HB 434-NATUROPATHIC MEDICINE Number 0067 CHAIR WILSON announced that the only order of business would be HOUSE BILL NO. 434, "An Act relating to the practice of naturopathic medicine; and providing for an effective date." She reminded the members that the committee has previously heard this bill, but a new version will be heard today. Number 0115 REPRESENTATIVE SEATON moved to adopt CSHB 434(HES), 23-LS1574\W, as the working document. There being no objection, CSHB 434(HES), version W, was before the committee. CHAIR WILSON explained that the differences between this bill and [SB 306] are that two provisions were removed from the bill. The provision which said that medical doctors would not be held responsible was removed; and also, the sunset provision has been removed from the bill. In response to an unidentified person in the audience's question if minor surgery is still in the bill, Chair Wilson responded that the minor surgery provision has also been removed. CHAIR WILSON commented that there has been some confusion related to definitions of naturopaths versus naturopathic physicians. Number 0301 JASON HARMON, N.D., Alaska Association of Naturopaths, testified on HB 434, and answered questions from the members. He explained that currently it is unlawful to utilize the term "physician" in a naturopath's title, so the terms naturopath or doctor of naturopathic medicine are used. In other states where naturopaths are licensed the term naturopathic physician is utilized in most of those states, he said. Dr. Harmon explained that in Seattle, Washington, where he attended school, he graduated as a naturopathic physician. The current bill would reflect the standards as are addressed in other states so those who graduate with doctorate degrees would be called naturopathic physicians, he added. CHAIR WILSON pointed out that there are individuals who take a course in naturopathy and hang up a shingle. What is the difference between those folks and those who are being addressed in this bill, she asked. Number 0369 DR. HARMON said that he understands that there is concern for those who do not have an undergraduate degree; who have not attended a five-year medical school; and have not passed Naturopathic Physicians Licensing Examination (NPLEX). The State of Alaska requires that these exams be passed before a doctor of naturopathy can practice. He emphasized that it has been that way since the law was first passed 17 years ago. Dr. Harmon commented that the Division of Occupational Licensing can confirm what he is telling the committee. Copies of statutes related to licensing of naturopathic doctors have also been provided to the committee, he added. Number 0455 CHAIR WILSON asked if HB 434 changes those statutes. DR. HARMON replied that this bill does not change the statutes. It clearly states that an individual would have to have completed an undergraduate degree, graduated from a four to five year medical university for a post-graduate degree, and then pass the NPLEX board exams in order to apply for a [license to practice] naturopathy in the state of Alaska. CHAIR WILSON announced for the record that Representative Kapsner has joined the meeting. Number 0504 REPRESENTATIVE SEATON clarified that this bill does change the current situation in Alaska where anyone can hang up a shingle as a naturopath. He pointed out that if HB 434 passes doctors of naturopathy, naturopaths, and naturopathic physicians would be reserved terms and could only been used by those who have gone through the Division of Occupational Licensing process. DR. HARMON said that the current bill maintains the current standards in statute. Since 1985 it has been unlawful to practice naturopathy in Alaska unless the individual has gone through an undergraduate degree, four to five year accredited naturopathic medical school, and passed the NPLEX board exams. He commented that he can see how the committee could be confused because some physicians who have testified have told the committee something different. Dr. Harmon added that that misunderstanding could have been one of the reasons for concern among physicians also. He acknowledged that if individuals who where not educated at the level naturopathic doctors are, and were asking for the ability to practice as this bill sets out, there would be danger to the public. He said he hopes that process clarifies that point. Number 0649 Robert Urata, M.D., testified in opposition to HB 434, and answered question from the committee. He told the committee that he is a family physician and has lived and worked in Juneau since 1984. Dr. Urata shared that he was born and raised in Wrangell and graduated from the high school in Wrangell, a picture of which is on the wall behind the members. A beautiful school, he commented. DR. URATA said he is here to testify in opposition to HB 434 and the [SB 306] which gives naturopaths the authority to do minor surgery and prescribe medicine. He commented that he understands that minor surgery is no longer included in the current version of the bill. Dr. Urata stated that he is testifying in opposition to the bill because he believes this will affect the safety of his fellow Alaskans. DR. URATA shared some experiences he has had with patients here in Juneau. One patient who had breast cancer was undergoing chemotherapy which caused a low white blood cell count. She was also seeing a naturopath who was not aware of that, he said. The naturopath was giving the patient a colonic to remove her body of toxins. These colonics forced bacteria that normally live in the colon into her bloodstream which caused a severe infection call sepsis. She was hospitalized several days, where she was given IV medications to get rid of the infection. Dr. Urata shared that he has now changed his practice and always asks his cancer patients if he/she is seeing a naturopath, advises patients to never take a colonic when receiving a therapy, and advises patients not to take treatments and herbs because of the potential for drug interaction with the chemotherapy. It could make the chemotherapy less effective or more toxic, Dr. Urata explained. Number 0781 DR. URATA pointed out that it is now found that Chinese herbs can cause liver damage. This experience reflects the differences in ideas in how a naturopath believes the body works, and how a medical doctor believes the body works, which is based on medical training. DR. URATA shared that another problem he has experienced with safety issues is related to ineffective naturopathic treatments. A common example is the drug Laetrile, which was a big cancer treatment by naturopaths a few years ago. It has since been found to be ineffective and toxic, he said. He explained that it builds up cyanide and the result is cyanide poisoning. Dr. Urata told the members that he believes his patient who had stomach cancer suffered and died from cyanide poisoning. What occurred is that the patient would stop his medical therapy to go get Laetrile therapy, he said. Unfortunately, he died on his way from Mexico to Alaska. Number 0877 DR. URATA said that this example illustrates a problem with naturopathic science. When naturopaths do research it does not necessarily involve good scientific methods which employ double- blind studies and also sometimes using placebos. Naturopathic studies involve cases that have been "successful." There are no long-term double-blind studies, so individuals know what they getting and what they are not getting, he explained. Medical research done by naturopaths does not follow the same rules of medical science and he said he believes it can lead to safety issues, he reiterated. DR. URATA commented that naturopath's diagnosis methods are also different. For example, naturopaths use electro-diagnosis and hair analysis to check mineral levels [in the body]. Some of their diagnosis methods for chronic yeast infections and toxemia are also different. Naturopaths' theories of why diseases occur include things like toxins in the body, so they like to do things to clear the body of toxins, he explained. Medical science has developed theories over the past century including germ theory and genetic theory of diseases. Dr. Urata acknowledged that there are also toxins so in that way medical doctors' diagnosis may be similar to naturopathic doctors. He summarized that medical science is different, developed over many years of research, and treatment by a medical doctor is different than that of a naturopath. Number 0950 DR. URATA pointed out that medical doctors train differently than naturopathic doctors. He stated that medical doctors are exposed to much more rigorous training with sick patients. That is true particularly in medical hospital and medical centers, he said. Medical doctors do four years of pre-medical school, and four years of medical school. In the first or second year of medical school students are exposed to sick patients, and it gets more intense until the student is spending 100 percent of his/her time with sick patients in the hospital. It is then required to do an internship and residency which now blends into what is called a residency. The shortest residency is three years long. Dr. Urata shared that during the residency the doctor is taking care of patients with supervision at multiple levels. For example, a surgeon takes at least five years of this intensive training, he commented. He told the members that he did three years of intensive training to become a family physician. In Alaska medical doctors are required to have two years of an internship in order to get a license to practice medicine, to do minor surgery, and prescribe medications, Dr. Urata said. Number 1053 DR. URATA reiterated that naturopath and medical physicians approach the human body in different ways. Naturopaths have different theories of diseases, treatments, and diagnosis. Physicians have their own which has been developed over many years in a very scientific way, he emphasized. Dr. Urata commented that it is puzzling to him that naturopaths want to expand their scope of practice to include medications without the same education and training that physicians are required to have. In addition, he said he believes that naturopaths who wish to expand their scope of practice need to accept medical science's point of view and approach to prescribe medications, treatments, and diagnosis. Dr. Urata stated that if that is not the case it is his opinion that it would not be safe. He said he believes it would work better for naturopaths to stay in their own arena and worked cooperatively with physicians rather than copying them. DR. URATA pointed out that there is a model of that happening today. The University of Washington Cancer Center has hired a naturopath who works on staff and who does research on a lot of the naturopathic medications. It is important to have a good understanding of what these medications do, what the side effects are, and what the drug interaction might be with medications that are prescribed. Dr. Urata