SENATE BILL NO. 306 "An Act relating to the practice of naturopathic medicine; and providing for an effective date." This was the second hearing for this bill in the Senate Finance Committee. Co-Chair Wilken explained that this bill, which is sponsored by Senator Ralph Seekins, would enact an Act relating to the practice of naturopathic medicine. Initially, consideration was given to implementing a Board to oversee naturopathic medicine; however, that is not now being considered. The Department of Community and Economic Development was asked to explain the Department's Division of Occupational Licensing flow chart, titled "Implementation of CSSB306(FIN)" [copy on file] that depicts how licensed Naturopathic Physicians would be monitored. RICK URION, Director, Division of Occupational Licensing, Department of Community and Economic Development, clarified that the Governor Frank Murkowski Administration has no position in regards to this legislation. Were the Legislature to adopt regulations in regards to Naturopathic medicine, the Department would implement supporting rules and regulations. However, the Department has been regulating this profession and numerous others without assistance from a Board, for approximately seventeen years and could continue to do so absent any new legislation. Co-Chair Wilken asked the current process through which a complaint against a Naturopath might be reviewed. Mr. Urion responded that the Department's investigative staff would address the complaint, and, were it deemed necessary, it might be forwarded to a hearing officer. A multitude of different processes, including such things as memorandums of agreement, have been established through which issues regarding each profession are addressed. Co-Chair Wilken asked whether the flow chart provided by the Department [copy on file] would depict the process involving naturopaths. Mr. Urion affirmed. Co-Chair Wilken asked that the flow chart be explained. Mr. Urion explained that currently when a complaint is filed, the Division's investigative staff who, based on a priority list that heavily ranks Life/Safety issues, would determine whether charges should be filed addresses it. Were that the case, a hearing officer would be assigned, a trial might ensue, and the hearing officer would render a decision including the level of punishment. This could include such things as license removal, suspension and fines. Were the defendant to reject the decision of the hearing officer, they have the right to appeal to a higher court. Mr. Urion shared that in situations in which there is a Board, the Board would have the authority to act on the complaint. Co-Chair Wilken asked whether the Department, in conjunction with Naturopaths, developed the chart. Mr. Urion concurred. Co-Chair Wilken asked whether the Division's investigators are trained professionals. Mr. Urion responded that while none of the Division's investigators are trained in any of the fields that they investigate, they are trained investigators. He noted however, that they do consult with the appropriate medical professional pertinent to each situation. He noted that the Medical Board recently adopted a procedure that specifies that complaints dealing with such things as sexual abuse, alcohol, or drug misuse be immediately forwarded to the Division's investigators. However, determinations regarding standards of care complaints are determined by the Board and then forwarded to the investigators, who could independently make a determination if they so chose. Co-Chair Wilken asked for confirmation that this is the current practice relating to Medical Board. Mr. Urion affirmed. Co-Chair Wilken opined therefore that a procedure akin to a triage occurs at the investigative level in that the investigator consults with a medical professional. The investigator would receive a complaint from a patient, and then the triage would occur in which it would be determined whether the complaint is serious enough to advance immediately to a hearing officer. Mr. Urion clarified that in serious cases, the state investigator would have the authority to make the determination. Complaints regarding standards of care might require an investigative review that might include a medical professional. Co-Chair Wilken understood that an investigator would be expected to consult with the appropriate medical professional. Mr. Urion agreed. He stated that this is the current procedure utilized when reviewing complaints against naturopaths. SENATOR RALPH SEEKINS, the bill's sponsor, noted that language on the bottom of the flow chart specifies that in the case of non- threatening public safety issue or a Standards of Care complaint, investigators could consult with the Qualified Trade Association of Naturopathic Physicians (NP/QTA), which would consist of volunteers from the field. Co-Chair Wilken asked whether this organization exists today or would be established by this legislation. Senator Seekins responded that while this organization does not currently exist, its establishment would be clearly defined in