04/03/2024 01:30 PM Senate LABOR & COMMERCE
| Audio | Topic |
|---|---|
| Start | |
| SB204 | |
| SB44 | |
| Adjourn |
+ teleconferenced
= bill was previously heard/scheduled
| += | SB 204 | TELECONFERENCED | |
| += | SB 44 | TELECONFERENCED | |
| + | TELECONFERENCED | ||
ALASKA STATE LEGISLATURE
SENATE LABOR AND COMMERCE STANDING COMMITTEE
April 3, 2024
1:33 p.m.
DRAFT
MEMBERS PRESENT
Senator Jesse Bjorkman, Chair
Senator Click Bishop, Vice Chair
Senator Elvi Gray-Jackson
Senator Kelly Merrick
Senator Forrest Dunbar
MEMBERS ABSENT
All members present
COMMITTEE CALENDAR
SENATE BILL NO. 204
"An Act relating to the issuance of certificates of fitness for
plumbers and electricians; relating to fees for certificates of
fitness for plumbers and electricians; and providing for an
effective date."
- MOVED SB 204 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 204
SHORT TITLE: CERT. OF FITNESS: PLUMBERS/ELECTRICIANS
SPONSOR(s): RULES BY REQUEST OF THE GOVERNOR
01/24/24 (S) READ THE FIRST TIME - REFERRALS
01/24/24 (S) L&C, FIN
02/26/24 (S) L&C AT 1:30 PM BELTZ 105 (TSBldg)
02/26/24 (S) Heard & Held
02/26/24 (S) MINUTE(L&C)
04/03/24 (S) L&C AT 1:30 PM BELTZ 105 (TSBldg)
BILL: SB 44
SHORT TITLE: NATUROPATHS: LICENSING; PRACTICE
SPONSOR(s): GIESSEL BY REQUEST
01/25/23 (S) READ THE FIRST TIME - REFERRALS
01/25/23 (S) HSS, L&C, FIN
02/23/23 (S) HSS AT 3:30 PM BUTROVICH 205
02/23/23 (S) Heard & Held
02/23/23 (S) MINUTE(HSS)
03/07/23 (S) HSS AT 3:30 PM BUTROVICH 205
03/07/23 (S) Moved CSSB 44(HSS) Out of Committee
03/07/23 (S) MINUTE(HSS)
03/08/23 (S) HSS RPT CS 1DP 4NR SAME TITLE
03/08/23 (S) NR: WILSON, TOBIN, KAUFMAN, DUNBAR
03/08/23 (S) DP: GIESSEL
05/15/23 (S) L&C AT 1:30 PM BELTZ 105 (TSBldg)
05/15/23 (S) -- MEETING CANCELED --
03/04/24 (S) L&C AT 1:30 PM BELTZ 105 (TSBldg)
03/04/24 (S) <Bill Hearing Canceled>
03/15/24 (S) L&C AT 1:30 PM BELTZ 105 (TSBldg)
03/15/24 (S) Heard & Held
03/15/24 (S) MINUTE(L&C)
04/03/24 (S) L&C AT 1:30 PM BELTZ 105 (TSBldg)
WITNESS REGISTER
KIM KOLVIG, Legislative Liaison
Department of Labor and Workforce Development (DOLWD)
Juneau, Alaska
POSITION STATEMENT: Gave invited testimony on SB 204.
SCOTT DAMEROW, Chief of Mechanical Inspection
Labor Standards and Safety
Department of Labor and Workforce Development (DOLWD)
Anchorage, Alaska
POSITION STATEMENT: Answered questions on the fiscal note for SB
204.
SENATOR CATHY GIESSEL, District E
Alaska State Legislature
Juneau, Alaska
POSITION STATEMENT: Sponsor of SB 44.
LAURA CULBERSON FARR, Executive Director
American Association of Naturopathic Physicians
Washington, D.C.
POSITION STATEMENT: Gave invited testimony in support of SB 44.
DR. KRISTIN MITCHELL, President Elect
Alaska State Medical Association (ASMA)
Soldotna, Alaska
POSITION STATEMENT: Gave invited testimony in opposition to SB
44.
JOSEPH (JOE) ROTH, MD, representing self
Juneau, Alaska
POSITION STATEMENT: Gave invited testimony in opposition to SB
44.
KATHY GALLARDO, MD, representing self
Juneau, Alaska
POSITION STATEMENT: Gave invited testimony in opposition to SB
44.
JANE CONWAY, Staff
Senator Cathy Giessel
Alaska State Legislature
Juneau, Alaska
POSITION STATEMENT: Gave closing comments on SB.
ACTION NARRATIVE
1:33:50 PM
CHAIR JESSE BJORKMAN called the Senate Labor and Commerce
Standing Committee meeting to order at 1:33 p.m. Present at the
call to order were Senators Dunbar, Gray-Jackson, Merrick and
Chair Bjorkman. Senator Bishop arrived thereafter.
SB 204-CERT. OF FITNESS: PLUMBERS/ELECTRICIANS
1:34:41 PM
CHAIR BJORKMAN announced the consideration of SENATE BILL NO.
204 "An Act relating to the issuance of certificates of fitness
for plumbers and electricians; relating to fees for certificates
of fitness for plumbers and electricians; and providing for an
effective date."
1:35:15 PM
KIM KOLVIG, Legislative Liaison, Department of Labor and
Workforce Development (DOLWD), Juneau, Alaska, read a prepared
summary of SB 204.
[Original punctuation provided.]
Hearing for HB 290 & SB 204
Certificate of Fitness (COF)
Opening Remarks
An act relating to the issuance of certificates of
fitness for plumbers and electricians; relating to
fees for certificates of fitness for plumbers and
electricians; and providing for an effective date.
Thank you, Chair Bjorkman and members of the
committee.