said that he believes that may be the direction of the future; however, he does not support giving naturopaths the power to prescribe medications and collaborate at this point. It is too early in the development of these two different specialties. Dr. Urata stated that he does not believe it is right to force the issue because he believes it is unsafe. Number 1158 REPRESENTATIVE WOLF asked if it is normal practice to ask patients if they are taking anything for an illness. DR. URATA asked if he is referring to the example he posed with the breast cancer patient. REPRESENTATIVE WOLF noted that the patient did not inform him of her actions. DR. URATA replied that is correct, she did not inform him and he did not ask. REPRESENTATIVE WOLF asked if it is fair to blame the naturopath. DR. URATA questioned that his example was blaming the naturopath. He said he wonders if the naturopath knew that he was giving her chemotherapy. Dr. Urata emphasized that he was not blaming the naturopath. He said he believes naturopaths have a role in caring for patients, just as he accepts that chiropractors can help people with back pain. DR. URATA stated that if everyone sticks to what they know, everyone should be safe. By mixing and matching areas of expertise, philosophy, and culture there will be trouble. He stated that he does not give Chinese herbs or colonics to his patients because he does not understand those practices. By the same token, why would a naturopath want to prescribe penicillin to patients, he asked. If a naturopath wants to prescribe medication then they should be required to have the same training that medical doctors go through, which is seven years of education and training after college. He commented that this does not make sense to him. DR. URATA said that he would be happy to work with naturopaths, but does not want to work in a collaborative arrangement as is provided in [SB 306]. Number 1304 REPRESENTATIVE SEATON pointed out that surgery is no longer included in this bill and that drugs must be prescribed in collaboration with a medical doctor. He acknowledged that Dr. Urata does not want to work in a collaborative arrangement with naturopaths, but asked if he wishes to prohibit other physicians who might wish to have this kind of arrangement. Number 1337 DR. URATA replied that there is no model for that kind of arrangement, and would not want to see it become legal until it is determined that it would work well. He acknowledge that it may be happening in other states, but it would be an experiment in Alaska. He offered that doctors have collaboration with nurses, nurse practitioners, and physician's assistants, but those people are trained very similarly to the way a medical doctor is trained. There understanding of how the body works is very similar, he commented. For example, if a naturopath determined that a patient has strep throat, he would not be sure how it was diagnosed. Dr. Urata said he would have to work with a naturopath and understand how he/she works and develop a trust, but is not ready for that now. REPRESENTATIVE SEATON pointed out that this legislation has no requirement that any physician would have to enter into a collaborative agreement. He said he does not understand one physician saying he does not trust another physician to exercise his/her responsibility in forming that kind of collaborative relationship. DR. URATA said he understands what Representative Seaton is saying. He told the members that he cannot answer for other doctors because he has never asked other physicians about that point. Dr. Urata emphasized that he is speaking for himself in answering these questions. Number 1431 REPRESENTATIVE CISSNA asked for more information about the model at the University of Washington Cancer Center. DR. URATA replied that he does not know how it is being done. He told the members that an oncologists and naturopath came to Alaska and gave a lecture on upgrading cancer therapy. He said he has not heard anything since and is not even sure if the naturopath is still there. Dr. Urata said he is very curious to see how it goes as it could be the wave of the future. REPRESENTATIVE GATTO asked if he practices at Bartlett Regional Hospital. DR. URATA responded yes, that's correct. REPRESENTATIVE GATTO asked if he also has his own office. DR. URATA said yes. Number 1486 REPRESENTATIVE GATTO asked if he has a nurse practitioner and physician's assistant who operate within earshot of him. DR. URATA said yes. REPRESENTATIVE GATTO surmised that it is no problem for the nurse practitioner and the physician's assistant to get an approval to write a prescription because they are within earshot of him. He asked if he understands correctly that this bill would permit a naturopath to be at a separate location and request approval for a prescription. Representative Gatto questioned if that is the source of Dr. Urata's problem with the bill. DR. URATA acknowledged that distance may play a role, but in Alaska where there are a lot of rural areas, and there are many nurse practitioners practicing in rural areas without a physician onsite. A physician is a phone call away, and by law chart reviews are required to ensure that the standard of care is maintained. The relationship between a medical doctor and a naturopathic doctor is so far apart because the sciences are different, that he believes it would be difficult to have a good healthy collaborative relationship. Dr. Urata told the committee that if the work at the University of Washington works and other states' collaborative agreements work, then in the future this may be a good idea. At this point he said he does not believe it is safe to do this. Number 1624 CHAIR WILSON announced that due to time constraints she would be limiting testimony to three minutes. SHARON FISCHER, M.D., testified in opposition to HB 434 and answered questions from the members. She told the members that her testimony would focus on the patient safety issue with respect to prescription medications. Dr. Fischer said as a physician she is aware that prescribing medications is a complex task. Most have read about the incidents of medication errors and the potential consequences of these errors which include things like allergic reaction and in some cases death. If that happens when medications are prescribed by people who are extensively trained in prescription medications then those who are not as well trained are even more likely to make those sorts of errors, she added. Dr. Fischer shared that what she believes makes a good physician, whether a naturopathic physician or medical doctor, is appreciating his/her limitations, understanding the scope of his/her practice, and understanding when something is outside of that scope. She said she thinks that prescription of medications is outside the scope of practice of naturopathic physicians, and therefore, the ability to prescribe should not be granted to them because it is too much of a safety issue. Number 1720 REPRESENTATIVE SEATON commented that while Dr. Fischer may not want to have a collaborative relationship with a naturopath, if a physician was comfortable with that collaborative relationship how would it be different from that of a nurse practitioner or physician's assistant [prescribing medications]. DR. FISCHER clarified that a nurse practitioner does not have to have a collaborative agreement with a physician in the state of Alaska; however, a physician's assistant does. She shared that she has been in a collaborative agreement with a physician's assistant and said it is difficult to provide the oversight because of distance and weather. A lot will happen because often it is not possible to give oversight for every prescription that is written. It would be less of a concern if the collaborative agreement were with someone in the same office, she said. REPRESENTATIVE SEATON asked if a collaborative agreement works with a physician and a physician's assistant that are not in the same locality, why wouldn't it work between a naturopathic physician and a medical doctor. Perhaps, all collaborative agreements between doctors and physician's assistants should also be prohibited, he commented. DR. FISCHER responded that she believes it is the scope of practice that is the issue. It is fully within the scope of practice for a physician's assistant to learn about prescribing medications, infections, blood pressure, etc., but that is not within the scope of practice for a naturopathic physician. She emphasized that is not what naturopaths learn in school. The training in pharmacology is more extensive than that of a naturopathic physician. Naturopath school's focus is on natural healing techniques, not prescription of medicines, Dr. Fischer commented. REPRESENTATIVE SEATON asked if it is true that it is the physician's oversight that allows that prescriptive ability for physician's assistants. Number 1844 DR. FISCHER replied that is correct. She said she would argue that is okay because the physician's assistant is trained to prescribe medicine. Number 1853 REPRESENTATIVE KAPSNER asked how different is the naturopath's education. It is not like someone who is educated as an engineer or someone with completely different educational background prescribing medicine. She pointed out that medical doctors not only collaborate with physician's assistants in Alaska, but also with health aides. In Rural Alaska if a community has a health aide it is fortunate. She said she knows health aides are provided with huge algorithms and questioned whether medical doctors would be required to create algorithms for naturopaths if this legislation were to pass. DR. FISCHER said she believes that is what would happen if she understands the bill correctly. In response to an affirmative answer by an unidentified person, Dr. Fisher suggested that some of her colleagues might be better able to address some of these questions. Number 1945 JOY DO NEYHART, M.D., testified in opposition to HB 434 and answered questions from the committee. She told the members that she is a pediatrician in Juneau and agrees with her colleagues that have testified in opposition to HB 434. She said she is concerned that expanding the scope of practice for these health care practitioners, whom are less educated and trained, would not enhance patient care, but could very well be unsafe for those seeking health care from naturopaths. To be able to safely and effectively prescribe pharmaceutical substances it is essential to be trained in the diagnosis and treatment of diseases. Dr. Neyhart told the members that she found in her review of several curriculum of schools that educate individuals to become naturopaths only one school listed pharmacology as a course offering. She read a definition of naturopathy that was published by one of the colleges as follows: Naturopathy is a system of therapy that employs natural forces such as light, heat, air, water, and massage. This system differs most significantly from allopathy by focusing