help
fill this requirement and SB 44 would make them primary care
doctors in the state.
1:42:11 PM
MS. CONWAY advanced to slide 3:
[Original punctuation provided.]
WHAT ABOUT THEIR EDUCATION?
Education
4-Year Medical School Program accredited by the
Council of Naturopathic Medical Education with
• 2 years of medical sciences (anatomy, physiology,
microbiology, immunology, etc.)
Pre-requisites
• 4-yr undergraduate degree and additional pre-med
coursework
Residency
• Less common because they are not trained as
hospitalists
• 1-3 year residency options available; nationwide
there's a shortage
• Note that residencies are not required for
independent primary care providers who hold
prescriptive privileges
Licensing
Naturopaths must pass the two-part Naturopathic
Physicians Licensing Examination (NPLEX) before being
licensed to practice
MS. CONWAY noted that Dr. Carrie Baldwin, who is an authority on
ND education, is available for questions on this topic.
1:43:33 PM
MS. CONWAY advanced to slide 4:
[Original punctuation provided.]
WHO IS NOT A NATUROPATHIC DOCTOR?
• Other conventionally-trained or allied health
care providers practicing integrative,
functional, or holistic healthcare such as
Medical Doctors (MD), Doctors of Osteopathy (DO),
Chiropractors (DC), Nurse Practitioners (NP),
Physicians Assistants (PA), or Massage Therapists
(LMT)
• Other licensed or unlicensed providers marketing
themselves as natural care providers, holistic
healthcare providers or healers
• Health food store employees
• Essential oil sales representatives
• Someone who completed an online certificate
course
1:44:12 PM
MS. CONWAY advanced to slide 5, displaying a multi-colored US
map with the heading, "Regulation of Naturopathic Doctors in the
United States." She explained that 24 states regulated NDs while
10 states have active licensure initiatives. Texas and Wyoming
have active advocacy initiatives; there is growing interest in
the practice of naturopathy across the country.
1:44:59 PM
MS. CONWAY advanced to slide 6, displaying a multi-colored US
map with the heading, "Scope of Practice by State: Prescriptive
Authority." She pointed out that Alaska is among the 10 states
that do not allow NDs prescriptive authority. 12 states do give
NDs prescriptive authority and California gives limited
prescriptive authority. She noted that Dr. Clyde Jenson is
available to answer related questions.
1:45:42 PM
MS. CONWAY advanced to slide 7, displaying a multi-colored map
titled, "Scope of Practice by State: Controlled Substances." She
pointed out that six states allow NDs to prescribe controlled
substances. She clarified that SB 44 would not allow NDs to
prescribe controlled substances.
1:46:09 PM
MS. CONWAY advanced to slide 8:
[Original punctuation provided.]
SENATE BILL 44
• Modernizes statutes for Naturopaths
• Cleans up outdated language
• Imposes the same public health duties on
Naturopaths as other medical providers
• Updates scope of practice for Naturopaths that
includes limited prescriptive authority
• Allows minor office procedures
• NO MORE duplicative office visits
• Improved access to care for Alaskans
• More choice for patients
MS. CONWAY emphasized that NDs would most likely prescribe basic
medications as a last resort. This would be more convenient and
less costly for patients. She gave examples of minor office
procedures.
1:48:02 PM
MS. CONWAY stated that increasingly, people are seeking
alternative healthcare options that can help them understand why
they feel a certain way - without relying heavily on
prescription medications.
1:48:43 PM
SENATOR BISHOP asked for clarification that Senator Giessel had
worked in a facility with a ND and a medical doctor (MD) and
asked if this is a common practice.
1:49:10 PM
SENATOR GIESSEL replied that this is correct and explained that
it was an integrative healthcare facility, meaning that
practitioners of allopathic (conventional medicine) and
alternative medicine worked alongside one another in an
"alternative medicine" clinic. She shared that she visits a
clinic that is owned by a nurse practitioner who employs
naturopaths.