Legislation changes:
• The legislation before you changes the trainee level
certificates of fitness for plumbers and
electricians from two years to six years.
o Currently, if a trainee fails to renew their COF,
those hours worked during that lapse will not be
counted.
o The training period is typically accomplished in
4 years.
• Increases the fee for issuance of journeyman level
certificates or renewal certificates from $200 to
$300.
o The journeyman two-year certificate cost has been
in effect since 2006.
o The fee increase will partially cover the loss in
revenue created by the changes to the training
level certificate.
• The elimination of the requirement for trainees to
apply for and pay for renewals during their training
period will expedite the apprenticeship procedure
overall.
• And will avoid the difficult situation of having to
reject training hours because a certificate of
fitness is not valid.
• With me today is the Chief of our Mechanical
Inspection Unit, Mr. Scott Damerow, to give a
presentation of the Certificate of Fitness (COF)
process.
1:37:32 PM
CHAIR BJORKMAN opened public testimony on SB 204; finding none,
he closed public testimony.
1:38:03 PM
SCOTT DAMEROW, Chief of Mechanical Inspection, Labor Standards
and Safety, Department of Labor and Workforce Development
(DOLWD), Anchorage, Alaska, said the fiscal notes primarily will
result in a decrease of approximately $58,000 in revenue due to
the non-renewal of Certificates [of Fitness] (COF) at the
training level, based on a five-year survey. Assuming COF
renewal continues at the expected rate, he said DOLWD would lose
money and the COF program would be unsustainable. SB 204
includes an increase in fees that would make up for the past
seventeen years with no increase in COF application fees and for
the decrease in trainee licensing. It would also bring [the COF
program budget] more in line with inflationary changes and allow
normal business. He said the estimated revenue increase of
$164,000 would result in $105,000 annual expenditure increase.
The expenditures would be used for: increased travel throughout
the state for enforcement staff. It would also be used for
training education and memberships in national level
organizations. He noted that Alaska is secluded from the rest of
the U.S. both geographically and code-wise from the lower 48
states. He said more national organization membership and more
training would equip [DOLWD certifying personnel] to be
recognized industry experts in their areas. He also said the
current software database was developed in the 1990's and is in
desperate need of updating to increase the level of service to
the community and to allow for on-line application, payments and
on-line receipt of COFs. He said DOLWD would upgrade equipment
and machinery and credit card processing to allow online payment
processing. He said the state equipment fleet would receive a
large percentage of the fund and explained that DOLWD had 14
vehicles, ten of which were more than ten years old. He said the
staff were primarily field workers, spending most of their time
in the vehicles. He emphasized the need to upgrade the fleet of
vehicles to reduce the number of vehicle breakdowns. He also
said funds would be spent to upgrade computers and monitors and
infrastructure to support Information Technology (IT) for the
Labor Standards and Safety Division.
MR. DAMEROW concluded that the fiscal note was straightforward
and mostly reflected a lack of infrastructure spending over the
past seventeen years, during which there had been an increase in
spending but not in fees.
1:41:41 PM
SENATOR GRAY-JACKSON referred to the fiscal note from the
Department of Labor and Workforce Development, OMB Component
Number 346, dated February 29, 2024, noting that it called for
one new car per year for the State Equipment Fleet. She asked
how many cars the department needs and how they are used.
1:42:01 PM
MR. DAMEROW answered that the department has 14 vehicles, one
assigned to each of the current inspectors with some flexibility
for their use. Due to the age of the fleet, the cars suffer
significant breakdown, leading to setbacks in conducting field
inspections. He said the department does not maintain an excess
of vehicles, so when a vehicle is down, an inspector is not in
the field. He explained that some of the vehicles are not road-
worthy for longer trips, requiring inspectors to switch cars. He
said he hoped to standardize the fleet by selecting a single,
standard compact SUV, replacing one vehicle per year and
allowing for parts and tires to be interchangeable among the
vehicles. He noted that this would improve the efficiency of
maintaining the fleet and reduce waste of otherwise usable parts
and equipment.
1:43:31 PM
SENATOR GRAY-JACKSON appreciated the clarification.
1:43:41 PM
CHAIR BJORKMAN solicited the will of the committee.
1:43:46 PM
SENATOR GRAY-JACKSON moved to report SB 204, work order 33-
GS2370\A, from committee with individual recommendations and
attached fiscal note(s).
1:44:05 PM
CHAIR BJORKMAN found no objection and SB 204 was reported from
the Senate Labor and Commerce Standing Committee.
1:44:10 PM
At ease
SB 44-NATUROPATHS: LICENSING; PRACTICE
1:47:57 PM
CHAIR BJORKMAN reconvened the meeting and announced the
consideration of SB 44(HSS) [CSSB 44, Work Order:33-LS0297\S]
"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."
1:48:22 PM
SENATOR CATHY GIESSEL, District E, Alaska State Legislature,
Juneau, Alaska, sponsor of SB 44 provided an overview of SB 44.
She said SB 44 deals with the practice of Naturopathy and
Naturopathic doctors. She said SB 44:
• Modernizes statutes for Naturopaths
• Cleans up outdated language
• Imposes the same public health duties on Naturopaths as
other medical providers
• Creates a regulatory board for Naturopaths, which includes
a seat for a medical doctor
• Updates scope of practice for Naturopaths that includes
limited prescriptive authority, excluding prescriptive
authority for controlled substances, such as opioids and
testosterone, for example
• Allows minor office procedures
• No more duplicative office visits
• Improved access to care for Alaskans
• More choice for patients
SENATOR GIESSEL said Naturopathy focuses on wellness and the
prevention of illness. She noted that approximately 80 percent
of healthcare spending is spent on lifestyle choice illnesses
such as obesity, hypertension, insulin resistance, etc. and that
is the focus of Naturopaths.