a forthcoming committee substitute. Mr. Urion declared that this would be an opportunity in which government and private enterprise could work together to regulate an industry. No professional entity would benefit from "condoning bad behavior" within its profession. Co-Chair Wilken summarized that the complaint process would be that a wronged patient would go to the State, It would then be directed to an investigator. The investigator could consult with the three- member NP/QTA panel. Senator Olson questioned "the wisdom" of allowing naturopaths to have their own board, as currently the process provides an investigator the ability to consult with professionals. In addition, he asked whether there could be the option of having naturopathic complaints heard by the eight-member Medical Board. Mr. Urion voiced concern to the appropriateness of having these complaints heard before the Medical Board due to the negative comments the medical field has made in regard to naturopaths. Continuing, he noted that at this point, the Division could monitor the Naturopathic profession without implementation of a Board. Senator Bunde countered that currently the Board of Medicine has oversight over a wide range of medical professions including Physician Assistants (PAs), Nurse Practitioners (NPs), Registered Nurses (RNs), Oseopathics, dentists, and paramedics. All these professions are included under the term "physician" and, since this bill would expand that term to include Naturopaths, it would be logical that they be included in those professions monitored by the Board. Senator Seekins responded that he would not object to the inclusion of a naturopath on the Medical Board, were it suggested. Inclusion of a naturopath on the Board would provide some insight to the Board regarding Standards of Care for the profession. However, due to the fact that naturopathic medicine presents competition, naturopaths "have a fear that there may be some objection "from the more recognized medical professions. Co-Chair Wilken recalled that, until a few years ago when they were granted voting rights, Physician Assistants were ex officio members of the Medical Board. Perhaps this might be an option with naturopaths. AT EASE 10:28 AM / 10:28 AM Senator Olson clarified earlier information regarding which professions the State Medical Boards oversees. While it does govern paramedics, physicians, and physician assistants, it does not have direct regulatory oversight in regards to dentists, nurses, and nurse practitioners. Senator Olson also noted that when he, a medical doctor, was on the State Medical Board, its seven-person membership consisted of five physicians and two lay people. He subsequently supported the representation of a PA on the Board due to their increasing numbers in the State. He noted that the number of naturopaths in the State is limited. Co-Chair Wilken noted that there are currently 27 Naturopaths in the State. Senator Seekins countered that any board that regulates a profession should have, as part of its membership, a representative of each profession in order to negate such things as "hostility" against that profession. Co-Chair Wilken asked for confirmation that PAs were, at one time, ex officio members of the Board. Senator Olson specified that PAs were diligent in attending every meeting even before they had representation on the Board. In that regard, once they were admitted to the Board, they became voting members. He agreed with Senator Seekins that representation at the Board level is important. Co-Chair Wilken pointed out that the definition of minor surgery is included in the bill in Section 13, subsection (6), page six, line 19 and reads as follows. (6) "minor surgery" (A) means the use of (i) operative, electrical, or other methods for surgical repair and care incidental to superficial lacerations and abrasions or superficial lesions, and the removal of foreign bodies located in superficial tissues; and (ii) antiseptics and local anesthetics in connection with methods authorized under (i) of this subparagraph; definition; (B) does not include use of general or spinal anesthetics, major surgery, surgery of the body cavities, or specialized surgery, such as plastic surgery, surgery involving the eyes, or surgery involving tendons, ligaments, nerves, or blood vessels. Co-Chair Wilken asked Senator Olson to address his concern regarding allowing naturopaths to conduct "further tests." Senator Olson voiced the understanding that one of the reasons that naturopaths are requesting prescriptive authority is because their position is that they have similar education and training levels to that of medical doctors. However, while many of the initial educational courses were the same, there was a "divergence later on" as the foundation of the naturopathic delivery system was one of being "basically drug free." Senator Olson voiced that, with the care of the patient in mind, there is concern that in the continuance of their care, limiting prescriptive treatment to medical doctors would be appropriate to the balance. He