Legislature(2005 - 2006)CAPITOL 120
02/03/2006 01:00 PM House JUDICIARY
| Audio | Topic |
|---|---|
| Start | |
| Commission on Judicial Conduct | |
| Violent Crimes Compensation Board | |
| HB318 | |
| HB150 | |
| Adjourn |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
| + | TELECONFERENCED | ||
| *+ | HB 353 | TELECONFERENCED | |
| += | HB 318 | TELECONFERENCED | |
| += | SB 132 | TELECONFERENCED | |
| += | HB 150 | TELECONFERENCED | |
| += | SB 172 | TELECONFERENCED | |
| += | TELECONFERENCED |
HB 150 - LICENSING RADIOLOGIC TECHNICIANS 3:13:16 PM CHAIR McGUIRE announced that the final order of business would be HOUSE BILL NO. 150, "An Act requiring licensure of occupations relating to radiologic technology, radiation therapy, and nuclear medicine technology; and providing for an effective date." [Before the committee was the proposed committee substitute (CS) for HB 150, Version 24-LS0470\S, Mischel, 4/11/05, which had been adopted as the work draft on 4/11/05.] HEATH HILYARD, Staff to Representative Tom Anderson, Alaska State Legislature, sponsor, relayed on behalf of Representative Anderson that committee packets contain a new proposed committee substitute (CS) for HB 150, Version 24-LS0470\R, Mischel, 1/12/06. REPRESENTATIVE ANDERSON, speaking as the sponsor, moved to adopt the proposed CS for HB 150, Version 24-LS0470\R, Mischel, 1/12/06, as the work draft. There being no objection, Version R was before the committee. MR. HILYARD remarked on some of the language in Section 2 of Version R that is identical to language in Section 2 of Version S: proposed AS 08.89.100(b)(1)-(4); and proposed AS 08.89.150(a)(3), which he suggested may allow those in rural areas to substitute sufficient experience for an approved program when seeking to be licensed as a limited radiologic imager - all persons seeking such licensure will still have to pass an examination as set forth in the bill. REPRESENTATIVE ANDERSON concurred. 3:19:05 PM REPRESENTATIVE WILSON opined that some of the older x-ray machines in rural areas are not going to be familiar to those currently taking classes in this field; conversely, those who know how to use such machines competently might not be able to pass the proposed exam. MR. HILYARD surmised that such older technology would require an even higher level of proficiency. He suggested that others could better address Representative Wilson's concerns. 3:21:06 PM CHAIR McGUIRE noted that the reason the bill was given a referral to the House Judiciary Standing Committee was because it includes prohibition, penalty, and disciplinary provisions, which start on page 7, line 28. She asked the committee to focus on the issues of whether the penalties, both criminal and civil, are appropriate, and whether violations warrant a jury trial. She suggested that those who have been giving radiologic exams without any formal education in this field will not like the idea of having to go to school, take an exam, and get licensed. MR. HILYARD, in response to a question, said that the presumption is that those being exempted from the licensing requirements - those listed in proposed AS 08.89.100(b) - already have a minimum level of training in medicine and human physiology and anatomy, and so even though that training may not specifically pertain to radiologic issues, it was felt that that training is sufficient to mitigate concerns [regarding the risk of subjecting someone to] radiation overexposure. [Chair McGuire turned the gavel over to Representative Anderson.] REPRESENTATIVE GARA expressed dissatisfaction with that reasoning. REPRESENTATIVE ANDERSON, referring to the students being exempted via proposed AS 08.89.100(b)(4), posited that an [instructor or] physician will be monitoring their work in the schools listed; a student shouldn't have to first be licensed in order to learn how to operate the equipment that the license pertains to. REPRESENTATIVE GARA opined that at least a competency test ought to be required. MR. HILYARD noted that the list of those being exempted has not been changed in Version R, and reiterated his argument that those being exempted will be assumed to have a minimum level of training in medicine and human physiology and anatomy. 3:31:20 PM DONNA J. RUFSHOLM, R.T., Chair, Licensure Committee, Alaska Society of Radiologic Technologists (AKSRT), confirmed that those students being exempted via proposed AS 08.89.100(b)(4) would be working under the direct supervision of a licensed practitioner or a licensed radiologic technologist and would not be working independently while going through the training process. As long as a person is enrolled in a program, she relayed, the AKSRT doesn't feel that limited scope licensure would be necessary at the time the person is attending the program, though it certainly would be necessary once he/she has finished the program if he/she is not specifically exempted from licensure via other provisions in the bill. [Representative Anderson returned the gavel to Chair McGuire.] REPRESENTATIVE GARA opined that dental assistants and students should not be exempted from licensure unless the radiologic exams they are conducting are occurring under the direct supervision of [a licensed radiologic technologist]. MS. RUFSHOLM said she didn't have a problem with adding language to that effect. REPRESENTATIVE WILSON indicated that it is disconcerting to see that licensed practitioners are being exempted since they often don't always have any knowledge of radiologic equipment, and to see that students under the supervision of such licensed practitioner would be exempt. CHAIR McGUIRE suggested that to require a physician to be licensed in every little "subset" of medicine would be too cumbersome. MR. HILYARD in response to a question, pointed out that currently there is no standard of competency, for anyone, with regard to conducting radiologic exams. REPRESENTATIVE ANDERSON noted that receiving either too much radiation or too little radiation poses a danger to the public, recounted several of the other groups of people who are required by the state to be licensed in their field of practice, and opined that the state should move ahead with some sort of licensure requirements for performing radiologic exams regardless of the [continuing] reluctance of certain groups to comply with the proposed standards. 