1:50:17 PM
SENATOR GIESSEL said she worked with naturopaths as a clinician
and found them very knowledgeable, more knowledgeable than she
in physiology. One argument against SB 44 has been that
Naturopaths should not be prescribing. She pointed out that
Nurse Practitioners (NPs) have had full prescribing rights in
Alaska for over 40 years, though Alaska has no residency
requirement [for NPs]. She said Physician Assistants (PAs),
optometrists and dentists can all prescribe though there are no
residency requirements for those professions beyond their
initial education program. She said one of the arguments against
SB 44 is that Naturopaths should be subject to a residency
requirement as are doctors, but, she argued, we are holding
naturopaths to a higher standard than most of the prescribers in
Alaska.
SENATOR GIESSEL mentioned expanding Telehealth authority and
pointed out that practitioners from out of state have the
authority to prescribe in Alaska. She emphasized that these
Naturopaths live in Alaska; they are our neighbors and the
clinicians that residents seek out for health care.
SENATOR GIESSEL noted malpractice insurance costs and
characterized malpractice insurance to be an objective measure
of the safety of a clinician. She said the cost of a
practitioner's malpractice insurance is a reflection of the risk
that the insurance company perceives for a specific type of
practice. She pointed out that naturopaths have exceedingly low
malpractice insurance costs.
SENATOR GIESSEL recalled that Doctors of Osteopathic Medicine
(DOs) were the subject of controversy in the past and one
argument was that they were not medical doctors and should not
be allowed to practice. She pointed out that many are in
practice today and often patients don't recognize the
difference. She opined that Naturopaths are considered odd
people out and they should not be. She concluded that SB 44's
purpose was to allow Alaskans to have more [health care] choice,
particularly choices based on wellness, lifestyle and how to
care for oneself.
1:54:01 PM
LAURA CULBERSON FARR, Executive Director, American Association
of Naturopathic Physicians, Washington, D.C., sought to support
SB 44 by offering her experience with other states where NPs
have prescribing authority. She quoted written testimony offered
by Ms. Pam Ventgen of the Alaska State Medical Association: "The
legislature should support and utilize different practitioners
in the manner they each are educated and trained in." She
concurred with Ms. Ventgen's statement and said naturopathic
education and training comprehensively covers pharmacology and
prescribing.
1:55:01 PM
MS. FARR emphasized that the schools for naturopaths must
educate graduates to practice in every licensed state, including
those that have very broad prescribing authority, including for
controlled substances as appropriate in a primary care setting.
She noted that SB 44 does not include broad prescribing
authority for NDs and emphasized this proposal is not bringing
an "experiment" to Alaska. She said every western state that
licenses NDs allows for similar prescribing rights except for
Alaska.
MS FARR said conventional medical doctors claim NDs don't
receive the same training and that giving NDs prescribing rights
would jeopardize public safety, etc. She said these arguments
are not grounded in any actual data. She shared data points from
statistics where Naturopathic Doctors are prescribing
pharmaceuticals every day, safely.
1:55:47 PM
SENATOR BISHOP arrived.
MS. FARR noted Senator Giessel's reminder that several other
providers, dentists, optometrists, NPs in Alaska have
prescribing privileges without residency requirements. She said
there is evidence that residencies do not equate to safety in
prescribing. She referred to a comparison chart of education of
several different types of medical providers. She said the
sample in the handout is from Washington State and is comparable
to Alaska. She noted that NDs have more pharmacology-specific
classroom hours than most other professions, more than double
the credits. She noted that the professions represented on the
chart, without residencies, do practice and prescribe safely.
MS. FARR referred to another comparison chart from Oregon
compiled by the government agencies responsible for regulating
NDs. She said Oregon has one of the broadest formularies in the
country, and the chart compares disciplinary actions between
Medical Doctors (MDs), Doctors of Osteopathy (DOs), and NDs. Of
the three professions, the percentage of licensees disciplined
for prescribing problems is higher for both MDs and DOs than it
is for NDs. She said the data for the chart was from the
regulatory boards.
MS. FARR confirmed data mentioned by Senator Giessel, that
malpractice rates are dramatically lower for naturopathic
doctors than for other practitioners, even in states with the
broadest prescribing rights. She said there is no better
indicator of safety in prescribing than the actuarial data of
insurers.
1:57:29 PM
MS. FARR said SB 44 would help patients by allowing naturopathic
doctors to prescribe, reducing the need for duplicate visits,
and reducing the cost to the health care system of duplicate
visits to allow for prescriptions. She said SB 44 is not about
gaining market share or solving provider shortages in rural
communities. She said it is about providing appropriate and
timely care for patients.
MS. FARR said she does testify in a number of state
legislatures, and she said there is rarely opposition from
patients concerned about their safety. She said there is
opposition from medical societies affiliated with the AMA,
unfortunately. She opined that sharing beliefs that are not
tethered to data and statistics is inappropriate. MS. FARR said
she supports SB 44 and she encouraged the committee to support
it. She urged that as the committee heard other testimony, they
would stay grounded in the evidence provided from other
regulatory boards in states that have taken this step.
1:58:57 PM
CHAIR BJORKMAN recounted concern brought up in a previous
hearing regarding the prescription and possible overuse of
thyroid by naturopathic doctors. He asked whether this
occurrence is at a level the industry would deem normal.
1:59:37 PM
MS. FARR said that [thyroid] is something that naturopathic
doctors do prescribe. She said it is a common concern that
patients go to naturopathic doctors for. She said prescribing
pharmaceutical drugs is not first line of defense for
Naturopathic Doctors. She said, of the modalities used, it is
the fourth or fifth most common and NDs will turn to other
supportive ways to help the body manage symptoms that could be
related to thyroid [dysfunction]. In the case when prescription
is necessary, naturopaths will prescribe but will do so
conservatively. She said she knows this from speaking with a
pharmacist in Oregon who has filled hundreds of thousands of
prescriptions from NDs. She said prescribing complaints [of NPs]
are rare, and complaints around thyroid prescription are
infinitesimal if it even exists.
