Legislature(2017 - 2018)BUTROVICH 205

02/03/2017 01:30 PM HEALTH & SOCIAL SERVICES

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01:30:07 PM Start
01:30:38 PM SB36
02:58:40 PM Adjourn
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
*+ SB 36 OPTOMETRY & OPTOMETRISTS TELECONFERENCED
Heard & Held
-- Public Testimony --
                   SB 36-OPTOMETRY & OPTOMETRISTS                                                                           
                                                                                                                                
1:30:38 PM                                                                                                                    
CHAIR WILSON announced the consideration of SB 36.                                                                              
                                                                                                                                
1:31:08 PM                                                                                                                    
SENATOR  CATHY   GIESSEL,  sponsor  of   SB  36,   Alaska  State                                                                
Legislature, Juneau, Alaska,  read the sponsor  statement for SB
36 as follows:                                                                                                                  
                                                                                                                                
     SB  36  would update  the  Alaska  optometry statutes,                                                                     
     aligning  it with  optometrists' modern  day  scope of                                                                     
     practice and allow the  Board of Optometry to regulate                                                                     
     that profession as other boards do. The current Alaska                                                                     
     statute defining the practice of optometry is 41-years                                                                     
     old.                                                                                                                       
                                                                                                                                
She revealed  that she had been  on the Alaska  Board of Nursing                                                                
for seven  years and explained  that a  regulation project takes                                                                
about  a year  to  process. She  detailed  the  board regulation                                                                
process as follows:                                                                                                             
                                                                                                                                
  · The board writes regulations with an assistant attorney                                                                     
     general who is present and assists with the writing.                                                                       
  · Regulations go out for a public-comment period.                                                                             
  · Alaska Department of Law reviews the regulations and                                                                        
     comments.                                                                                                                  
  · Regulations go to the lieutenant governor for signing.                                                                      
                                                                                                                                
She pointed  out that  the regulatory process  is not  rapid and                                                                
reiterated that  the process takes  about a year.  She specified                                                                
that the Legislature enacts  statutes which are broad statements                                                                
of  authority that  a board  then defines  out the  specifics in                                                                
regulation;  all  boards  go  through  this  same  process  when                                                                
regulating a profession.                                                                                                        
                                                                                                                                
SENATOR GIESSEL  disclosed that the Board  of Optometry consists                                                                
of four  professional members and  one public member.  She noted                                                                
that  including one  or two  public  board members  is a  common                                                                
procedure  for  professional  regulatory  boards  because  their                                                                
purpose  is to  address the  public's safety  and  concerns. She                                                                
revealed that  board memberships  are typically  four-year terms                                                                
with an optional second-term renewal.                                                                                           
                                                                                                                                
She pointed  out that  while board members  may change,  the law                                                                
does not change. She detailed that an assistant attorney general                                                                
is always present to  assist and oversee the regulation writing.                                                                
She asserted that regulation writing is  not done on a whim, the                                                                
process is  highly overseen  and board  members take  their role                                                                
very seriously.                                                                                                                 
                                                                                                                                
1:34:47 PM                                                                                                                    
She  asserted  that  understanding  the  health-care  industry's                                                                
prescription "drug schedules" is  a nuance that a  lot of people                                                                
don't know.  She pointed out  that optometrists can  prescribe a                                                                
prescription drug, noted as "controlled substance" in Section 3,                                                                
page 2,  lines 12-15  in SB  36. She said  she would  talk about                                                                
controlled   substances   to   illustrate   the   problem   that                                                                
optometrists face.                                                                                                              
                                                                                                                                
She explained that "controlled drugs" are classified by the U.S.                                                                
Drug Enforcement Administration  (DEA) and the  state of Alaska;                                                                
the drugs  are controlled  due to  their potential for  abuse or                                                                
dependency and are ranked in different "schedules." She detailed                                                                
the five distinct categories or "schedules" as follows:                                                                         
                                                                                                                                
  1. Schedule I                                                                                                                 
       a) Schedule I drugs, substances, or chemicals are defined                                                                
          as drugs with no currently accepted medical use and a                                                                 
          high potential abuse.                                                                                                 
       b) Schedule I examples:                                                                                                  
          ¨ Heroin                                                                                                              
          ¨ LSD                                                                                                                 
          ¨ Marijuana                                                                                                           
          ¨ Ecstasy                                                                                                             
          ¨ Peyote                                                                                                              
                                                                                                                                
  2. Schedule II                                                                                                                
       a) Schedule II drugs, substances, or chemicals are                                                                       
          defined as drugs with a high potential for abuse, with                                                                
          use potentially leading to severe psychological or                                                                    
          physical dependence. These drugs are considered                                                                       
          dangerous.                                                                                                            
       b) Schedule II examples:                                                                                                 
          ¨ Cocaine                                                                                                             
          ¨ Vicodin (Hydrocodone)                                                                                               
          ¨ Methadone                                                                                                           
          ¨ Fentanyl                                                                                                            
          ¨ OxyContin                                                                                                           
                                                                                                                                
  3. Schedule III                                                                                                               
       a) Schedule III drugs, substances, or chemicals are                                                                      
          defined as drugs with a  moderate to low potential for                                                                
          physical  and psychological  dependence. Schedule  III                                                                
          drugs  abuse potential  is less  than  Schedule I  and                                                                
            Schedule II drugs but more than Schedule IV.                                                                        
       b) Schedule III examples:                                                                                                
          ¨ Codeine                                                                                                             
          ¨ Ketamine                                                                                                            
          ¨ Testosterone                                                                                                        
                                                                                                                                
  4. Schedule IV                                                                                                                
       a) Schedule IV drugs, substances, or chemicals are                                                                       
          defined as drugs with a low potential for abuse and                                                                   
          low risk of dependence.                                                                                               
                                                                                                                                
  5. Schedule V                                                                                                                 
       a) Schedule V drugs, substances, or chemical are defined                                                                 
          as drugs with lower potential for abuse than Schedule                                                                 
          IV.                                                                                                                   
                                                                                                                                
1:38:26 PM                                                                                                                    
SENATOR  GIESSEL reiterated  that  SB 36  calls  out "controlled                                                                
substance." She pointed  out that a  bill was passed  in 2014 in                                                                
response   to  a   federal  government   schedule   change  when                                                                
hydrocodone was  changed  from Schedule  III to  Schedule II,  a                                                                
necessity because  optometrists are only  permitted to prescribe                                                                
Schedule  III  medication.  She  noted  that  if  the  Board  of                                                                
Optometry had  its  full authority,  legislation would  not have                                                                
been  required and  the board  would  have simply  been able  to                                                                
update  their  regulations.  She  set forth  that  her  previous                                                                
example  illustrates why  it's  so important  for  the Board  of                                                                
Optometry to have some  latitude to update their regulations and                                                                
their scope of practice  as technology changes or drug schedules                                                                
change.                                                                                                                         
                                                                                                                                