3:39:37 PM ED HALL, P.A., Legislative Liaison, Alaska Academy of Physician Assistants (AKAPA), characterized the bill as confusing, and remarked that in general, physician assistants do not agree that basic radiology has presented a problem because no one has presented any such data. The AKAPA can't support HB 150 because it is being presented that providers in clinics are shooting x- rays without any training; however, the AKAPA has questioned its members and found that every clinic it has discussed this bill with has some form of training program in place. He suggested that those who perform computed tomography (CT) imaging, magnetic resonance imaging (MRI), and other more invasive radiography procedures ought to receive formalized training and be subject to licensure, but the bill should be changed such that those who "shoot x-rays" needn't receive training beyond what they are receiving on the job and needn't be subject to licensure - such requirements could prove onerous particularly for those practicing in rural areas of the state. CHAIR McGUIRE said her concern revolves around the fact that currently, anyone can operate x-ray machines without any training, regulation, or licensure even though overexposure to radiation can have severe consequences. MR. HALL noted that most physician assistant (PA) programs train PAs how to read x-rays but not how to operate x-ray equipment. He concluded by saying that the AKAPA is happy that PAs are exempt from the licensure requirements of HB 150, but there is the perception that the bill could be improved. 3:44:50 PM CHRIS DEVLIN, Executive Director, Eastern Aleutian Tribes, Inc., relayed that his organization has nine clinics, four of which have x-ray [equipment], out in the Aleutian Islands, and that most x-rays are being performed by people who would be exempt under the bill. He said the penalties proposed by HB 150 seem a little steep and he is not in favor of the bill moving forward as currently written. He asked whether, if the bill passes, there would be additional penalties such as not qualifying for "federal tort coverage." He relayed that his organization does eventually send it employees out for training and meanwhile people are shown at the work site how to operate the equipment, and so he not sure that there is a great need for this [legislation]. He opined that although the bill has been improved, it will have a negative impact on rural clinics, which will be faced with the question of whether to provide x-ray service at all. 3:47:39 PM CLYDE E. PEARCE, Radiologic Health Specialist II, Radiologic Health, Laboratories, Division of Public Health, Department of Health and Social Services (DHSS), relayed that he conducts inspections of radiology equipment for the state. During his inspections, he said he has observed many instances of alarmingly high exposure to radiation, one in which the person was trained by someone with absolutely no background in radiology and told the person to do exactly the opposite of what was correct. He relayed that the DHSS favors protecting the public from exposure to excessive radiation, and offered his belief that training is important and that it is also important for that training to be conducted by those who know what they are doing. In conclusion, he characterized the penalties proposed by the bill as appropriate. MR. PEARCE, in response to a question, explained that the DHSS registers radiologic equipment and he then inspects that equipment. He noted that some facilities in Alaska operate under the purview of the federal government and so the radiology equipment at those facilities is inspected by a federal inspector, though he also conducts federal inspections of certain equipment through a program administered by the DHSS. REPRESENTATIVE ANDERSON surmised, then, that currently no one monitors the operation of radiology equipment. MR. PEARCE concurred. REPRESENTATIVE ANDERSON asked how many states currently license radiologic technicians. MR. PEARCE said 39 according to his understanding. In response to another question, he acknowledged that such licensure appears to be the trend. REPRESENTATIVE GARA indicated that he is no longer concerned that the training requirements of the bill are too onerous, but said he is not thrilled with a complete exemption for certain groups of people. MR. PEARCE, on that first point, acknowledged that there are a number of online sources for training and thus people will be able to obtain the required training without having to leave the community. 3:53:20 PM BARBARA HUFF TUCKNESS, Director, Governmental and Legislative Affairs, Teamsters Local 959, relayed that her organization supports the original version of HB 150, and that her organization is fortunate to represent radiologists in hospital facilities who are already under collective bargaining agreements to be certified. She said her organization supports certification, and noted that nurses' aides are required to be certified as nurses' aides in both urban and rural settings; in other words, there is no exemption from certification for nurses' aides in rural settings. Notwithstanding support of the original bill, her organization is willing to accept the fact that adoption of the proposed CS will be a step in the right direction. She concluded by asking that HB 150 be moved from committee. 