1:49:47 PM
SENATOR BISHOP asked for an example of what is considered
"limited prescriptive authority."
SENATOR GIESSEL explained that NDs may need to prescribe thyroid
hormones (a common medication for women over 40) or hormone
replacement therapy (HRT). Occasionally, they may need to
prescribe antibiotics (most often a last resort). She stated
that these were the main prescriptions she wrote for NDs while
working at the aforementioned clinic.
1:50:45 PM
SENATOR BISHOP shared his understanding that NDs would not be
able to write prescriptions for schedule class III drugs and
asked if this is correct.
SENATOR GIESSEL agreed that this is correct - NDs would not be
able to write prescriptions for controlled substances. She
explained that the ability to write prescriptions for controlled
substances is limited - even for conventional healthcare
providers - and briefly explained the requirements. She offered
to provide a handout describing the five categories of
controlled substances (e.g. oxycodone and certain sleeping
pills). She explained that medications on this list are commonly
addictive.
1:52:03 PM
TIMOTHY BIRDSALL, ND, Avante Medical Center, LLC, Anchorage,
Alaska gave a brief overview of his educational and work
experience. He explained that NDs have worked in Alaska for over
35 years and in the US for over 100. He described the
educational requirements and clinical hours needed to become an
ND and noted that there is an immense about of oversight by NDs,
MDs, and Doctors of Osteopathy (DO) during training. He stated
that ND training programs are subject to the same accreditation
and oversight as other medical training programs. He named
Bastyr University and the National University of Health Sciences
as the two oldest Naturopathic medical schools in the US. They
are accredited by the same agency that accredits the University
of Alaska. He noted that the naturopathic programs each have
additional accreditation through the Council on Naturopathic
Medical Education. Once students have graduated from an
accredited program, they sit for the national board exam, which
includes an exam on pharmacology. He stated that the education
received by ND is comparable to that of nurse practitioners, who
have broader prescriptive authority than what is proposed by SB
44.
1:55:08 PM
DR. BIRDSALL asserted that, with this level of training, NDs
have shown themselves to be safe and effective providers. SB 44
allows NDs to practice to the extent of their education,
experience, and training. He said that this education training
includes the use of minor office procedures and prescriptions
when appropriate. He stated that he would personally prescribe
less than 10 percent of the time. He gave an example of a
patient who needed an antibiotic for strep but he couldn't
prescribe due to restrictions on his ND license in Alaska. He
added that he had to refer this patient to a nurse practitioner
for the prescription and reiterated that his ND training is as
extensive as a nurse practitioner's. He said that being unable
to prescribe necessary medications results in treatment delays,
added costs, and some patients do not follow through to receive
the necessary care. He pointed out that Alaska has a shortage of
primary care providers that NDs can help to fill. He asserted
that NDs are safe primary care providers who are trained to
understand their scope of practice and will refer patients to
other providers when necessary. He shared a story of a patient
he recently referred to a specialist and emphasized his desire
for his patients to have the best care and the most positive
outcome, regardless of the therapies employed.
1:58:22 PM
DR. BIRDSALL discussed the safety of an ND scope of practice
that includes limited prescriptive authority. He referred to the
rate of disciplinary action and directed attention to a document
from the Federation of Naturopathic Medicine Regulatory
Authorities to gain perspective on the rates of disciplinary
action in all states that regulate NDs. The rate of disciplinary
action for NDs is one tenth of that for MDs and half of that for
DOs. He then turned his attention to malpractice insurance
claims against NDs nationwide, the rate of which is 0.0001
percent. He emphasized that this is a very low number and added
that this is reflected in the premiums, which are also low. He
pointed out that currently, NDs are not required to report
malpractice claims and added that SB 44 closes this reporting
loophole. He reiterated that NDs receive formal education and
training that is comparable to nurse practitioners and supports
independent prescribing rights. He stated that SB 44 is a
comprehensive rewrite that adds additional responsibilities and
expressed his support for these changes. He asserted that these
changes would allow NDs to practice as trained while ensuring
the safety of Alaskans and requested support.
