SENATE CS FOR CS FOR HOUSE BILL NO. 113(L&C) "An Act relating to the prescription and use of pharmaceutical agents, including controlled substances, by optometrists; and providing for an effective date." This was the first hearing for this bill in the Senate Finance Committee. 9:22:08 AM REPRESENTATIVE RALPH SAMUELS, the bill's sponsor, identified the State's geography and small population base as factors that limit access to health care in the State. This bill would enhance health care services by extending prescriptive authority to optometrists. Alaska would join 45 other states that allow similar practice. Representative Samuels declared that expanding the ability of optometrists, who far outnumber ophthalmologists in the State, "to do more" would benefit Alaskans. Representative Samuels stated that the experience of states that allow optometrists to have prescriptive authority has been positive. 9:24:02 AM Senator Thomas understood that college level optometry training programs include instruction on the use of needles as a matter of routine. Thus, the seven hours of training identified in this legislation would be in addition to that training. 9:25:07 AM Representative Samuels could not speak to that matter, but was confident it could be addressed by one of the medical professionals who would be testifying on the bill. 9:25:15 AM Senator Olson asked how the bill before the Committee differed from the original bill. 9:25:44 AM Representative Samuels stated that changes were made to the education requirements. 9:25:57 AM In response to a follow-up question from Senator Olson, Co-Chair Stedman and Representative Samuels advised that the seven hour training requirement for injecting nontopical therapeutic pharmaceutical agents, specified in Section 2 subsection (d)(2) on page 2 lines 16 and 17, was added to the bill. Representative Samuels also noted that language pertaining to the use of Botox was added as specified in Section 3 subsection (a)(1)(E) page 3 lines 2 through 4. 9:26:14 AM SIDNEY MORGAN, Staff to Representative Ralph Samuels, further discussed the various provisions that had been added to the bill to address concerns about injectibles including the provision that would specify a January 1, 2009 effective date for their use. Ms. Morgan also noted that numerous changes had been made by the House Health, Education & Social Services (HES) Committee, so much so that the bill increased from two to four pages. The HES amendments addressed such things as the types of types of narcotics that could be prescribed and limited the duration of a prescribed medication to four days. 9:28:37 AM Co-Chair Stedman asked whether the bill's sponsor was confident that the zero fiscal note from the Department of Commerce, Community and Economic Development was a true reflection of the costs associated with the bill. 9:28:58 AM Representative Samuels affirmed the accuracy of the fiscal note. In response to a question from Senator Olson, Co-Chair Stedman disclosed that numerous ophthalmologists and optometrists had signed up to testify on the bill. 9:29:48 AM DR. DAVID CHAMBERLAIN, Ophthalmologist, testified via teleconference from an offnet location and informed the Committee that he has practiced in the State for more than ten years. Dr. Chamberlain sought to correct misstatements made by a [unspecified] testifier before another committee of referral regarding access to health care. Contrary to that testimony, ophthalmologists do travel to small communities in the State such as Klawock and Craig. Dr. Chamberlain stressed that this correction is important as supporters of the bill tout lack of access as "a big problem" and thus, reason to support this bill. This is not true. For example, either he or his practice partner conducts eye clinics in Klawock once or twice a year. Furthermore, he also regularly conducts clinics through his job with the Alaska Native Medical Center, in other small communities including Barrow, Nome, Kotzebue, Bethel, Dillingham, and Kodiak, and Sitka. The clinics are conducted in a cooperative effect with optometrists in those areas. Dr. Chamberlain pointed out that the Alaska Native Medical Center also employs optometrists throughout the State. They serve both their community and its surrounding area. Dr. Chamberlain continued. When a person with an eye problem "is sick enough to require an oral or an injectible medicine", the community's optometrists or village health aide or physician or nurse practitioner call an ophthalmologist. The State typically has two ophthalmologists or medical doctors on call at all times. The point was that this bill "does not increase access to an optometrist, and actually it may decrease access to an ophthalmologist, accidentally." Dr. Chamberlain professed that this bill would reduce training requirements pertaining to injecting and prescribing medicines. It would also force a redefinition of the role between ophthalmologists and optometrists. 