on building health rather than treating disease. The techniques used are noninvasive and may include foods, herbs, fasting, nutritional supplements, bodywork, hydrotherapy, forms of exercise, body movement and/or meditation. DR. NEYHART said that given that definition, prescribing pharmaceutical substances is beyond the scope of practice of naturopathy. As a physician who has earned, through seven years of education and training, the privilege to diagnose and appropriately treat patients who choose me as their health care provider, she urged the members not to approve this legislation. REPRESENTATIVE GATTO asked if Dr. Neyhart would oppose any of the remedies that she quoted in the definition of naturopathy. DR. NEYHART replied no. REPRESENTATIVE GATTO asked if she would choose to incorporate them in her own practice. DR. NEYHART responded that if she chose to learn about them she could incorporate them in her practice. Number 2066 KIM POOLE, Registered Pharmacist, testified on HB 434, and answered questions from the members. She told the members that she has a lot to lose no matter how this bill goes. Economically to allow naturopathic physicians to prescribe would boost business. She commented that there is a bill to take away the privilege of collaborative agreements with pharmacists. Ms. Poole said she has a problem with one group being given the privilege of having a collaborative practice, while her own profession is being called into question. She acknowledged that she believes naturopathic and allopathic medications are not mutually exclusive, but not mutually inclusive either. For that reason, she opposes the bill. Ms. Poole said that drugs are very different than herbs. Homeopathic medications are very different than the medications that pharmacists go to school [to learn about]. To be an entry-level pharmacists it is now necessary to graduate with a doctor of pharmacy degree for six years. During that time only medications and the body are learned, not the diagnostic skills of a physician, she explained. MS. POOLE explained that for many years the simple practice of homeopathy has been to take a substance and dilute it into very small portions to get the body to heal itself. Medications that pharmacists prescribe do not work like that and many are very toxic and dangerous. She told the members that physicians make errors in prescribing as well. Ms. Poole said that she does not believe the training in homeopathic field is to the level where safety of the public can be assured and for that reason she opposes HB 434. She told the members that she agrees with Dr. Urata's statement that the future may be in collaborative work with naturopaths, but not yet. In summary she said she would not feel comfortable filling a prescription that comes from a homeopathic physician. Number 2179 REPRESENTATIVE GATTO asked if pharmacists have an option to refuse to fill a prescription if the doctor is not someone the pharmacist is comfortable with. MS. POOLE replied yes. If a prescription is presented that a pharmacists does not feel is good, it will not be filled. She told the members that she has refused to fill prescriptions from a licensed provider in Alaska. REPRESENTATIVE GATTO asked Ms. Poole what she says to the patient. MS. POOLE responded that she tells the patient that it is her opinion that the prescription would be dangerous for his/her best interest. She said she would explain that she needs to talk with the prescribing physician. The patient is free to go elsewhere to get the prescription filled, however. REPRESENTATIVE GATTO asked where she works. MS. POOLE responded that she works in the city of Juneau. Number 2221 REPRESENTATIVE SEATON clarified that this bill requires collaboration with an M.D. and N.D. He asked Ms. Poole if a prescription comes to her from a health aide or physician's assistant who works with the oversight of a medial doctor, does she view the prescription in the same way. Representative Seaton asked if she would have philosophical problem with that. MS. POOLE replied that she would have both a philosophic and ethical problem with it. However, she agreed that the only way to provide health care for all Alaskans is to move to collaborative orders for many of the health fields. She pointed out that Alaska is too small a state, without a medical school, dental school, pharmacy school, or law school. There needs to be trained professionals in Bethel, Wrangell, Gustavus, and Petersburg. It is almost impossible to sustain a medical practice in those areas, she said. Ms. Poole told the members that if there is a health professional who wishes to dedicate his/her time to a community it is important to allow him/her to do that. She asked the members not to rush this through. Ms. Poole suggested next year the bill be reintroduced and more work could be done. In that case, she might speak differently, she summarized. Number 2310 KATHERINE GRIESEL, Advanced Nurse Practitioner, testified in opposition to HB 434. She reiterated some statements by earlier speakers by saying that she is concerned that naturopaths are not trained in the use of conventional pharmaceuticals. It is important for the committee to be aware that there is a difference between a collaborative relationship and supervisory relationship, she commented. A collaborative relationship is much looser. The bill refers to a review at six months, then once a year, she said. This is much loser that what a health aide has with a supervising physician in a medical center such as Anchorage. For example, a health aide at Fort Wainwright will speak with the supervising physician on a daily basis so all his/her actions are closely monitored, she said. TAPE 04-41, SIDE B  MS. GRIESEL summarized that there are only four states in the country that allow naturopaths to prescribe controlled substances. Three of those four states significantly limit which those controlled substances are, she said. Ms. Griesel told the members that Arizona allows naturopaths to widely prescribe drugs and has a regulatory oversight board in place. If this bill is passed she urged the members to create a regulatory board. Number 2278 DONALD LEHMANN, M.D., testified in opposition to HB 434. He told the committee that he has practiced in sports medicine in Fairbanks, Bethel, and Sitka. He said he believes HB 434 is unnecessary, unsafe, and not in the best interest of the welfare of Alaskans. Naturopaths prescribe herbs, and do not have the training necessary to do what medical doctors do, nor should the legislature give it to them. He said he has listened to the discussions concerning collaborative relationships physicians have with nurse practitioners, physician's assistants, and health aides. It is important to note that these health care professionals are all singing off the same page. DR. LEHMANN commented that naturopaths have said that a four- year undergraduate degree is required for admission into a naturopathic college; however, the facts speak otherwise. He told the members that his nephew is currently a first year student in naturopathy at Bastyr University in Seattle. That is one of the premier naturopathic schools in the country. His nephew was accepted without a four-year degree, he said. DR. LEHMANN told the members that his medical training has reinforced his belief in science and the scientific methods and the value of double blind studies. Naturopathy relies on antidotal reports. If naturopaths wish to prescribe drugs or perform surgery then he believes they should be required to go to medical school. DR. LEHMANN summarized that it does not make sense to have a collaborative relationship with naturopaths because their training is so different than physician's assistants and nurse practitioners. Number 2188 JOHN TROXEL, M.D., Plastic Surgeon; Member, Alaska State Medical Board, testified in opposition to HB 434 and answered questions from the members. He told the members that the Alaska State Medical Board discussed HB 434 and sent a letter to the governor in which its position on the bill was presented. It is the Alaska State Medical Board's position not to support this bill because of the training of naturopaths. He said that naturopaths are trained to rid the body of toxins and the use of natural medicines. DR. TROXEL commented that since he is a surgeon he was most interested in that element of the bill. He told the members that he called [Bastyr University] in Seattle, one of the largest naturopathic medicine schools in the country, and found that neither its students nor residents are trained in any type of surgical procedures. CHAIR WILSON advised Dr. Troxel that there is a committee substitute before the committee which has removed the minor surgical provision. DR. TROXEL said that the last he heard there was discussion about collaborative agreements with physicians and asked if the prescriptive authority is the basic issue of the bill in its current form. CHAIR WILSON replied that is correct. Number 2055 REPRESENTATIVE SEATON explained that the current bill requires an ongoing collaborative agreement, not one that is for a short period of time, between medical doctors and doctors of naturopathy. The bill also includes a requirement for a formulary to be part of that collaborative agreement. There is also a requirement that the agreement be in writing with the extent of supervision required by the physician delineated. Representative Seaton clarified that no physician is required to enter into this kind of agreement. With those requirements in place, he asked if he trusts physicians to enter into this kind of agreement and protect themselves with respect to the supervisory function that would be incurred. DR. TROXEL commented that his sense is that the board would probably still be opposed to collaborative agreements with naturopaths. Speaking only for himself he said if he had been asked this question a year ago he would have considered the request pretty reasonable. In the physician community there 95 percent of the medical doctors are in mainstream thinking; however, there probably are about 5 percent of medical doctors that are outside the mainstream. Dr. Troxel acknowledged that there probably are doctors who would enter into these collaborative agreements, but he said he is not convinced that the collaborative agreement would guarantee that good medicine would be practiced. REPRESENTATIVE SEATON surmised that what Dr. Troxel is saying is that if there are doctors that cannot be trusted, then the collaborative agreements cannot be trusted either. DR. TROXEL responded that it is a difficult question to answer. He emphasized that he is not saying there are a lot of bad doctors out there, there are not. He explained that there could be one physician who would enter into a collaborative agreement who is not in that mainstream. There is a risk with any collaborative agreement, Dr. Troxel said. Number 1873 DOUGLAS EBY, M.D., Physician Executive, South Central Foundation, Alaska Native Medical Center, testified