Legislature(2023 - 2024)BUTROVICH 205

02/23/2023 03:30 PM Senate HEALTH & SOCIAL SERVICES

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Moved CSSB 45(HSS) Out of Committee
                    ALASKA STATE LEGISLATURE                                                                                  
      SENATE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE                                                                    
                       February 23, 2023                                                                                        
                           3:31 p.m.                                                                                            
MEMBERS PRESENT                                                                                                               
Senator David Wilson, Chair                                                                                                     
Senator James Kaufman, Vice Chair                                                                                               
Senator Löki Tobin                                                                                                              
Senator Forrest Dunbar                                                                                                          
Senator Cathy Giessel                                                                                                           
MEMBERS ABSENT                                                                                                                
All members present                                                                                                             
COMMITTEE CALENDAR                                                                                                            
SENATE BILL NO. 45                                                                                                              
"An Act relating to insurance; relating to direct health care                                                                   
agreements; and relating to unfair trade practices."                                                                            
     - MOVED CSSB 45(HSS) OUT OF COMMITTEE                                                                                      
SENATE BILL NO. 44                                                                                                              
"An  Act relating  to the  practice of  naturopathy; establishing                                                               
the  Naturopathy Advisory  Board;  relating to  the licensure  of                                                               
naturopaths; relating to  disciplinary sanctions for naturopaths;                                                               
relating to  the Department of Commerce,  Community, and Economic                                                               
Development; and providing for an effective date."                                                                              
     - HEARD & HELD                                                                                                             
PREVIOUS COMMITTEE ACTION                                                                                                     
BILL: SB  45                                                                                                                  
SHORT TITLE: DIRECT HEALTH AGREEMENT: NOT INSURANCE                                                                             
SPONSOR(s): SENATOR(s) WILSON                                                                                                   
01/25/23       (S)       READ THE FIRST TIME - REFERRALS                                                                        

01/25/23 (S) HSS, L&C 02/07/23 (S) HSS AT 3:30 PM BUTROVICH 205 02/07/23 (S) Heard & Held 02/07/23 (S) MINUTE(HSS) 02/09/23 (S) HSS AT 3:30 PM BUTROVICH 205 02/09/23 (S) Heard & Held 02/09/23 (S) MINUTE(HSS) 02/21/23 (S) HSS AT 3:30 PM BUTROVICH 205 02/21/23 (S) Scheduled but Not Heard 02/23/23 (S) HSS AT 3:30 PM BUTROVICH 205 BILL: SB 44 SHORT TITLE: NATUROPATHS: LICENSING; PRACTICE SPONSOR(s): SENATOR(s) GIESSEL BY REQUEST


01/25/23 (S) HSS, L&C, FIN 02/23/23 (S) HSS AT 3:30 PM BUTROVICH 205 WITNESS REGISTER JASMIN MARTIN, Staff Senator David Wilson Alaska State Legislature Juneau, Alaska POSITION STATEMENT: Provided a summary of changes from version S to version U for SB 45. LORI WING-HEIER, Director Division of Insurance Department of Commerce, Community & Economic Development Juneau, Alaska POSITION STATEMENT: Answered questions on SB 45 JANE CONWAY, Staff Senator Cathy Giessel Alaska State Legislature Juneau, Alaska POSITION STATEMENT: Presented the sectional analysis for SB 44. NATALIE WIGGINS, ND Alaska Association for Naturopathic Doctors Juneau, Alaska POSITION STATEMENT: Testified by invitation on SB 44. MELANIE HENRIKSEN, ND, President National University of Natural Medicine Portland, Oregon POSITION STATEMENT: Testified by invitation for SB 44. CLYDE JENSEN, Ph.D. Professor of Pharmacology Rocky Vista University Saint George, Utah POSITION STATEMENT: Testified by invitation on SB 45. SEAN HIGGINS, representing self Anchorage, Alaska POSITION STATEMENT: Testified by invitation for SB 44. JON LIEBERMAN, MD Fairbanks, Alaska POSITION STATEMENT: Testified by invitation on SB 44. SCOTT LUPER, ND Alaska Association of Naturopathic Doctors Fairbanks, Alaska POSITION STATEMENT: Answered questions on SB 44. BRUCE CAMPBELL, representing self, Fairbanks, Alaska POSITION STATEMENT: Testified in support of SB 44. ANNETTE O'CONNELL, representing self Nikiski, Alaska POSITION STATEMENT: Testified in support of SB 44. ACTION NARRATIVE 3:31:50 PM CHAIR DAVID WILSON called the Senate Health and Social Services Standing Committee meeting to order at 3:31 p.m. Present at the call to order were Senators Tobin, Kaufman, Giessel, Dunbar, and Chair Wilson. SB 45-DIRECT HEALTH AGREEMENT: NOT INSURANCE 3:32:16 PM CHAIR WILSON announced the consideration of SENATE BILL NO. 45 "An Act relating to insurance; relating to direct health care agreements; and relating to unfair trade practices." He noted that there was a committee substitute for the committee to consider. 