9:33:34 AM Dr. Chamberlain declared that he has a good working relationship with optometrists throughout that State and that a good system is in place to address the State's eye care needs. Dr. Chamberlain advised that medical issues concerning eye-care are complex. Oftentimes, an eye problem is associated with another medical issue such as diabetes; few medicines "treat just the eye". A topical medication applied by an optometrist in a remote area would allow for sufficient eye examination. Dr. Chamberlain declared that safeguards must be in place to protect patients from eye injuries due to "inadvertent intra- ocular injections". This "accidental perforation of the eyeball" can occur even when the procedure is conducted by ophthalmologists and anesthesiologists. However, the highest percent of this incidence occurs when an injection is administered by someone other than an ophthalmologist. 9:35:17 AM Dr. Chamberlain contended that access to quality medical "care would be reduced" under this bill. Furthermore, "the complexity of the human organism is such that we need to listen to the best" medical advice including that of the Controlled Substance Advisory Committee and the State Medical Board. "Ophthalmologists are uniquely qualified to provide medical information, particularly in regards to when it would be acceptable for a non-ophthalmologist to perform a medical procedure. 9:36:10 AM DR. ERIC COULTER, Ophthalmologist, testified via teleconference from an offnet location to voice concern about the legislation. He rebuffed the argument that this legislation would assist in addressing the "lack of care" in the State. He also thought that adopting this legislation would reduce the quality of eye care in the State as allowing optometrists "to delve into greater therapeutic options without proper training" would likely delay referral to an ophthalmologist. Dr. Coulter pointed out that topical eye drops and other therapeutic medicines currently utilized by optometrists are the standard medical response to eye problems even by ophthalmologists. The need for injectibles is relatively ""rare" and, when administered, is typically in the form of an intravenous antibiotic. A person requiring that level of care is likely receiving in-patient hospital care. Dr. Coulter contended that a medical situation occurring in a remote area that required more than topical treatment would likely require more extensive medical care than an optometrist could provide. Dr. Coulter advised the Committee that he had submitted written remarks [copy on file] which outlined many of his concerns. It also overviewed the optometry field's attempt to broaden their scope of practice nationwide. One of their arguments is that Alaska is behind the times because it has not passed similar legislation. To that point, he thought that each state should address its needs independently. Dr. Coulter shared that the American Academy of Ophthalmology's research department considered this legislation to be "a more loosely written" and broader bill than any but five of the 45 States that have adopted legislation on this issue. Dr. Coulter urged the Committee to conduct a thorough review of the bill before taking action on it; specifically in that passage of the bill in its current form might have" unintended consequences". The argument that "a lack of care in the State warrants expanded pharmacologic privileges, in my mind, is just misleading". He urged the Committee to seek supporting evidence to that claim, particularly in respect to rural areas of the State. Dr. Coulter argued that many communities experience regular eye care service and referrals to ophthalmologists are readily available. Dr. Coulter shared that an ophthalmologist who practiced on the Kenai Peninsula for more than 30 years found very little use for injectibles and even let his narcotics license expire. 9:41:38 AM Dr. Coulter urged the Committee to respect "the historical validity of our medical system and try not to rewrite what constitutes competent medical care in our communities." He reminded the Committee that the Alaska State Medical Board, the Alaska State Medical Association, the Alaska Ophthalmology Society, and the American Academy of Ophthalmology did not support this bill. 9:42:14 AM Senator Thomas would have expected the American Academy of Ophthalmology to be against the bill. Continuing, he asked whether the concern is that "some obscure eye diseases would not be diagnosed properly based on" a patient being treated solely by an optometrist and that the patient would not seek further care because they had been treated by an eye doctor, irrespective of the fact the eye doctor was not an ophthalmologist. 