on HB 434, and answered questions from the committee. He explained that part of the reason the foundation has a lot of interest is because it has worked on a great deal of integrated health care service delivery. The Alaska Native Medical Center now employs allopath, osteopaths, chiropractors, massage therapists, acupuncturists, and Native traditional healers. Naturopaths are also employed under contract as the center explores how naturopathy might fit into the health care delivery system. He read the following statement into the record: The Southcentral Foundation is very interested in the integration of allopathic and other health professionals as much as possible. To this point we have integrated allopath, osteopath, chiropractic, massage therapy, acupuncture, and Native traditional healers. We employ naturopaths to incorporate their skills and knowledge into the system. We feel they do add to the additional value to spectrum of services we offer, but the details we are still working out. With the question regarding prescriptive authority, which is currently under discussion and debate, we at present, do not have a position. We think it is an important conversation and one that we are very interested in being part of. However, we do not have a position yet and at present we do not feel that we will be able to arrive at one in the immediate future. Our request would be that we opt for any decision particularly around prescriptive authority be delayed for a number of months to allow for a more thorough evaluation of the various possible options, and for the medical community and the community at large to be able to give more informed input and have the time and opportunity to have an informed debate. We look forward to continue to participate in this process. DR. ELY summarized that Alaska Native Medical Center is very supportive of integrated health care. The center is becoming recognized as one of the national leaders in funding integrated health care. He said that prescriptive authority is not an issue the center has addressed and said that he believes there needs to be more time to deal with this in an informed manner. Number 1713 CHAIR WILSON asked Dr. Ely to comment on the naturopaths that have recently been hired at the Alaska Native Medical Center. DR. ELY replied that two naturopaths have recently been hired. One has been there for six months, and it has been a slow process to determine how the naturopath might fit into the system effectively. There has been a significant shift in the way the center is operating. There is a more systematic approach to cost effective decisions and quality health care, he added. REPRESENTATIVE SEATON asked if he has a copy of the most current version of the bill that removes the minor surgery provision and also provides for an on-going collaborative relationship between medical doctors and naturopaths, established formulary, and the extent of supervision delineated in writing. He asked if those provisions were what he was testifying on or only the prescriptive authority issue. DR. ELY said that he has a copy of [SB 306], which was given to him today and assumes it is the most current version. He commented that more oversight is always a good idea for any profession. It is the prescriptive piece that needs more time and processing before an informed decision can be made by all the people weighing in on the conversation. He said that he does applaud having a physician involved in the oversight, but it is very broad prescriptive authority. REPRESENTATIVE KAPSNER asked Dr. Ely to tell her how many of the professions prescribe medicine at this point. DR. ELY responded that only the allopathic and osteopathic doctors prescribe medicines. He told the members that there is a credentialing and privileging process by which the medical center controls the scope of practice within the system. Number 1518 JOSEPH KLEJKA, M.D., Medical Director, Yukon-Kuskokwim Health Corporation, testified on HB 434. He told the members that their main concern is about prescriptive authority. It is important that more thought go into this issue. Dr. Klejka said serious problems could occur. He explained that health aides are trained by physicians to think as they do. Health aides work under very specific algorithms which spells out exactly what can and cannot be done; if there is any variation, then the health aide must speak with the physician. The health aides do speak with the physician every day, he commented. Dr. Klejka said he would be very cautious about providing prescriptive authority to naturopaths. Number 1447 ELIZABETH ROLL, M.D., Medical Staff President, Yukon-Kuskokwim Health Corporation, testified in opposition to HB 434. She said she is concerned about providing prescriptive authority to naturopaths at this time. When reviewing education received by naturopaths it does appear that they do not receive much pharmacology training. There could be serious side effects by prescribing the wrong medication. Dr. Roll encouraged the members not to vote in favor of this bill. REPRESENTATIVE KAPSNER asked if she could provide copies of the e-mails sent her from Dr. Roll and Dr. Klejka. In response to their affirmative response she thanked them. CHARLES STEINER, M.D., Tanana Valley Clinic, testified in opposition to HB 434. He told the members that there are three doctors at the clinic who would like to testify. He told the members that they share the same main point and that is that naturopaths do not have the same training as medical doctors. It is a public health issue because the opportunity for misadventure are huge, simply out of ignorance. Dr. Steiner summarized that he has not seen or heard of anything with respect to training of naturopaths that would convince him that they are capable of managing medications safely or effectively. He urged the members not to support HB 434. Number 1325 DONALD IVES, M.D., Tanana Valley Clinic, testified in opposition to HB 434. He told the members that his main concern with the bill is related to public health. Once prescriptive authority is open there is the ability to do great harm. Dr. Ives shared that he has personally cared for patients who have been under naturopathic care for hypertension that was poorly controlled and not referred properly. Some of these patients had kidney failure. He encouraged the members not to support HB 434. Number 1231 CLAY TRIPLEHORN, M.D., Tanana Valley Clinic, testified in opposition to HB 434. He told the members he opposes HB 434 for two reasons. The current bill is similar to one written in the state of Arizona in which there was a board of naturopaths providing oversight for themselves. Dr. Triplehorn explained that what happened is that naturopathic physicians actually increased the scope of their care without notifying the legislature to get authorization to do so. There were some disastrous consequences of this. Subsequently the state of Arizona had to significantly modify the scope of practice for the naturopaths. Dr. Triplehorn told the members that this report could be viewed on the Internet. It is the [State of Arizona, Office of the Auditor General, Naturopathic Physicians Board of Medical Examiners (June 2000, Report No. 00-9)], which requires naturopaths to have direct observation with a collaborating physician and substantially increases the amount of therapeutic training that naturopaths receive, he said. DR. TRIPLEHORN said he is also concerned with statements made by naturopaths that their training is equivalent or adequate. He said he would dispute that statement. The state of Massachusetts actually reviewed naturopaths training in the United States and the findings were that naturopathic physicians only received about two-thirds the amount of material that is provided to traditionally trained osteopaths or allopathic students. As a result the state of Massachusetts declined to allow naturopathic physicians to prescribe medication. Dr. Triplehorn said he agrees with the comments made by the family practice physician who spoke earlier. Dr. Triplehorn asked the members to look at the experience of other states, as he believes they will find that Alaska would be unusual to allow naturopaths to practice in the state of Alaska with prescriptive rights. He encouraged the members to look at naturopathic training, as he believes it is substantially less than what is being represented. Number 0942 ROSEMARY HEWITT, testified in support of HB 434, version W. She questioned why physician's assistants can write prescriptions without adequate supervision and naturopaths cannot. Number 0893 PATRICIA SENNER, Past President, Alaska Nurses Association, testified on HB 434. She told the members that the association agrees with Dr. Eby's comments that it is important to be deliberate and systematic in approaching this issue. The nurses association believes there are four criteria that the legislature should apply to all instances. First, the basic education that the health care provider receives should be from an accredited institution and cover the areas that the providers are allowed to practice. Second, the licensure/certification exams that the health care providers must pass are conducted by a reputable entity and cover the area in which the provider wishes to practice. Third, the provider should be engaged in continuing education to ensure continued competency. Fourth, a regulatory board should be established which oversees the profession and ensures that complaints by the public are addressed and that individual providers can seek advice concerning the change in scope of his/her practice. Number 0813 MS. HEWITT told the members that she has some concerns regarding the way the collaborative model is set out in this bill. Under this bill the individual physician that is supervising the naturopath could decide which medication the naturopath could prescribe. She questioned how the pharmacists is suppose to know what those limitations are. It may be a nightmare for pharmacists in determining what the individual's scope is, Ms. Hewitt added. MS. HEWITT shared that another concern is that the board of three naturopaths will overseeing their own profession. She said that the association believes there should always be room for the consumer to be involved in regulating health care professions. Since physicians have a significant role in all of this she suggested that perhaps the oversight should go under the Alaska State Medical Board. MS. HEWITT summarized that she believes the legislature should take its time on this; address some of these issues by involving other health care professionals, and come back with a committee substitute that protects the public next year. Number 0740 MEGAN LeMASTERS, M.D., testified in opposition to HB 434. She told the members that the training received by medical doctors in the field of pharmacology is a 27-credit course which is completed over the course of a year. There is nothing in any naturopathic school that comes close to that level of