3:55:16 PM CHAIR McGUIRE referred to Amendment 1, which, with handwritten corrections and some formatting changes, read [original punctuation provided]: Insert at p.2 line 21 (d) "under the supervision" and "under the direct supervision" in this subsection shall include, but not be limited to, under supervision needed to ensure a radiological examination is performed safely and appropriately. CHAIR McGUIRE [although no formal motion to adopt Amendment 1 had been made] objected for the purpose of discussion. REPRESENTATIVE GARA, speaking as the author of Amendment 1, indicated that Amendment 1 would provide some guidelines for those exempted from the training requirements of the bill. 3:56:51 PM DONNA M. ELLIOT, Alaska Native Tribal Health Consortium (ANTHC), said she would be speaking in opposition to HB 150 for reasons similar to those expressed by Mr. Hall and Mr. Devlin. She said the ANTHC believes that the bill is poorly written and contains room for changes so as not to place an unnecessary burden on existing radiological technicians who are employed throughout the Alaska tribal health system. It's already a complex and costly network of delivery of care, and additional criteria for technicians would require a lot of time and money. The ANTHC trusts that staff are capable of training and overseeing necessary training so that imagery services are performed with competence, and feels that [HB 150] does not fit the scope of providing care in the rural healthcare model, she concluded. 3:58:09 PM DON SMITH, P.A., President, Alaska Academy of Physician Assistants (AKAPA), after relaying that he co-owns two medical clinics, said that he agrees with Mr. Hall's comments. If the bill is really intended to address a safety issue, he remarked, then he is not sure how exempting "licensed practitioner" furthers that goal. Just because one has advanced training in the field of medicine doesn't mean that he/she is competent in the operation of radiologic equipment. He asked that the bill be changed to separate out "in-office" or "in-clinic" and especially "rural clinic" x-rays from the requirement of licensure. "I highly agree that persons taking nuclear medicine studies, CT scans, high radiation studies ... should be regulated and licensed, but I do not see the safety issue nor has anybody offered any safety data that in-office in-clinic x- rays are a huge harm to the public," he concluded. CHAIR McGUIRE asked whether Mr. Smith is suggesting that licensed practitioners, and licensed PAs, should not be exempted from the bill's licensure requirement. MR. SMITH said he is simply suggesting that the committee be careful with the concept of exempting "licensed practitioner" because such a person may not be competent to take x-rays. REPRESENTATIVE ANDERSON remarked that PAs were exempted at the request of the AKAPA. CHAIR McGUIRE said the committee would consider removing "licensed practitioner" from the list of those who would be exempt from the licensure requirements of the bill. 4:00:59 PM MARK RESTAD, P.A., Clinical Administrator, Ninilchik Community Clinic, noted that he has practiced in Tok, Healy, Delta [Junction], Ninilchik, Fairbanks, Kotzebue, and Kenai. He opined that there should be a distinction between basic radiography and advanced radiologic studies, mammography, and advanced nuclear studies. He said that from his perspective, he is concerned about access to care, unneeded medevacs, not having access to emergency medevacs for those that really need it, putting [fishing] crews at risk of needing medevacs for shoulder dislocations - because such cannot be treated without a basic x- ray - and an inability to have a person on site when there is a small staff serving a large geographic region. MR. RESTAD opined that "a dichotomy of basic radiology studies needs to be done." He noted that his clinic currently has a physicist [funded] through the federal system that does look at exposure rates in the clinic to ensure that they are within a safe range; the clinic's equipment is registered and the clinic has used due diligence to ensure the safety of the public. In conclusion he asked that the proposed fines be reviewed with the perspective of ensuring access to healthcare services by all Alaskans. 4:03:13 PM MARILYN KASMAR, Executive Director, Alaska Primary Care Association, Inc. (APCA), relayed that the APCA represents 150 community health centers in Alaska and other "safety net providers," and that health centers are private not-for-profit clinics that operate on very slim margins, typically, and of which the great majority are in remote and rural areas of the state. She said that the APCA appreciates that HB 150 now contains the alternative of demonstrated experience in lieu of graduating from a program, and pointed out that there has not yet been an adverse case or lawsuit attributed to poor radiography practices in community health centers. MS. KASMAR said that health centers have always had to answer to federal program expectations, which helps to ensure that they consistently practice safe radiography. She said that the APCA agrees with the comments of Mr. Devlin, Mr. Hall, and Ms. Elliot with regard to the potential hardship and negative impacts the bill could cause. She requested that "bullets" 3 and 4 of the letter provided by the APCA be considered as possible changes to HB 150: Extensions to temporary permits be granted to [community health center] CHC staff when necessary so that sites will not be forced to transport patients to larger cities for radiography services; Temporary permits be granted to CHC staff that do not have two years of prior experience if the lack of said temporary permit would translate into CHCs having to transport patients into larger cities MS. KASMAR noted that there would be an increased cost to state Medicaid if people have to be transported out for radiological services. 