SENATOR  GIESSEL  divulged  that  optometrists cannot  prescribe                                                                
Schedule I, Schedule II,  or any drug without authorization from                                                                
the  DEA. She  pointed  out that  health-care  providers require                                                                
federal  authorization to  receive an  identification  number to                                                                
prescribe controlled  substances, a  highly vetted  process that                                                                
shows the level of  care given to optometrists to use controlled                                                                
substances.                                                                                                                     
                                                                                                                                
1:40:49 PM                                                                                                                    
She emphasized that SB 36  does not expand the scope of practice                                                                
of optometry. She said a clear majority of Alaskans visit one or                                                                
more of  the state's  150 optometrists that  take care  of their                                                                
eye-care needs, vision tests, eyewear prescriptions, and general                                                                
eye  exams.  She  pointed   out  that  optometrists  are  spread                                                                
throughout Alaska; by contrast, there is an access to care issue                                                                
due to the approximate 20 ophthalmologists in the state.                                                                        
                                                                                                                                
She set  forth that  the state's  optometrists are  credible and                                                                
safe  health-care  providers.  She   asserted  that  the  bill's                                                                
significant pushback is  unwarranted. She reiterated that  SB 36                                                                
does not  expand optometrists' scope of  practice and emphasized                                                                
that  optometrists  are  very   safe  clinicians  with  a  sound                                                                
education program that are carefully vetted by their board.                                                                     
                                                                                                                                
She noted  that the previous year's  Medicaid reform legislation                                                                
contained a significant reform that she championed for mental-                                                                  
health  therapists to  practice  more fully  in  their scope  of                                                                
practice.  She  detailed   that  mental-health  therapists  were                                                                
restricted   due  to   a  high-bar   presence   requirement  for                                                                
psychiatrists  that  added  to  the cost  of  health  care.  She                                                                
referenced a committee meeting that  occurred earlier in the day                                                                
where  the high  cost  of  health care  was  a  concern for  the                                                                
teaching staff  throughout the  state.  She summarized  that the                                                                
Legislature has some control  over the limitation of health-care                                                                
professionals.                                                                                                                  
                                                                                                                                
1:44:05 PM                                                                                                                    
She set forth  that one of the  measures for clinician-safety is                                                                
their  malpractice   insurance  cost.   She  pointed   out  that                                                                
optometrist malpractice insurance rates are very low and suggest                                                                
that insurance agencies do not see them as high-risk clinicians.                                                                
                                                                                                                                
She affirmed that SB 36  would simply allow optometry to conduct                                                                
itself  just like  all  the other  health-care  professions. She                                                                
pointed  out  that  the  three  other  prescribing  professions'                                                                
statutory  board language  for nursing,  pharmacy  and dentistry                                                                
have a common phrase for practice, "under regulations adopted by                                                                
the  board,"  a  common  practice  also  seen  for  chiropractic                                                                
examiners, dentistry, occupational therapists, and pharmacy. She                                                                
summarized that it  is time for  the Board of  Optometry to have                                                                
the same ability to regulate their profession.                                                                                  
                                                                                                                                
1:46:19 PM                                                                                                                    
SENATOR BEGICH  asked if  the lower malpractice  insurance rates                                                                
could be  driven by the  statutory limitations on  less invasive                                                                
surgeries.                                                                                                                      
                                                                                                                                
SENATOR GIESSEL replied that  Senator Begich's question would be                                                                
addressed by an insurance agency or optometrist.                                                                                
                                                                                                                                
SENATOR VON IMHOF asked if  a particular Schedule II drug should                                                                
be specified in SB 36  like hydrocodone was in 2014. She assumed                                                                
that a  Schedule III drug  that is changed  to a Schedule  II is                                                                
done for a reason and  inquired why a doctor that is not allowed                                                                
to prescribe a Schedule II drug can receive an exemption.                                                                       
                                                                                                                                
1:49:15 PM                                                                                                                    
SENATOR GIESSEL replied that  the current statute specifies that                                                                
an  optometrist  may   use  a  pharmaceutical  agent  containing                                                                
hydrocodone. She added  that if a drug  used by optometrists was                                                                
moved up to a Schedule II, then another bill would have passed.                                                                 
                                                                                                                                
She addressed Senator  von Imhof's second question  and said the                                                                
bill  allows an  optometrist to  continue using a  drug  that is                                                                
moved into a  new schedule. She specified that  the bill states,                                                                
"Including a  controlled substance in the  practice of optometry                                                                
if the pharmaceutical agent is  used in a manner consistent with                                                                
standards adopted by the board."                                                                                                
                                                                                                                                
SENATOR VON IMHOF asked how  often drugs are reclassified into a                                                                
new schedule.                                                                                                                   
                                                                                                                                
SENATOR GIESSEL replied that she could not respond.                                                                             
                                                                                                                                
CHAIR WILSON asked for a sectional analysis of SB 36.                                                                           
                                                                                                                                
1:53:05 PM                                                                                                                    
JANE CONWAY,  Staff, Senator Giessel,  Alaska State Legislature,                                                                
Juneau,  Alaska,  provided a  sectional  analysis  on SB  36  as                                                                
follows:                                                                                                                        
                                                                                                                                
     Section 1:                                                                                                             
       AS 08.72.050 allows the board to continue to adopt its                                                                   
     regulations updated to its current practice.                                                                               
                                                                                                                                
     Section 2:                                                                                                             
     Moves the continuing  education requirements back into                                                                     
     regulation, something that the Department of Commerce,                                                                     
     Community,  and  Economic   Development  had  desired.                                                                     
     Continuing  education  is  still required  by  current                                                                     
     statute; however, it could be noted that the hours and                                                                     
     subjects to be  determined by the board  as with other                                                                     
     professions.  Our current  regulations  for continuing                                                                     
     education hours and the Board of Optometry regulations                                                                     
     are higher than  what is actually in  statute, so this                                                                     
     is a very  obsolete section of the  bill that we would                                                                     
     like to change.                                                                                                            
                                                                                                                                
     Section 3:                                                                                                             
     AS 08.72.272(a) clarifies the  current statute for the                                                                     
     board  to determine  prescribed  drug  schedules which                                                                     
     Senator  Giessel  has  outlined in  detail,  including                                                                     
     standards and  limitations  on practice  determined by                                                                     
     the board.                                                                                                                 
                                                                                                                                
