HB 91-NATUROPATHS: LICENSING; PRACTICE  3:26:03 PM CO-CHAIR WOOL announced that the first order of business would be HOUSE BILL NO. 91, "An Act relating to the practice of naturopathy; relating to the licensure of naturopaths; relating to the Department of Commerce, Community, and Economic Development; and providing for an effective date." 3:26:20 PM CO-CHAIR WOOL opened public testimony. 3:27:09 PM ROSS TANNER, Alaska State Medical Association, informed the committee that he is an internal medical physician in Anchorage and has practiced for the last 30 years. He recounted a patient with Type 1 diabetes and liver failure who was instructed to discontinue all medications, including insulin, by a naturopathic doctor (ND), which resulted in a prolonged hospitalization and near death. He opined that NDs show a lack of clinical experience that put patients in harm in Alaska. He continued by saying that Naturopaths tend to prescribe numerous supplements that lack "therapeutic efficacy and any kind of data." He concluded by stating that a lack of residency, lack of insurance, personal experience, and no improvement to access of care are his primary [objections]. 3:29:50 PM REPRESENTATIVE HANNAN asked how Mr. Tanner's comments relate to the extended scope of practice that the bill proposes. MR. TANNER said it's one example that illustrates lack of competence due to lack of clinical training, knowledge and expertise. He added that "even non-medical people would know not to discontinue medication." REPRESENTATIVE HANNAN asked if Mr. Tanner's objection is to NDs practicing medicine period, not just this bill's proposal to give them a scope of practice that includes prescription and minor surgery. MR. TANNER offered his belief that NDs should stay in their scope of practice, adding that they're trained to be complementary to physicians. He continued by saying that less than 5 percent of naturopaths do residencies and that to call NDs doctors is misleading to patients and harmful to Alaska's communities. 3:33:57 PM MELINDA RATHKOPF, MD, Alaska State Medical Association, informed the committee that she is a board-certified allergist immunologist who has practiced in Alaska for 13 years. She shared her educational background, which included 4 years of medical school, 3 years of a pediatric residency training, and 2 years of allergy and immunology fellowship. She discussed her experience with patients who received misinterpreted allergy testing from naturopaths. She explained her opposition to the bill, saying that increasing ND's scope of practice would increase the number of patients that seek their care and think they are equivalent to MDs. 3:36:00 PM LAURIE MONTANO, Alaska State Medical Association, shared several experiences with patients who had previously been mistreated by NDs, adding that they were not backed by science. She expressed major concern and strongly opposes HB 91. 3:37:49 PM STEVE SIVILS, Alaska State Medical Association, stated that he is a pediatric anesthesiologist in Anchorage and expressed his opposition to the bill, especially including surgery in the increased scope of practice. He offered his understanding that NDs don't receive any formal surgical training which would put Alaskans at risk. 3:39:49 PM IRINA GRIMBERG, Alaska State Medical Board, stated her opposition to HB 91. She opined that it is potentially dangerous when naturopaths act as a legitimate MD. year after year, she said, naturopaths are pushing measures for prescriptive authority. She offered her belief that they should be an alternative option to conventional medicine. 3:44:14 PM TONYA CAYLOR, Alaska State Medical Board, informed that committee that she is opposed to HB 91 and credited her many encounters with poor judgement made by naturopathic providers. She gave a brief summary of two such encounters. She offered her belief that naturopaths lack clinical knowledge in pathophysiology and clinical judgement that is needed to practice medicine. She said they should not be granted the ability to prescribe medication. 3:47:31 PM MARY ANN FOLAND, Alaska State Medical Board, voiced her opposition to HB 91. She alleged that the state medical board also opposes the bill and considers these changes "the practice of allopathic medicine." She stated that physicians require 12,000-15,000 more hours of training than NDs and shared two stories of patients who were mistreated by naturopaths. She added that all the examples being shared today reflect the lack of education in pharmacology. She continued by saying that naturopaths don't need to have prescriptive and surgical privileges and instead, can continue to practice within the definition of naturopathy. CO-CHAIR LEDOUX asked if, theoretically, a medical school graduate would be licensed to perform brain surgery. MS. FOLAND answered yes. She offered her belief that she possesses a medical surgical license, which would theoretically allow her to do that; however, she said that her credentials don't allow her to [perform brain surgery] and if she were to practice outside the scope of her training she would have to answer to the state medical board. 