training, she said. This does not even address the additional training medical doctors received in residency. Naturopaths have no residency training, only clinical trials that they receive during their four years of medical school. She agreed that naturopathic medical schools are similar to medical school for M.D.s. Dr. LeMasters shared that she believes there is a role for naturopaths and was the president of the integrated medicine society at the medical school she attended. DR. LeMASTERS acknowledged that Alaska has a very unique situation with PAs being offsite in remote situations. She said that actually only about 10 percent of what PAs do is overseen by a physician. When physicians come to review the paperwork it is usually a quarterly visit to look at a select group of charts. Due to the limitations in care in Alaska it has to be done this way, she said. If the question is no care versus some care it is better to have a provider with some training, Dr. LeMasters stated. DR. LeMASTERS summarized her comments by saying that to spread that collaboration even thinner than it is now would jeopardize the safety of the public. Number 0570 LYNN HORNBEIN, M.D., testified in support of HB 434. She read the following statement into the record: I am a board certified family physician and have been practicing mainstream medicine in Anchorage for about 14 years. Over the last three to four years I have gotten to know some of the naturopathic physicians in Anchorage and Eagle River, and consider them colleagues in the care of some of our mutual patients. I gather that some of my allopathic colleagues think that naturopathic physicians don't have any formal training or maybe got their training through the mail with a mail order degree. The doctors or naturopathic physicians that I know are graduates of accredited naturopathic medical schools. I'm not sure most allopathic physicians know what the course content is of a naturopathic medical education. Before I went to medical school I was considering going to naturopath medical school so I researched both of them in great detail. My impression was that the training in the first two years was very similar. There were courses in radiology, lab medicine, and pharmacology. The second two years was similar in that there were few chances to have hands-on experiences with patients. My training was spent a lot of time in the hospital. As I understand it naturopaths do all of their training in an out patient setting. You are probably wondering why didn't I go to naturopathic school. I decided to attend allopathic medical school at the University of Washington so I could pursue a masters in public health at the same time. Number 0486 Other committees have heard the testimony of Dr. Jensen who has been involved in the training of osteopathic, allopathic, and naturopathic physicians for many years. I heard him speak to the Senate Finance Committee and he pointed out that the pharmacology courses that are taught in naturopathic medical schools are taught by Ph.D.s in pharmacology. Those are the folks that are trained in conventional allopathic pharmacology. So it seems to me that the basic knowledge is the same, how we use it later in our training is what differs. I think that naturopathic physicians are very adept at using drugs that come from natural sources like bio-identical hormones, antibiotics, and thyroid medications. State regulations prevent them from prescribing them to their patients. I know that and have been hearing concerns that naturopathic physicians do not have as much training as allopathic physicians, as they do not do residency. This is true, but I am not sure that that necessarily supports disallowing them to have prescriptive rights. Many allopathic physicians actually work with and employ physician's assistants and nurse practitioners and they do not have residency training but do have prescriptive rights. As has been discussed P.A.s do have collaborative agreements with M.D.s and can practice independently. As a died-in-the-wool allopathic physician, I do believe in the scientific process and practicing evidence-based medicine, but naturopathic physicians I know do also practice evidence-based medicine and they keep up with both allopathic and alternative medical research. They have a clear vision of their scope of practice and know when to refer a patient for allopathic medical care. I have heard some horror stories about harm to patients by naturopaths. I have also heard some horror stories about allopathic physicians. I am not aware of any reliable evidence based data that elucidates whether patients are harmed more often by naturopathic physicians than allopathic physicians or any data that suggests that naturopathic physicians with prescriptive rights harm their patients more frequently than do allopathic physicians. DR. HORNBEIN summarized her comments by saying that there are good reasons to support HB 434 as it will provide a possibility of oversight of naturopathic medicine and will increase more primary care available to Alaskans. It will give naturopaths the ability to work to the full scope of their training, she added. Number 0070 JANICE SHEUFELT, M.D., Medical Director, SEARHC, testified on HB 434. She told the members that she is speaking in opposition to HB 434 only on behalf of herself. Her specific objection is the prescriptive authority that would be given to naturopaths, she said. Much of the discussion has been on collaborative agreements. Dr. Sheufelt explained that she believes the level of collaborative agreements that would ensure patient safety in Alaska would have to be for every single prescription for any drug. Without that level of detail of oversight there would be a serious risk of endangering patient safety. That is clearly not feasible. DR. SHEUFELT summarized her comments by saying that she does not believe naturopathic training covers a wide scope of treatments and she does not believe there is adequate time in four years of training to be adequately prepared to prescribe medications. Number 0023 JAMES THOMPSON, M.D., testified in opposition to HB 434. He told the members that he is an emergency room physician, has worked with many health aides, and has had over 25 collaborative agreements in the 29 years he has been here. Dr. Thompson said he is very concerned about the prescriptive authority that is provided for in this bill. Collaborative agreements work not by what is written on a page, but how the practitioner has learned how to apply it. The practitioner needs to know his/her limitations because if they do not it does not matter what is written on the paper, they can still make a mistake. He shared that he was on the Alaska State Medical Board for eight years and has seen instances where there have not be tight quality review. TAPE 04-42, SIDE A  DR. THOMPSON explained the process of recertification for a physician and noted that there are naturopaths that have practiced in Alaska for over 17 years. He pointed out if that individual had a pharmacology class 17 years ago there is no way that naturopath is trained to prescribe medicine today. There needs to be some kind of mechanism which provides for an internship with the collaborating physician to ensure that there is competency, he suggested. He said it really does not have anything to do with training, but really how it is applied. Dr. Thompson summarized that he believes it is premature to authorize prescriptive authority and should not be approved this year. Number 0160 CAROLYN BROWN, M.D., testified in opposition to HB 434. She told the committee that she is a practicing gynecologist. She came to Alaska in 1965 and has spent most of her career in Alaska with the exception of 12 years when she taught at the University of Vermont School of Medicine, she said. Dr. Brown shared that she has worked with health aides, physician's assistants, and advanced nurse practitioners, and that in her clinical experience she has dealt in a collaborative way with a number of naturopaths. Dr. Brown commented that most of the naturopaths she respects highly and believes that there is a place for naturopathy in the care of patients. She told the committee that while she collaborated with naturopaths across the years, she did not interfere with their herbs and botanicals and they did not interfere in allopathic medicine. Dr. Brown stated that she would never be comfortable collaborating with prescriptive authority for naturopaths because they do not have the same training that physicians have. Physicians spend a great deal of time doing intensive inpatient care, while naturopaths do not. Number 0254 DR. BROWN pointed to the section of the bill related to services excluded from coverage [page 8, lines 21 and 22] which states that naturopaths cannot provide medical services to persons in the custody of the Department of Corrections. She questioned if that is not discriminatory care. DR. BROWN commented that she sees giving naturopaths prescriptive authority as a slippery slope and urged the members not to approve this bill. Number 0376 TIMOTHY PETERSON, M.D., testified in opposition to HB 434, and answered questions from the members. He told the members that he does not want to be redundant, but keeps hearing the discussion about education. He shared that he has a good friend who is a naturopathic physician and they have shared notes of their training. The first two years of training was indistinguishable, he said. At that point there was a divergence, where he went into the hospital and started taking care of sick people, and his friend went to an outpatient setting. In comparing the training he said he assumes everyone went to college and then there is a naturopathic medical school or allopathic medical school, but those last two years of medical school and three years of residency is a period of time when medical doctors are dealing with drugs and patients on a daily basis. During that time medical doctors become aware of the many nuances of prescribing drugs. Once a doctor has worked in that environment a healthy respect is developed when bad things happen and it is necessary to respond quickly, he said. DR. PETERSON told the members that he has had collaborative agreements with midwives, health aides, and nurse practitioners. Dr. Peterson pointed out that it is most important to know the point where he/she is not sure. Representative Seaton's questions about collaborative agreements was excellent, he said. Any doctor that is willing can have a collaborative agreement with another person, but the difference is that in a P.A.'s training they work with the doctor. They learn to work side-by- side, as opposed to being an independent entity where there is a little bit of a philosophical disagreement about how things should be done, he commented. Number 0603 DR. PETERSON summarized that the latitude that is being asked for in this legislation is huge. Since Alaska does not have a medical school or research facilities, he does not believe this