     Section 4:                                                                                                             
     AS 08.72  sets limitations on  practice, ensuring that                                                                     
     no licensee may perform any procedure beyond the scope                                                                     
     of the licensee's  education, training, and experience                                                                     
     as established  by the  regulatory board;  this allows                                                                     
     for   future   new   and   improved  diagnostics   and                                                                     
     therapeutic  procedures  as  determined by  the  board                                                                     
     while  not having  to  return to  the  Legislature for                                                                     
     every new development or technological advance.                                                                            
                                                                                                                                
     Section 5:                                                                                                             
     AS 08.72.300(3) updates  the definition of "optometry"                                                                     
     because it  is  decades old  and it  was  repealed and                                                                     
     reenacted and  rewritten  by the  legal  department to                                                                     
     keep  it current  with  current practice  and  be more                                                                     
     readable.                                                                                                                  
                                                                                                                                
1:55:49 PM                                                                                                                    
SENATOR BEGICH  noted that  the old definition  being eliminated                                                                
specifically  prohibited "Other  than by  use  of  laser, x-ray,                                                                
surgery,  or  pharmaceutical  agents."  He  asked  why  the  old                                                                
definition is being eliminated.                                                                                                 
                                                                                                                                
MS. CONWAY explained that optometrists currently can order x-                                                                   
rays and use diagnostic lasers. She specified that the new                                                                      
wording parallels optometrists' current authorities and makes                                                                   
the former definition obsolete.                                                                                                 
                                                                                                                                
1:57:18 PM                                                                                                                    
At ease.                                                                                                                        
                                                                                                                                
1:58:17 PM                                                                                                                    
CHAIR WILSON opened public testimony on SB 36.                                                                                  
                                                                                                                                
1:58:41 PM                                                                                                                    
DR. FORREST MESSERSCHMIDT, optometrist, Juneau, Alaska, revealed                                                                
that  he has  been an  optometrist in  Juneau for  28  years and                                                                
recently  completed a  four-year  term  on  the  State Board  of                                                                
Optometry. He read a statement in support of SB 36 as follows:                                                                  
                                                                                                                                
     I believe SB 36 is good legislation, it modernizes the                                                                     
     statutes,   allows  details   of   regulation  to   be                                                                     
     determined  by  the  state  board as  is  the  current                                                                     
     standard through  dentistry, nurse  practitioners, and                                                                     
     medicine. There's no  question that Alaskan optometric                                                                     
     physicians should be held to the same high standard of                                                                     
     care as other medical  professionals, but it is absurd                                                                     
     to suggest  that other professions  can regulate their                                                                     
     own  and  optometry can't,  there  really  is no  good                                                                     
     reason for that.                                                                                                           
                                                                                                                                
     Over 28  years of  practice, much  has changed  in eye                                                                     
     care,  more than  half of  my practice  is  medical in                                                                     
     nature,  routinely  diagnosing  and  managing  complex                                                                     
     cases that  have  required referral  even a  few years                                                                     
     ago.  Many  of   these  cases  require  close  working                                                                     
     relationships with  eye surgeons, mutual  trust allows                                                                     
     me to consult with  other medical providers on a daily                                                                     
     basis; conditions  that used to  require travel south,                                                                     
     Seattle or Anchorage, are  now managed competently and                                                                     
     effectively with reduced travel or no travel at all.                                                                       
                                                                                                                                
     Even though much of  what we do now  was not allowed a                                                                     
     few short  years  ago, state  law has  been incredibly                                                                     
     slow,   41-years  slow   in   recognizing  the   rapid                                                                     
     improvements  in   skills  and  training   of  current                                                                     
     optometrists and  new  graduates. You  will  hear some                                                                     
     concern  with regard  to surgery  and  its definition,                                                                     
     it's  important  that  you  know Alaskan  optometrists                                                                     
     perform  surgery   now  as  defined   by  the  medical                                                                     
     community. We routinely do things such as foreign-body                                                                     
     removal,  incision  and   drainage  of  eyelid  cysts,                                                                     
     corneal scraping or debridement, lacrimal dilation and                                                                     
     irrigation, even  things as simple  as eyelash removal                                                                     
     is considered surgery.                                                                                                     
                                                                                                                                
     All surgery  is not  invasive surgery,  no optometrist                                                                     
     wants  to perform  procedures that  we  aren't trained                                                                     
     for. We simply want  to do what we can  do and what we                                                                     
     are trained  to do,  competently. You will  hear other                                                                     
     "cry wolf"  about  patient harm  that will  occur once                                                                     
     again if SB 36 is  passed, when they know for the past                                                                     
     40 years of  optometry law that this has  not been the                                                                     
     case.  Optometry  malpractice   insurance,  as  you've                                                                     
     heard, are the  lowest of all doctoral-level providers                                                                     
     for a  reason  and I  urge you  to review  that Senate                                                                     
     document that  you  should have  regarding malpractice                                                                     
     insurance. Opponents  of this bill  miss the  point of                                                                     
     why it  is  important, it's  about the  patient's best                                                                     
     interest and it's not about us doctors.                                                                                    
                                                                                                                                
     Simple math, no  matter how you look at  it, there are                                                                     
     not  enough  skilled  ophthalmologists  to  serve  our                                                                     
     rapidly  aging  population.  As  skills  and  training                                                                     
     expand, we need all  eye-care physicians onboard to be                                                                     
     able  to practice  for a  full level  of  training and                                                                     
     expertise. As  a former board  member, I can  tell you                                                                     
     that nothing is more  important than protection of the                                                                     
     public.                                                                                                                    
                                                                                                                                
     I don't foresee any  dramatic change in how optometric                                                                     
     physicians practice in Alaska with the passage of this                                                                     
     bill, it  certainly will  not  change how  I practice.                                                                     
     Optometrists  will continue  to  provide quality  care                                                                     
     protecting our patient's wellbeing as they would their                                                                     
     own. I  do foresee  a streamlining of  the legislative                                                                     
     process  to  take  on   more  pressing  issues  and  a                                                                     
     tremendous savings  in time,  effort and  money wasted                                                                     
     debating issues that should be common sense.                                                                               
                                                                                                                                
     Optometry   is  a   well-trained   and  highly-skilled                                                                     
     profession that  provides  the majority  of first-line                                                                     
     eye   care  in   Alaska.   As   our   educational  and                                                                     
     professional standards  evolve, we  should be  able to                                                                     
     practice to the highest  level of care consistent with                                                                     
     our training and  education. Optometry has always been                                                                     
     a cautious profession and will  continue to be so into                                                                     
     the future.  I have no  doubt that the  board is fully                                                                     
           capable of providing oversight and maintaining                                                                       
     standards needed to safeguard the public.                                                                                  
                                                                                                                                