4:05:51 PM MS. RUFSHOLM, adding to her previous testimony, said: As a radiologic technologist, I know that radiation is a carcinogen and that the operators of medical x-ray equipment deliver the largest portion of manmade radiation to the general public. (Indisc.) the average patient doesn't know this; they aren't aware of the facts, and they just have confidence in the fact that the healthcare worker who's performing the procedure knows what they're doing. Passage of [HB 150] will establish the standards for individuals performing x-ray exams, standards that don't exist in some clinical sites as shown by the examples of misuse of radiation, documented by the State of Alaska, [office] of Radiological Health. There's a copy of this list included in [committee packets] ...; it's quite an extensive list and it does show that there are incidents happening in the state, today, where the operators of x-ray equipment do not know what they are doing. We can't blame the operators - they're uneducated - we can't blame them for the errors that they've made; they've not been required to get the education that they need to do the job correctly, nor have they been given the opportunity. Opponents of [HB 150] state that it is a financial burden, [but] $229, the cost for one individual to take an extensive online limited scope program, is equal to the reimbursement for one x-ray procedure - a small amount to pay to [ensure] ... patient safety. House Bill 150 will not change the way that small businesses and rural clinics operate. The committee recognizes the fact that the rural areas of the state have different needs than the urban areas, and we've worked with groups around the state to address those needs. We understand the importance of being able to provide radiology services for patient care, especially in the rural areas. MS. RUFSHOLM continued: We've made provisions in the bill to ensure that the individuals who currently perform x-ray procedures at those sites will (indisc. - coughing) do so, the clinics will have no interruption in services while their staff receives training, [and] there'll be no loss of services in the rural areas or a reduction in patient access to quality and complete point of care. Given that requiring operators to be trained and tested does not increase costs, does not restrict access (indisc. - coughing), will not increase salaries, will not force clinics to close, will not cause staffing shortages, will not create burdensome financial obligations to facilities, and [that] training can be completed at a place and time convenient to the operators, there should be no reason for any of us not to be the patient advocate and establish standards ... for persons (indisc. - coughing) radiology procedures. Thank you for giving me the opportunity to testify. 4:08:42 PM REPRESENTATIVE ANDERSON asked what would be required of someone who has already been operating radiological equipment. MS. RUFSHOLM said that such a person would have two options. If he/she has the basic concept of radiology positioning and radiation, and patient and operator safety, and can pass the aforementioned proposed exam, then he/she will be able to get a limited radiological imager license. If he/she is either not able to pass the exam or doesn't have enough experience, he/she can enroll in one of the courses available - one through the University of Alaska Anchorage (UAA) or another online course that has been identified as being available to anyone at anytime and that consists of approximately 240 online hours - pass the exam for that program, get a certificate, and then be eligible for a limited scope license. She reiterated that the course programs cost $229. REPRESENTATIVE WILSON asked what would happen in "hard to serve" areas when a clinic must fill an open position. She then opined that the bill will make it harder to fill such positions. MS. RUFSHOLM noted that most people employed in clinics aren't just performing x-ray procedures, and so anyone newly hired would be performing those other tasks and would be expected to immediately enroll in the required program, get a temporary permit, and also start performing x-ray procedures; patients in those areas would not be denied radiology services in any way. Perhaps that is not the best way to go about it, she acknowledged, but it is not the intent of the legislation to impact care in rural areas; there is simply still a need for education. She suggested that adoption of the standards proposed in HB 150 will create a new career path for people in rural areas and is thus providing them with an incentive to stay in the village. CHAIR McGUIRE surmised, then, that as long as one is enrolled in an approved course, then one can begin taking x-rays. MS. RUFSHOLM concurred with that summation, reiterating that although that is not the ideal, it will allow those in rural areas to continue to provide radiologic services; currently people are performing radiologic procedures without any education. House Bill 150 will ensure that such people will have the education needed to perform radiologic procedures while also protecting both themselves and the patient - radiation safety for both the patient and the operator is one of the first components of the aforementioned course. MS. RUFSHOLM, in response to a question, clarified that before a person could start performing radiologic procedures, he/she would have to have temporary license which in turn requires proof that he/she is enrolled in a program and begun it - that temporary license would then be good for a year. 4:15:45 PM KEN G. TRUITT, General Counsel, Southeast Alaska Regional Health