2:01:32 PM
KRISTIN MITCHELL, President Elect, Alaska State Medical
Association (ASMA), Soldotna, Alaska, said she was board
certified in internal medicine by the American Board of Internal
Medicine, and practiced in Soldotna for 25 years, serving adults
with highly complex medical conditions. She said she was faculty
at the Alaska WWAMI (Washington, Wyoming, Alaska, Montana,
Idaho) Medical School, serving on the admissions committee and
clinical faculty and professor at the University of Washington
School of Medicine where she taught third year medical students
in their six-week internal medicine rotation and also medical
residents. She served on national committees for the American
College of Physicians. She expressed appreciation for the
opportunity to speak about the scope of practice for NPs in
Alaska.
2:02:39 PM
DR. MITCHELL said she was testifying in her role as President of
ASMA and a physician with extensive experience caring for adults
[with complex medical conditions] to encourage the committee to
oppose SB 44. She said her concern was for patient safety. She
said Alaskans deserve excellent, safe, reliable, evidence-based
medical care and she said this care is best provided by teams
led by a physician. She said physicians have extensive
education, skills and training that make them most qualified to
exercise advanced clinical responsibilities within teams.
DR. MITCHELL noted previous testimony which discussed the
accreditation of Naturopathic schools and said that, while
accreditation is an important tool to create a minimum
acceptable standard and uniformity across schools, she opined
that Naturopathic School standards are not equivalent to
standards for physicians. She specifically compared standards of
education and training to those of family physicians because the
Council on Naturopathic Medical Education (CNME) standards
states that the goal of their accredited institutions is to
train "primary care/general practice physicians/doctors." CNME
is the accrediting body that creates educational standards for
the Naturopathic schools. She said there has been some testimony
that it is the same body that accredits naturopathic schools as
well as medical schools. She opined that the quality of the
accreditor does not have a bearing on the scope of practice of
individuals trained under the programs. She said the Alaska
Family Medicine residency, for example, is accredited by the
same agency that accredits Neurosurgery residencies, and no one
would claim that Alaska Family Medicine residents should be
practicing Neurosurgery if they are not trained to practice
Neurosurgery, so the identity of the accreditor does not really
bear on this.
2:04:40 PM
DR. MITCHELL noted that according to the CNME standards,
pharmacology is a required academic component of Naturopathic
education. She mentioned testimony in the Alaska House of
Representatives reporting that the same lectures are delivered
to Naturopathic students and to first year medical students. She
said while she appreciated her Ph.D. colleagues teaching basic
science courses to many disciplines, first year medical students
are not given full prescriptive authority just because they've
gotten through a lecture. She said, in medicine, it is the
combination of lectures and thousands of hours of supervised
clinical practice that make a physician competent to safely
prescribe pharmaceuticals. She claimed that it is difficult to
produce evidence because many of the accreditation exams are
proprietary and the questions are not available for open
examination. She said she reviewed the Naturopathic
pharmaceutical study guide, and, for context, she said there are
272 medications and vaccines listed in the medications for the
elective pharmacology exam that Naturopathic students can elect
to take or not to take. She said there are over 32,000 generic
medications approved by the FDA, and 55 novel drugs were
approved by the FDA in 2023 alone. She said 272 medications is a
very small fraction of the medications for which an internal
medicine or family medicine physician would be responsible. She
noted that the study guide did not include any of the class of
proton pump inhibitor medications, acid-blockers that are
commonly used in gastric ulcer disease. The study guide does
include some unusual extended-spectrum antibiotics that would
only be given intravenously in the hospital and it includes some
novel cancer therapeutic agents that should not be prescribed by
a primary care practitioner of any type. She summarized that
those are some of the limitations of the elective pharmacology
exam [offered to Naturopath students].
DR. MITCHELL reported another CNME accreditation standard is for
Naturopathic students to have 850 hours, fewer than 1,000,
"involved in patient care." She noted the students were not
necessarily responsible for patient care but may have been
observing the care. She said they also must have a minimum of
225 patients for whom they act as the primary student clinician
before they are allowed to graduate.
2:07:25 PM
DR. MITCHELL noted there are no residency requirements for NPs.
In contrast, she said, medical students have completed 3,000 to
5,000 hours of clinical practice by the time they graduate and
are still not able to obtain a license to practice
independently. Physicians are required to complete a minimum of
two years of residency to be licensed in Alaska. She said the
reason for this is the knowledge that additional supervised
practice is needed to fully learn and appreciate the full
complexity of medicine and how to safely diagnose and treat
patients. Family Medicine and Internal Medicine doctors have an
additional three years or approximately 10,000 to 12,000 hours
of supervised residency practice prior to becoming independent
practitioners. She acknowledged that competency timelines vary
from human to human, but she and other residency faculty have
concluded that residency students are typically not ready for
independent practice until the two to three-year mark has been
met.
2:08:27 PM
DR. MITCHELL said much of this is comparing apples to oranges
and the full prescribing authority of the full scope of western
pharmaceuticals is an unqualified ask for Naturopathic scope
practice and too risky for the Alaskan community.
DR. MITCHELL said, of specific interest to the Labor & Commerce
Committee, malpractice implications and insurance coverage, she
noted the testimony highlighting low rates of disciplinary
action for NPs and said to keep in mind that disciplinary action
is reviewed by a board composed of Naturopaths and there is no
established standard of care for naturopath practice with which
to compare a complaint. If naturopaths were to be granted
prescribing authority privileges parallel to those granted by
the State of Alaska for licensed medical physicians, she would
argue that NPs should also be held to the same standard of
malpractice liability as medical physicians. She said most
medical physicians carry several millions of dollars in
malpractice insurance because of the high risk of medication and
other aspects of practice.