is the place to try to develop a program like this because there is no way to monitor what happens. Dr. Peterson said, however, that he believes in the future it will happen. DR. PETERSON explained for example, that there is a drug called Celebrex that is used on a daily basis that if used with a blood thinner can cause serious side effects. Dr. Malter has a copy of a "PDR" that is very thick, he commented. REPRESENTATIVE KAPSNER asked what a PDR is. DR. PETERSON said a PDR is a physician's desk reference. Number 0699 SCOTT LUPER, N.D., testified on HB 434 and answered questions from the committee. He explained that what is being asked for in HB 434 is not new. In 14 states that license naturopathic physicians 12 of them have some sort of prescriptive rights. Only one of the 12 states has a collaboration agreement; all the others have independent formularies or a broad list of drugs that can be prescribed, he added. On a personal note, he told the committee that he was able to write prescriptions both in Oregon and Arizona. He told the members that he only writes a prescription once every two weeks because he tends to not use drugs whenever possible. Number 0759 DR. LUPER shared that in Oregon and Arizona, where naturopaths have the broadest prescriptive rights the safety record in those states is very good. The mark of safety in this case is the number of disciplinary actions that have been taken against doctors. That includes letters of reprimand all the way up to suspended licenses. The rate in Arizona is about half of that for N.D.s as it is for M.D.s, he stated. For M.D.s it is about one percent and for N.D.s it is about .5 percent. In Oregon the rate is better, the rate for M.D.s is about .5 percent and for N.D.s .3 percent. Dr. Luper shared that the rate of complaints nationwide is about one-third of a percent. He emphasized that N.D.s have been using prescription medications for years safely. The reason why prescriptions are being used safely is that naturopaths are well trained and it is a reasonable levelheaded profession. People who become naturopathic doctors are high quality people with good strong backgrounds, he said. DR. LUPER shared his own background. He said that he got a four-year degree from Portland State University and graduated with honors in history. He then taught school for two years, after which he went to naturopathic school. Dr. Luper commented that he could have gone to medical school, but resonated with the approach of naturopathic medical school. He went on to say that he graduated from naturopathic medical school with honors in research. The area of research that he worked on was hypothyroidism. He told the members that he knows a lot about thyroid disease. In the state of Alaska when someone comes to him with thyroid disease, he can diagnose it, but cannot prescribe medication for it. He shared that it is frustrating for his patients to have to go to another doctor who will run the test and say, "oh yes, you do have thyroid disease." Dr. Luper clarified that it is not that he wants to do everything for everyone, it is that he wants to give the best possible care to his patients. He said he is here testifying before the committee because he is frustrated that he has one hand tied behind his back. Dr. Luper told the members that he doesn't know everything, but does know his limitations. With the collaborative agreement, which provides more safety than any other state with the exception of California, the patients are well served. DR. LUPER shared that for three years he taught at the Southwest College of Naturopathic Medicine where he was chairman of diagnostics. There were two M.D.s and one D.O. on staff working with them. There were two M.D.s and one D.O. that presented information at a recent naturopathic conference in Oregon. It was mentioned earlier that one naturopath, Dr. Dan Labriola, is working with oncologists in Washington state. The quality of people and the science naturopaths bring can help to solve problems, he said. Dr. Luper emphasize that he wants to provide the best quality of care that he can to his patients and that is the reason why he is asking to write prescriptions in collaboration with medical doctors. REPRESENTATIVE KAPSNER asked Dr. Luper if he could collaborate on every single prescription. DR. LUPER replied yes, but it would slow him down if he had to call every time he wanted to do a prescription. It is possible he acknowledged. REPRESENTATIVE KAPSNER commented that he said earlier that he does not like to prescribe medication and only prescribed infrequently. The committee heard testimony that said ultimately that would be the best-case scenario for safety purposes. DR. LUPER replied that he believes it would be more appropriate to create protocols. For example, if someone tests low in his/her thyroid, then you prescribe thyroid medication. If someone has a bladder infection then this is the appropriate type of antibiotic to use. He added that of course a culture and sensitivity test would be done which would indicate the appropriate antibiotic to use. With protocols in place Dr. Luper said he believes it would be redundant and unnecessary to run every prescription through an M.D. That is not to say that if he believes he is outside of his area of expertise, then he would call someone on the phone or refer the patient to another doctor. Dr. Luper stated that he is trained as a primary care physician and he knows his limitations. Number 1052 REPRESENTATIVE KAPSNER asked Dr. Luper if he believes it is appropriate to limit what can be prescribed or does he believe naturopaths should be able to prescribe everything. DR. LUPER responded that he believes it is appropriate to limit the scope of what is prescribed. There should be a rational system that takes into account a physician's area of expertise or focus of their practice. He explained that he believes the best system would be one in which the naturopathic physician and the collaborating physician sit down and create a list of medications that is appropriate for that particular practice. It is important for the naturopathic physician to make a case about wanting to use a particular kind of medication. Number 1097 REPRESENTATIVE KAPSNER asked who would do the oversight on that kind of list. It sounds like an administrative nightmare trying to determine which naturopath can prescribe which medication, she commented. DR. LUPER suggested that the collaborative agreements be modeled after physician's assistants agreements. He added that naturopaths have much more education that physician's assistants and nurse practitioners and have asked for less prescriptive authority than any of the other profession. Dr. Luper shared that the way he envisions it, he will send a list to the pharmacy on what drugs he can prescribe, and then will write prescriptions on rare occasions as he did in Arizona. REPRESENTATIVE KAPSNER commented that Dr. John Troxel [Member, Alaska State Medical Board] said that he would be most comfortable if this legislation had more time to go through the system. She explained that one of the things that concerns her as a public policy issue is that this bill was only recently introduced and it is difficult to push legislation like this through in the final days of the session. Representative Kapsner acknowledged that a lot of energy has gone into the legislation, but asked how Dr. Luper would feel if it did not go through this year. She suggested that it is worthy of seeing it go through next session. Number 1199 DR. LUPER replied that he would be disappointed. He said his patients would also be disappointed because it would require them to go to another doctor to get an anti-biotic or estrogen. He said he realizes it is a process, and the original bill requested prescription rights and then as the bill evolved more and more was negotiated away. Dr. Luper commented that it is now down to the thing we care about the most, the ability to provide the best possible care for our patients. He told the members that if he looses the ability to prescribe some medications, then he looses the ability to help people in the best way he knows how. Number 1244 REPRESENTATIVE CISSNA shared that she has been through cancer treatment this year. She said when she looks at the profession of naturopathy she thinks of prevention; the integration of ancient knowledge, and the way to keep people well. Representative Cissna stated that when she thinks about disease she wants the latest knowledge. She said she thinks the health system integration is still in its infancy; there is a lot to learn; and it is okay if this process goes slower. Number 1389 DR. LUPER responded that his experience with patients is that what works best is for him to pay attention to them, and to use his knowledge and experience to understand the patient's particular problems. As a naturopathic physician he focuses on the basic foundations of health, diet, circulation or exercise, sleep, and purpose in life. Dr. Luper said it is his abilities to observe and understand, run lab tests, and do physical exams, which help him to know patients and that helps him to find the obstacles to achieving health on their own. Everyone has the capacity to be healthy, he said, it is his job to find what is in the way. Occasionally people need a crutch. For example, if a person twists their ankle, he/she may need a crutch for a while. A naturopath's job at that point is to find out what can be done with that ankle to speed up the healing so the patient can throw the crutch away. Medications are a crutch to used on rare occasions to assist someone to manage the symptoms. Dr. Luper shared that it is in that way that he wishes to use prescriptions. It is an aide to buy time while working to find out what the real problem is and solve the problem. He said if it is necessary to spend time to educate everyone then he accepts that. Dr. Luper said he believes the time is now, the constraints in this bill ensure Alaskans are quite safe, and patients are going to get better care. This bill is quite appropriate today, he stated. Number 1510 JASON HARMON, N.D., Alaska Association of Naturopaths, testified in support of HB 434 and answered questions from the members. He told the members that he is a fourth generation Alaskan, grew up right up the street from the Capitol, and has two beautiful daughters. Dr. Harmon said he understands the perspective of his medical colleagues who are concerned for the welfare of Alaskans. He commented that there has been a lot of testimony against this bill, and many reasons to vote against this bill have been put forth. He asked the members to understand that for example, his education included an undergraduate degree, five years of medical school at Bastyr University in Washington with a degree in biochemistry. He told the members that he considers himself a scientist, interested in studies, and he does not prescribe natural remedies that do not have science based substances. He does not do