2:01:15 PM
SENATOR BISHOP asked if NDs have the ability to do physicals for
Federal Aviation Administration (FAA) flight exams and
Commercial Driver's License (CDL) exams.
DR. BIRDSALL replied that he does not know the answer and
offered to find out. He shared his understanding that this is
not currently done by NDs and stated that he is not aware that
SB 44 would address this.
2:02:40 PM
CARRIE BALDWIN-SAYRE, ND, Associate Vice President, Advancement
and Community Engagement, National University of Natural
Medicine, Portland, Oregon, gave a brief work history. She
stated she can speak to the education and training that NDs
receive - and how this is overseen and regulated by national
accreditation organizations. She explained that all NDs attend
accredited naturopathic medical schools. The National University
of Natural Medicine has both a program accreditation (via the
Council on Naturopathic Medical Education (CNME)) and an
institutional accreditation (via the Northwest Commission on
Colleges and Universities (NWCCU))- both are overseen by the US
Department of Education. CNME sets the standard for the
naturopathic program, ensuring that graduates are well-trained
to provide excellent and safe patient care. NWCCU is the same
accreditor for the state's allopathic medical school (Oregon
Health Sciences University) and the University of Alaska. She
stated that the processes are rigorous and expressed pride that
NUNM meets the same high standards as these institutions.
2:04:32 PM
DR. BALDWIN-SAYRE discussed the content of Naturopathic Medical
training programs, which are four-year graduate training
programs. NUMN's program includes 5047 hours of total education,
including 1254 hours of direct student involvement in clinical
care. She detailed the admissions requirements, pointing out
that the prerequisite requirements are nearly identical to DO
and MD programs throughout the US. She emphasized that the 1254
clinical training hours are comparable to the requirements for
many other medical programs and exceed the 1000-hour requirement
for the two-year nurse practitioner program at OHSU. She pointed
out that, though they have less training than naturopathic
doctors, nurse practitioners have fully autonomous prescription
authority - including controlled substances. She added that
nurse practitioners do not have a post-graduate residency
requirement, yet they play a vital role in Alaska's healthcare
system.
2:05:36 PM
DR. BALDWIN-SAYRE explained that ND Education covers the
following areas of study:
Years 1-2
Biomedical Sciences and Diagnostic Training, courses
include:
• Anatomy
• Physiology
• Biochemistry
• Histology
• Pathology
• Microbiology
Diagnostic methods and procedures, courses include:
• Physical examination
• Laboratory diagnosis
• Diagnostic imaging
Years 3-4
Translating basic scientific knowledge into clinical
application, courses include:
• Cardiology
• Gastroenterology
• Gynecology
• Endocrinology
• Disease management & prevention
• Nutrition
• Lifestyle medicine
• Botanical medicine
• Pharmaceutical prescribing
• Minor surgical procedures
• And more
DR. BALDWIN-SAYRE emphasized that, in years 3-4, students
receive education specific to prescribing pharmaceuticals
throughout 15 courses. This is in addition to the prescribing
they do in a primary care clinical setting during their
internship. They receive extensive didactic and hands-on
clinical training in dermatologic and minor surgical procedures
during their final two years. This includes suturing techniques,
biopsies, cryotherapy, and laceration repair. Students receive
hands-on training in a variety of clinical settings, with
increasing levels of responsibility as they progress. They must
pass three hands-on clinical examinations to graduate. The final
exam occurs after a full year of their own supervised patient
load in a state credentialed, primary care medical home -
serving mostly Medicaid patients with complicated medical needs.