       SB 36 is good for optometry, it removes a reoccurring                                                                    
           burden for precious legislative time and most                                                                        
     importantly it is good for Alaskans.                                                                                       
                                                                                                                                
2:03:44 PM                                                                                                                    
SENATOR VON IMHOF noted that lasers were previously mentioned as                                                                
being  used  for making  diagnoses.  She  asked  to verify  that                                                                
optometrists do not use lasers to  cut the eye or anything along                                                                
that line.                                                                                                                      
                                                                                                                                
DR. MESSERSCHMIDT  replied correct. He  specified that optometry                                                                
does not  perform any  procedures that physically  penetrate the                                                                
eye in  a cutting manner;  however, there are  three states that                                                                
use lasers in a therapeutic manner that is considered surgery.                                                                  
                                                                                                                                
SENATOR VON IMHOF  asked to confirm that the  therapeutic use of                                                                
lasers does not penetrate the eye.                                                                                              
                                                                                                                                
DR.  MESSERSCHMIDT specified that  the laser's  light penetrates                                                                
the eye, but a laser does not cut except where it is focused, so                                                                
it's just like  regular daylight coming into your  eyes until it                                                                
is  actually focused,  so you  can  cut inside  the  eye without                                                                
cutting  to penetrate  the eye.  The procedure  is  called laser                                                                
posterior capsulotomy  which is  done  as a  secondary procedure                                                                
after cataract  surgery, but  there are a  few states  where the                                                                
procedure is performed by optometrists.                                                                                         
                                                                                                                                
SENATOR VON IMHOF asked if posterior capsulotomy is performed by                                                                
optometrists in Alaska.                                                                                                         
                                                                                                                                
DR. MESSERSCHMIDT answered no.                                                                                                  
                                                                                                                                
SENATOR VON IMHOF pointed out that the same legislation has been                                                                
forwarded to the  Legislature for several years.  She noted that                                                                
Dr. Messerschmidt  served on  the Board  of Optometry  and asked                                                                
what are the  opponents' concerns, particularly with lasers, and                                                                
how can their concerns be mitigated.                                                                                            
                                                                                                                                
2:05:22 PM                                                                                                                    
DR.  MESSERSCHMIDT replied  that  mitigating  their concerns  is                                                                
something that he is not necessarily concerned about. He pointed                                                                
out  that he  has been  practicing for  30 years  and  uses non-                                                                
focusing lasers every day for diagnostic purposes, but he is not                                                                
going to be performing posterior capsulotomy on his patients. He                                                                
noted that doctors  coming out of Oklahoma are  fully trained in                                                                
posterior capsulotomy and if they  graduated and are licensed in                                                                
Oklahoma, then they can do those procedures.                                                                                    
                                                                                                                                
SENATOR VON IMHOF asked if Oklahoma doctors trained in posterior                                                                
capsulotomy can perform the procedure anywhere in the U.S.                                                                      
                                                                                                                                
DR. MESSERSCHMIDT  replied that  as long as  the law  allows the                                                                
procedure. He added  that there may be  some oversight involved.                                                                
He said  everything is  changing and a  "turf war"  has resulted                                                                
because new abilities to  treat disease has changed. He asserted                                                                
that optometrists with  the education, background, training, and                                                                
can perform a procedure competently, optometrists should be able                                                                
to perform  the procedure.  He pointed  out that  an enucleation                                                                
(removal)  of  the eye  would  obviously  would require  medical                                                                
school  and medical  training that  an ophthalmologist  has, but                                                                
that's not  what optometrists do. He said  pulling eyelashes out                                                                
is a surgical example of a procedure that optometrists do.                                                                      
                                                                                                                                
2:07:11 PM                                                                                                                    
SENATOR  MICCICHE   noted  that   Dr.  Messerschmidt  referenced                                                                
Oklahoma's  optometric training  for  posterior capsulotomy  and                                                                
asked  if the  procedure  is a  state  requirement or  out of  a                                                                
certain university.                                                                                                             
                                                                                                                                
DR. MESSERSCHMIDT  answered certain universities and  noted that                                                                
several  states allow  for  the practice  of  various procedures                                                                
under law.                                                                                                                      
                                                                                                                                
SENATOR MICCICHE  asked if  there is  reciprocity in  Alaska for                                                                
individuals that graduate from a  university with a program that                                                                
Dr. Messerschmidt described.                                                                                                    
                                                                                                                                
DR. MESSERSCHMIDT answered that the  individual would have to be                                                                
licensed in the state. He said there is reciprocity, but pointed                                                                
out  that just  because an  individual comes  into the  state of                                                                
Alaska does not mean they  can practice more than what the state                                                                
of  Alaska  allows, adding  that  the  Board  of Optometry  also                                                                
provides oversight through regulation.                                                                                          
                                                                                                                                
SENATOR MICCICHE asked if the  university graduates will have an                                                                
optometrist  degree  with  a  separate  certification  or  noted                                                                
qualification.                                                                                                                  
                                                                                                                                
DR. MESSERSCHMIDT  surmised that graduates  are going to  have a                                                                
section of their education  and clinical training that specifies                                                                
their abilities as part of their degree.                                                                                        
                                                                                                                                
SENATOR MICCICHE asked  how the board might  look at regulations                                                                
regarding an optometry graduate with the extra certificate.                                                                     
                                                                                                                                
DR.  MESSERSCHMIDT  answered  that the  board  would  be  pretty                                                                
guarded  and there  would have  to  be some  sort  of oversight,                                                                
particularly with a new graduate. He  said as long as the person                                                                
passes  muster with  the  attorney general's  office and  public                                                                
comment, then  yes, as  long as  the person  is trained  and can                                                                
perform competently.                                                                                                            
                                                                                                                                
2:09:40 PM                                                                                                                    
SENATOR BEGICH noted that Louisiana, Oklahoma and Kentucky allow                                                                
surgical procedures  by  optometrists. He  set forth  that "turf                                                                
wars" do not matter to him,  but public safety does. He said one                                                                
of his concerns  is that surgery in  Oklahoma was explicitly not                                                                
allowed by  its board, but  by its legislature. He  addressed an                                                                
American Medical Association (AMA) report where out of 1100 eyes                                                                
that received laser  trabeculoplasty (LTP) surgery for glaucoma,                                                                
17 percent that were done  by ophthalmologists had to be redone,                                                                
and 36 percent done by  optometrists had to be redone. He stated                                                                
that he is concerned by the AMA report as a public safety issue,                                                                
but acknowledged the respect  that optometrists need to regulate                                                                
themselves. He revealed that he reviewed curricula for different                                                                
universities   that  had   high   ratings   for  optometry   and                                                                
ophthalmology and pointed out that there is a radical difference                                                                
between   how   an   optometrist   is  educated   and   how   an                                                                
ophthalmologist is educated.                                                                                                    
                                                                                                                                