Consortium (SEARHC), said he's came to offer testimony in opposition to the "existing" version of HB 150, and relayed that SEARHC appreciates the recognition of work experience towards meeting the qualification requirements. He went on to say: We share the concerns that this is really going to reduce access to care. And so if ... patient ... health and safety [is what's] ... driving this, this bill ... - in the adopted version that you had before the work draft - would reduce access to care and would reduce patient safety instead, and so we agree with the other rural providers that testified on that. ... In a previous life I would have been one of the assistant attorney generals advising the medical board ... [and] the division that would be implementing this law. In general, there was a passing reference earlier in the hearing to, "There's always going to be opposition to this," and I think that it's hard ... for folks that are opposing [the bill] ... when that's made light of, because you've got two very strong competing interests, here, whenever you talk about regulating a profession - specifically, the constitutional right to liberty. You're impacting somebody's liberty by doing this; you're taking a profession that before this has not had regulation or state oversight ..., and you're taking that liberty away. That's juxtaposed against the reserved power for the states, under police power, to watch out and safeguard the public health. So those are [two very] strong competing interests, and it is difficult to hear ... the opposing interests made light of. ... Professor Freidman (ph), in his seminal work on the history of American law, ... when he chronicles the history of the regulation of professions, he characterizes it, and its whole treatment of it, [as] a holdover from the guild era, from the guild age, where the primary responsibility of the guilds was to protect the economic interests of those members of the profession, and those members of the profession have a very vested interest in reducing the number of people in their profession, to keep their services in demand and the prices for those services high. And what we have here on the legislative record is that this bill has been drafted by the members of this profession that want to be regulated. ... Again, it's hard to hear that made light of, the opposition to that, when it looks like this is the "guild" trying to "circle the wagons," reduce the number of providers that are competent and licensed to perform this service, thereby driving up the costs of those services and reducing the access to those services. And that is our fear, in general, with this, ... [though] we appreciate the work draft - we think that goes a long way towards helping those of us who are going to be subject to it find alternative ways to meet those regulations - and we look forward to continuing to work on that. 4:19:32 PM CHAIR McGUIRE said her motivation is public safety, and she views the issue as being one of public health rather than economics [for industry members]. She said she is satisfied that the sponsor has worked to a reasonable point to reduce the barriers to obtaining training and licensure. She indicated that it is not her intent to raise healthcare costs. MR. TRUITT, on the issue of "licensed practitioners", said that perhaps [someone from the Department of Law] should speak to that issue, particularly with regard to the definition of the practice of medicine as that term applies to portions of the bill. "By removing 'licensed practitioner' from this bill you might have to ... then say that this particular activity is exempted from the definition of the practice of medicine not regulated by the medical board," he added. He said that the SEARHC would support keeping "licensed practitioner" in, but then the committee must face the conundrum that some doctors may not even know how to turn on the radiologic equipment in their office. REPRESENTATIVE GARA said he wants to ensure that the proposed standards are achievable and that rural and small clinics are able to provide needed services on the budgets they have. REPRESENTATIVE GRUENBERG asked Representative Wilson whether nurses are trained to use radiologic equipment. [Representative Wilson shook her head.] REPRESENTATIVE GRUENBERG remarked, "So it's assumed that you'll have somebody else do them?" REPRESENTATIVE WILSON replied, "Or else that if you go to work in a clinic ..., there's someone there that will train you and show you what to do ...." CHAIR McGUIRE remarked, "Boy, that's scary." MR. TRUITT offered to continue working [with the sponsor] on the issue of experience requirements. 4:25:18 PM MICHAEL FORD, Alaska Native Health Board (ANHB), relayed information about the ANHB, and noted that he has seen a lot of bills similar to HB 150. He relayed that the ANHB is very committed to providing the best and safest medical assistance possible, but does have serious concerns with a bill like HB 150 in terms of cost, particularly in rural areas. He offered his opinion that the fact that the costs and benefits of regulating this industry are hard to identify is one of the primary reasons for this legislation not having become law for the last 10 years. He added that he appreciates the sponsor's work and would be willing to assist him in coming up with language that would alleviate the ANHB's concerns. MR. FORD then referred to the penalty provisions of HB 150 and noted that it will be a class A misdemeanor for unlicensed practice, whereas it will be a class B misdemeanor for fraudulent practice. He suggested that one who uses fraud to obtain a license should receive a harsher penalty than one who simply practices without a license. He then characterized the exemption provisions of HB 150 as critical, adding, "You have, in a sense, excluded certain areas of practice." For example, under Version R, dentists won't have to change their current practice; a prior version required dentists to be in the same room with the person performing the x-ray procedure. He said he doesn't necessarily know why performing x-ray procedures under the supervision of a licensed practitioner should be exempted, particularly given that it does not necessarily follow that licensed practitioners have experience in the operation of radiological equipment. MR. FORD said he would like to put together a work group that would formulate language addressing everyone's concerns. REPRESENTATIVE ANDERSON noted that the bill still has other committee referrals. 