3:32:44 PM CHAIR WILSON solicited a motion. 3:32:48 PM SENATOR GIESSEL moved to adopt the committee substitute (CS) for SB 45, work order 33-LS0211\U, as the working document. 3:32:59 PM CHAIR WILSON found no objection and CSSB 45 was adopted. 3:33:11 PM JASMIN MARTIN, Staff, Senator David Wilson, Alaska State Legislature, Juneau, Alaska, presented the summary of changes from version S to version U of SB 45. [Original punctuation provided.] "An Act relating to insurance; relating to insurance; relating to direct health care agreements; and relating to unfair trade practices." Version S to U 5 changes from first V.S to V.U: 1) Technical changes, non-substantive: a) Language is rearranged for clarity. b) Definition of "direct health care agreement" is moved to the definitions section. c) Language is adjusted for consistency though out. 2) Page 2, line 15-18: Language is added requiring that a direct health care agreement must identify a contact person for a representative of the health care provider that is responsible for receiving requests to amend the agreement, in addition to the person responsible for receiving complaints. 3) Page 3, line 2-12: Language allowing a provider to immediately terminate the agreement if a patient does not comply with a treatment plan is removed from this section. A provider may still cancel and agreement with 30 days' notice. 4) Page 3, line 16-22: In version S, a health care provider may raise the periodic fee no more than once a year and must provide the patient 45 days' notice that they plan to do so. Version U has language added that allows the patient to cancel with no penalties if they decided to not continue an agreement when the provider raises the fees. 5) Page 6, line 9-21: A "false advertising" clause was added. This section prohibits a provider from false advertising regarding a direct health care agreement. It specifically prohibits advertising these agreements as insurance or as an alternative to insurance. 3:35:17 PM SENATOR KAUFMAN arrived at the meeting. 3:35:29 PM SENATOR TOBIN asked whether the complaint process should remain in the Attorney General's office or if it should be moved to the Division of Insurance. 3:36:06 PM LORI WING-HEIER, Director, Division of Insurance, Department of Commerce, Community & Economic Development, Juneau, Alaska, stated that the division has worked on SB 45 for several years and realizes consumer protection is a concern. She said there had been good discussion regarding the overlap between insurance and contracts. She stated she was upfront during discussions and said if oversight came to her division, it would not have a fiscal note. The division would handle contracting and insurance complaints in the same manner. 3:37:30 PM CHAIR WILSON found no further questions and solicited a motion. 3:37:34 PM SENATOR GIESSEL moved to report the CS for SB 45, work order 33- LS0211\U, from committee with individual recommendations and attached zero fiscal note(s). 3:37:57 PM CHAIR WILSON found no objection and CSSB 45(HSS) was reported from the Senate Health and Social Services Standing Committee. 3:38:10 PM At ease B 44-NATUROPATHS: LICENSING; PRACTICE 3:41:02 PM CHAIR WILSON reconvened the meeting and announced the consideration of SENATE BILL NO. 44 "An Act relating to the practice of naturopathy; establishing the Naturopathy Advisory Board; relating to the licensure of naturopaths; relating to disciplinary sanctions for naturopaths; relating to the Department of Commerce, Community, and Economic Development; and providing for an effective date." 3:41:24 PM SENATOR CATHY GIESSEL, District E, sponsor of SB 44 spoke to the following sponsor statement: [Original punctuation provided.] "An Act relating to the practice of naturopathy; establishing the Naturopathy Advisory Board; relating to the licensure of naturopaths; relating to disciplinary sanctions for naturopaths; relating to the Department of Commerce, Community, and Economic Development; and providing for an effective date." Senate Bill 44 establishes a clear scope of practice for Alaska naturopathic doctors and will allow these primary healthcare providers to practice consistent with their education and training. The state's nearly 50 licensed naturopaths provide valuable healthcare services to thousands of Alaskans and can play an important role in helping address our current primary care provider shortage. However, our outdated statutes contain vague language that dictate the authorities of naturopaths; consequently, this lack of clarity and interpretation has led to the adoption of some of the most restrictive naturopathic medicine regulations in the nation. Senate Bill 44 would set clear statutory guidelines, including, among other things, allowing licensed naturopathic practitioners to perform minor office procedures and to prescribe vitamins, minerals and other non-controlled substance medications. Naturopathic doctors practice safely in other states under the same scope of practice that this bill would allow. Naturopathic medicine can provide valuable and complementary care in the Alaska health care setting for many Alaskans who struggle to find an accessible primary care physician. The ability for naturopaths to practice the scope of medicine consistent with their training would immediately expand the availability of primary care in Alaska. Many Alaskans face challenges with chronic diseases like obesity, diabetes and hypertension that are issues for which Naturopaths are very equipped to treat. Their education focuses on disease prevention, rather than just treating symptoms and prescribing medications. In the long run, Naturopathic care will provide cost savings and improved health outcomes for patients, insurers and the state, while allowing Alaskans to choose the style of health care most suitable to them. Please join me in support of Senate Bill 44. 