HOUSE BILL NO. 142 "An Act relating to provider responsibility for ocular postoperative care; and providing for an effective date." REPRESENTATIVE CHERYLL HEINZE, SPONSOR provided information about the bill. She explained that the legislation focused on patient care, and noted that a number of her constituents were of an age when their eyesight was deteriorating and they were in need of surgical procedures. She stated that the bill ensures post-operative care following ocular surgery. She maintained that care by an ophthalmologist following surgery was imperative for good patient care. Today's technology makes surgical procedures appear to be routine. She maintained that although most often the surgeries are successful, serious complications might occur. HB 142 provides appropriate ocular postoperative care by an appropriate professional. She noted that the legislation required the surgeon to be physically available to a patient in the community where the surgery is performed for 120 hours following surgery. She added that, after that period, the surgeon may delegate post operative care to another person that the surgeon determines qualified to treat the patient. Representative Heinze noted the changes proposed by Amendment #1, which reduces the number of hours from 120 to 72 hours, or three days. ERIK CHRISTIANSON, OD, KETCHIKAN, testified via teleconference in opposition to the bill. He noted that in Ketchikan, the population was not large enough to employ a full time ophthalmologist. He read from prepared testimony as follows: HB142 is a good example of poorly thought out legislation. I am opposed to the spirit of this bill. By that I mean that entire premise on which it is founded is wrong. The premise is that post- operative care after eye surgery or co-management needs to be regulated. Co-management of surgical patients by optometrists is already regulated under federal law. No other state has this type of law. If you are regulating co-management between ophthalmologists and optometrists then why not other types of surgical specialties arid the local doctors who will follow their patients. This is not the job of the legislature!!! It questions the clinical competence of optometrists to co-manage patients. Optometrists have been performing this to a high level for more than 20 years. I have been a member of the Board of Optometry for 5+ years and we have never had a case brought us where an optometrist caused a patient harm. It is an attempt to legislate clinical decision making on the part of ophthalmic surgeons. If a surgeon is performing "bad surgery" federal law, malpractice, referring providers, and the PATIENTS themselves will cause this surgeon to stop. It is bad for rural Alaska in that it limits the potential choices available to these patients. Currently certain eye surgical procedures are performed at Ketchikan General Hospital (KGH) and the ophthalmologists who perform them would have a hard time managing the 5-day time limit. I do not manage with these doctors except when their patients develop problems after they leave. In the 13 years I have been in Ketchikan I have had to only help out a handful of times. FIB 142 would not allow me as an optometrist to help out within the critical first 5 days. Even though only 35 surgeries per year are done at KGH it offers a choice for those persons who have difficulty traveling or are cover by Medicaid or Medicare and cannot afford travel. Optometrists live where the patient lives. We are the eye care experts in rural Alaska limiting our ability to care for our patients is bad for these patients and the communities we serve. HB 142 is an attempt to limit patient access to care it is obviously special interest legislation, and is both anti-consumer and anti-patient. Representative Croft asked about the typical surgical schedule. Mr. Christianson stated that surgeons who came to Ketchikan, typically from Juneau, generally performed procedures on Mondays and stayed in Ketchikan until Thursday, whereas a surgeon from Anchorage might leave the day after a procedure was performed. He noted that there was a local optometrist who specialized in early postoperative care for patients of ocular surgery. He responded to sentiments by Anchorage ophthalmologists that don't want to deal with patients treated by an outside surgeon. He noted that the follow-up optometrist specializes in the area of postoperative care. Representative Croft asked if a three-day vs. five-day period made a difference. Mr. Christianson maintained that the crux of the problem was that the legislation in the guise of being helpful affected an entire profession. He noted that different surgeries had various complication rates and recovery times, depending on the surgeon and the procedure. Representative Stoltze noted that in his community of 35 thousand, there was no practicing ophthalmologist. He asked about the demographics of practitioners per capita. Mr. Christianson noted that generally a population of 8 thousand could sustain an optometrist, whereas an ophthalmologist with a more extensive education background generally required a community of at least 100 thousand to sustain a practice. Co-Chair Harris cited an oracular surgical procedure performed on a family member by an outside physician. He noted that the initial post-operative care was completed the same day by the surgeon, with subsequent care being the responsibility of the patient and the clinic that provided facilities for the surgeon. He asked if this was a typical schedule. Mr. Christianson confirmed that this was a standard procedure. He added that occasionally patients would sometimes choose to have a procedure performed elsewhere due to lower costs. He noted that this kind of procedures worked if Dr. Christianson retained control over making referrals and was able to do continuous follow-up. He noted that certain complications would require a further visit to the surgeon, but stated that these complications were rare if a patient went to a quality surgeon. Co-Chair Harris asked how the bill, with the change from 120 to 72 hours, affected the procedure. Mr. Christianson referenced page 2, and maintained that the bill did not allow an optometrist to be involved within the set time period. He stated that only an ophthalmologist or a physician would be allowed to do immediate follow-up. HELEN BEDDER, STAFF, REPRESENTATIVE HEINZE referred to line 25 of page 2, and quoted that a co-management agreement could be agreed to "only if the surgeon confirms that the person to whom the care is