3:53:17 PM CO-CHAIR WOOL pointed out that nurse practitioners (NPs) have prescriptive powers and questioned how Ms. Foland justifies that. MS. FOLAND offered her understanding that NPs and physician assistants' training is allopathic, adding that naturopathic training is completely different content. 3:54:41 PM ALEXANDER VON HAFFTEN, Alaska State Medical Board, said he opposes HB 91. Nonetheless, he noted that he supports the values of naturopathy and the wholistic approach to preventing disease and optimizing wellness. he further noted that he has discussed naturopathy during lessons as a teacher in the WHAMI medical program and has referred patients to NDs when naturopathy offers a viable or better alternative to allopathic or osteopathic medicine. However, he said, "the proposed changes eliminate the prerequisites for a person to be considered qualified as a position and have little adherence to the core values of naturopathy." He questioned whether NDs are qualified to prescribe and offered his belief that HB 91 would change the standard for disclosure, change the standard of care, and communicate that "truth in advertising is irrelevant." He concluded by reiterating that, while he values naturopathy as an alternative to allopathic medicine, physicians possess expertise in judgement in accordance with minimum nationally established requirements for education, training, and skill-competencies. 4:02:04 PM REPRESENTATIVE FIELDS asked if Mr. Von Hafften would support allowing "some degree" of prescriptive authority for naturopaths who went through a residency equivalent to that of an MD. MR. VON HAFFTEN said no, "the devil is in the details." He added that a scope of practice already exists in statute and he sees no reason to change that. REPRESENTATIVE FIELDS asked if there are any types of medicine that would be appropriate for naturopaths to have prescriptive authority for. MR. VON HAFFTEN stated, "I'm regarding prescriptive responsibility." 4:04:17 PM PATRICK NOLAN, Alaska State Medical Board, informed the committee that he is a board certified endocrinologist and a member of the American Association of Clinical Endocrinologists, the American College of Endocrinology, and the International Endocrine Society; as well as a member of the American College of Physicians and a fellow with the American Association of Clinical Endocrinology. He also served as a former state Medical Board member for four years. He expressed his opposition to HB 91 "for many of the reasons that were already stated." He reflected on cases that, in his opinion, were misdiagnosed by NDs. 4:09:07 PM CAMERON O'CONNELL, ND, expressed her support for HB 91. She said she would not take up the committee's time by relating some of the patients she has treated that were under the care of Medical Doctors and were overprescribed medication and "had bad outcomes from medication they were given." Instead she addressed the ways in which a limited scope of practice influences her day-to-day care of patients. She concluded by asking the members to consider updating [indisc.] to a more modern scope, noting that naturopathic medicine has grown a lot as a profession and the legislation should reflect that. 4:11:57 PM CO-CHAIR WOOL asked if residency was a required part of her degree program in Portland, Oregon. MS. O'CONNELL said, currently, they don't have the funding and there aren't enough residencies for the amount that would be needed for every ND to go. She added that completing a residency is highly encouraged and competitive. CO-CHAIR WOOL asked if Ms. O'connell's residency was naturopathic, allopathic, or some combination of the two. MS. O'CONNELL replied that it was a combination of both. 4:13:24 PM DAVID SCHLEICH, MD, Alaska Association of Naturopathic Physicians, informed the committee that is the president of the National University of Natural Medicine, the oldest federally and regionally and state accredited university in the U.S. that prepares naturopathic physicians for clinical practice and careers. He shared his background and experience working for many different universities and colleges across the U.S. and Canada and expressed his support for HB 91. He noted that the professional preparation of NDs has been referenced erroneously and often. He said it translates into four years of fulltime study beyond a bachelor's degree. He states that his colleagues in the allopathic profession who have said that the content and learning objectives of naturopathy are different, are mistaken. He added that the clinical record of NDs is more substantial than their colleagues would suggest. He concluded by encouraging the members to endorse the current bill. CO-CHAIR WOOL said there has been reference to a philosophy or underlying statement behind naturopathy and asked Mr. Schleich to speak to that. DR. SCHLEICH replied that his University has recently published 12 volumes, 6,000 pages, on the history, philosophy, and derivation of naturopathic practice. He added that the underlying philosophies are not that different. 