DR.  MESSERSCHMIDT explained that  an optometrist  goes straight                                                                
from undergraduate to primarily concentrate on the eye, the rest                                                                
is secondarily with  the body and  systemic health. He confirmed                                                                
that the  surgical portion  of on  ophthalmologist's training is                                                                
something optometry does not get.                                                                                               
                                                                                                                                
SENATOR BEGICH  asked if  the legislation's  debate is  over the                                                                
surgery component and  the removal of the  definition of surgery                                                                
for a tighter and clearer definition.                                                                                           
                                                                                                                                
2:12:43 PM                                                                                                                    
DR. MESSERSCHMIDT set forth that the problem with the surgery is                                                                
optometrists perform surgery now.  He asserted that optometrists                                                                
do not want to lose what they already have and what they do on a                                                                
daily basis. He  said surgery can be very  minor in the doctor's                                                                
eyes, whether an  ophthalmologist, brain surgeon or optometrist.                                                                
He summarized that integrity didn't  stop getting doled out with                                                                
ophthalmology. He said, "We're all professionals, we all need to                                                                
be able  to practice  to where the  standard we are  trained and                                                                
almost all  of us, there  are bad apples  everywhere, regard the                                                                
patient's interests, wellbeing, quality of care as the utmost of                                                                
what we do every day."                                                                                                          
                                                                                                                                
2:14:19 PM                                                                                                                    
CHAIR  WILSON  opined  that  the  committee should  invite  some                                                                
experts back  to give expert  testimony to go  further with what                                                                
Dr. Messerschmidt addressed.                                                                                                    
                                                                                                                                
SENATOR GIESSEL  revealed that  she had served  on the  Board of                                                                
Nursing and noted two cases that the board reviewed and provided                                                                
opinions on.  She detailed  that the  board determined  based on                                                                
individual  review that  two  neonatal-nurse  practitioners were                                                                
qualified to  do circumcisions,  a surgical  procedure; whereas,                                                                
fluoroscopy   performed   by   advanced   nurse   practitioners,                                                                
registered   nurses,  licensed   practical   nurses,  or   nurse                                                                
assistances was found  to be beyond their scope  of practice for                                                                
administering x-rays  without additional education.  She pointed                                                                
out that the  two cases she referenced were  the kinds of things                                                                
that are  done by a regulatory  board and asked if  the Board of                                                                
Optometry has ever been able to regulate in a similar manner.                                                                   
                                                                                                                                
DR. MESSERSCHMIDT answered  that during his limited  time on the                                                                
board that he  did not see any instances  were an individual was                                                                
approved to  perform a  task and  not another. He  recalled that                                                                
during his career, optometrists  where ultimately allowed to use                                                                
diagnostic and topical drugs.                                                                                                   
                                                                                                                                
2:17:12 PM                                                                                                                    
SENATOR  GIESSEL  remarked  that  the example  provided  by  Dr.                                                                
Messerschmidt would  be  the type  of thing  where  training was                                                                
evaluated, and  a  slight expansion  was approved  for qualified                                                                
individuals to function under their profession.                                                                                 
                                                                                                                                
DR. MESSERSCHMIDT answered yes.                                                                                                 
                                                                                                                                
CHAIR  WILSON announced  that the  committee would  adhere to  a                                                                
public testimony format and call optometrist and ophthalmologist                                                                
experts back for future committee testimonials.                                                                                 
                                                                                                                                
2:18:11 PM                                                                                                                    
DR.  DAVID  ZUMBRO,  M.D.,  ophthalmologist, Anchorage,  Alaska,                                                                
testified in opposition to  SB 36. He explained that  he was not                                                                
testifying  for  a  "turf  war,"   but  rather  to  educate  the                                                                
differences between  ophthalmologists and optometrists regarding                                                                
eye-care training and experience.                                                                                               
                                                                                                                                
DR. ZUMBRO  set forth that  SB 36  is not a  simple housekeeping                                                                
bill for  the Board  of Optometry.  He opined  that SB  36 would                                                                
dramatically  redefine   a  profession  and   allow  non-medical                                                                
doctors, doctors of  optometry, to do eye  surgery. He explained                                                                
that  optometry does  not  include surgical  training, does  not                                                                
provide the same  experience, and does not require  a mastery of                                                                
the entire human body's different systems.                                                                                      
                                                                                                                                
He opined that the term "non-invasive surgery" is misleading and                                                                
all surgery has  risks and complications no  matter who performs                                                                
the surgery  or how minimal the  surgery may seem.  He set forth                                                                
that  patient safety  is paramount  and the  one  performing the                                                                
surgery  should have  the proper  training. He  stated  that the                                                                
current eye surgeons  and physicians should be  part of crafting                                                                
regulations.  He  asserted   that  SB  36   would  allow  "globe                                                                
injections"  and   the  ability   for  licensees   to  prescribe                                                                
controlled substances in  a manner consistent  with standards of                                                                
the board.                                                                                                                      
                                                                                                                                
He summarized that he is  for the Board of Optometry to regulate                                                                
the  practice  of  optometry,  but  asserted  that  there  is  a                                                                
difference  between ophthalmology  and optometry.  He  set forth                                                                
that the  pathway already exists  for an  optometrist to perform                                                                
surgery  by  becoming  an  ophthalmologist via  medical  school,                                                                
residency, and board certification.                                                                                             
                                                                                                                                
                                                                                                                                
2:25:58 PM                                                                                                                    
DR.  RACHEL REINHARDT, M.D.,  ophthalmologist, advocate  for the                                                                
American  Academy  of  Ophthalmology,  Mill  Creek,  Washington,                                                                
testified in opposition to SB 36 for the following reasons:                                                                     
                                                                                                                                