3:45:15 PM JANE CONWAY, Staff, Senator Cathy Giessel, Alaska State Legislature, Juneau, Alaska, presented the sectional analysis for SB 44 as follows and noted a correction to Section 3 stating it amends AS 08.45.020: [Original punctuation provided] "An Act relating to the practice of naturopathy; establishing the Naturopathy Advisory Board; relating to the licensure of naturopaths; relating to disciplinary sanctions for naturopaths; relating to the Department of Commerce, Community, and Economic Development; and providing for an effective date." Section 1 Amends AS 08.02.010(a) Professional designation requirements Requires naturopathic practitioners to use appropriate letters, titles and specialist designations. Section 2 Amends AS 08.45.015 and adds a new section: Establishes a five-person Naturopathy Advisory Board for the purpose of making recommendations on adoption of regulations and other matters relating to the functions of the department under AS 08.45. 3:46:27 PM Section 3 Amends AS 05.45.020 Application for license Requires applicants applying for licensure to use a form provided by the department; to submit fingerprints for purposes of a criminal history background check for licensure; and pay a fee established by the department. Section 4 Amends AS 08.45.030 Issuance of license Requires an applicant to: • have graduated with a doctoral degree from an accredited naturopathic college • complete a 2-year externship program • have passed a pharmaceutical examination approved by department • have passed the Naturopathic Physicians Licensing Examination • is not subject to an unresolved disciplinary action in another jurisdiction • comply with application requirements; and • have not been convicted or, or pled guilty, or no contest to a crime that adversely reflects on the applicant's ability to practice or jeopardizes the safety of a patient. Removes outdated language requiring that to be issued a license to practice naturopathy in Alaska, if an individual graduated before 1988, they must also have been issued a license to practice in another state previously. Section 5 Amends and adds a new section under AS 08.45.032 Documentation of license refusals and revocations Requires the department to provide in writing, a concise statement for refusal to issue licenses or for license revocation. 3:47:59 PM Section 6 Amends AS 08.45.035(a) Temporary licenses Allows the department to issue a temporary license to a naturopath if they are signed up to take a licensing exam at the next available date after the date of the application and meets all the other licensing requirements. Section 7 Amends and adds new sections under AS 08.45 08.45.037 Continuing Education Requirements: • applicant must submit evidence that education requirements have been met set under regulations, equivalent to those of a physician assistant, and has received education in pain management and opioid use/addiction within 2 years of application renewal date the department may exempt applicant from this requirement due to extenuating circumstances • department will require over 15 hours of continuing education every 5 years as well as education in pain management and opioid use/addiction 08.45.038 Standards for License Renewal: • applicant must pay required fee, meet continuing education requirements, has not been convicted of a crime that proves incompetency or jeopardizes safety of the patient; applicant has current CPR certification, has submitted to fingerprinting and paid fees to meet Public Safety for purposes of background check within previous 6 years. Section 8 Amends and adds new section AS 08.45 Practice of naturopathy 08.45.045 Allows naturopaths to: • practice within the standards and scope of their education and training • prescribe natural and therapeutic substances, natural therapies, and contraceptive devices • prescribe allowed drugs only if the Naturopath has passed the Naturopathic Physicians Licensing Examination pharmacology portion and • perform minor surgeries and order diagnostic procedures • Defines "naturopathic physical application" 3:49:10 PM Section 9 Amends AS 08.45.050 Restrictions on practice of naturopathy • Removes the prohibition for prescribing drugs, performing minor surgeries • Prohibits Naturopaths from giving, recommending or prescribing cancer drugs and controlled substances Section 10 Amends and adds new sections under AS 08.45 08.45.053: Public health duties: Requires Naturopaths to abide by duties followed by licensed physicians regarding public health laws, reportable and communicable diseases, recording of vital statistics, health exams and laws outlined by municipal boards of health AS 08.45.055 Duty of naturopaths to report: If treating another naturopath who is being treated for alcoholism or other mental health disorders and who may constitute a danger to themselves or others, they must report individual with name and address of that person. Upon receipt of report the department shall investigate and may appoint a committee to examine and report on its findings. The department has authority to suspend the person prior to appointing the committee and receipt of its report. The department shall suspend, revoke or limit the Naturopath's license if it finds the reported is unable to continue with reasonable safety for patients/public. A Naturopath may not refuse to report or withhold information disclosed in patient relationship or under a confidentiality agreement under AS 18.23.030. An action cannot be taken against the reporting Naturopath or other investigating agency, administrator or judicial entity. AS 08.45.058 Naturopaths to report certain injuries. This section imposes the same public health duties on naturopaths as other physicians such as 3rd degree burns, bullet wounds, firearm discharge wounds, knife or other blade wounds, life-threatening wounds, unless incidences were purely accidental; protects the Naturopath from civil liability for making the report. 