HOUSE BILL NO. 150 "An Act requiring licensure of occupations relating to radiologic technology, radiation therapy, and nuclear medicine technology; and providing for an effective date." 2:40:28 PM Representative Stoltze MOVED to ADOPT the Committee Substitute (CS) for HB 150, labeled 24-LS0470\N, Mischel, 2/9/06. There being NO OBJECTION, it was so ordered. HEATH HILYARD, STAFF, REPRESENTATIVE TOM ANDERSON, explained that the bill establishes a full licensure for radiological technicians and a partial licensure for limited radiologic imagers. Mr. Hilyard related that the new CS removed language from House Judiciary Version U. On page 2, lines 20-23 of Version U were removed because licensed practitioners already have no restrictions on the ability to perform x-ray examinations for diagnostic purposes. Mr. Hilyard explained that in Version N, page 4, lines 24- 27, the language regarding limited radiologic imagers, was changed to stipulate a requirement of two years of clinical experience. Two years was chosen because the bill has a two-year delayed effective date. Anyone performing these duties, from the time the bill passes until the time the law becomes effective, would qualify for the applied experience and would not need to enroll in a new program. Mr. Hilyard related that the third change is on page 5, beginning on line 18 of Version N, "or if the program is instructed by and under the supervision of a fully licensed radiographer or licensed practitioner and sponsored by a medical facility, as defined in AS 18.26.900". The language was added due to a concern that there are a number of facilities in rural Alaska that are providing training programs that would not qualify under the earlier definitions. This language clarifies that any facility providing training under the supervision of a radiologist or a licensed practitioner is acceptable. The intention of the new language is to address concerns brought by practitioners in rural Alaska. 2:45:50 PM Representative Kerttula asked where the licensed practitioner language was changed. Mr. Hilyard referred to Version U, page 2, line 5, and lines 20-23, to clarify which language was removed. Representative Stoltze requested information about serious health risks. Mr. Hilyard referred to two articles in the members' packets, a report from the University of California, Berkley (copy on file), and a story from the Sacramento Bee (copy on file), which offer evidence of over- exposure to radiation through standard medical x-rays. Mr. Hilyard read from the Berkley report: "There is the assumption that, at these doses, radiation doesn't make a significant contribution," he said. "But x-rays are very potent mutagens, even at low doses. It's a disaster that people still believe the `safe dose myth', that low doses are harmless". Representative Stoltze wondered what motivated the sponsor to write this bill. Mr. Hilyard reported that he does not know why Representative Anderson took this subject on. Representative Foster inquired if the bill applies to dental x-ray technicians. Mr. Hilyard replied that it does not. 2:50:38 PM Representative Weyhrauch inquired which groups are in favor of the bill. Mr. Hilyard replied that the Alaska Association of Radiologic Technicians, the Alaska State Hospital Nursing Association, and the Alaska State Medical Association support HB 150. The language for the bill was taken from the American Association of Radiologic Technicians who is leading the movement for licensure. There are 41 states that currently have licensures. Representative Weyhrauch inquired how many people would lose their jobs if the bill passes. Mr. Hilyard reported that he couldn't answer that question definitively. Great measure has been taken to try to prevent job loss. There is a two- year effective date and temporary permits to allow people time to pass the examination. Most of the people acting as full radiographers today already have a certification from a national organization and would only have to pass a state exam. 2:52:36 PM Representative Weyhrauch asked how many complaints have been lodged because of the current situation. Mr. Hilyard responded that he did not know of any. Representative Weyhrauch asked why the legislation is needed. Mr. Hilyard related that it is a serious public health issue and technicians need training to operate safely. Co-Chair Meyer noted that the training could be done on- line. Mr. Hilyard agreed. He explained that there is a training program available from Washington for $229. The additional change in the bill states that any facility in the state with a program taught by a radiographer or doctor would also qualify. 2:54:13 PM Representative Kerttula noted a letter in members' packets from the Alaska State Medical Association (ASMA) that states they would prefer and registration system, rather than licensure. She wondered if ASMA has since changed this opinion. He noted that he has been working all along with ASMA. He asked that Mr. Jordan, president of ASMA, respond to that question at a future date. 2:55:09 PM Representative Kerttula said she understood the alarm about unneeded x-rays. She asked for more information from ASMA. Representative Holm asked why dental technicians do not need to be registered. Mr. Hilyard replied that dental x-rays do not present nearly the carcinogenic effect as standard x- rays. They represent roughly 1/10 the level of exposure. 