2:07:15 PM
DR. BALDWIN-SAYRE said that following the completion of their
education, all NDs must pass two board examinations. She
asserted that this medical training ensures that NDs are
competent, safe, effective healthcare providers and are prepared
to care for patients. She stated that allowing NDs to perform
minor surgeries and giving them prescriptive authority for non-
schedule C drugs is a very low risk addition to their current
scope of practice. She added that this is well within the
confines of their training.
2:08:29 PM
CLYDE JENSEN, PhD, representing self, Saint George, Utah, gave a
brief overview of his work history in pharmacology and teaching
MDs, DOs, NDs, among others. As a result, he is in a position to
compare the pharmacology education received by these
professions. He added that he is currently a professor of
pharmacology at an osteopathic medical school with campuses in
Colorado, Utah, and Montana. He stated that when he has taught
and designed pharmacology courses for naturopathic medical
students, he has ensured that the number of pharmacology contact
hours - along with the content of the hours - is identical to
what is taught in MD and DO schools. He has done this in order
to ensure that naturopathic physician graduates are prepared to
prescribe in jurisdictions where they have pharmaceutical
prescription authority. He explained that this also ensures that
NDs can collaborate with their MD and DO colleagues to provide
patient care. In addition, teaching NDs to the same level as MDs
and DOs ensures that naturopathic medical graduates are aware of
important drug/herb and drug/nutrient interactions. He stated
that he testifies at hearings like this one because
professionals need to be allowed to work to the level that they
have been trained.
2:13:37 PM
ROB DOWNEY, MD, Founder, Seaworthy Functional Medicine, Homer,
Alaska, gave a brief education and work history and stated that
the education he received is similar to what is taught at
naturopathic universities. He stated that he has worked in both
Montana and Alaska and is a strong advocate for SB 44. He shared
an account of an ND who treated a patient with an auto immune
difficulties that had not responded to conventional medical
treatment. The patient suffered from psoriatic arthritis and
responded well to naturopathic treatment. He shared that this
inspired him to seek additional training at the Institute for
Functional Medicine. He continues to work alongside NDs and he
expressed great respect for these doctors. He expressed his
belief that NDs are well-trained and perfectly suited to provide
much needed primary care to patients in Alaska. He said that the
NDs he works with are very well trained in the use of
pharmacologic agents. He said that he is not surprised by
testimony that the curriculum used for ND education is the same
as that of MDs and DOs. He stated that concerns related to the
ND scope of practice proposed by SB 44 are unfounded and added
that no evidence supports claims of harm. He pointed out that
many states have an expanded scope of practice for NDs - and
there is a low incidence of malpractice allegations.
2:17:13 PM
DR. DOWNEY stated that nurse practitioners do a wonderful job
prescribing for Alaskans and pointed out that NDs receive post
graduate education that that is equal to - or that exceeds -
that of nurse practitioners. He opined that it is a dark irony
that naturopathic physicians are not prescribing in Alaska
already and added that this is an understatement. He commented
that, while NDs tend to use medications as a last resort, they
are very well-trained to know when a medication is necessary -
and offered examples. However, patients must seek secondary
appointments in order to receive treatment - which can have dire
consequences. He explained that currently, there can be a lag of
many days between appointments. He referred to the chain of
treatment and stated that more links mean more delay - and more
points for the chain to break. In this scenario, many suffer. He
noted that NDs are trained to work with patients to determine
when lifestyle changes can mitigate underlying health problems -
and if ongoing medication is necessary. This is no different
from a good MD or nurse practitioner would provide. He compared
restricting NDs to restricting mechanics or tax accountants and
recommended that common sense be used when determining the
appropriate regulations. He stated that Alaska's primary care
shortage limits access to affordable care and asserted that NDs
who have graduated from accredited programs, passed post-
graduate exams, and passed the new exam required by SB 44 should
be able to prescribe the medications allowed by this
legislation.