9:43:00 AM Dr. Coulter stated that the concern goes beyond that circumstance; it includes the complete evaluation of such things as "whose training is more adequate." Dr. Coulter affirmed there was a good working relationship between the two professions as evidenced by the fact that he refers patients to optometrists and they refer patients to him. The concern "is not so much a turf battle" as it is the misconception that expanded pharmacologics is somehow going to improve the care in rural areas if it is delivered by people that are more accessible. Dr. Coulter agreed that there were more optometrists than ophthalmologists' practicing in the State, but that is true in every State in the nation "because of the different training requirements". The concern is not that optometrists are incapable of utilizing pharmacologics, it is to the "casual comments about the lack of care in communities because there are so few ophthalmologists". This is a misguided argument. Dr. Coulter reiterated that a person who does not respond well to the topical medications currently available to optometrists is likely a person with a serious medical condition. Thus, if the intent is to enhance the quality of care in communities, the Committee should consider the fact that this legislation might be "counter-intuitive" to the goal: it might actually delay a referral to a specialist. 9:45:03 AM DR. CARL ROSEN, Ophthalmologist and President, Alaska Society of Ophthalmology, testified via teleconference from an offnet location. He reviewed his extensive medical background and noted that as a result of his experience he had "a unique vantage point" regarding eye injections. Dr. Rosen stated that the Society considers this a bad bill for a number of reasons. "One is that it is so extremely difficult to acquire acceptance into a medical school"; ophthalmology programs are very selective and once admitted, students are subjected to six years of rigorous training. Dr. Rosen also pointed out that, unlike optometrists, ophthalmologists have hospital privileges and are on-call in case of an emergency. This has been the practice for more than 30 years. 9:47:15 AM Dr. Rosen informed the Committee that ophthalmologists typically undergo 24,000 hours of clinical training; optometrists however typically undergo 2,000 hours of such training. Dr. Rosen declared that this bill would expand optometrists' "scope of practice enormously," specifically their prescriptive authority. They would be authorized to prescribe Class III, IV, and V medications, including codeine, pain medications, valium, cardiac, diabetic, and anti-seizure medications to children, pregnant women, infants, and the elderly. Dr. Rosen recommended the formation of a committee to determine "exactly what is needed". Their task should include a review of current health care services, timetables, limitations, and even what diseases should be addressed. He was confident that such a committee could develop workable solutions to the issues, with "better limits and boundaries that the ophthalmology and medical community can live with". 9:49:45 AM REPRESENTATIVE BILL THOMAS declared that this bill is about the availability of adequate eye care, specifically for people living in rural communities. A person living in Haines, for example, would be required to spend approximately $1,000 dollars to get their child to Juneau or Anchorage for treatment. Such costs would be alleviated where there an opportunity to be treated by an optometrists in their community. Representative Thomas observed that the Legislature routinely strives to allow those in the medical field to "maximize their abilities". Rather than this being "a turf war", the effort should be on taking care of people. Representative Thomas discussed a problem a family member had with treatment provided by an ophthalmologist. It was exacerbated by the fact that she had to travel from a rural community to Juneau for treatment. Representative Thomas respected the services provided by ophthalmologists and urged them to respect the abilities of optometrists. The on-going challenge of attracting medical professionals to the State could be lessened by allowing them to perform duties they were trained for. Representative Thomas urged the Committee to pass the bill. "It is important to small communities." 9:53:05 AM BOB LOESCHER testified in Juneau and informed the Committee that as a legally blind man, he has received treatment from both optometrists and ophthalmologists. Mr. Loescher, on behalf of health care consumers, questioned the reason the bill was not accompanied by a fiscal note that addressed whether this legislation would increase costs or risks to consumers. Mr. Loescher provided a list of questions [copy on file] that should be asked on behalf of consumers. He contended that the legislation would impact the Department of Commerce, Community and Economic Development since they administer and assist boards pertinent to this legislation such as the State Medical Board and the Board of Optometry Examiners. New regulations, testing and monitoring pertaining to the expanded scope of practice for optometrists would be required. Mr. Loescher agreed that the bill would increase service to people living in rural Alaska. However, there is concern that this expanded service might increase the cost of Medicaid for young people and the elderly. This should be addressed in a fiscal note. Mr. Loescher has spent considerable time tracking this bill during its progression through the