  · Optometrists state that there is no increase in claims                                                                      
     because they do not have report to a national database like                                                                
     medical doctors have to do.                                                                                                
  · Optometrists    and   ophthalmologists  receive   the   same                                                                
     reimbursement from Medicare and private payers, the cost of                                                                
     care is identical.                                                                                                         
  · Malpractice insurance increases when surgery is done.                                                                       
    · Lasers are as sharp as a scalpel and are a surgical tool.                                                                 
  · SB 36 would allow optometrists to perform any and all                                                                       
     surgeries including scalpels, lasers, and needles.                                                                         
  · SB 36 would have a profound effect on patient safety by                                                                     
     making Alaska the only state that allows the Board of                                                                      
     Optometry  to  have  total  self-regulation over  scope  of                                                                
     practice.                                                                                                                  
  ·  SB 36  would allow non-medical doctors  and non-surgeons to                                                                
     completely  redefine  the  practice  of  optometry  into  a                                                                
     surgical specialty.                                                                                                        
  ·  The glaucoma-laser-surgery study in  Oklahoma illustrated a                                                                
     189 percent increased hazard requiring additional surgeries                                                                
     when performed by an optometrist versus ophthalmologist.                                                                   
  ·  The ratio of ophthalmologists to  the population is similar                                                                
     for the states of Washington and Alaska.                                                                                   
  ·  The state  of Washington has  a definition of  surgery that                                                                
     optometrists  helped  write  and agreed  to  that  is  very                                                                
     specific.                                                                                                                  
  ·  Narcotic  deaths are  the  number one  cause  of unintended                                                                
     death in the U.S.  and legislators should be thinking about                                                                
     how  to take  away the  right to  prescribe  medications in                                                                
     certain groups.                                                                                                            
  ·  A national consumer league showed  that 95 percent of those                                                                
     polled want only a medical doctor to operate on the eye.                                                                   
                                                                                                                                
DR.    REINHARDT     summarized    that     optometrists'    and                                                                
ophthalmologists' separate  skill sets  should be  respected for                                                                
good patient care.                                                                                                              
                                                                                                                                
2:34:32 PM                                                                                                                    
DR. LADD NOLIN,  optometrist, President of the Alaska Optometric                                                                
Association (AOA), Anchorage, Alaska, testified in support of SB
36. He set forth that AOA believes that authorizing the Board of                                                                
Optometry, who will  work with the Alaska Department  of Law, to                                                                
do its job  and regulate its own profession  within the scope of                                                                
its  education will  better  serve the  patients  of Alaska.  He                                                                
asserted that SB 36 allows the Board of Optometry to do what the                                                                
boards  of  the  other  prescribing professions  in  Alaska  are                                                                
already doing.                                                                                                                  
                                                                                                                                
2:36:08 PM                                                                                                                    
DR.  JEFF  GONNASON, optometrist  and  advocate  for the  Alaska                                                                
Optometric Association, Anchorage, Alaska,  testified in support                                                                
of SB 36 and made the following claims:                                                                                         
                                                                                                                                
  ·  Optometry is a  professional doctors' degree with four-year                                                                
     undergraduate  degree,   four-year   graduate  professional                                                                
     doctor program with available one to two-year residency for                                                                
     advanced education.  The first two  years at  many schools,                                                                
    the medical and optometry students attend the same classes.                                                                 
  ·  Alaska  became the  fiftieth  and  last  state in  1988  to                                                                
     authorize optometrists to use drugs  in practice. The delay                                                                
     was   due  to   opposition  from   organized  ophthalmology                                                                
     protecting their "turf."                                                                                                   
  ·  Medicine,   dentistry,   optometry,  and   advanced   nurse                                                                
     practitioner  nurses are  all  independent  with their  own                                                                
     boards and authorization by  Alaska law to prescribe drugs,                                                                
     including controlled narcotics with DEA numbers.                                                                           
  ·  Alaska  optometrists  have  had narcotic  drug  prescribing                                                                
     authority for  the past  ten years with  no issues  and the                                                                
     board will continue to limit narcotic supply.                                                                              
  ·  Section 3 in  SB 36 states that  the standards must include                                                                
     limitations on practice.                                                                                                   
  ·  Optometrists  are  defined   as  physicians  under  federal                                                                
     Medicare and  are held  to  the same  standard of  care for                                                                
     Medicare and Medicaid patients.                                                                                            
  ·  Optometrists are on the preferred provider insurance panels                                                                
     in Alaska.                                                                                                                 
  ·  Optometry's low  malpractice insurance  rates in  Alaska is                                                                
     the  same  as  in   states  that  have  broader  authority:                                                                
     Kentucky, Oklahoma, and Louisiana.                                                                                         
  ·  Optometrists in  Alaska provide  the  vast majority  of eye                                                                
     care,   serving  over   80-remote   locations.  The   local                                                                
     optometrists are called  upon in rural  hospitals for their                                                                
     expertise.                                                                                                                 
  ·  Treatment and  travel costs  increase greatly  when routine                                                                
     care is  provided by urban  specialists, the cost  is often                                                                
     travel and loss of work.                                                                                                   
  ·  Alaska needs  the  best new  doctors of  optometry  and the                                                                
     state's antiquated statutes are a barrier to attracting the                                                                
     best and brightest.                                                                                                        
  · SB 36 does not authorize any optometrist to do anything.                                                                    
  ·  SB  36 updates  45-year-old  statutes and  gives the  board                                                                
     authority  to  regulate  with emphasis  on  protecting  the                                                                
     public, the same as dentists and advanced-practice nurses.                                                                 
  ·  SB  36  allows   optometry  to  not  have   to  return  for                                                                
     legislation  for   every  new   advance  in   education  or                                                                
     technology.                                                                                                                
  ·  Statutes for the boards of dentistry, medicine, and nursing                                                                
     do not  have extensive lists  of procedures that  cannot be                                                                
     done, their boards set the details in regulation.                                                                          
  ·  The  Legislature  licenses   professionals  which  includes                                                                
     professional judgement  as  to when  to  refer patients  to                                                                
     specialists.                                                                                                               
  · Current optometry statutes still require optometrists to                                                                    
     refer to medical doctors when appropriate.                                                                                 
  · Optometrists do not perform any of the invasive eye                                                                         
     surgeries that ophthalmologists perform that are outside of                                                                
     their scope of  education, all cases are  referred out, the                                                                
     same as  family  doctors refer  to orthopedic  surgeons and                                                                
     dentists refer to oral surgeons.                                                                                           
  · Family doctors are not trained the same as a neurosurgeon,                                                                  
     but there is nothing in the state law that tells what the                                                                  
         family doctor can and cannot do, that's all board                                                                      
     regulated.                                                                                                                 
  · The optometry board would never authorize optometrists to                                                                   
        perform anything they are not educated, trained and                                                                     
     qualified to do as specified in Section 4 of SB 36.                                                                        
                                                                                                                                