4:23:17 PM JOHN CULLEN, American Academy of Family Physicians, stated that he is the president of the American Academy for family Physicians and expressed his opposition to "the extent of this bill." He said he would like to see the data to that naturopaths are capable of prescribing medication safely. He opined that this bill will not solve the solution to rural healthcare problems and objected to the "naming of naturopaths as physicians." He encouraged members to vote no on this bill. 4:26:42 PM KRISTIN MITCHELL, American College of Physicians, offered her belief that the training for naturopaths is not equivalent to scientific medical training and should be complementary. She expressed concern about a lack of sufficient evidence showing that it is safe for patients to receive care from naturopaths in terms of prescribing pharmaceuticals and performing surgery, which in her opinion, they are not trained for. She said patients have a difficult time distinguishing between licensed practitioners and it is the state's role to protect the safety of patients. 4:30:45 PM The committee took a brief at-ease. 4:31:28 PM JOSEPH RETH expressed his opposition to HB 91, offering his belief that naturopaths don't have the training needed to prescribe medicine and perform minor surgeries effectively and safely. He addressed the concept of residency. He argued that physicians are required to complete a 3-year residency after 4 years of medical school, during which they are taught how to safely and effectively prescribe medicine along with performing surgical procedures. In contrast, he said, naturopaths have 4 years of schooling and no residency requirement. He mentioned the placebo affect and pointed out that it can account for more than 50 percent of positive outcomes. He said that he and his colleagues have had too many interactions with naturopaths where it was clear that they did not adequately and sufficiently understand the science of medicine and as a result have put patients health and their lives at risk. 4:35:39 PM REPRESENTATIVE REVAK sought clarification on the placebo effect. MR. RETH stated that it is very powerful and can occur up to 80 percent of the time. 4:36:35 PM CO-CHAIR WOOL pointed out that many naturopaths do clinical residency after medical school in states that grant prescriptive authority to NDs. He asked if some go get the proper training to prescribe drugs, given that they came from that background. MR. RETH replied that there are significantly more residencies available for naturopaths now than there were years ago. He described naturopathic residencies as "going to someone else's office and hanging out with them," adding that it wasn't consistent. He said one year of residency is not enough to learn how to safely prescribe medication. CO-CHAIR WOOL pointed out that NPs have prescriptive ability and do not complete the same amount of school as physicians. He asked how Mr. R justifies that. MR. RETH said that NPs are trained in allopathic medicine as opposed to "natural substances." 4:39:23 PM CO-CHAIR LEDOUX asked if both PAs and NPs work under a doctor. MR. RETH said he was unsure. He offered his understanding that PAs work under a "collaborative agreement" and, although oversight is present, they are free to do what they need to do. CO-CHAIR LEDOUX equated NDs to osteopaths, regarding their history, specifically their desire to be recognized as physicians. 4:42:37 PM REPRESENTATIVE FIELDS referenced previous comments about naturopathy being complementary to MDs as opposed to interchangeable and asked if that is true. MR. RETH opined that they are not interchangeable, adding that NDs and MDs have divergent approaches to the human body. He said he was surprised that naturopaths want prescriptive authority for medicine that isn't "natural." REPRESENTATIVE FIELDS asked if the two practices are complementary. MR. RETH opined that it comes back to the placebo affect; meaning that if an individual believes and trust in someone, he or she will get a lot of benefit from that person. He further stated that "going to a naturopath for some people is the way to go." However, he added that a patient with a serious problem will need the addition of allopathic medicine. REPRESENTATIVE FIELDS asked if there could be a sufficiently rigorous process of residency for naturopaths that would prepare them for prescriptive authority. MR. RETH acknowledged that a more limited or "restrictive" prescriptive ability could be considered, while reiterating his concern about granting NDs complete prescriptive authority. 