4:31:27 PM RICHARD MANDSAGER, M.D., Director, Central Office, Division of Public Health, Department of Health and Social Services (DHSS), commented that access and safety are both important issues and therefore a balance between the two must be found, and that he is encouraged by Version R. He noted that at one of his jobs, all of the doctors got on-the-spot training in how to use radiological equipment, and he thinks that they all probably performed x-rays safely, but what was safe 25 years ago may no longer be considered safe, particularly considering the cumulative effects of radiation exposure. DR. MANDSAGER, in response to comments, noted that dental x-rays expose a person to only a fraction of the radiation that other types of x-ray procedures expose a person to, and that those who perform CT scans, for example, receive a lot of training. The argument, he surmised, is all about how much training is necessary for what type of radiologic procedures. "I think the safety argument is still really important, and as we get online training and so on available to improve the safety but maintain access, we can strike a balance point that will be good for the state," he remarked. CHAIR McGUIRE asked Dr. Mandsager whether the Division of Public Health could play an instrumental role with regard to outreach and assembling online courses. DR. MANDSAGER indicated that that issue is one that ought to be considered by the division, and noted that with regard to licensure of radiological technicians, the state is on a journey. He concluded by remarking that the penalties in the bill seem fairly high. LINDA FINK, Vice President, Alaska State Hospital and Nursing Home Association (ASHNHA), stated simply that the ASHNHA supports HB 150. 4:36:43 PM LAURIE HERMAN, Regional Director, Government Affairs, Providence Health System-Alaska; Member, Legislative Committee, Alaska State Hospital and Nursing Home Association (ASHNHA), stated that both Providence Health System-Alaska and ASHNHA continues to support HB 150. MS. HERMAN, in response to a question, said she doesn't know whether licensed nurse practitioners receive training in performing radiological procedures as a matter of course. REPRESENTATIVE GARA said he is concerned that the bill would exempt certain people, such as licensed practitioners, even when they don't have sufficient training. REPRESENTATIVE ANDERSON noted that the definition of "licensed practitioner" can be found on page 10, lines 26-19; HB 150 is proposing to exempt licensed practitioners from the training and licensing requirements contained therein. 4:40:43 PM REPRESENTATIVE WILSON cautioned against requiring licensed practitioners to have training in performing radiological procedures because it could negatively impact access to care. REPRESENTATIVE GRUENBERG, referring to a letter from B.J. Anderson, Radiology Manager, Anchorage Neighborhood Health Center (ANHC), he read: Dear House Judiciary Committee, I am writing in regard to HB 150, which relates to the licensing of radiologic technicians in the state of Alaska. This bill continues to be flawed in that it does not allow organizations to begin training radiologic technicians on the job at the time of hire. This flexibility is absolutely necessary for: one, Alaska health centers who cross-train personnel for several job tasks; and, two, Alaska health centers that have to draw personnel from their communities because there is a lack of certified personnel available or willing to live in rural Alaska. I would propose that the limited temporary permit be written to include on-the-job training that can begin immediately upon hire with the stipulation that the person must be enrolled in an approved radiologic training program as soon as possible. The temporary [permit] ... could be written to give organizations up to six months ... - or whatever the committee deems reasonable - ... to enroll employees in an approved program. ... It is imperative that the bill allow the flexibility, and recognize the value and reasonableness, of on-the-job training. ... 4:44:08 PM REPRESENTATIVE GRUENBERG asked Ms. Rufsholm whether she would be amenable to a conceptual amendment that would allow the department to issue a nonrenewable temporary permit, valid for up to 90 days for an employee of a nonprofit neighborhood health center, to an applicant who pays a fee determined by the department if the applicant enrolls in an approved training program as a radiological technician within that period of time and is training on the job under a person licensed or permitted under [proposed] AS 08.89.110(a)(a). MS. RUFSHOLM pointed out that the language on page 5 [lines 18- 24] of Version R already provides for such a limited permit though it would be valid for up to one year rather than just 90 days as Representative Gruenberg is proposing; furthermore, a person can enroll immediately into the aforementioned online course and begin that course without going through any waiting period. She relayed that Mr. Pearce knows of an instance in which a person was given 64 times the amount of radiation