2:56:45 PM MIKE FORD, ALASKA NATIVE HEALTH BOARD, JUNEAU, testified in opposition to HB 150. He addressed costs to rural Alaska. He pointed out that there have no complaints in Alaska to date. The current system is very expensive and the proposed legislation will increase that cost. The legislation adds requirements to those already trained. To add another licensing requirement raises issues of access, disruption in services, and cost. Mr. Ford mentioned the possible danger of exposure for dental hygienists. He credited Representative Anderson for attempting to make the legislation "user friendly". The bottom line is it is another expense passed on to the client. Representative Stoltze commented on a complaint by a constituent regarding costs to tele-medicine in rural areas. Mr. Ford replied that this legislation would disrupt tele- medicine and tele-radiology. Representative Stoltze offered that in the zeal to over- protect, some services may be denied. Mr. Ford acknowledged that the motivation for the legislation is good. However, there will be a layer of additional licensing; in the rural setting, it will be a significant cost. 3:01:36 PM Representative Hawker referenced the newly adopted committee substitute and asked if Mr. Ford agreed that the incorporated changes would be helpful to rural areas. Mr. Ford stated that the legislation is user friendly, but the reality is there will be additional costs to the client. Representative Hawker asked Mr. Ford if he would have a different opinion of the bill if it were limited to dealing with the radiologic technologist. Mr. Ford stated it "might" change his opinion. Representative Hawker asked if the argument was about performing x-ray services as opposed to those people administering nuclear medicine. Mr. Ford replied that would relieve some of the concerns. 3:03:53 PM CLYDE PEARCE, RADIATION INSPECTOR, DIVISION OF PUBLIC HEALTH, LABORATORIES, RADIOLOGICAL HEALTH, DEPARTMENT OF HEALTH AND SOCIAL SERVICES, ANCHORAGE, disagreed with Mr. Ford. He apologized that he had not provided back up material on the number of complaints lodged. He related several personal experiences when he inspected medical clinics. He listed several problems with poor training. He voiced support of HB 150. Representative Kerttula referred to a handout provided to the committee about proper training. She asked how many people operate out of Mr. Pearce's office. He explained his set up as the only radiation inspector for the State of Alaska. Representative Kerttula asked if more inspectors, plus better education, or a system to track the number of x- rays might be better than legislation for licensure. He discussed lack of adequate training. Mr. Pearce explained that 40 percent of repeat exposures were due to mis- positioning of patient. He spoke of the latent affect of exposure to radiation and pointed out that few practitioners recognize a radiation injury. Representative Hawker asked for Mr. Pearce's affiliation. He replied that he is the Chief of Radiologic Health for the Department of Health and Social Services. 3:15:12 PM DR. WILLIAM W. RESINGER, RADIOLOGIST, MATSU, spoke in support of HB 150. He pointed out that there is a balance between the benefits and the risks of employing ionizing radiation for medical diagnosis. Education and experience are needed to maintain this balance. A limited radiographic imager should have the basic training and experience, which the bill proposes. HB 150 is not designed to burden medical providers, but to assure that minimum standards are met. Dr. Resinger shared that, as a radiologist, he would not be the person to train or supervise medical personnel in modern medical therapy or surgery. Neither should a physician train or supervise medical imagers. He defined a "blind spot" as a problem, which one cannot see. He speculated that if he misses an abnormality on a radiograph, that finding becomes a blind spot. Radiologists are constantly fine-tuning their skills in order to reduce missed diagnoses. There are occasional abnormalities missed on radiographs performed in remote areas. Sometimes the problem is the quality of the image. Compliance to national standards can be burdensome, but when criteria are reasonable, the extra effort is worth improving the standard of care. Dr. Resinger opined that the proposed requirements of HB 150 are reasonable and should result in a beneficial effect. He stated a belief that the bill would reduce "blind spots" in Alaska's medical imaging community. Representative Hawker asked for clarification of the line between preparing the image vs. interpreting the image. He wondered if this bill would license limited radiologic technicians to read the images. Dr. Resinger said the radiologists would do that. Representative Hawker asked about the burden on rural Alaskan providers. Dr. Resinger noted that there have to be minimum standards balanced with reasonable regulations. Representative Hawker asked if there is a legitimate risk to address and a need to establish regulations. Dr. Resinger elaborated on past diagnostic concerns. 