delegated is qualified to treat the patient during the postoperative period". She pointed out that they must be "licensed or certified to provide the care if license or certification is required by law." She maintained that the language was specifically to allow care in remote areas where optometrists may not be available. She noted that following the five (or three) day period, the surgeon could delegate anyone who is available. Mr. Christianson questioned the need for the legislation and asserted that the clinical decision-making of a surgeon was not within legislative purview. He maintained that the bill opened this issue for other types of referrals and questioned why this regulation was required. Ms. Bedder stated that ophthalmologists had raised the concern about patient care with Representative Heinze's office. She noted out that in other surgical areas, surgeons were responsible for patient care following surgery. She stated that problems had occurred in Anchorage with a surgeon who comes to town and leaves without communicating with an ophthalmologist for follow-up care. She pointed out that many times the patients were elderly and it was a burden for them to be treated by a physician with whom they were unfamiliar. CARLOS BUZNEGO, M.D., ACADEMY OF OPTHAMOLOGY, D.C. testified via teleconference in support of the bill. He explained that this organization represent 27 thousand ophthalmologists throughout the nation. He explained that whereas federal regulations address patient protection, state legislatures were the forum for health policy merits to be debated and acted upon. He noted that he serves on the Academy's Governing Committee for State Affairs, as well as practicing ophthalmology with a focus on cataract treatment. He maintained that the bill addressed an abuse of surgical trust between a patient and surgeon. He noted that ocular care was a rare area when non-physicians may inappropriately perform postoperative care following surgery. Dr. Buznego explained that co management was the sharing of postoperative responsibilities between the operating surgeon and another health care provider. He stated that an arrangement might be entered into only if it was in the best interest of a patient, as in cases where the patient cannot travel. He maintained that unethical behavior occurred when a surgeon enters into a co management arrangement with an allied health provider to economic considerations, as for an inducement for surgical referrals. He asserted that the bill would eliminate this unethical behavior by carefully regulating surgical referrals. He noted that under the bill, referral would occur only when in the best interest of the patient and by the judgment of the surgeon to determine appropriate postoperative care. He stressed that they key issue was not a commercial considerations, but the ethical treatment of surgical eye patients. Dr. Buznego pointed out that cataract surgery or Lasik surgery often involved complications. He gave the example of an early postoperative infection. He maintained that there was no such thing as a specialist in postoperative cataract surgery. He noted that if a wound was not properly closed, it required a surgeon to complete the surgery. He stressed that optometrists were not trained or licensed to perform such procedures, or to determine postoperative infections or other surgical complications. He suggested that surgeons should not be free to leave the state and leave someone who is not properly trained or licensed to resolve potential problems. CHERYL LENTFER, O.D., ANCHORAGE, testified via teleconference in opposition to the legislation. She refuted the statement that optometrists were not trained or licensed in postoperative surgical care, but acknowledged that they could not close sutures. She also maintained that many patients in Alaska had been seeing their optometrists for 30 years, and that it was the optometrists who referred the patient to a surgeon. She pointed out that she had been seeing postoperative patients for many years. Dr. Lentfer referenced her written testimony provided in member's packets. She pointed out that co-management was an aspect of health care that had already existed successfully for many years, and questioned the need to regulate it at this time. She maintained that such regulation would ultimately apply to all fields of health care, including cardiology, oral surgery, etc. She stated that surgeons suspected of unethical practices should be brought before the Medical Board, and not regulated by the legislature. She also pointed out that the bill regulated the amount of time a surgeon was required to be present in a given location, which was unrealistic given the variety of follow- up needed for different procedures. Representative Stoltze referenced earlier testimony regarding nurses handling post-operative care. He asked if in any situation that would be appropriate. Dr. Lentfer replied that this would only be appropriate in unique situations, such as if the nurse had specific oracular expertise. DR. CARL ROSEN, M.D., ANCHORAGE, testified via teleconference in support of the bill. He stated that he was a surgeon specializing in oracular procedures, and noted that he often performed eyelid reconstruction following trauma. He commented that, although co-management originally carried good intentions, a patient protection bill is currently needed to address abuse of the practice. He explained that the legislation was needed to support the patient's best interest, and suggested that in the case of co-managed care, an equally trained surgeon, preferably an ophthalmologist, be responsible for the patient's postoperative care. He maintained that optometrists did not fill this need, not being trained in the nuances of oracular surgery. He noted that the current situation in Anchorage involved organizations that perform oracular surgery, and then leave the patients to the care of optometrists. He maintained that this sometimes resulted in delayed care, and noted that he saw patients with potentially serious post-operative complications that resulted from such care. He also pointed out that occasionally patients were "dumped" on the emergency room, forcing a local ophthalmologist who is uninformed to assume the care and liability. DR. JILL GEERING, O.D., JUNEAU, testified in opposition to the bill. She read from written testimony as follows: TAPE HFC 03 - 62, Side A  Arguments Against Alaska Co-Management 1. Co-management of surgical patients by optometrists is already adequately regulated under Federal law. In 1980, Congress amended the Medicare statute to allow payment to doctors of optometry for cataract post-operative care. The report from the then Department of Health, Education, and Welfare upon which this legislation was based concluded, "The services appear to be effective in patient management, including the management of aphakic and cataract patients. They are reasonable, non- experimental, safe and generally acceptable to the vision/eye care community and the public." The Federal law is quite extensive in providing patient protections and should not be tampered with. States are avoiding doing this, and the Alaska bill would be an unwise change. 