3:50:55 PM Section 11 amends AS 08.45.060 Grounds for suspension, revocation, or refusal to issue a license Amends and applies the same suspensions, license revocation, or refusal to issue a license grounds on naturopaths as other physicians Section 12 Amends and adds a new subsection under AS 08.45.060 Grounds for suspension, revocation, or refusal to issue a license. Adds a new subsection to clarify the authority of the entity taking disciplinary action against a license under AS 08.45.060(a)(14) which states that a Naturopath can have licensed revoked/suspended if he/she has had license revoked/suspended in another state or Canada for violations of practice or failure to pay fees. Section 13 amends AS 08.45.070(a) Disciplinary sanctions Clarifies that disciplinary sanctions apply for AS 08.45 and imposes a limit of $25,000 for civil penalties. Section 14 Amends and adds new subsection under AS 08.45.070 Allows department to reinstate a license if applicant is deemed able to practice safely, allows suspension of license if department received proof of license revocation or suspension in another state or Canada; requires department to report to the National Practitioner Data Bank any licensure refusals, suspensions and fines. 3:52:18 PM Section 15 Amends 08.45 by adding new sections 08.45.105 Automatic suspension for mental incompetency: License is automatically revoked if Naturopath is found to be mentally incompetent by a judicial proceeding or voluntary commitment. License can be restored with court finding of restored competency, or restorative opinion issued by a psychiatrist approved by the department. 08.45.110 Voluntary surrender: The department can accept a voluntary surrender of a license and can reinstate the licensee if department deems them competent to resume practice, but cannot reinstate license if the license was surrendered because of a civil or criminal charge against the licensee. 08.45.115 Medical and psychiatric examinations: the department may require a drug or alcohol test as part of an investigation of a licensee, with the test to be paid by the department 08.45.120 Reports relating to malpractice action and claims: A licensee must report to the department any malpractice or civil claim brought against them within 30 days after resolution or termination of civil action. 08.45.125 Penalty for practicing without a license: Makes it a class A misdemeanor to practice without a license, and each day of unauthorized practice is a separate offense. 08.45.130 Prohibited use of title: a Naturopath cannot use or advertise as a naturopath unless licensed by the state. 3:53:18 PM Section 16 Repeals and reenacts AS 08.45.200(3) Definitions Repeals and replaces definition for "naturopathy" Section 17 Amends and adds new paragraphs under AS 08.45.200(4) & (5) Definitions Defines "approved naturopathic medical school" and "naturopath" Section 18 Amends AS 12.62.400(a) National criminal history record checks for employment, licensing, and other noncriminal justice purposes. Adds Naturopaths to list of other professions requiring them to submit fingerprints to complete the national criminal history record check Section 19 Transitional Language for current licensees Allows currently licensed naturopaths to continue to practice under current law until licensee's normal renewal period, under which they must comply with language contained in this legislation. 3:54:06 PM Section 20 Transitional Regulations Allows the Department to adopt transitional regulations immediately following passage and prior to the bill's effective date. Section 21 Effective date Establishes immediate effective date for Section 20 Section 22 Effective date Establishes effective date for Sections 1 19 as January 1, 2024 3:54:37 PM CHAIR WILSON began invited testimony on SB 44. 3:55:18 PM NATALIE WIGGINS, ND, Naturopathic Physician Alaska Association for Naturopathic Doctors, Anchorage, Alaska, said she works in an integrative clinic with two nurse practitioners and a physician assistant. Voting in favor of SB 44 is in the best interest of Alaskan residents because Alaska is experiencing a healthcare crisis. Alaska needs more providers living in the state to take care of residents. Access to care contributes to Alaska's ranking as the state with the highest medical care costs in the nation. Areas with low numbers of medical care providers experience more expensive care. Naturopathic doctors (NDs) are available and ready to support community needs. However, naturopaths must be allowed to practice medicine to the full extent of their training to help. SB 44 would update the scope of practice to reflect the training naturopaths receive. The need for an update has yet to occur out of concern for safety. SB 44 requires the legislature to decide if naturopathy is safe. She spoke about the following key points regarding safety: • All licensed naturopathic doctors in Alaska have completed a four-year bachelor's degree program, including pre- medical training. • All licensed naturopathic doctors in Alaska have completed a four-year doctoral program at a naturopathic medical school. • The Council on Naturopathic Medical Education accredits naturopathic schools under the US Department of Education. • Medical training includes approximately 140 hours of pharmacology training. • 1,200 hours of clinical training, including prescriptive management and instruction in minor office procedures 3:57:32 PM MS. WIGGINS said naturopathic training is commensurate with nurse practitioners and physician assistants, yet the scope of practice for naturopathic doctors is less. The updated scope in SB 44 is like what other states have safely allowed for a long time. She said she had a DEA (Drug Enforcement Agency) number and prescriptive authority, which included scheduled drugs when she worked in Arizona. Also, Arizona state permitted her to perform sutures and administer vaccines. The ability to perform such tasks is necessary for primary care providers. Naturopaths are well-trained in the use of such tools. Alaskan patients need naturopaths that are allowed to practice. Ironically, in Arizona, she was a physician who oversaw physician assistants at the clinic where she worked. Now she must refer to her physician assistant colleague for medication management. Patients learn to trust their established medical provider and want their medication managed by them. Duplicative appointments are costly and time-consuming for patients and contribute to the state's healthcare burden. She said she returned to Alaska to raise her children, but it came at the considerable cost of surrendering her ability to practice medicine in accordance with her training. Alaska has 50 licensed naturopath doctors who can safely prescribe medications and perform office procedures, just like colleagues safely do in other states. Voting in favor of SB 44 is a safe step in the right direction toward reducing healthcare costs and providing patient choice. 