3:22:19 PM DONNA ELLIOT, ALASKA NATIVE TRIBAL HEALTH CARE (ANTHC), agreed with Mr. Ford's comments. ANTHC is a network of tribes which ensures that all Alaska Natives have health care. She noted that it is difficult to retain qualified licensed x-ray technician staff in rural areas. HB 150 is a concern for ANTHC because it would place an unnecessary burden on x-ray technicians within the tribal health system. Representative Joule asked what the impact of this legislation would be to the delivery system in rural Alaska. Ms. Elliot replied that it would negatively impact the delivery of health care because it means another hoop to jump through. Representative Joule asked if it would impact the workforce. Ms. Elliot replied that it would. Representative Hawker asked if there is a distinction between urban and rural service deliveries. He wondered if ANTHC's concerns would be alleviated if, in the exemption section, radiologic imaging would remain under current statute on an unregulated basis in rural Alaska. Ms. Elliot agreed that would be a step forward. Representative Joule asked why the current rural workforce should not be licensed and more qualified. Ms. Elliot responded that would be a positive situation. 3:29:47 PM DONNA RUFSHOLM, CHAIR, ALASKA SOCIETY OF RADIOLOGIC TECHNOLOGISTS, Homer, shared that her organization helped to write HB 150. She elaborated on why minimum standards and additional training are needed. She mentioned the carcinogenic qualities of radiation of which the average patient is unaware. She referred to a handout on misuse of radiation in Alaska (copy on file.) Blame should not be put on the uneducated operators for radiation errors. They have not been required to receive the correct training. She argued that on-line training for $229 is not a financial burden. HB 150 will not change how small businesses and rural clinics operate. There are provisions in the bill for rural area concerns. Representative Holm referred to earlier testimony about dental technicians and the comment that they were not working with a high enough dosage. He inquired about the carcinogenic effects of low doses. He also wondered about no reported cases of damage. Ms. Rufsholm stated that dentists and hygienists are regulated under separate statutes. She said she hopes there is never a case of dental-related radiation damage. Future cases would be hard to track because there is a latent effect. There have been misdiagnosed cases that cannot be reported. She hoped that HB 150 would protect both the patient and the technician. 3:37:44 PM Representative Hawker commented on various categories of risk. He inquired where the delineation is between low and high risk factors. He asked about basic X-rays. Ms. Rufsholm gave examples of high and low risk procedures. Rural areas lack sophisticated equipment used for CT's and MRI's, and only general radiological procedures are seen in the clinics. Representative Hawker asked if basic x-rays could be permitted without additional training. Ms. Elliot cited her experience with untrained technicians and said she could not support that idea. Representative Hawker referred again to the basic level of x-ray and asked why there is such strong opposition. Ms. Elliot emphasized a need for high standards of education, no matter where the service is performed. She highlighted strong points in the bill; it would create more jobs, and rural jobs would not be lost. She reported that it is hard to understand why this bill would be opposed. 3:47:43 PM Co-Chair Meyer announced that HB 150 would be held over. SHELLY HUGHES, ALASKA PRIMARY CARE ASSOCIATION (APCA), MATSU, spoke of the health centers located in rural areas of the state. She read from a letter sent to the members of the committee (copy on file.) She related that APCA has been monitoring HB 150 to make sure that rural sites would not face hardships as a result of the bill. She suggested that other methods, such as onsite quality assurance checks be taken to ensure safety improvements, rather than licensing. She thanked the bill's sponsor for reworking the bill to better accommodate community health centers. Ms. Hughes turned attention to page 6, lines 9 and 13. She suggested a change from "one" to "two" in section (b). She requested that the Committee carefully weigh the safety vs. access issues of the bill and address the disparity in temporary permits. 3:51:24 PM BARBARA HUFF TUCKNESS, DIRECTOR OF GOVERNMENTAL AND LEGISLATIVE AFFAIRS, TEAMSTERS LOCAL 959, spoke in support of CSHB 150. She stated that she represents radiologist technologists in Homer who are already required by the hospital to be certified. Certified nursing assistants and truck drivers are required to have a license. This bill would provide certification that ensures that the training is done at the same level and that the service is consistent. The bill has gone through many renditions. In response to Representative Hawker's question, she noted that there is career ladder training, which allows for multiple levels of training. Representative Hawker reported that the strongest opposition to the bill was from the Alaska Academy of Physician Assistants. He questioned why they were not here to testify. 3:56:23 PM LOUANNE CHRISTIAN, STAFF, HOUSE FINANCE COMMITTEE, informed the Committee that Mr. Hall from the Alaska Academy of Physician Assistants wanted to testify but was unable to. Representative Hawker asked that he be present at the next hearing. Representative Kelly noted that Don Smith who is strongly opposed to this bill should also be invited to speak. Co- Chair Meyer said he is not in agreement with requesting more public testimony. Representative Kelly stated that he is concerned about costs and lack of depth of experience in rural areas. He requested more information and discussion of the bill. HB 150 was heard and HELD in Committee for further consideration.