needed because the person doing the procedure had been trained incorrectly on the job; not all on-the-job training is the same, and this example illustrates a real need for standardized training. It will not be a burden to enroll in a training program and at least start it before doing any radiologic procedures, she opined; furthermore, not all facilities have registered technologists that could supervise a trainee as would be required under Representative Gruenberg's suggested change, and although she knows that the standards set by the ANHC for performing radiologic procedures are very high, those standards are not being followed statewide. REPRESENTATIVE ANDERSON relayed that he has already discussed this issue with the executive director of the ANHC, and offered to discuss it further. REPRESENTATIVE WILSON said she doesn't know why they would not want Representative Gruenberg's suggested change to also apply to for-profit clinics. 4:49:50 PM REPRESENTATIVE GRUENBERG indicated a willingness to work with the sponsor on the issues raised. REPRESENTATIVE GARA withdrew Amendment 1 [text provided previously]. REPRESENTATIVE GARA made a motion to adopt Amendment 2, which, with handwritten corrections, read [original punctuation provided]: Insert at p.2 line 21 "(d) In this subsection "under the supervision" and "under the direct supervision" in this subsection shall include, but not be limited to, under supervision needed to ensure an exam or test under this section is performed safely and appropriately. (e) a licensed practitioner shall be allowed to perform an exam or test under this section if otherwise performed in compliance with law, and if the practitioner has obtained education or training to ensure the exam or test is performed safely & appropriately." REPRESENTATIVE GARA explained that Amendment 2 would insert new subsections (d) and (e) into proposed AS 08.89.100, and would say that if one is exempted from any of the bill's training or testing requirements, then one must either be trained to or have the knowledge to, or be supervised by someone specifically trained to or have the knowledge to, ensure that the procedure is performed safely and appropriately. 4:51:24 PM REPRESENTATIVE ANDERSON indicated that he has no objections to Amendment 2. REPRESENTATIVE WILSON objected, and expressed concern that Amendment 2 will negatively impact rural areas, adding that she's not heard from anyone that there is a problem. She opined that those who are currently performing radiological procedures in rural areas have received sufficient on-the-job training and don't need certification or licensure. CHAIR McGUIRE offered her understanding that Amendment 2 will make allowances for just that sort of on-the-job training. "The concern is that if you just simply say ..., 'Well you're a licensed practitioner, therefore you can perform it', we're really kind of going against the grain of the bill, which is to say, 'We want you to have some training ... in this area'," she added. Under [Amendment 2], she posited, the folks that Representative Wilson is referring to would qualify. REPRESENTATIVE ANDERSON reiterated his support of Amendment 2, but expressed discomfort with the concept of allowing someone who had a little bit of training 25 years ago to qualify for performing or supervising the performance of radiological exams. REPRESENTATIVE WILSON reiterated that she is concerned about rural areas. CHAIR McGUIRE noted that times are changing and people have to realize that radiation is a carcinogenic. Those that are performing radiologic exams currently and those who have obtained some kind of training will be allowed to continue, but those that aren't currently performing such exams or haven't received some form of training will have to fulfill the educational requirements of the bill. She acknowledged that perhaps some clinics operating in rural areas will come to the state and ask for the money to cover the costs of that training. Radiation is serious stuff, she remarked, and suggested that the reason Representative Wilson hasn't seen any evidence of harm is that the effects of over-radiation cannot often be seen immediately. REPRESENTATIVE WILSON said she doesn't know what the long-term ramifications of Amendment 2 will be, again expressed concern that access to care in rural areas will decrease, and suggested that simple x-rays are not harmful. CHAIR McGUIRE noted that the proposed temporary licenses last one year, and so a future legislature could address any issues that arise as a result of the proposed educational and licensure requirements. 4:58:31 PM REPRESENTATIVE ANDERSON called the question. CHAIR McGUIRE instead offered members another opportunity to speak. REPRESENTATIVE GARA noted that Amendment 2 pertains to the exemption provisions of the bill, and suggested that without it, licensed practitioners will be allowed to perform radiologic procedures even if they don't know how to do them safely. REPRESENTATIVE WILSON argued that this will result in a cost to rural clinics. REPRESENTATIVE GARA countered that under Amendment 2, only those licensed practitioners that have had no training whatsoever will be precluded from performing radiologic exams. REPRESENTATIVE WILSON opined that licensed practitioners have never had any such training; furthermore, they don't perform radiologic exams. REPRESENTATIVE GARA pointed out, then, that Amendment 2 won't change current practice and therefore it won't result in increased costs; Amendment 2 only applies to those that are performing radiologic exams. REPRESENTATIVE KOTT noted that dental assistants are not included in the definition of "licensed practitioner". MR. HILYARD pointed out, though, that via language on page 2, lines 6-7, of Version R, dental assistants under the supervision