4:00:26 PM At ease 4:01:09 PM CHAIR WILSON reconvened the meeting. 4:01:20 PM SENATOR DUNBAR referred to page 7 of the handout Senate Bill 44 Naturopaths; Licensing; Practice, and asked for an explanation of the gray areas of the map. 4:01:58 PM MS. CONWAY stated her belief that the gray areas represent states where the naturopath profession is under-regulated. She deferred the question. 4:02:45 PM SENATOR DUNBAR wondered how a naturopath's four years of training at medical school relates to prescriptive authority. He asked why Schedule I and cancer drugs are exempt if naturopaths received training. 4:03:38 PM DR. WIGGINS replied that some drugs, like cancer drugs, fall into a specialty category, so although naturopaths know of them, they should be prescribed by a specialist. A naturopath's pharmacology training is very similar to that of a nurse practitioner or physician assistant. The training includes pharmacokinetics, side effects, and drug/herb interactions. 4:04:35 PM SENATOR DUNBAR asked if nurse practitioners and physician assistants could prescribe Schedule I drugs and why naturopaths could not prescribe Schedule I drugs if they have the same training. 4:04:47 PM DR. WIGGINS replied that Schedule I drugs are not for medical use. The drugs that nurse practitioners and physician assistants prescribe are listed on Schedules II - V. There are many medications in those categories, including pain medication. She said she does not know the reason for pushing against naturopaths' ability to prescribe. 4:05:46 PM SENATOR GIESSEL stated that Dr. Wiggins testified that she had a DEA number and controlled substances authority in Arizona. She asked what DEA stands for, what controlled substances are, the different schedules, and what a person does to obtain a DEA number. 4:06:16 PM DR. WIGGINS responded that DEA stands for Drug Enforcement Agency, which regulates high-risk abuse medications, which is why Schedule II drugs include opioids. There are medications in that category suited for family practice, such as testosterone. However, because of the risk of abuse, it is a scheduled medication. 4:06:58 PM SENATOR GIESSEL asked what Dr. Wiggins did to get a DEA number and authorization to prescribe medication. 4:07:05 PM DR. WIGGINS said that to receive a DEA number, an individual has passed the education and training requirements set by the DEA. 4:07:30 PM SENATOR GIESSEL commented that the DEA is a federal agency and authorization renewal is required. She asked Dr. Wiggins to elaborate more about the DEA. 4:07:42 PM DR. WIGGINS stated she was unsure what more to elaborate about. 4:07:56 PM SENATOR GIESSEL said the agency scrutinizes who receives an authorization number and requires renewal every five years, which means authorized individuals must prove their credentials and ability to be safe. A single violation results in a permanent banning of one's controlled substance prescriptive authority. 4:08:19 PM SENATOR TOBIN said she noticed that SB 44 contains mandated reporting. She asked Dr. Wiggins to expound on what naturopathic doctors are required to report as it is important to ensure people report the signs of abuse to the proper authority. 4:08:55 PM DR. WIGGINS answered that naturopaths are trained mandatory reporters. 4:09:16 PM SENATOR TOBIN asked if SB 44 states that naturopaths are mandatory reporters. 4:09:30 PM SENATOR GIESSEL said the language in SB 44 is uniform across the healthcare and education professions. 4:09:42 PM SENATOR KAUFMAN asked if there is a book that defines all minor surgeries. 4:10:12 PM DR. WIGGINS said she did not know if there was a list. 4:10:22 PM At ease. 4:10:30 PM CHAIR WILSON reconvened the meeting. DR. WIGGINS said the definition of minor surgery is "limited to superficial repair." Minor would refer to superficial structures such as skin repair. The definition would not include body cavities. 4:10:59 PM SENATOR KAUFMAN said a minor repair would refer to skin damage but not spleen damage. 4:11:15 PM SENATOR KAUFMAN asked if a four-year bachelor's degree and four- year naturopathic medical degree constitute a Ph.D. program. 4:11:36 PM DR. WIGGINS stated it equates to a doctoral degree. The degree is a doctorate in naturopathic medicine. 4:11:45 PM SENATOR DUNBAR said the fiscal note is almost zero and would establish a new board to make regulations. He presumed there would be licensing fees and expressed concern that with only 50 naturopathic doctors in Alaska, the fees to cover the cost of the board would be high. 4:12:25 PM MS. CONWAY said Dr. Luper could answer. However, she opined that the fee increase might be smaller than anticipated. 4:13:00 PM SENATOR DUNBAR asked if naturopaths already pay a licensure fee. MS. CONWAY replied yes. The increased fee will depend on the department's cost to construct the advisory board and promulgate the regulations. 4:13:44 PM SENATOR TOBIN said on page 5, lines 2-9, that there is direction regarding education on pain management and opioid use. She asked about mandatory reporting concerning opioids. 4:14:21 PM MS. CONWAY said she did not understand the question. 