DR. MITCHELL mentioned the primary care access shortage and
opined that expanding Naturopathic practice would not solve the
primary access to care problem. She said Naturopathic care is
not recognized by Medicare, Tricare or the Veteran's
Administration (VA), and so the populations in Alaska most in
need of primary care access would not be covered [by their
health care insurance] to see a Naturopath. She noted that
according to maps from the American Medical Association (AMA)
show that NPs tend to practice in urban areas, places that are
already served by physicians and not in areas that are under-
served.
2:10:32 PM
DR. MITCHELL said the practice of medicine is highly complex and
she speculated that it would be difficult for a legislator to
understand all the issues in depth. She suggested looking
outside Alaska for guidance and mentioned that it is completely
unlawful to practice Naturopathy in three states, there are 28
states that do not license Naturopaths, and there are only
eleven states that allow any prescribing authority for
Naturopaths for pharmaceutical medications. She suggested
earlier testimony was misleading with regard to optometrists,
for example, prescribing medications comparable to those NPs
would be able to prescribe under SB 44. She said Alaska law
allows optometrists to prescribe medications appropriate for eye
disease, a much more limited scope than what is requested by
Naturopaths. She said the state medical association had a series
of conversations with the Naturopaths about putting together a
limited formulary that would be appropriate for their scope of
care and they were not open to a more limited formulary. She
opined that while what is requested does not include controlled
substances, it does include a very broad formulary with cancer
drugs, diabetes drugs and medications that can have significant
effects on antibiotic resistance. She said it is misleading to
characterize it as a limited formulary just because it doesn't
include opioids.
2:12:24 PM
DR. MITCHELL noted that in the United Kingdom (UK), the National
Health Service (NHS) stopped funding homeopathic remedies in
2017 and in Australia, the medical advisory body concluded that
homeopathy should not be used to treat health conditions that
are chronic or serious or could become serious. She said
Alaska's current statute defines Naturopathy and places
restrictions that do not allow a person who practices
Naturopathy to give, prescribe or recommend in practice a
prescription drug, a controlled substance, a poison, engage in
surgery or use the word physician in the person's title. She
argued that Naturopathic education in the absence of residency
training does not make them equal to primary care physicians.
She said it would be confusing, misleading and frankly dangerous
to pass SB 44, certifying to Alaskan patients and consumers that
Naturopath training is sufficient to allow broad prescription of
pharmaceutical medications and the practice of minor surgery.
She urged the committee to reject SB 44.
2:13:28 PM
SENATOR DUNBAR referred to the suggestion that Naturopaths would
have to carry more malpractice insurance if they are given the
full scope of practice of Medical Doctors (MDs). He referred to
AS 08.45.045, and said the procedures allowed for Naturopaths
seemed to him to be quite different from full surgical
abilities. He asked Dr. Mitchell to share her interpretation of
the statue.
2:14:27 PM
DR. MITCHELL said the surgical issues requested in SB 44 are
"minor surgery" and she suggested there could be a lot of
discussion about the definition of minor surgery. She said in
Arizona there is discussion of whether minor surgery includes a
Brazilian Butt lift procedure, which she characterized as an
involved procedure with a high complication rate. She said in
other states, surgical abortion is considered "minor surgery",
so there are a lot of surgeries that could be interpreted as
minor office procedures because they don't require a hospital to
be performed. She said the way SB 44 is written, it includes
much more than laceration repair, which is what some of the
testimony has suggested NPs would limit their care to.
DR. MITCHELL sought to clarify her remarks about malpractice
insurance, and said anyone practicing medicine should be held to
the same standard of care. She said NPs are currently held to a
Naturopathic standard of care which explicitly says that
something that is unusual or unconventional should not be
considered malpractice because of the experimental nature of the
practice, acknowledging that people try a lot of things that are
unconventional. In medicine, there is a standard of care and
scientific evidence and a group of peers in the same specialty
[determine whether] the practice is standard or not. Naturopaths
are judged by a different standard than physicians are for doing
the same thing. She gave a hypothetical example in which she, as
a physician were to infuse ozone into a patient, she would
expect her colleagues to request that she relinquish her
license, because that would not be considered standard care. She
suggested that for Naturopathic physicians, that might be a
reasonable thing to do for a patient. She said she did not
intend to suggest that there should be a specific dollar amount
of malpractice insurance, but that the judgement of whether an
act of practice was judged to be malpractice or not should be
judged by the same standard if the prescriptive authority is the
same for people with different licenses.
2:16:50 PM
SENATOR DUNBAR suggested that it might inform the sponsor with a
possible path forward for SB 44, suggesting language to provide
for uniform standard of care. He referred to AS 08.45.045,
Section 3, and quoted "superficial lacerations, abrasions, and
lesions and removal of foreign bodies". He said that language,
in his view, would not suggest the major surgery she suggested
and he further pointed to the next sentence in the statute which
explicitly excludes such procedures. He opined the language
around surgeries was already "tight". He noted her opinion that
the language for prescriptions was not narrow enough and asked
whether there was a level of independent prescriptive authority
that she would support.
2:17:56 PM
DR. MITCHELL said a number of physicians from the Alaska State
Medical Association (ASMA) and other groups throughout Alaska
did meet with a previous iteration of a bill similar to SB 44
and requested from the Naturopaths a list of drugs they thought
they would use in order to have a conversation about the list.
She reported that the Naturopaths did not provide a list. She
said the Naturopaths would have a much better sense of what they
[would prescribe] in their practice than a medical doctor would;
and so, she said it would be more appropriate for the
Naturopaths to come to the physicians with a list of medications
that they think they would use and ask to come to agreement
about it rather than expecting physicians to understand their
practice and say what they could use. She said there are a
variety of other states that have some limited formularies [for
Naturopaths to prescribe] and that they have reported some
problems. She said, from her perspective as a residency trained
internal medicine practitioner, she does not think NPS get the
education and supervised training and residency experience to be
able to prescribe a formulary of pharmaceutical FDA approved
medications safely. She said she would be willing to engage in a
conversation about a limited formulary but would not propose
that at the Senate Committee level. She opined that would be a
collaborative discussion between the people who might be
prescribing.