noted that there has been an abiding identification within the medical profession that medical doctors prescribe medication. In order to expand rather than restrict naturopath prescriptive authority, it could be suggested that naturopaths should be required to qualify for Part One, Two, and Three of the National Medical Board examination rather than being required to pass only Parts One and Two. Part Three is the section that tests prescriptive knowledge. Therefore, their ability to pass all three sections of the examination would indicate that their training was comparable to that of a medical doctor and would allow them to have prescriptive authority. Senator Seekins, being respectful of Senator Olson, clarified that rather than seeking to be recognized as medical doctors, naturopaths are seeking to have prescriptive rights that are less than a PA and NP. This was clarified in Amendment #1 which the Committee during its first hearing on the bill. That amendment inserted a new subsection into Section 11, subsection Sec. 08.45.120 on page five, line 16 that reads as follows. (4) after becoming registered with the federal Drug Enforcement Administration, prescribe only those controlled substances allowed under Schedules III, IV, and V. Senator Olson clarified that a PA could only practice medicine under a collaborative agreement and direct oversight by a medical doctor (MD). Were something to go wrong, the MD would also be held liable. Senator Bunde asked how an NP's training would differ from that of a PA in this regard. Senator Olson stated that while he is familiar with PA requirements and the associated prescriptive limitations, he is unfamiliar with the requirements for a NP. Senator Seekins shared that he is familiar with the NP requirements as his wife is a nurse and a close friend is a NP. SFC 04 # 63, Side B 10:40 AM Senator Seekins noted therefore, that NPs could prescribe all levels of prescriptive medications as they have a higher level of training than PAs. "It would be inconceivable" that any practitioner … would not seek assistance from other caregivers when encountering serious situations. Co-Chair Wilken noted that concerns have been raised due to the understanding that Naturopathic Doctors (ND) would not have medical malpractice insurance. He referred the Committee to Item #3 on page two of a letter [copy on file] dated February 24, 2004 from Dr. Scott Luper, ND that Co-Chair Wilken had received in response to comments in a letter [copy on file] dated February 9, 2004 that Co- Chair Wilken had received from Tom Wilson, PA-C. The comment and response, as written in Dr. Luper's letter are as follow. #3. The bill is too broad. Currently one could prescribe antibiotics to dangerous heart medications, to chemotherapy. Allopathic M.D. would most likely not prescribe medication outside of their specialty, as it would be considered outside of the "standard of care". If a bill were passed a formulary would be much more acceptable and safe. 3). Response: Mr. Wilson suggests that an ND might be tempted to prescribe outside of their training/education and that an MD "would most likely not" prescribe inappropriately. This is not realistic. A good "DOC" is a good "DOC". NDs will be liable for malpractice on par with MD's and under the auspices of the Div. of Occupational Licensing. DR. SCOTT LUPER, Naturopathic Doctor, testified via teleconference from Fairbanks and clarified that NDs are able to acquire malpractice insurance and that ND malpractice insurance is less costly that MD malpractice insurance due to the fact that the complaints against them are fewer. He stated that, while he pays $3,000 a year, the majority of his ND colleagues pay between $600 and $2,000 annually. Co-Chair Wilken surmised that NDs carry malpractice insurance in line with their standards of care. Dr. Luper affirmed. He noted that the standard ND medical malpractice coverage would provide one million dollars per occurrence and three million dollars total. Senator Bunde surmised that MDs pay higher medical malpractice insurance due to the fact that they write prescriptions and perform surgeries. Therefore, he opined that ND's rates might increase were this legislation adopted. Dr. Luper responded that this has been investigated and it has been determined that the rates would not increase. He further noted that the Alaskan ND rates are comparable to those being charged in states that provide NDs prescriptive and minor surgery authority. Dr. Luper disclosed that in order to address the question of safety, he had conducted a survey of states that license NDs. He had acquired the number of ND disciplinary actions in Arizona, Oregon, Hawaii and Connecticut. ND disciplinary actions including such things as license suspensions and other punishing actions are approximately half of the amount pertaining to allopathic or MD disciplinary actions. In Arizona, for instance, the disciplinary rate for MDs is about one percent of those licensed, and about half a percent for NDs. Nationwide the rate for NDs is .34 percent. No disciplinary action