DR.  GONNASON summarized  that every  time optometrists  come to  any                                                           
state legislature  over the past  45 years, the  ophthalmologists and                                                           
their national academy have  testified using outrageous scare tactics                                                           
that optometrists will cause tragic harm to the public.                                                                         
                                                                                                                                
2:41:50 PM                                                                                                                    
DR. PAUL  BARNEY, optometrist and Chairman for  the Alaska Board                                                                
of  Examiners  in  Optometry,  Alaska  Department  of  Commerce,                                                                
Community,   and   Economic   Development,  Anchorage,   Alaska,                                                                
testified  in  support  of  SB  36.  He  noted  that  he  is  an                                                                
optometrist at  the Pacific Cataract and  Laser Institute (PCLI)                                                                
in Anchorage. He detailed that PCLI is a referral center limited                                                                
to medical and surgical eye care. He specified that his practice                                                                
is entirely devoted to medical eye care in pre-and post-surgical                                                                
eye care.  He said  he works  with an  ophthalmic surgeon  and a                                                                
certified registered-nurse anesthetist and together they provide                                                                
quality, affordable, surgical eye care to Alaskans. He specified                                                                
that PCLI's approach to eye care is to work collaboratively as a                                                                
team  and  optimize  each  practitioners' training  and  skills,                                                                
noting that he performs pre-surgical examinations, pre-operative                                                                
counseling, and  post-operative care.  He explained  that PCLI's                                                                
nurse anesthetist administers anesthesia  for surgery and PCLI's                                                                
surgeon performs the cataract surgery.                                                                                          
                                                                                                                                
He pointed out that the committee has heard arguments against SB
36 from both  organized optometrists and ophthalmologists; those                                                                
arguments   are   exclusionary   and    state   that   only   an                                                                
ophthalmologist is trained medically and only an ophthalmologist                                                                
is capable of  performing the very tasks that the  he and PCLI's                                                                
nurse anesthetist have performed on a  daily basis for years. He                                                                
pointed  out   that  modern  health  care   is  often  delivered                                                                
collaboratively with team members  from multiple professions, an                                                                
approach  that  maintains  the  quality of  care  that  provides                                                                
patients  with better  access to  care that  is  frequently more                                                                
affordable. He opined that exclusionary attitudes and approaches                                                                
suggesting that only someone who has attended medical school can                                                                
deliver medical  care are  antiquated and  do not  assure better                                                                
quality; in fact, they often limit patient access to care.                                                                      
                                                                                                                                
DR. BARNEY noted that the committee also heard opposition to the                                                                
bill  where  optometrists will  be  allowed  to  do surgery  and                                                                
perform procedures that they are  not trained to do, even though                                                                
the bill specifically states  the board cannot write regulations                                                                
or procedures that licensees aren't  trained and educated to do.                                                                
The Alaska  Department of  Law oversees all  health-care boards,                                                                
including optometry, to ensure that regulations written by those                                                                
boards are within  the confines of the  statutes. He assured the                                                                
committee that while he is  on the Board of Optometry, the board                                                                
will  not   write  regulations   allowing  optometrists   to  do                                                                
procedures that they are not trained to do.                                                                                     
                                                                                                                                
He specified  that SB 36  does allow  the Board of  Optometry to                                                                
determine the  details of the  practice of optometry,  but noted                                                                
that previous  arguments where  the board  cannot be  trusted to                                                                
establish and enforce regulations. He  asserted that as Chairman                                                                
of the  Alaska Board  of Optometry, the  primary concern  of the                                                                
board is the  safety of the public. He revealed  that in the six                                                                
years  that he  has served  on the  board, the  board  has never                                                                
received  a public  complaint that  was serious  enough  to even                                                                
consider disciplinary action, a track record that he is doubtful                                                                
in many other health-care professions in Alaska can claim.                                                                      
                                                                                                                                
He  set forth  that optometrists  are conservative  and cautious                                                                
practitioners and  the passage of  SB 36 would  not change their                                                                
conservative nature. He said  SB 36 would be  good for the state                                                                
of  Alaska  by  placing  the  regulatory details  regarding  the                                                                
practice  of  optometry  in  the   authority  of  the  Board  of                                                                
Optometry. He asserted that the changes from SB 36 are important                                                                
to allow the profession and practice of optometry to incorporate                                                                
new  technologies and advances  in eye  care  as they  occur. He                                                                
pointed out that  current statute requires optometry  to come to                                                                
the Legislature to incorporate changes. He summarized that SB 36                                                                
would allow  optometry to regulate itself  similar to dentistry,                                                                
advanced-practice nurses, and medicine.                                                                                         
                                                                                                                                
2:47:19 PM                                                                                                                    
DR.  KELLY  LORENZ,  M.D.,  ophthalmologist, Anchorage,  Alaska,                                                                
testified in opposition to  SB 36 because the bill  is too vague                                                                
for any  serious consideration. She specified  her opposition as                                                                
follows:                                                                                                                        
                                                                                                                                
  · Section 1, page 1, line 13: there is no definition for what                                                                 
     is  considered ophthalmic  surgery or  what  a non-invasive                                                                
     procedure is, and the definition is left up to the Board of                                                                
     Optometry at  some  later date  which is  irresponsible and                                                                
     should be defined now and not later.                                                                                       
  · Section 2, page 2, lines 1-10: specific recommendations for                                                                 
     continuing   education    regarding   pharmaceuticals   and                                                                
     injections  are noted,  but  no  recommendations are  given                                                                
     regarding proposed surgical procedures, an omission that is                                                                
     again to be  determined at some later date by  the Board of                                                                
     Optometry without any  input from the  Alaska State Medical                                                                
     Board.                                                                                                                     
  · Section 3, page 2, lines 21-23, how will a licensee's                                                                       
     education,  training   and   experience  be   evaluated  to                                                                
     determine whether they are fit to perform surgery, and what                                                                
     kind of training would be required.                                                                                        
                                                                                                                                
She  disclosed that  she has  four years  of  full-time surgical                                                                
training  that   is  beyond   medical  school  and   a  surgical                                                                
internship. She  inquired if  an optometrist's training  will be                                                                
comparable to what  he has received, or will  the training be an                                                                
occasional  weekend  course.  She  set  forth  that  the  larger                                                                
question  is whether  the  Board of  Optometry  can solely  make                                                                
decisions without  any oversight  from the Alaska  State Medical                                                                
Board. She  noted  that she  practices under  both the  Board of                                                                
Ophthalmology and the Alaska State Medical Board. She summarized                                                                
that in the interest of  the public that the issues regarding SB
36  be addressed  now to  allow  for a  fully  informed decision                                                                
rather than  claiming the bill  is a general  update that leaves                                                                
details to be determined later.                                                                                                 
                                                                                                                                