4:14:34 PM SENATOR GIESSEL stated the reason for the education requirement in SB 44 was that clinicians that have DEA numbers and prescribe opioids are required to complete two hours of training every two years. Naturopaths provide care to people that are on opioids. By requiring the same training as other clinicians, naturopaths will have the same ability when providing care. If someone appears to have an addictive behavior, they could order a urine drug screen and then contact that person's prescriber or even the board of pharmacy that manages the prescription drug monitoring program. 4:16:03 PM MELANIE HENRIKSEN, ND, President, National University of Natural Medicine, Portland, Oregon, provided her work history and stated that she comprehensively understands both conventional and integrated care requirements and expectations. She highlighted the following details of the naturopath program: • 5,047 hours of education for the four-year graduate training program • 1,254 hours of direct clinical exposure, which is comparable to the education requirements for many types of medical providers. • Graduation from an accredited four-year college with a bachelor's degree • Science and social science prerequisites are nearly identical to other medical doctorate programs • Two years of biomedical sciences diagnostic training and human sciences diagnostic training including: anatomy, physiology, biochemistry, pathology, embryology, microbiology, physical examination, laboratory diagnosis and diagnostic imaging. • Successful completion of the Biomedical Science National Board Exam • Two years of clinical application that is anatomy specific to organ systems and courses on teaching disease management and prevention through therapeutic modalities such as nutrition, botanical medicine, physical medicine, lifestyle counseling, minor office procedures, and pharmacology. • Participation in clinical skills rotations. 4:18:46 PM DR. HENRIKSEN said all faculty must have terminal degrees in their teaching disciplines. Curriculums are updated and assessed regularly through the curriculum committee as mandated by federal accreditors. The Council for Naturopathic Medical Education is the accrediting agency that monitors naturopathic medical programs according to federal guidelines. The rigorous accreditation process requires annual reports, self-studies, and site visits. Regional accreditors also oversee colleges. 4:19:55 PM DR. HENRIKSEN said that 26 US states license naturopathic physicians. The scope of licensure varies widely. Some states have comprehensive prescriptive authority, while others are limited. All naturopath students must complete two different sets of exams to graduate. Residencies are available in all the naturopathic colleges in the country and some individual medical sites. Unfortunately, they are not covered through federal programs like medical doctors (MDs) and osteopathic doctors (DOs), which limits the number of students that complete residency. Residency is not a requirement for licensure except in one state. She said the educational program of naturopathic medical colleges prepares graduates to be competent, safe, and effective healthcare providers who can assess primary care needs, particularly in medically underserved states. 4:21:36 PM CLYDE JENSEN, Ph.D., Professor of Pharmacology, Rocky Vista University, Saint George, Utah, stated he teaches pharmacology to medical doctors (MDs), osteopathic physicians (DOs), and naturopathic physicians (NDs). The amount of pharmacology and the topics within the subject of pharmacology taught in naturopathic medical schools are identical to those taught in osteopathic and allopathic schools. 4:22:51 PM DR. JENSEN said training in all health sciences institutions includes training in clinics and hospitals. If there were any difference in the pharmacology and pharmaceutical training between naturopaths, osteopaths, and allopaths, it would be that DOs and MDs receive training in hospitals. NDs are trained in the basic sciences of drugs but devote more of their time in naturopathic medicine to treating patients on an outpatient basis and utilizing alternative forms of therapy like nutrition and herbal medicines. He opined that NDs prefer to use those forms of therapy and are inclined to use fewer drugs than MDs. NDs are responsible for continuing medical education in the same number of hours and on similar topics as MDs and DOs. He stated that as a person who has led and taught continuing medical education programs, he knows that the pharmacology training that naturopathic physicians receive is virtually identical to that of MDs and DOs. He stated that his purpose in testifying is to encourage all healthcare professionals to be allowed to practice to the limit of their scope. Many individuals are seeking health care, and it's wasteful not to allow NDs, DOs, and MDs to practice and use all the skills they have learned. He stated his belief that naturopathic physicians are sufficiently trained and have sufficient skills to dispense and utilize pharmaceutical products, especially those listed in SB 44. 4:26:12 PM SENATOR DUNBAR asked if there were specialized drugs other than cancer drugs. He said he is trying to understand why the prescriptive authority was formulated in this precise way. 4:27:01 PM DR. JENSEN said he does not know why Alaska excluded particular drugs from SB 44. NDs in other states can use the excluded drugs. Cancer drugs are more dangerous and are intravenously administered. The nature of naturopathic medicine makes using cancer drugs less common in the profession. He opined that opioids were probably excluded as a means of compromise in aiding the passage of SB 44. He said no other drugs needed excluding. There are other dangerous drugs, but MDs, ODs, and NDs have the training, know the dangers, and avoid them. 4:29:18 PM SEAN HIGGINS, representing self, Anchorage, Alaska, provided a brief work history and stated he is an emergency room (ER) physician at Alaska Regional Hospital. Washington permits NDs a work scope that represents their skill sets and training. The US is experiencing many barriers to primary care access, particularly in Alaska. Primary care doctors cannot see their patients promptly, resulting in more ER trips for primary care- related issues. He said that as an ER doctor, he