2:19:57 PM
CHRISTINE SAGAN, NP, Owner, Vitae Integrative Medical Center,
Anchorage, Alaska, stated that her clinic serves patients all
over the state and has a large demand for primary care
providers. The clinic's ND has openings to see patients but not
the ability to prescribe, which precludes patients from
establishing care. This delays access to primary care - the
demand for which is significantly higher post Covid-19. She
stated that nurse practitioners and naturopaths are filling this
role. She added that access to healthcare is an urgent issue in
Alaska and pointed out that many healthcare providers retired
during the Covid-19 pandemic. Patients may wait up to a year for
an office visit and some clinics are not accepting new patients.
Primary care providers see an average of 2100 visits per year
and NDs could take up 1000 of these visits.
MS. SAGAN stated that she has worked alongside NDs for the
entirety of her 17 years in the field and added that her
experience working with NDs puts her in a position to speak to
their competency and training. She explained that this includes
a knowledge of pharmaceutical medications and said that she
often consults her ND colleagues for their expertise in this
area. She has attended naturopathic continuing education courses
- including pharmacology courses - and learned a great deal
which she was then able to apply to her medical practice. She
said that it is common for her ND colleagues to request that she
see one of their patients in order to prescribe medications. She
explained that this requires her to duplicate exams - only to
prescribe the same medication that her colleague would have
prescribed. She asserted that seeing multiple providers is not
in the patient's best interest, as it wastes resources,
finances, and time. She pointed out that nurse practitioners
faced this issue 40 years ago when they updated their scope of
practice to include prescriptive authority. She explained that
some argued against this change, claiming that nurse
practitioner education was inadequate because it does not
include a post-graduate residency. However, the legislature
decided to extend their scope of practice in spite of this,
which has allowed nurse practitioners to serve a vital role in
Alaska's healthcare system. She asserted that this work is done
safely, in spite of the concerns raised previously. She pointed
out that NDs receive extensive training; however some argue that
they are not adequately trained since, like nurse practitioners,
they are not required to complete a residency. She emphasized
that currently, NDs - who have a four-year doctorate degree -
must turn to nurse practitioners to complete a component of
their patient's care and opined that this situation defies
logic. She urged support of SB 44 to extend NDs scope of
practice.
2:24:32 PM
DR. NATALIE WIGGINS, ND, Vitae Integrative Medical Center,
Anchorage, Alaska, urged support of the SB 44 for the benefit of
Alaskans. She stated that the changes proposed by this
legislation mirror what has been done in many other states for
years. She shared a brief work history in Arizona, which
included prescriptive authority, superficial wound repair, and
biopsies; while there she worked alongside an MD and supervised
students. She gave an overview of her education, which gave her
the knowledge to perform these tasks. She said that when she
came to Alaska, she had to give up the ability to work to the
extent of her knowledge - a disservice to herself and to
Alaskans. She pointed out that she is entrusted to perform the
same tasks as a primary care provider and gave examples.
However, when the treatment protocol includes prescribing
medications, she is must refer them to other providers. She
shared examples from her practice when medications were needed.
She pointed to her experience in Arizona as proof that the
expanded scope of practice proposed by SB 44 is both safe and
essential for comprehensive patient care.
2:29:05 PM
CHAIR BJORKMAN referred to page 6 of SB 44, which describes the
proposed scope of practice - including minor surgery. He asked
what types of surgery are considered minor.
DR. WIGGINS replied that this would include stitches,
superficial wound repair, and superficial lesions.
SENATOR BJORKMAN said that he has heard reports of NDs
performing liposuctions in Arizona and asked if Dr. Wiggins is
familiar with this.
DR. WIGGINS stated she had also heard this report and emphasized
that she does not consider that to be a minor office procedure.
She surmised that the ND had received additional training. She
added that liposuction is not routinely included in ND training
and would therefore would not be included in the expanded scope
of practice.
2:31:44 PM
CHAIR BJORKMAN held SB 44 in committee.
#
2:31:50 PM
At ease