2:49:32 PM                                                                                                                    
DR.  JILL MATHESON,  optometrist, Juneau,  Alaska,  testified in                                                                
support of SB 36. She  asserted that having broad language in SB
36  allows the  Board of  Optometry  to react  with  the shorter                                                                
regulatory process to changes in technological advances. She set                                                                
forth that the  public is protected by  optometrists who are all                                                                
called to  practice as professionals  at the highest  level. She                                                                
pointed out that optometrists are the  first line of eye care in                                                                
nearly every community in the  state and can treat Alaskans with                                                                
the most modern  methods without costly referral to specialists.                                                                
She contended that optometrists know best as to methods and what                                                                
the education should be to perform the methods.                                                                                 
                                                                                                                                
DR.  MATHESON revealed  that  she  has served  on  the Board  of                                                                
Optometry and asserted  that board members in  the past, present                                                                
and future  are and will  be conservative. She  pointed out that                                                                
the Legislature will  not be totally  out of the  loop and noted                                                                
their indirect oversight via  the board member approval process.                                                                
She summarized  that checks  and balances  exist in  addition to                                                                
regulations that go through the Alaska Department of Law.                                                                       
                                                                                                                                
2:51:49 PM                                                                                                                    
DR. SCOTT  LIMSTROM, M.D., ophthalmologist and  President of the                                                                
Alaska Association  of Eye  Physicians and  Surgeons, Anchorage,                                                                
Alaska, testified in  opposition of SB  36. He said  the bill is                                                                
the most  expansive optometric scope of  practice legislation in                                                                
the nation. He  said SB 36 would give  the optometric board full                                                                
authority to  determine which invasive,  diagnostic and surgical                                                                
procedures  optometrists  may  perform  on  patients'  eyes.  He                                                                
revealed that the optometry  board consists of four optometrists                                                                
and one layperson. He pointed out that the optometry board makes                                                                
decisions  regarding medical  treatments  and surgeries  without                                                                
having a  medical doctor or  surgeon as a  member. He reiterated                                                                
previous  testimony that  optometrists  lack  the education  and                                                                
training to  perform surgeries. He  summarized that the  care of                                                                
patient  sight  is a  privilege  earned  through  many years  of                                                                
education and  should not be  taken lightly. He stated  that the                                                                
protection of the public is paramount.                                                                                          
                                                                                                                                
2:54:42 PM                                                                                                                    
DR.  DAVID  KARPIK,  optometrist,  Kenai, Alaska,  testified  in                                                                
support of SB 36. He disclosed that he owns the largest eye-care                                                                
facility on the  Kenai Peninsula. He detailed  that his business                                                                
receives  referrals  from  medical  specialists  throughout  the                                                                
region and  provides vision  care for injuries,  infections, and                                                                
chronic-systemic diseases with  eye implications. He  added that                                                                
referrals  occur   back  and   forth  to   various  primary-care                                                                
providers,  sub-specialists,   and  ophthalmologists  throughout                                                                
Alaska, state of Washington and beyond.                                                                                         
                                                                                                                                
He disclosed  that he  had moved  to Alaska  12-years previously                                                                
despite the state's antiquated  optometry law that initially did                                                                
not allow him to practice to  the full scale of his training. He                                                                
noted that the  optometry law was patched and  improved in 2007,                                                                
but  times and  training has  continued to  advance in  the past                                                                
decade.                                                                                                                         
                                                                                                                                
DR. KARPIK specified that  his support for SB 36  is due in part                                                                
to its simplicity as well  as replacement of a patched together,                                                                
rigid and aging optometry law  that has needed to be continually                                                                
changed  to keep  up  with  updates and  practice.  He said  the                                                                
prescribing professions  are typically regulated by  their state                                                                
boards as is the  case with dentistry, medicine, and nursing; SB
36 sets up an elegant framework parallel to these boards.                                                                       
                                                                                                                                
He   summarized   that   education,  technology   and   research                                                                
continuously change best practices. He set forth that regulation                                                                
by  the Board  of  Optometry ensures  protection  of the  public                                                                
alongside timely  updates in  practice  which allow  for optimum                                                                
care for Alaskans.                                                                                                              
                                                                                                                                
2:57:44 PM                                                                                                                    
CHAIR WILSON closed public testimony and announced he would hold                                                                
SB 36 in committee for future consideration.                                                                                    

Document Name Date/Time Subjects
SB 36 30-LS0328 Version A.pdf SHSS 2/3/2017 1:30:00 PM
SB 36
SB 36 Sponsor Statement 1-26-17.pdf SHSS 2/3/2017 1:30:00 PM
SB 36
SB36 Sectional Analysis 1-26-17.pdf SHSS 2/3/2017 1:30:00 PM
SB 36
FN #1 1.17.17.PDF SHSS 2/3/2017 1:30:00 PM
SB 36
SB 36 Optometry SHSS Hearing Request 1-26-17.docx.PDF SHSS 2/3/2017 1:30:00 PM
SB 36
SB36 Historical Backup Letter LesWalls, OD, MD Letter.pdf SHSS 2/3/2017 1:30:00 PM
SB 36
SB36 Supporting Document Geographical locations.pdf SHSS 2/3/2017 1:30:00 PM
SB 36
SB36 Supporting Document Villages Served.pdf SHSS 2/3/2017 1:30:00 PM
SB 36
SB36 Supporting Document Malpractice Fact Sheet.pdf SHSS 2/3/2017 1:30:00 PM
SB 36
SB36 Supporting Document Ohio State Optometry Curriculum.pdf SHSS 2/3/2017 1:30:00 PM
SB 36
JAMA Abstract on Comparison 7.28.16.pdf SHSS 2/3/2017 1:30:00 PM
SB 36
Sen. Giessel.Support.PDF SHSS 2/3/2017 1:30:00 PM
SB 36
Sen Wilson Yes 1.pdf SHSS 2/3/2017 1:30:00 PM
SB 36
Sen Wilson Yes 2.pdf SHSS 2/3/2017 1:30:00 PM
SB 36
Sen Wilson No 1.pdf SHSS 2/3/2017 1:30:00 PM
SB 36
Sen Wilson No 2.pdf SHSS 2/3/2017 1:30:00 PM
SB 36
Wilson yes 3.pdf SHSS 2/3/2017 1:30:00 PM
SB 36
SB 36 side by side SB bickford.pdf SHSS 2/3/2017 1:30:00 PM
SB 36
AK Society of Eye Physicians and Surgeons.pdf SHSS 2/3/2017 1:30:00 PM
SB 36