2:20:09 PM
JOSEPH (JOE) ROTH, M.D., Juneau, Alaska, representing self, said
he was a family physician in Juneau, born and raised in Alaska,
a WWAMI graduate and a past Chief of Staff at Bartlett Regional
Hospital. He said he opposed SB 44 and he said he did not think
Naturopaths had the training necessary to prescribe medicine or
perform minor surgeries effectively and safely.
DR. ROTH said, before being allowed to practice medicine in the
State of Alaska as a physician, one must complete four years of
medical school, followed by at least two years of supervised
residency training. During this time residents are directly
supervised in how to safely and effectively prescribe medicine
along with how to monitor patients for potential side effects.
He said residents are also supervised at that time for all
surgeries. In contrast, he said, Naturopaths have four years of
Naturopathic school and no residency requirement. He said the
elective residencies they do have are inconsistent in their
expectations.
2:21:24 PM
DR. ROTH said, as physicians, we all know that allopathic
medicine does not have the answers to how our bodies work. But,
he said, physicians do take a scientific approach to how they
treat patients and there is a huge field of medicine devoted to
research and improving the understanding of how human bodies
work. He said that is how we know, for instance, about the
placebo effect and that it can account for a positive effect in
over 50 percent of outcomes. He said he found Naturopaths to be
well-meaning people, but that he and his colleagues had had too
many interactions with them when it was clear that they did not
adequately and sufficiently understand the science of medicine
and, as a result, put patients' health and sometimes lives at
risk.
DR. ROTH told about a partner of his who had a patient with a
severely compromised immune system due to cancer treatment. He
said a Naturopath in Juneau was doing high colonic therapy to
try to purge the toxins from the patient's system. He said the
Naturopath talked about cleaning built-up plaque and toxic
sludge from the wall of the colon. He said he had performed
colonoscopies and upper endoscopies and had looked at a lot of
colons and had not seen plaque or toxic sludge built up on the
wall of the colon with adequate preparation. He said
pressurizing the colon can cause bacteria to move through the
[intestinal] membrane wall and into the [abdominal] cavity. He
said by giving the patient high colonics, the Naturopath was
putting the patient at severe risk of becoming septic, going
into shock and potentially dying. Luckily, he said, his partner
stopped the treatment, and prescribed antibiotics and the
patient did require hospitalization. He said the Naturopath did
not understand why that was a potential problem.
2:23:13 PM
DR. ROTH told of another colleague who had a patient that was
instructed by a Naturopath to place a slice of onion against
their cervix to fight precancerous cervical changes. He said
that one of his own patients with a terminal illness had a
medicine recommended by a Naturopath based on good scientific
evidence, yet that scientific evidence was composed of one
person's blog and the resulting commentary on that blog.
2:23:38 PM
DR. ROTH said his problem with these experiences was not the
unconventional therapy, but the lack of what good scientific
evidence entails. He explained good scientific evidence means
studies that are reproducible by other people with large numbers
of subjects involved to have statistical significance.
DR. ROTH related a recent example of a patient who was taking a
plethora of vitamins that were prescribed by a Naturopath. He
said the Naturopath had done $1,000 worth of vitamin testing,
not based on any clinical findings and treated the patient
unnecessarily. When he reviewed the lab results, he found no
vitamin deficiencies, though the Naturopath had assured the
patient there was something wrong. He said everyone makes
mistakes, including himself and he said these mistakes are not
the result of human error, rather they are the results of
fundamental misunderstanding of the science of human physiology
and scientific research. He said SB 44 would create an
environment in which medical mistakes are not only overlooked
but are allowed to proliferate at an even higher state level.
2:24:54 PM
SENATOR GRAY-JACKSON asked whether the anecdotal examples
presented were from the same person.
2:25:07 PM
DR. ROTH said the examples referred to different people, some
who were no longer practicing Naturopathic medicine in Juneau
and some were still practicing medicine.
2:25:16 PM
SENATOR GRAY-JACKSON asked how many NPs the examples
represented.
2:25:27 PM
DR. ROTH said he was referring to two, and then four people
practicing. He added that one of the other naturopaths said they
had no desire to prescribe medicine. He said he had no problem
with what they [those who chose not to prescribe medicine] were
doing, but with the other two.
2:25:52 PM
SENATOR GRAY-JACKSON noted that Naturopaths do not have
residency requirements and neither do Nurse [Practitioners]
(NPs) or Physician's Assistants (PAs). She asked him to share
his thoughts about residency requirements.
2:26:04 PM
DR. ROTH explained that a Nurse Practitioner (NP) has practiced
medicine as a nurse, seeing patients and dealing with
medications. He said NPs then receive more training in a
practice which includes prescribing medication. He opined that
they are much more highly trained than naturopaths. He opined
PAs do not have the same level of training [as an NP] but they
cannot prescribe without a collaborating physician, who is
responsible for every single thing they do and for every
prescription the PA writes. He concluded that the scope of
practice for a PA is much different than for an independently
practicing NP.
2:27:08 PM
SENATOR DUNBAR said his understanding of SB 44 is that it sought
to raise the standards [for NPs]. He read from SB 44, Section
11(9), page 10, line 20-21 and asked Dr Roth and Ms. Farr to
comment on the examples of practitioners prescribing an onion
for cervical cancer or enemas for colorectal cancer. He asked
whether that example would be considered malpractice under SB
44.