Legislature. The questions he has provided have been well-researched and should be addressed. For instance, this bill would require optometrists to undergo continuing education; the question is where and who would provide that training. This might require the involvement of the Department of Labor and Workforce Development. Other State agencies and departments might also be affected by this bill. 9:58:46 AM Mr. Loescher summarized his goals. One is that adequate consumer protection be provided. This would require State boards and agencies to be involved in certifying and monitoring doctors. The other goal would be to ensure that the State has the "highest qualify medical care for all Alaska citizens performed by the most qualified persons." State government is responsible for insuring these standards. Mr. Loescher concluded that these responsibilities must be addressed in a fiscal note and reviewed by the Committee. 9:59:56 AM Senator Elton informed the Committee he had previously met and discussed this bill with Mr. Loescher, who is one of his constituents. During that discussion, Mr. Loescher asked Senator Elton to read his list of questions to the Committee, however, Senator Elton did not deem that necessary now as it was part of the record and each Member of the Committee had received a copy of it. Senator Elton stated that the list of questions was quite extensive and an immediate response was unlikely. Therefore, he committed to being responsible for getting the appropriate entities to respond. Co-Chair Stedman acknowledged. Time would be available to further address concerns since the intent was to hold the bill in Committee. 10:00:54 AM Senator Huggins addressed the concern raised in a May 11, 2007 letter [copy on file] from Mr. Loescher that optometrists would be allowed to administer Botox: optometrists would not be allowed to administer that drug under the Senate Labor and Commerce version of the bill before the Committee. Mr. Loescher appreciated the clarification. Optometrists had been allowed to administer Botox in an earlier version of the bill. 10:02:01 AM DR. MICHAEL BENNETT, Optometrist and President, Alaska Optometric Association testified in Juneau on behalf of the Association's 107 members and their patients. Dr. Bennett considered the scope of the bill to be "far more limited" than it was being portrayed. Nine states have approved legislation allowing optometrists to utilize injectibles with zero requirements and limitations. At least ten states do not impose limits on the length of time a drug could be prescribed. The variety of approaches taken by states on this type of legislation makes comparisons difficult. Dr. Bennett expressly clarified that this bill "does not grant surgical privileges" to optometrists. Such privileges were not being sought by optometrists. There was no desire "to usurp the position" of ophthalmologists. 10:04:27 AM Dr. Bennett reviewed the education received by optometrists. The "four rigorous years" of training beyond that required for a bachelors' degree, qualified them as a "doctoral level profession". The 200 hours of pharmacological training enables them to be well-qualified for the prescriptive rights provided in this bill. Other training they receive is closely aligned with that required of doctors and dentists. Dr. Bennett stated that the 2,000 hours of "supervised direct patient contact" optometrists undergo is not limited to healthy young individuals. A large number of eye care problems "arise in people who are older or have other debilitating diseases." This is reflected in the patient contact training. Optometrists also participate in hospital-based training. Dr. Bennett informed the Committee that optometrists conduct a complete medical background, including a review of the patient's medications, on each patient's initial visit. Optometrists are also trained to spot signs of such things as high blood pressure during an eye examination. Optometrists also work closely with patients' primary care doctors on a variety of health issues. Dr. Bennett clarified that the course work identified in this bill, such as the seven hour training requirement pertaining to the injection of nontopical therapeutic pharmaceutical agents, should be viewed as "refresher" training, as that training is conducted in optometry school. Dr. Bennett stated that the use of these new privileges would be rather limited and would not be utilized on a day to day basis. Typical infection treatment would tend to be an oral antibiotic or a topical medication. Extreme cases would continue to be referred to another doctor. 