2. Federal law is premised on protecting patients from financial exploitation in co-management arrangements. Neither Federal law nor any state law has ever questioned the clinical competence of optometrists to co-manage patients, and optometrists have been doing so successfully for over twenty years. There is no public health justification for the Alaska co-management bill. 3. The Alaska co-management bill effectively eliminates optometrists from the co-management of patients by preventing them from being involved in patient care for 5 days following surgery. This is harmful to patients. 4. The Alaska bill forces patients to seek out less available and more expensive ophthalmologic care for no legitimate health care reason. Again, the co management regulation adopted by the Federal laws was not premised on patients being in any health care danger, but was premised on protecting patients from being taken advantage of financially. Both an optometrist's and an ophthalmologist's ordinary obligations not to commit medical malpractice would work to prevent any harmful clinical co-management decisions within the first five days of surgery. This bill adds nothing to those protections, and Is a step backwards from Federal law in that it limits patient access to care and makes it more likely that patients will unnecessarily pay more for care (from ophthalmologists) - exactly what the Federal law was aimed at preventing. 5. Even if I believed that co-management should be limited, I would argue against this bill. It is full of technical flaws and ambiguities. a) While this doesn't specifically prohibit optometrists from performing post op care after the 5-day period, it is a harrier. It eliminates patient's freedom of choice, and creates fear. According to the bill (section C, number 5, and letter g), the patient is to be made aware of special risks that may happen to them if they enter into a co-management agreement. Since there are no special risks (as Determined by Congress over 20 years ago), I would like to see what such a description would say, because optometrists and other ophthalmologists, are licensed and qualified to perform such care, b) There seems to be a double standard in regards to many of the exceptions. The Alaska bill shifts the determination of patient travel hardship onto the shoulders of the patient, which is an unworkable legal standard. The exemption for the surgeon's travel that says, if the surgeon will not be available for postoperative care. ..as a result of the surgeon's personal travel, illness, etc " is obviously self serving on the surgeons part. If the true intent of this bill is to protect the public, why is it unsafe and not good medicine for other well trained eye care professionals to co-manage in normal circumstances, but if a surgeon is going on vacation, then it is Ok for others to co-manage safely? c) The agreement can only be entered into if the surgeon confirms that the co-manager is qualified to treat the patient. This is not the surgeon's job, this is the licensing department's job. Does this mean that the surgeon must contact occupational licensing before entering into a co-management agreement? d) The co-managing doctor cannot further delegate care to another. What if the co- managing doctor is sick, ill, or called out of town on an emergency and the surgeon is off on vacation? Any referral to a third doctor would violate this law, but the co- managing doctor is ethically bound to arrange care for that patient. e) An exception is made to US Public Health Service doctors or US Armed Forces doctors who are volunteering without pay or other remuneration. This implies that patients are safe for co-managing if follow up care is free, but not safe if it isn't free? Or does this just mean that the ophthalmologists shouldn't have to provide free follow up care...but they are the only one who should provide follow up care if it is paid for? f) Midwives are exempt. This bill would pass into law a provision that allows midwives to perform follow up care for someone who had cataract surgery. As some of you may know, there is an unfortunate duel between ophthalmologists and optometrists in this state. Most of which is professional jealousy. Optometrists seek to move forward by way of improving on and learning new techniques to better serve the citizens of Alaska, Including adding oral medications to our licensure. Ophthalmologists have opposed that 1 this bill is another attempt at limiting our scope of care and superseding the Alaska Board of Optometry. This bill would not only limit us, but it would move our profession back to the 1960's. I encourage you to vote no. DAVID KATZEEK, ALASKA NATIVE BROTHERHOOD, JUNEAU, is a member of the Tlingit tribe, from the Chilkat tribes in Haines. He testified in Tlingit and English in support of the bill. He gave information about the history of his people's migration to different areas. He maintained that the bill was supportive of patient's needs. He expressed his opinion that the bill closes loopholes that allow professionals from other states to perform services in Alaska without responsibility to Alaskans. He referenced the limited entry legislation in regard to salmon fishing. He maintained that the legislation provided higher quality care for people not only in rural communities but for all Alaskans. He observed the contention between professional groups and emphasized that the eyesight of Alaskans were of utmost importance and value. He encouraged members to take the safety of the people into consideration. Mr. Katzeek stated that, according to the Department of Health and Social Services, over 50 percent of Native Americans suffer from type two diabetes, which causes problems with eyesight. HB 142 was heard and HELD in Committee for further consideration. Co-Chair Williams began a brief at ease at 3:30 pm. The meeting reconvened at 3:45 p.m.