2:28:06 PM
DR. ROTH suggested that was what Dr. Mitchell referred to when
she questioned who was looking at what the standard of care
should be. He opined that if he [as a practicing physician] was
doing something that was not considered good medical practice,
he would be reprimanded by the State Board of Medicine. He said
he didn't know what the board of naturopathic medicine would do.
He wondered whether it would be appropriate for naturopaths to
police themselves and who would determine the standard. He also
opined that it may not be appropriate for physicians [to oversee
naturopaths] and said physicians use a different standard. He
concluded that he [as a physician] would not be in a position to
determine whether naturopaths were appropriately prescribing
homeopathic or naturopathic remedies and NP's would probably
take umbrage if a physician or physician board said they were
going to monitor NP's to see if they were working or prescribing
appropriately.
2:29:23 PM
SENATOR DUNBAR asked whether Ms. Farr could address the
question.
2:29:35 PM
MS. FARR sought to clarify the question.
2:29:45 PM
SENATOR DUNBAR restated the question. He summarized the examples
presented by Dr. Roth and asked whether the treatments described
as having been prescribed by naturopaths would have resulted in
discipline by the board or a finding of malpractice for the
practicing naturopath.
2:30:07 PM
MS. FARR answered that naturopaths do have standards of care and
that they are not fundamentally different from the standards of
care of medical doctors. She noted naturopaths may consider
modalities of care that are not typically used in [allopathic]
medical practices. She said naturopathic medicine has standards
of care, a guidance of care developed by a professional
association and a code of ethics. She said most of the
regulatory boards that she is familiar with refer to those
documents. She said the regulatory boards also review
disciplinary actions, just as medical boards do, by a panel of
peers. She noted that those peers must take every circumstance
under consideration, just as a medical board would; and would
absolutely discipline a doctor that is considered to be
practicing medicine that their naturopathic medicine peers would
deem to be outside the standard of care and outside the norm
that is taught in Naturopathic Medical School so the processes
we use are absolutely the same. She pointed out perhaps the most
important thing, that in a court of law the standards are
applied in the same way across all medical professions. She said
there is not a completely different set of standards for
naturopaths.
2:31:52 PM
SENATOR DUNBAR proposed that SB 44 be amended to hold
naturopaths to the same standard of care as other medical
professionals, PAs, NPs, medical doctors, and asked whether that
would prevent naturopathic doctors from practicing, especially
if they were then exposed to malpractice suits.
2:32:24 PM
MS. FARR said it would depend on the wording of the legislation.
She explained that some modalities used by naturopathic doctors
are not taught in medical school, for example herbal medicine
and botanical medicine and hydrotherapy that are not dangerous
therapies and are not typically taught in medical school. She
said a peer panel of medical doctors would not be as familiar
with those modalities.
2:33:40 PM
DR. KATHY GALLARDO, MD, Juneau, Alaska, introduced herself and
said she was a member of the Alaska State Medical Association
(ASMA), American Medical Association (AMA), American Psychiatric
Association (APA) and that she is the legislative affairs
representative to the APA. She said she has concerns regarding
the proposed expansion of Naturopath scope of practice in Alaska
and she urged the committee to oppose SB 44.
DR. GALLARDO gave an overview of her extensive education and
professional experience in medicine, psychiatry and medical
science. She said the training she received prepared her to
function as a physician scientist with granular expertise in
medicine and science and able to function at a high level in
both worlds, for the benefit of patients. She detailed her
medical training and said she has lived and worked extensively
across the U.S. and abroad and had the privilege of working
with, learning from and referring patients to indigenous,
complimentary, alternative, functional, integrative, Eastern and
Western medicine trained healers. She said she currently
collaborates with and refers liberally to complimentary
alternative practitioners where appropriate, aligning with
patient values and safety. She expressed appreciation and
respect for the variety of approaches, systems and belief
related to health and wellbeing.
DR. GALLARDO emphasized the importance of ensuring the highest
standards of care and expertise in the health care system. She
said the public's trust in [the health care industry's] ability
to deliver safe and effective treatments relies heavily on
rigorous education, training, and experience of health care
providers. She said it is in this context that she sought to
highlight the profound differences between allopathic and
osteopathic physicians as compared to Naturopaths.
2:36:05 PM
DR. GALLARDO referred to earlier testimony that allopathic and
osteopathic physicians undergo extensive and rigorous education.
She said the comprehensive didactic, laboratory, clinical and
apprenticeship education and training include a deep
understanding of human anatomy, physiology, pharmacology,
pathology and the latest evidence-based medical practices. She
said physicians training is overseen at every level by
independent, not-for-profit regulatory bodies and subject to
stringent licensing requirements, ensuring that practitioners
meet the highest standards of competence and professionalism
throughout their careers.
2:36:56 PM
DR. GALLARDO said, in contrast, the education and training of
Naturopathic doctors differs fundamentally in focus and intent.
She said Naturopathic doctors use a variety of interventions
such as homeopathy, herbology, nutrition and practitioner-guided
detoxification to help people maintain health and well-being.
Only those Naturopathic medical schools accredited by the
Council on Naturopathic Medical Education (CNME) and recognized
by the U.S. Department of Education require four years of post-
high school, in-person education at their respective school.