4:46:30 PM REPRESENTATIVE FIELDS asked if the medical association has ever considered the idea of a more regular and regulated residency process for NDs. MR. RETH related that the medical associate has never discussed residency, as it is a newer concept for naturopaths. 4:47:40 PM REPRESENTATIVE HANNAN said many of the doctors who testified today spoke broadly in opposition to naturopaths rather than against the specifics of HB 91, which is prescriptive authority. She questioned whether the Alaska Medical Association is opposed to all naturopathic medicine or if their objection is just in response to the surgical and prescriptive authority that this bill addresses. MR. RETH affirmed that the AMA specifically opposes the prescriptive authority. He noted that they have no problem with NDs being licensed in Alaska. REPRESENTATIVE HANNAN pointed out that pharmacists don't complete a residency for the administration of drugs and more specifically vaccines. She asked if the Medical Association opposes that. MR. RETH countered with the assumption that pharmacists know how to administer drugs, adding that he was unsure if the AMA opposes that. He clarified that the AMA's opposition to Naturopath's prescriptive authority is not about the ability to prescribe vaccines, but that it would allow them to prescribe anything apart from scheduled controlled substances and chemotherapeutic agents. REPRESENTATIVE HANNAN asked if the Alaska Medical Association has a position on midwives and doulas and their treatment of patients. MR. RETH said he was unsure if the AMA has a formal policy on midwives. 4:51:10 PM The committee took a brief at-ease. 4:51:13 PM ANNETTE O'CONNELL, reflected on being diagnosed with celiac disease. She said she was misdiagnosed by MDs until finally going to an ND who retested her and figured out that she was allergic to gluten. She noted that she has been better ever since that diagnoses as long as she follows her NDs suggestions. She offered her belief that the American Medical Association is campaigning to discredit NDs and blamed MDs for the opioid epidemic. She concluded that Alaska needs both naturopathic and medical doctors and expressed hope that NDs will be given the right to exercise within their full scope of practice. 4:55:26 PM DANIEL YOUNG, ND, Center for Natural Medicine, expressed his support for HB 91 and, referencing the previous testifiers, indicated that MDs are not the experts on naturopathic medicine. He offered that NDs are not trying to be MDs, instead they are providing a different model of healthcare that is very affective and works for their patients. He said the fact that NDs still exist is testament to that. He stated that naturopathic medical and clinical training consists of more than 2 years of supervised care with patients. The goal, he said, is to provide effective care for patients and added that the state has recently taken away their ability to provide things with prescription labels, such as B12, B-Complex, and homeopathic medicine, which is all medicine they regularly use. He reiterated that the previous testifiers' comments are anecdotal, some of which, he said he has before which makes him question their validity. 4:58:38 PM WAYNE ADERHOLD, Board of Chiropractic examiners, stated that he fully supports HB 91 as a clear, concise and comprehensive statute that will give naturopaths the structure needed to practice to the full extent of the training level they choose within a scope of practice defined by the profession. He continued by praising his experience using naturopaths as his primary care doctor since 1993. He offered his belief that this committee has the duty to promote a free market that maximizes competition by properly trained professionals. He added that the tools used by professionals, including prescriptive authority, should be determined by the regulated profession itself, not the competing profession. He pointed out that he has had numerous instances in his treatment history where a prescriptive drug was considered a necessary part of a larger treatment plan, adding that he deserves the option of receiving the maximum level of treatment. He requested that the members pass HB 91 out of committee and increase healthcare competition in Alaska, adding that consumers deserve nothing less. 5:01:16 PM STEVE FRANK noted that he has been seeing a naturopath for many years as a primary healthcare provider and received excellent care. He pointed out that his ND has referred him to MDs, such as an internist and cardiologist, when appropriate. He added that the opposition to this bill seems to be characterized by anecdotal fearmongering and implored members to stick to the facts and make fact-based decision. He continued by saying he would like to see this bill moved out of committee. 5:04:34 PM The committee took a brief at-ease. CO-CHAIR WOOL closed public testimony on HB 91. [HB 91 was held over.] 5:05:10 PM