has occurred against NDs in Alaska during the seventeen years in which they have been licensed in the State. This is a reason why the rates are low and is a testament to the quality and care provided by the profession. He clarified that there are 39 licensed NDs in the State. BARRY CHRISTENSEN, Practicing Community Pharmacist and Legislative Chair, Alaska Pharmacists Association, testified via teleconference from an offnet site to voice concern on behalf of the Association's 200 plus members in regards to the prescriptive authority being proposed in the bill for NDs. He informed the Committee that while he heard reference to Amendment #1, he is unaware of its contents. Co-Chair Wilken informed the testifier that Amendment #1 removed the requirement regarding Prescriptive Schedules I and II and retained Schedules III, IV, and V in the authority being proposed for NDs. Mr. Christensen addressed the position that NDs education is "equivalent or nearly equivalent" to that of an MD because, similarly, they also have a four-year degree. "While this may be true in an academic sense, our membership has had little if any interaction with naturopaths during our professional training" but have had extensive training with PAs, NPs, and MDs "and have developed good working professional relationships with these professionals. This relationship is very important when working with patients and recognizing "problems with dosing, drug interactions and drug abuse." He questioned the fact that while the definition of naturopathy that is included in the bill does not include medicine, the bill would provide full prescriptive authority to NDs. He noted that most states that allow ND prescribing provide NDs with limited prescriptive authority. He stated that pharmacists would be more comfortable with this legislation were NDs required to work collaboratively with other licensed prescriptors. Lastly, he raised concern regarding the prescriptive authority of controlled substances, or narcotics, and stated that control of such substances should be closely guarded. Absent a presciptor-based narcotic tracking system, this issue would continue to be "the number one" concern of pharmacists. He assured that while there is no reason to believe that NDs would abuse this prescriptive authority, increasing their availability by expanding the number of prescriptors would provide another potential avenue for narcotic abusing patients. Mr. Christensen stated that while the amendment would limit ND prescriptive authority to Schedule III, IV, and V drugs, the majority of narcotic drugs are included in those categories. Therefore, the Membership would continue to voice concerns. Senator Olson asked, for clarification, the Association's position on Amendment #1. Mr. Christensen responded that a majority of the Membership would continue to have problems primarily due to the inclusion of Schedule III, which encompasses narcotic painkillers. He noted that since he was unaware of the amendment prior to this, the membership has not been conferred with in its regard. Senator Olson asked the percent of patients who might be receiving prescriptive relief from either Schedule II through V or III through V. Mr. Christensen responded that the majority of people who take pain relievers are utilizing Schedule III drugs, as it is the outpatient pain drug of choice. A written prescription is not required for Schedule III drugs whereas one is required for Class II drugs. Therefore, he estimated that approximately 70 percent of individuals who are taking painkillers are taking Schedule III drugs. Schedule IV drugs are anti-anxiety rather than painkiller types of drugs. Senator Bunde voiced that it would be an inconvenience were someone to seek naturopathic care and then discover that they would be required to go to another medical professional were a prescription drug required to treat, for instance, high blood pressure or an antibiotic such as penicillin. He asked what which schedule these types of prescriptions are included. Mr. Christensen responded that antibiotics are "not a scheduled narcotic" and therefore are not regulated by the Drug Enforcement Administration. They are instead classified as a prescription by the Food and Drug Administration (FDA) and would require a prescription. A narcotic-based pain reliever such as Tylenol #3 would be a Schedule III drug. Senator Olson clarified that the drugs included in "Schedules I through V are those that are directly related to the potential for abuse by either a patient or a patient prescriptor." An antibiotic would not fall in this category. Senator Seekins understood that as part of a pharmacist's training, they are taught how to recognize signs of abuse or mistakes. Mr. Christensen affirmed. Senator Seekins understood therefore that "even now" in the medical profession, abuse does occur. Mr. Christensen agreed. Co-Chair Wilken stated that the bill would be HELD in Committee in order to develop a committee substitute that would include Amendment #1 and clarify language regarding the voluntary review committee.