However, she said, with emphasis on homeopathy and rejection of
science and evidence-based medicine, they lack the same level in
rigorous, didactic training in the medical sciences. She said
the handful of [Naturopathic] residencies that exist are
optional. She said in the allopathic and osteopathic systems, a
student may complete medical school, but not yet be eligible to
practice medicine. In Alaska, physicians must be licensed to
practice medicine and to be licensed, the student must
successfully complete two years of internship or residency and
then apply and pass a state medical examination. She sought to
put this into perspective and said, under SB 44, Naturopathic
doctors, after four years of studying Naturopathy, will be able
to independently practice, providing prescription drugs,
ordering tests, and conducting procedures while at the same time
Alaska prevents a medical student receiving an M.D. after four
years of rigorous allopathic study would be precluded from the
same independent practice. She said looking at the Naturopath
examination is telling as to the training received through
Naturopathic schools. The national [Naturopathic] exam makes
pharmacology an optional part of the test. She queried what that
says about the importance of the [subject of pharmacology] in
the naturopathic education. She said pharmacology for allopathic
or osteopathic doctors is certainly not optional. She said
Naturopathic marketing efforts to consumers is frankly deceptive
and would lead one to believe that a Naturopaths skill set is
equivalent to a physician. She characterized this as not
factual, irresponsible and dangerous. She said, for all the
pejorative and demeaning rhetoric coming from the Naturopathic
field about allopathic and osteopathic physicians, in addition
to a fundamentally contradictory belief system which ignores
science, she suggests one must stop to consider why that is. She
wondered why a discipline based in homeopathy and herbology and
on the theory that diseases can be successfully treated or
prevented without the use of drugs, want or need prescribing
privileges.
2:39:25 PM
DR. GALLARDO wondered what training equips Naturopaths for
invasive office procedures, which procedures [they would need to
perform] and why would they need to perform them.
DR. GALLARDO said internship and residency programs of
mainstream medicine are integral to the development of clinical
expertise and the safe practice of medicine. In their absence,
Naturopathic doctors do not possess the same depth of knowledge
or clinical experience necessary to diagnose and manage complex
medical conditions safely. Furthermore, she said, the lack of
transparency, independent oversight and standardization in
Naturopathic education and practice raises concern about patient
and consumer safety and quality of care. Without the rigorous
training and oversight that allopathic and osteopathic
physicians undergo, there is a risk of misdiagnosis,
inappropriate treatment, harm to patients and death.
DR. GALLARDO said it is essential to recognize the role of
complimentary and alternative perspectives and interventions in
the healing arts. Wholistic approaches to health care are very
important and include extensive science-based approaches. She
said, as physicians, there is respect and support for rational
and science-based healing, however it is equally important to
ensure these interventions are provided by qualified health care
professionals within the bounds of evidence-based medicine and
patient safety.
DR. GALLARDO wondered what standard of care Naturopaths would be
held to if they are allowed to practice allopathic care in
addition to their Naturopathic practice. She noted testimony
that Naturopathic training is equivalent to allopathic training
and wondered whether Naturopaths would be held to the same
standard of care when:
• deciding to write a prescription or not write a
prescription
• ordering diagnostic tests and interpreting the results
DR. GALLARDO surmised that, under SB 44 Naturopaths prescribing
drugs would be held to the same standard as other Naturopaths.
If the claim is that training is equivalent, she proposed that
protections to the patient should be equivalent. If Naturopaths
object to being held to the same standard of care as primary
care MDs, she suggests the legislature should spend time to
understand the differences and the way constituents would be
protected.
2:41:37 PM
DR. GALLARDO concluded SB 44 is wrong in both intent and
proposed execution. She said the ability of professions to
circumvent quality and safety mechanisms to achieve their desire
for expanded scope of practice while placing patients at risk,
erode our well-delineated and accepted processes. She urged the
committee to consider the profound differences in education,
training and responsibility between allopathic and osteopathic
physicians as compared to Naturopathic doctors. She also asked
for consideration of the confusion SB 44 would introduce. She
said SB 44 would convey to patients that Naturopaths are
equivalent to allopathic and osteopathic doctors which, she
said, they are not. The safety and well-being of our citizens
should always remain our top priority and we must hold the
highest standard of care in our health care system.
2:44:05 PM
CHAIR BJORKMAN wondered whether there existed reliable data or
documentation of compromised patient safety related to or caused
by naturopathic care.
CHAIR BJORKMAN also wondered whether there are or could be more
conversations around the development of formularies and defined
prescribing authority and clearly defined parameters for
surgeries or procedures. He commented that the concerns
expressed by doctors are valid based on what is reported to be
happening in other states. He advocated a collaborative approach
to mitigate those concerns as and if SB 44 moves forward.
2:46:01 PM
SENATOR BISHOP concurred.
2:46:37 PM
JANE CONWAY, Staff, Senator Cathy Giessel, Alaska State
Legislature, Juneau, Alaska, said she had written down the
questions that were asked and said that her recollection with
regard to developing a formulary was that Senator Kawasaki had
had ongoing conversations with a group prior to handing the bill
to Senator Giessel. She said the idea of a formulary is that it
should not be required of Naturopaths when for decades it has
not been required of APRNs in Alaska and wondered why there
would be a different standard.
MS. CONWAY noted the testimony regarding education and rules and
patient safety and, she suggested, we forget about the patient.
She said more and more patients are looking to find the root
causes of their illness. They want to find the "why". They want
to do preventative care, how they can eat better, for example,
or how to change their lifestyle. She said these are reasons
people seek out Naturopaths. She said it is an inconvenience for
patients to have to go to the doctor of their choice and be told
that they must make an appointment and try to get on the
schedule for a primary care doctor to get a simple antibiotic.
She said that is not improving access for patients and it
creates a double billing for insurance. She said that is not
reducing health care costs and it's not providing the best
patient choice for the care they are seeking.
2:49:07 PM
SENATOR BISHOP asked if Ms. Conway was aware of any Naturopaths
that share an office with an MD.
2:49:32 PM
MS. CONWAY said Senator Giessel has spoken to her experience
working in an Anchorage office where she worked with MDs and NDs
and various other providers and experienced a positive
collaborative working situation. She also said there were a
couple of Emergency Room doctors who work with Naturopaths
frequently and have the utmost respect and confidence in
Naturopathic education and service.
2:50:26 PM
CHAIR BJORKMAN held SB 44 in committee.
2:50:46 PM
There being no further business to come before the committee,
Chair Bjorkman adjourned the Senate Labor and Commerce Standing
Committee meeting at 2:50 p.m.