sees an increase in patients visiting the ER for reasons that primary care providers should manage, such as medication refills and contraception. He estimated that 30 percent of the patients he sees should be seeing a primary care doctor. Visiting the ER is more expensive and strains ER staff and resources. It creates a lack of consistency and follow-up that is detrimental to a patient's primary care management, especially for chronic illness. He stated that he has worked with NDs and agrees that their training is comparable to the coursework and exams he received. He said he was baffled to learn that NDs in Alaska must refer their patients to physician assistants and nurse practitioners for medication management because he knows NDs receive more rigorous and lengthy training. In addition, NDs emphasize prevention, which reduces chronic disease complications that lead to emergencies such as heart attacks. He opined that NDs are thoughtful, deliberate, and forward- thinking. Allowing them to practice to the full extent of their training will help Alaskans receive needed primary and preventative care. 4:33:03 PM JON LIEBERMAN, Retired, Washington, stated he spent most of his career as a medical doctor (MD) in Fairbanks. He opined that there is an evolution in medicine, so legislators are trying to figure out how to keep the public safe. History shows that doctors were primarily MDs at the turn of the century, with osteopaths (DOs) beginning to practice manipulative therapy. Osteopaths became a strong group and now perform brain and cardiac surgery. Many DOs are family practitioners. DOs are on par with MDs. Nurse Practitioners and Physician Assistants who provide valuable healthcare experienced an uphill battle to have their abilities recognized. The government must focus on outcomes to protect the public instead of creating roadblocks. 4:35:41 PM DR. LIEBERMAN stated that society should not categorically fear naturopaths (NDs) and their professional duties. Surgeons and other medical professionals who think naturopaths are trying to take over their practice are unwittingly fearful and shortsighted. If all roadblocks had been historically successful, society would not have the benefit of osteopaths, nurse practitioners, midwives, and others. Monitoring outcomes and problems is the answer, not barring the door and failing to identify bad actors. There are standards for professional ethics that doctors are trusted to follow. Society needs to trust that naturopaths will be good doctors. If society is not going to trust them, it should be done based on evidence and not knee- jerk fear. He opined that society needs to be nonprejudicial as it opens the door to naturopathic services and evaluates them based on outcomes. 4:37:44 PM CHAIR WILSON asked Dr. Lieberman if he disagrees with the following portion of a letter: Surgeons will train as much as four times as long as naturopaths. The education and training of a naturopath is no way comparable to that of a medical doctor. It is dishonest to refer to naturopaths as naturopathic doctors, naturopathic physicians. 4:40:58 PM DR. LIEBERMAN replied that the statement is very specious and he does not believe it truthful. Naturopaths achieved a doctorate level of knowledge in their field. Although naturopathic medicine is evolving, naturopathic physicians know to work within the scope of the practice. A naturopath is not going to perform neurosurgery in their office. A family practitioner, general surgeon, any specialty field, or MD can open a practice and do what they want in their office until complaints occur and authorities investigate. He stated that the person who would write that letter is unwittingly fearful because they do not know the outcome. He said he would ask the author of the letter to show him the evidence. Naturopaths do not want to be plastic surgeons. He opined that there are too many stipulations in SB 44. The stipulations bow down to a fear that naturopaths will step over the line. Naturopaths are a very important part of evolution, and the public should not miss out on the good they could do because of fear. 4:42:38 PM SCOTT LUPER, ND, Alaska Association of Naturopathic Doctors, Fairbanks, Alaska, gave a brief history of his work background and said he would like to answer questions the committee asked. He said he loves practicing in Fairbanks but is irked that he cannot practice to the full extent of his training. He said the crux of the opposition to SB 44 is fear of change. Some think naturopathic medicine is weeds, beads, seeds, and feathers when naturopathic medicine is safe, and the doctors are well trained. Naturopathy has been on the West Coast for a long time, so there is a cumulative record of malpractice suits and complaints. The overall complaint record for naturopaths is 10 - 20 percent of MDs and DOs; admittedly, MDs and DOs do more risky procedures and surgeries. However, the rate of complaints and malpractice for naturopaths is low. Malpractice insurance rates for naturopaths are also 10 - 20 percent of the medical profession. Malpractice rates are not political. Companies set the rates by determining actual risk, which speaks to the safety of naturopathy. 4:46:05 PM DR. LUPER said political expediency answers Senator Dunbar's question regarding the reason for the lockout of controlled substances and chemotherapy from SB 44. Pushback from the medical profession focuses on prescriptions. Naturopathic doctors are making others feel better by taking away the most dangerous drugs. It is easy for naturopathic doctors not to include them in SB 44 because they are not inclined to use them. Naturopathic doctors are a group of sensible people. They are people who have gone through rigorous application and interview processes and training programs. Like any professional, naturopaths must be smart, earn good grades, and have moral character. MDs and ODs do not use everything at their disposal; they self-regulate because that is what professionals do. 4:47:51 PM DR. LUPER said Alaska statute does define minor surgery and summarized it as superficial procedures. He said the definition excludes body cavities, plastic surgery, and general or spinal anesthetics. Minor surgery excludes anything that a doctor would need special surgery training to perform. A naturopath's training is to be a primary care provider, not a surgeon. They have the skill and training to sew a laceration, but in Alaska must direct patients to the emergency room for care, which is very expensive. DR. LUPER said the last question was regarding naturopath licensing fees. The fee amount is $1,800 every two years because the profession is small. 