iridology or homeopathy. There are many times when he has to require medication for patients. Many times it is not just a case where the patient must be referred to another doctor and it costs them more money, it can be a life-threatening situation. DR. HARMON commented that he has heard some testimony that says naturopaths training is not up to par. Much of what has been presented here today is actually incorrect, he said. He told the committee that naturopaths are well-trained physicians. He commented that the term "physician" cannot be used in this state, but that is what naturopathic doctors are, he stated. Number 1628 DR. HARMON responded to Representative Cissna's question about the urgency in pushing this forward now. Some medical doctors who testified acknowledged that there is future potential for collaboration in these areas, he said. Dr. Harmon said that he believes this bill will encourage collaboration. The medical community does not have to move. It is a 100-year-old establishment. Naturopaths have things to offer the medical community through collaboration, and support. What we offer can help their patients. Dr. Harmon told the members that he has a practice in Anchorage and works with many M.D.s as a referral point. He said these colleagues work as a reference point for questions he might have and he works as a reference point for them. This law not only protects Alaskans, but also offers Alaskans an opportunity for health care that is a very high standard of medicine. DR. HARMON commented that there may be a perception that this is being rushed through, but he suggested that it is not rushed. For 18 years naturopaths have practiced in Alaska. Number 1697 DR. HARMON told the members that he works collaboratively with oncologists in Anchorage. In response to an earlier comment that naturopaths have given Laetrile to their patients, he stated that to his knowledge no naturopath has ever prescribed Laetrile in this state. However, it has been prescribed by medical doctors. He said he has no intention of using a drug that is in the realm of an oncologists. He said his role is to support those patients in any way he can. DR. HARMON shared one point that had not been mentioned about naturopaths' training. He told the members that naturopaths have externships of 1,000 hours. Dr. Harmon urged the committee to support this bill. It will bring the medical community together through the collaborative provision, he emphasized. Number 1803 REPRESENTATIVE GATTO commented that he is sure that Dr. Harmon has heard the axiom "do no harm.". He commented that Dr. Harmon said that patients would be unsafe if the bill does not pass. Representative Gatto stated that he does not believe that is true. At another hearing Dr. Harmon referred to himself as a naturopathic physician and he called him on that at the time. That is a violation of a statute. Representative Gatto told the committee that these issues concern him because he gets the impression that Dr. Harmon wants something and wants it now. Representative Gatto said he does not believe that a four-hour conversation with naturopathic doctors and a 30-minute conversation with medical doctors that a case has been made that he could support. In the example of a patient with pneumonia it seems it would be easy to send the patient to the emergency room or a medical doctor. If naturopaths are only writing a prescriptions once in two weeks this is not an impediment to their ability to practice medicine, he said. DR. HARMON responded that he does not recall saying that patients would be "unsafe" and if he did, he misspoke. He posed a hypothetical example that it could be unsafe for a patient in a rural setting that had pneumonia, and he had the ability to prescribe a drug for that patient, but was unable to do so, that would be unsafe for that patient. Dr. Harmon pointed out that it depends on the setting. He acknowledge that he has the luxury in Anchorage to do exactly what Representative Gatto suggests which is to send patients to the emergency room. In fact, that is exactly what he currently does. There are cases in rural Alaska where that is not an option, he commented. Dr. Harmon said that he does not see himself as a "cowboy." The nature of naturopaths' medicine is to first do no harm, but also to choose the least invasive therapy. He emphasized that if he has the option of using something that is noninvasive he would use that first. Number 1986 ALEX MALTER, M.D., President, Alaska State Medical Association, testified on HB 434, and answered questions from the members. He commented that he has already testified on HB 434 and does not want to reiterate that testimony. He shared that the medical doctors do not want to be disrespectful to the naturopaths, most respect them very much, and think that they do a very good job in their scope of practice. The concern is centered on the belief that the proposed expansion of the scope of practice by naturopaths into a sophisticated area is not merited because M.D.s do not believe naturopaths have adequate training. DR. MALTER shared that he was on faculty at the School of Public Health at the University of Washington before he came to Alaska. He added that he has an M.Ph. as well as an M.D. At one point he brought in the president of Bastyr University to give two or three lectures to a course he was teaching to second year medical students so there could be a clearer idea in how medical doctors and naturopaths could interact. He said he believes that most M.D.s are comfortable with naturopaths. Infact, he said he felt comfortable enough to bring them into the class to help raise awareness. Dr. Malter explained that the medical community is still uncomfortable with naturopaths broadening their scope of practice. He said he heard that there was some discussion about limiting prescriptive ability to simply allow anti-biotics and hormones. Dr. Malter stated that he would also be opposed to that. Even though it may seem simplistic to prescribe anti-biotics it really can be a complicated decision in many cases. DR. MALTER referred to Dr. Luper's statement about prescribing anti-biotics for a urinary tract infection and that culture and sensitivity [tests] should be done, and explained that current guidelines from the American College of Physicians say no culture and sensitivity tests for folks who have urinary tract infections should be done. He said he does not mean to imply that it is criminal to do them after prescribing the anti- biotic, his only point in mentioning this is that in general M.D.s do not do culture and sensitivity [tests] to further define the type of infection it is. He shared another example of a misstatement and said the important thing to note is that M.D.s' approach to medicine is based on science. DR. MALTER commented on Dr. Harmon's statement that he went to five years of medical school at Bastyr University. The University of Washington is a medical school; Oregon Health Sciences University, where he went to college, is a medical school; the University of Colorado, Health Sciences Center, where he did his internship and residency, is a medical school, Bastyr University is a naturopathic school, Dr. Malter stated. He cautioned that it is slippery slope when referring to Bastyr University as a medical school. Number 2124 REPRESENTATIVE GATTO asked in the case of a patient who came to the office and was diagnosed with hypothyroidism, would he simply prescribe medication, or try to determine how that condition came about. Would his approach be different than that of a naturopath, he asked. DR. MALTER responded that most of the well-trained naturopaths would order similar tests that he would order, and ultimately make the same decisions that he would make. He explained that some of the decisions are not that complex. However, he said Dr. Peterson alluded to something important to note in his testimony, and that is if a doctor has not seen some of the disasters that can happen when prescribing incorrectly, as a M.D. would see during residency, then it is possible to be a little cavalier in the use of medications. Residency training helps M.D.s be better physicians, he emphasized. Number 2170 REPRESENTATIVE SEATON referred to materials that Dr. Malter gave to the committee on training received in a variety of medical schools in which there was poor training of naturopaths. He asked if Dr. Malter wants to correct any of his earlier statements. DR. MALTER commented that Representative Seaton is referring to his April 27th testimony, in which Representative Seaton believes he misrepresented naturopath education and training. He admitted that he is not an expert in state law. REPRESENTATIVE SEATON interrupted Dr. Malter to say that he wants it on the record that the information Dr. Malter provided to the committee at the April 27th meeting was on naturopathic schools that are not accredited. In order to be licensed in Alaska a person would have to graduate from an accredited naturopathic school, Representative Seaton emphasized. Number 2180 DR. MALTER agreed that is a fair point. Number 2229 REPRESENTATIVE GATTO moved Conceptual Amendment 1. REPRESENTATIVE SEATON objected. REPRESENTATIVE GATTO explained that Conceptual Amendment 1 would remove sections of the bill dealing with prescriptive authority. REPRESENTATIVE SEATON told the members that he believes there is good language in HB 434 that provides for collaborative agreements in prescribing drugs. The bill sets forth that an M.D. would have to put in writing a formulary, procedures, the amount of supervision, and reviews that would be part of the collaborative agreement. Representative Seaton said that what he thinks the members are dealing with is fear of bad doctors. TAPE 04-43, SIDE A    [Due to technical difficulty recording was not continued on tape 42-B.] Number 0056 REPRESENTATIVE KAPSNER disagreed with Representative Seaton. She said what she heard is the concern about collaboration and the nature of differences between the two professions. One has inpatient treatment, the other outpatient treatment. The other difference mentioned is that after two years of medical school the training is very different. Representative Kapsner added that she did not hear any concern about board certified physicians working in Alaska. Representative Kapsner clarified that her comments are not concerning the amendment, but rather the previous speaker's statements. Number 0130 REPRESENTATIVE WOLF shared that his wife and children are treated by a naturopath. Dr. Alan Kessler, a surgeon in Beverly Hills, California, told him that medical doctors are like anyone else, very competitive. He commented that the medical world is changing and it is difficult for anyone to accept change. Representative Wolf said the naturopathic world is new and it is important to keep an open mind. He stated that he opposes the conceptual amendment. Number 0320 REPRESENTATIVE SEATON clarified that there is nothing in this bill that forces any physician to