of licensed practitioners are being exempted from the licensure provisions of the bill. 5:01:53 PM REPRESENTATIVE GRUENBERG pondered whether language could be added to the bill that would provide for educational grants. REPRESENTATIVE ANDERSON agreed to consider the addition of such language as the bill continues through the process. MR. HILYARD pointed out that [proposed AS 08.89.100] has a delayed effective date of two years. On the issue of whether radiological procedures have been demonstrated to be harmful, he relayed that members' packets include an article from the University of California, Berkeley, that says a noted expert on the health effects of radiation has concluded that a large proportion of deaths today from cancer and heart disease are due in part to past exposure to medical radiation. The expert was quoted in that article as saying in part: "There is the assumption that, at these doses, radiation doesn't make a significant contribution ... but x-rays are very potent mutagens, even at low doses. It's a disaster that people still believe the 'safe dose myth,' that low doses are harmless." CHAIR McGUIRE noted that the standards for what amount of radiation exposure is safe for pregnant women has changed over the years. MR. HILYARD concurred. 5:04:21 PM A roll call vote was taken. Representatives McGuire Anderson, Gruenberg, and Gara voted in favor of Amendment 2. Representatives Wilson and Kott voted against it. Therefore, Amendment 2 was adopted by a vote of 4-2. REPRESENTATIVE WILSON made a motion to adopt Conceptual Amendment 3, which read: Pg 2 after line 19 insert (5) from a hard to serve areas [sic] REPRESENTATIVE WILSON explained that Conceptual Amendment 3 will address her concern regarding access to care by exempting people in hard to serve areas from the licensure requirements of the bill. 5:05:49 PM REPRESENTATIVE GRUENBERG expressed favor towards such an exemption, but pointed out that the term, "hard to serve area" would have to be carefully defined because, as is, such a provision would be impossible to enforce. He suggested that Representative Wilson and the sponsor work together on this issue. REPRESENTATIVE ANDERSON objected to Amendment 3, said it would gut the bill, and concurred that "hard to server area" would have to be defined. He agreed to discuss the issue further as the bill continues through the process. REPRESENTATIVE WILSON offered her understanding that the Department of Labor & Workforce Development (DLWD) knows what a "hard to serve area" is. REPRESENTATIVE KOTT indicated agreement with Representative Anderson, and opined that defining the term, "hard to serve area" will be cumbersome and difficult. He said it would be helpful to see documentation from the DLWD referencing what constitutes a hard to serve area. REPRESENTATIVE GRUENBERG suggested crafting a letter of intent stating that the committee wants this issue addressed at some point. REPRESENTATIVE ANDERSON said he would prefer to simply make a commitment to research this issue further before the bill is heard in its next committee of referral. REPRESENTATIVE GRUENBERG said he would be satisfied with such a commitment by the sponsor. CHAIR McGUIRE noted that Representative Gara has suggested that institution of a "staggered" effective date for a definable hard to serve area might be a way of addressing this issue. REPRESENTATIVE WILSON withdrew Amendment 3. REPRESENTATIVE KOTT suggested the committee consider Mr. Ford's point regarding misdemeanors, and opined that the proposed penalties should be similar in nature. 5:10:06 PM CHAIR McGUIRE asked Representative Kott to describe how he wished to change the bill to that effect. REPRESENTATIVE GRUENBERG suggested allowing the sponsor to research this issue further as the bill continues through the process. MR. HILYARD, in response to a question, said he didn't know why the proposed penalties are not consistent with each other. MS. RUFSHOLM offered her understanding that the drafter chose the language pertaining to penalties, and said her organization is amenable to changing that language. REPRESENTATIVE GRUENBERG noted that under Version R, violation of proposed AS 08.89.100 will be a class A misdemeanor. REPRESENTATIVE GRUENBERG made a motion to adopt Amendment 4, to change "class B misdemeanor" to "class A misdemeanor" on page 8, line 12. REPRESENTATIVE WILSON said she would rather have any violation be a class B misdemeanor. REPRESENTATIVE GRUENBERG asked Mr. Ford whether the crimes of "unauthorized practice" are class A misdemeanors or class B misdemeanors. MR. FORD said he did not know. REPRESENTATIVE GARA noted that fraud is usually a felony, and said he would be comfortable allowing the sponsor to work on this issue before the bill is heard on the House floor. CHAIR McGUIRE noted that sometimes if something is a "lesser included" crime, it will result in a lower penalty, and so perhaps that was the intent behind having different penalties for different behaviors. She said she would not want to undo the balance that the current statutes regarding penalties provide. She, too, expressed satisfaction with allowing the sponsor to research this issue further as the bill continues through the process. REPRESENTATIVE ANDERSON said he would work with members and other interested parties regarding the concerns raised, though he cautioned that he may not be able to alleviate the concern regarding the "rural dynamic." 5:15:34 PM REPRESENTATIVE GRUENBERG moved to report the proposed CS for HB 150, Version 24-LS0470\R, Mischel, 1/12/06, as amended, out of committee with individual recommendations and the accompanying fiscal notes. There being no objection, CSHB 150(JUD) was reported from the House Judiciary Standing Committee.
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