4:49:57 PM CHAIR WILSON opened public testimony on SB 44. 4:50:11 PM BRUCE CAMPBELL, representing self, Fairbanks, Alaska, testified in support of SB 44. He stated that he uses a naturopath as his primary care provider and finds the doctor's insights and expertise invaluable. He stated his belief that fear comes from confusing a naturopath with an herbalist or other similar professions. He encouraged the passage of SB 44. 4:51:49 PM ANNETTE O'CONNELL, representing self, Nikiski, Alaska, testified in support of SB 44. She stated there was a point when she became extremely ill and saw three medical doctors who did not take her symptoms seriously. Finally, a naturopathic doctor diagnosed and treated her for chronic Lyme disease. She stated that naturopathic doctors are needed in Alaska and urged the passage of SB 44. 4:53:41 PM CHAIR WILSON closed public testimony on SB 44. 4:53:50 PM SENATOR KAUFMAN asked what relationship naturopathy has with private and government health insurance. 4:54:08 PM DR. LUPER said Alaska law requires insurance to cover naturopathic care. Insurance covers approximately 75-85 percent of his work. Federal policies supersede state policies, so naturopaths are not covered by Medicare, Tricare, or any federal policy because the naturopath profession is small, and many states have no licensing. He hopes political will changes as the profession grows. 4:55:46 PM SENATOR DUNBAR referred to a letter the committee received from Dr. Vainio, which stated: [Original punctuation provided.] Section 3 does not allow a naturopath to practice in the state unless they seek prescribing authority. (contradicted in Sec.08.45.045 (2) (D). The overwhelming majority of naturopaths are not seeking expanded scope of practice, per the discussions of our 2021 working group. At that time 3 of the approximate 50 naturopaths in the state were seeking expanded scope of practice. He asked Senator Giessel whether most naturopaths do not seek prescriptive authority and if she agrees with Dr. Vainio's interpretation of SB 44. 4:56:46 PM SENATOR GIESSEL replied that Section 3, page 3, lines 1 - 10 discusses the application for licensure. The application is on a form provided by the department and requires fingerprints, a criminal background check, and an application fee. These requirements are uniform across the healthcare professions. She stated she does not understand how Section 3 requires someone to apply for prescriptive authority. SENATOR DUNBAR responded that the letter states the contradiction occurs in Section 2(d). SENATOR GIESSEL said Section 2(d) is on page 2, line 26. 4:57:49 PM SENATOR DUNBAR interjected his belief that the letter referred to a different version of SB 44 and withdrew his question. 4:57:58 PM SENATOR DUNBAR said Dr. Vainio's letter references a collaborative agreement with naturopaths to achieve an expanded scope. He asked if a naturopath could speak to the collaboration, especially regarding prescriptive authority. 4:58:31 PM DR. LUPER stated that previously naturopathic doctors in California had to form relationships with prescribers. It sounds good in theory, but finding a prescriber willing to donate their time to work with other practitioners was difficult. He stated that collaboration is fabulous unless it gets in the way of providing care, which happens when relationships are mandated. 4:59:57 PM SENATOR GIESSEL said nurse practitioners had not had the physician oversight requirement since 1980 and opined that requiring physician oversight of naturopaths would be inappropriate. 5:00:27 PM CHAIR WILSON held SB 44 in committee. 5:02:02 PM There being no further business to come before the committee, Chair Wilson adjourned the Senate Health and Social Services Standing Committee meeting at 5:02 p.m.

Document Name Date/Time Subjects
SB44 version B.PDF SHSS 2/23/2023 3:30:00 PM
SB 44
SB44 Sponsor Statement 02.02.23.pdf SHSS 2/23/2023 3:30:00 PM
SB 44
SB44 Sectional Analysis 02.02.23.pdf SHSS 2/23/2023 3:30:00 PM
SB 44
SB 44 FN DCCED.pdf SHSS 2/23/2023 3:30:00 PM
SB 44
SB 44 FN DPS.pdf SHSS 2/23/2023 3:30:00 PM
SB 44
SB44 Support Emails 02-20-23_Redacted.pdf SHSS 2/23/2023 3:30:00 PM
SB 44
SB44 Support Kruger 02-20-23.pdf SHSS 2/23/2023 3:30:00 PM
SB 44
SB44 Support Lenger 02-18-23.pdf SHSS 2/23/2023 3:30:00 PM
SB 44
SB44 Support Waller 02-21-23.pdf SHSS 2/23/2023 3:30:00 PM
SB 44
SB44 Support Mosley 02-21-23.pdf SHSS 2/23/2023 3:30:00 PM
SB 44
SB44 Support Campbell 02-21-23.pdf SHSS 2/23/2023 3:30:00 PM
SB 44
SB44 Support Huntington 02-21-23.pdf SHSS 2/23/2023 3:30:00 PM
SB 44
SB44 Support Wiggins 02-21-23.pdf SHSS 2/23/2023 3:30:00 PM
SB 44
SB44 Support Sagan 02-21-23.pdf SHSS 2/23/2023 3:30:00 PM
SB 44
SB44 Support Emails 02-21-23_Redacted.pdf SHSS 2/23/2023 3:30:00 PM
SB 44
SB 44 Support Mitchell.pdf SHSS 2/23/2023 3:30:00 PM
SB 44
SB-44-WA-SenHSS_022023 Alderhold.pdf SHSS 2/23/2023 3:30:00 PM
SB 44 Tsigonis.pdf SHSS 2/23/2023 3:30:00 PM
SB 44
SB 44 Letter Vainio.pdf SHSS 2/23/2023 3:30:00 PM
SB 44
SB44 Letter Merkouris.pdf SHSS 2/23/2023 3:30:00 PM
SB 44
SB 44 ASPS NWSPS opposition 2.22.23.pdf SHSS 2/23/2023 3:30:00 PM
SB 44
SB44 Naturopathic Medicine Presentation SHSS.3.pdf SHSS 2/23/2023 3:30:00 PM
SB 44
CS SB 45 v U 2.22.23.pdf SHSS 2/23/2023 3:30:00 PM
SB 45
SB 45 Explanation of Changes v. S-U 2.23.23.pdf SHSS 2/23/2023 3:30:00 PM
SB 45
SB44 Support Luper 02-21-23.pdf SHSS 2/23/2023 3:30:00 PM
SB 44
SB44 Supporting Document FAQs.pdf SHSS 2/23/2023 3:30:00 PM
SB 44
SB 44 Supporting Document - Comparison.pdf SHSS 2/23/2023 3:30:00 PM
SB 44