10:08:44 AM Senator Olson asked the Board of Optometry's position on the bill. Dr. Bennett deferred to the next testifier, who was the Chair of that Board. Senator Olson, a medical doctor, asked regarding the training an optometrist would have in respect to treating a person who had an anaphylactic shock response to an injection. Dr. Bennett clarified that the most common cause of an anaphylactic reaction in an optometrist's office is from dilating agents. This risk is ever-present to him since he conducts an average of ten dilations a day in his practice. Current law prohibits him from even using an EpiPen to address an anaphylactic situation even though "anyone with a bee string allergy" can. This could be considered one of "the most critical aspects" of this bill. 10:10:22 AM Senator Olson inquired to the number of optometrists who possess an Advanced Cardiac Life Support (ACLS) certification, as that would allow them to administer to an anaphylactic individual. Dr. Bennett did not know. Senator Olson spoke to the testimony proclaiming that this legislation would provide optometrists in Alaska the authorities granted them in other states. Oklahoma, which is considered to have some of "the most liberal" regulations in this regard, has experienced some negative repercussions. Senator Olson asked Dr. Bennett to compare the prescriptive authority this bill would provide to those of other states. Even though the sponsor statement indicates that marijuana use would not be allowed under this legislation, he understood that marijuana is reportedly effective in treating glaucoma. Dr. Bennett affirmed that marijuana has been used to treat glaucoma; however, other medications are more effective. Senator Olson asked how this legislation compared to legislation adopted by other states. Dr. Bennett noted that Alaska currently ranks around 48th of 50 states in the authority granted to optometrists. This legislation would place Alaska in the fifteenth to twentieth place range. Senator Olson asked how the State would rank in terms of the prescriptive authority granted in this legislation. Dr. Bennett would provide that information. 10:12:26 AM DR. JILL MATHESON, Optometrist and Chair, Alaska State Board of Optometry, addressed a question asked earlier by Senator Olson by stating that the Board, which consists of four optometrists and one member of the public, was in unanimous support of the bill. Dr. Matheson next addressed some of the fiscal concerns that have been raised. The Board of Optometry is self-sufficient in that any expenses incurred to it by this bill or any other function it undertakes, are covered by optometrists' licensing fees. Therefore any expense incurred by the Department of Labor and Workforce Development or the Department of Commerce, Community and Economic Development as a result of this legislation would be addressed in that manner. Dr. Matheson also clarified that no expense would be incurred to the State for any continuing education programs as optometrists pay those themselves. Dr. Matheson informed the Committee that current regulations mandate that any continuing education program utilized by optometrists be from an accredited school of optometry. Since no such school is located in State, the Board would search for a national program that could provide the continuing education courses required by this bill. 10:15:09 AM Dr. Matheson addressed the expense this legislation might incur to patients, insurance companies, and to Medicaid. Some of those costs might be reduced. For example, expanding the scope of what an optometrist could do would negate costs a patient might incur by having to undergo another exam when referred to another provider. 10:15:52 AM Senator Olson asked the level of disciplinary action the Board has taken during Dr. Matheson's tenure on it. 10:16:08 AM Dr. Matheson stated that no disciplinary action has occurred in the two and a half to three years she has been on the Board. The open cases currently under review primarily deal with failure to renew a license. Senator Olson observed that the lone fiscal note accompanying the bill is a zero fiscal note from the Department of Commerce, Community and Economic Development. He asked whether expanding the scope of what optometrists could do might increase the number of disciplinary actions coming before the Board. Dr. Matheson expressed that the Board would be billed for any legal expenses incurred by the Department of Law's involvement in a disciplinary case. Senator Olson directed attention to language in Section 4 subsection (a)(2)(B), page 3 lines 9 through 13 of the bill, which references a licensee's federal Drug Enforcement Administration registration number for controlled substances. He asked how many optometrists currently have such a license. Dr. Matheson responded that no such license is held by any optometrist in the State because they currently do not have the authority to prescribe controlled substances. Senator Olson next directed attention to Section 3 subsection (a)(1)(E), page 3 line 2, which specifically excludes the prescription of a certain type of drug. The question was whether this language could be expanded to also exclude "synthetic Botox-type drugs". Dr. Matheson was unsure. Senator Olson expressed that this could be further investigated since the bill would be held in Committee. There being no further questions or testimony to come before the Committee, Co-Chair Stedman ordered the bill HELD in Committee. AT EASE 10:18:40 AM / 10:19:02 AM