collaborate. He emphasized that the person who has control is the collaborating physician. There appears to be a fear that there will be many prescriptions written without any supervision; however, that cannot be the case since the supervision is outlined in writing in a collaborative agreement with the M.D. Representative Seaton reiterated that he does not understand how anyone could believe that there will be prescriptions written without oversight. REPRESENTATIVE GATTO replied that if he were a naturopath he would shop for the best physician to match his intentions. He said that his intentions would be to get as much prescriptive drug rights as possible with the least amount of opposition or interference. Representative Gatto commented that if a physician were assigned to a naturopath that would be a different story. This bill makes no attempt to arrange for a board of physicians to assign naturopaths and physicians. It is a free market. In fact, all naturopaths could collaborate with a single physician under this bill. CHAIR WILSON clarified that the bill provides for a limit of six collaborative agreements. REPRESENTATIVE GATTO commented that the members can see how it would be possible to defeat the intent of the bill. Number 0472 REPRESENTATIVE SEATON responded that the entire argument that is being made is based upon the idea that naturopaths are going to want prescribe many different drugs. Naturopaths' entire focus and training in medicine is based upon whole body medicine in the least invasive way. This argument is in direct opposition to their discipline, he pointed out. REPRESENTATIVE CISSNA told the members that she believes this amendment is a good idea. The University of Washington and the Southcentral Foundation are both currently working on this very issue. She said she believes it is important to give it time and do it right. The amendment would allow for that, she added. Number 0640 REPRESENTATIVE COGHILL pointed out that this is a contract. He said he believes the collaborative agreement on prescriptive drugs should stay in the bill because those who have the most experience are the ones who will be driving the issue. Number 0785 A roll call vote was taken. Representatives Gatto, Cissna, and Kapsner voted in favor of Conceptual Amendment 1. Representatives Wolf, Coghill, Seaton, and Wilson voted against it. Therefore, Conceptual Amendment 1 failed to be adopted by a vote of 3-4. Number 0800 REPRESENTATIVE KAPSNER moved Conceptual Amendment 2 which would insert language that would require that collaboration be done on every single prescription. REPRESENTATIVE COGHILL objected. REPRESENTATIVE GATTO commented that if this is the initial stage in development of collaborative agreements and there is no willingness to go slow, then he said he believes this amendment would be important to ensure no harm is done. This legislation is a major change in authority, he stated. REPRESENTATIVE SEATON pointed out that the collaborative agreement as it is set out is to develop a formulary, procedures, and supervision. This amendment basically says there will be no formulary, but that every prescription must be called in to the medical doctor even if it is the same circumstance and the same prescription that was called in three days earlier, he summarized. Representative Seaton said he does not see this benefiting the collaborative agreement process. REPRESENTATIVE COGHILL told the members that one of the reasons he felt comfortable having the collaborative agreement in the bill is that it forces the issue of having a patient protocol. It also establishes a formulary in the arena that naturopath and medical doctor will be working on collaboratively. He said that if there is going to be an interface between two disciplines of medicine then there must be agreement on the protocol between them; not the legislature. Number 0928 REPRESENTATIVE WOLF said that this amendment would actually define the contract. He stated that he is not comfortable with that. REPRESENTATIVE KAPSNER commented that the members are thinking about a lot of issues right now. She pointed out that the chair is as close to a doctor as anyone on the committee, and the Vice Chair is the next closest to a doctor. She told the members that she is not comfortable giving prescriptive authority to naturopaths since she has no background in medicine and has never even been to a medical board meeting. The only medical expertise she has is that she's been to a doctor, she said. Representative Kapsner told the members that when she first talked with naturopaths she did not understand the issue at all. She shared that she believes it would be an abdication of her duty by allowing individuals who do not have the same level of medical expertise and pharmacology training to prescribe medication. REPRESENTATIVE KAPSNER said that perhaps she should amend Conceptual Amendment 2 to say that naturopaths must collaborate on every medication for a year. REPRESENTATIVE SEATON pointed out that this is defining away the authority of the medical doctor to develop a formulary and procedures. What this amendment says is that the legislature does not trust the medical doctor and naturopath to come together and collaborate on these points. He summarized his comments by saying he opposes the amendment. REPRESENTATIVE KAPSNER made a motion to amend Conceptual Amendment 2 to read as follows: ...to collaborate for the first 10 prescriptions, with monthly medical review of all prescriptions there after. Number 1136 REPRESENTATIVE COGHILL objected. He said he wants to review the amendment after it is written up. CHAIR WILSON replied that she believes it can be accomplished with a conceptual amendment. Chair Wilson restated Conceptual Amendment 2 which would say that naturopaths would have to talk with the doctor for the first 10 prescriptions and then have a monthly review there after. A roll call vote was taken. Representatives Cissna, Kapsner, Gatto, and Wilson voted in favor of Conceptual Amendment 2. Representatives Wolf, Coghill, and Seaton voted against it. Therefore, Conceptual Amendment 2 was adopted by a vote of 4-3. Number 1236 REPRESENTATIVE GATTO pointed out that there are seven members sitting on the committee making state policy on medical care, and none of the members are [medical doctors]. He pointed out that one member returned to the committee meeting who was out of the room through most of the debate and the entire outcome of a vote was changed. He said he is appalled by what has happened in the last three and a half hours with respect to this policy decision. Representative Gatto emphasized that this is a horrible way to determine public policy. REPRESENTATIVE KAPSNER commented that no insult is intended to the member. REPRESENTATIVE COGHILL said he is insulted and will at least respond to what has been said. He acknowledged that it is true that the members are not experts, this is a citizen legislature. That is true throughout this room, halls, and building he told Representative Gatto. If the members are to be experts in every field that comes before us in this body then he suggested that Representative Gatto quit and everyone else along side him should quit as well. Legislators are here on the citizen behest to look at the principles that drive public policy. Representative Coghill rejected the notion that members must be experts in every field in order to make policy calls. It is a benefit when someone is an expert, but many times experts come before us in testimony that have an agenda that it not principally driven. That is true whether it is childcare, speeding, or judiciary issues. He commented that he has been in three different committees with the same accusation and he stated he rejects it. Decisions are made on the floor when there are several bills per day, and the members are not experts on those issues, but are making those policy calls, Representative Coghill pointed out. REPRESENTATIVE COGHILL suggested that it is a good idea to allow collaborative agreements by letting those involved in different areas of medical care work together. By amending the bill there is now a bigger burden on the doctors, he pointed out. Without this amendment the doctors could have set up a protocol that would have been more easily and flexibly administered. With the passage of this amendment the committee has told the doctors what to do based upon the committee's vote. Representative Coghill summarized that when he comes to the committee he does not do it with the idea that he believes he is an expert in all areas. Number 1384 CHAIR WILSON agreed that when the people vote for their legislators it is done with the knowledge that the representatives are not experts, just everyday people trying to do their best. REPRESENTATIVE CISSNA said it is important to note that while the representatives are human we need to seek to do better. She commented that she would like to see this kind of conversation take place at a time when it is not the closing days of the legislature. The members are all dealing with so many things it is easy to get frustrated, but it is also important to spend time on issues this important, Representative Cissna stated. Number 1424 REPRESENTATIVE COGHILL responded that he has seen this bill in various versions not only this session, but also previous sessions. The policy call has been discussed before, he emphasized. CHAIR WILSON said for the record that it is her wish that the two groups, medical doctors and naturopaths, get together and discuss these issues because there is a place in our society for both. Work together to build the relationship so the trust is there, she urged. It is very frustrating for the committee to sit here listening to both sides, not knowing whom to believe. She pointed out that in the not too distant future there will be a shortage of doctors. By the year 2010 Alaska will be short 4,000 nurses. That being the case, the same thing will be happening with doctors. Chair Wilson suggested the president of the Alaska Medical Association take this message back and begin the process. She said a first good step would be to place a naturopath on the board. Number 1567 REPRESENTATIVE SEATON moved to report CSHB 434(HES), 23- LS1574\W, Mischel, 5/4/04, out of committee with individual recommendations and the accompanying fiscal notes. CHAIR WILSON objected. She commented that there was discussion about limiting prescriptive authority to anti-biotics and hormones. Does anyone wish to offer an amendment. There being no response, she order a roll call vote. A roll call vote was taken. Representatives Wolf, Coghill, and Seaton voted in favor of CSHB 434(HES), version W. Representatives Kapsner, Gatto, Cissna, and Wilson voted against it. Therefore, CSHB 434(HES) failed to be reported out of the House Health, Education and Social Services Standing Committee by a vote of 3-4. CHAIR WILSON urged the naturopaths not to give up. She reiterated her wish that naturopaths and medical doctors work together.