SB 107-NATUROPATHS  CHAIR DAVIS announced consideration of SB 107. 5:42:58 PM TOM OBERMEYER, Staff to Senator Davis, presented an overview of CSSB 107, Version \K, labeled 25-LS0702\K. This act related to naturopaths and naturopathic practice, establishing an Alaska Naturopathic Council, amending the duties of the Board of Pharmacy relating to naturopathic practice, and providing for an effective date. He explained that the CS before the committee was drafted after the committee hearing of February 13, because the committee chair concluded that changes were required in oversight, training and experience in order to expand naturopathic practice into areas that had formerly been reserved to MD's [Medical Doctors] and DO's [Doctors of Osteopathy]. Those areas included minor surgery, prescribing prescription drugs and ordering medical laboratory tests and imaging. Changes in the CS were as follows: 1) The Alaska Naturopathic Council was increased from 5 to 7 members including 3 naturopaths, 1 medical doctor, 1 pharmacist and 2 members of the public who have no direct financial interest in naturopathic practice or the health care industry. 2) Members of the Naturopathic Council would be appointed by the Governor. 3) Naturopaths would have to be in practice for 5 years before being allowed the expanded scope of practice in minor surgery, prescribing drugs and ordering medical laboratory tests. 4) Naturopaths who were licensed to prescribe drugs would have to take 15 hours of pharmacy education each year; those who would perform minor surgery must have received a minimum of 1200 clinical hours of training under the supervision of medical doctors, physician's assistants and [or] nurse practitioners. MR. OBERMEYER continued that the advisory council had no power to adopt regulations as a board under the Boards and Commissions; but it could advise the Department of Commerce, Community & Economic Development regarding regulation. He also noted that there was no attempt to recognize what other states had done, because he had spent a great deal of time looking at other states and found that each had a different way of dealing with this particular set of practices. CHAIR DAVIS asked Mr. Obermeyer to go back over the CS and point out each change from the original bill. MR. OBERMEYER recapped the changes. First, the council was increased from 5 to 7 members, to include 3 naturopaths, 1 medical doctor and 1 pharmacist appointed by their respective boards and recommended to the Governor for final appointment. Second, naturopaths would be required to practice for 5 years before being allowed the expanded scope of practice described. Third, prescribing naturopaths would have to take 15 contact hours of pharmacy education training each year after being pre- qualified as explained in the bill, with 60 hours of training and satisfaction of other specific requirements. Finally, they would have to complete clinical training under the supervision of medical doctors, physician's assistants or nurse practitioners in minor surgery and anesthetics. The effective date of the bill, as indicated in section 13, would be July 1, 2009. SENATOR THOMAS moved to adopt the proposed committee substitute CSSB 107, Version \k, as the working document of the committee. There being no objection, the motion carried. 5:51:05 PM SENATOR ELTON asked for clarification regarding the makeup of the council. He said the bill provided that "When appointing pharmacists and physicians … the governor may appoint a pharmacist from the list of names submitted by the Board of Pharmacy … and a physician from the list of names submitted by the State Medical Board," but there was no provision for the governor to request a list from the naturopaths. He wondered why the appointment of a doctor or pharmacist was different from the appointment of a naturopath. MR. OBERMEYER answered that the naturopaths did not have their own board at that time. SENATOR ELTON said that a quorum of the council was at least 4 members for the transaction of business; one of the most important chores of the naturopathic council was establishing and maintaining a list of prescription drugs and medical devices, but that could be done without a pharmacist present. He asked if that was correct. MR. OBERMEYER replied that he was probably correct, but doubted they would take action without the advice of the pharmacy board or the pharmacist who was responsible for it. He noted that even in Kansas they had 2 medical doctors on a formulary council and one on an advisory council under the medical board; so they were trying to keep those professionals totally involved in the naturopathic practice. He assumed they would involve the appropriate people to deal with any changes to the list of authorized drugs. CHAIR DAVIS added that the effective date on the bill gave them one year to work out those details and differences. That was why the effective date was moved from July 2008 to July 2009. 5:55:47 PM SENATOR ELTON directed Mr. Obermeyer to page 5, line 5. He said that what they had structurally was a council appointed by the governor. The council would have specific responsibilities that were delineated earlier in the bill; but the department [Department of Commerce, Community & Economic Development, Division of Corporations, Business and Professional Licensing] would set the fees. He questioned why the department, rather than the council, would set the fees. MR. OBERMEYER responded that was what made this an advisory board; it would not be like the State Medical Board or the Board of Pharmacy, which had regulatory powers. This board would still fall under the Department of Commerce, Community & Economic Development. CHAIR DAVIS advised that Alphaeus Bullard was on the line and could answer that question. 5:59:14 PM SENATOR ELTON asked if he would do so. He re-stated his question and added that, given Mr. Obermeyer's response that the council would be advisory in nature, he questioned the language on page 4 under "Duties of the Council," which stated that the council "shall (1) establish a list of prescription drugs and medical devices." He asked if that list would be only advisory and could be amended or modified by the department. ALPHEUS BULLARD, Attorney at Law, Legislative Legal and Research Services Division, Legislative Affairs Agency, replied that the council was completely advisory as indicated by the "may" in that paragraph. The department would enjoy the end authority to add, subtract or delineate what drugs would be on that list. SENATOR ELTON wondered why, if the department would have the final say on everything, they were establishing a council. CHAIR DAVIS said she thought, because members were appointed by the Governor's office, it would no longer be under the Department of Commerce; she asked what they would have to do to remove it from Department of Commerce purview. MR. BULLARD answered that they would be creating a state board or commission. It remained under the department because it was purely advisory. CHAIR DAVIS asked why the governor was appointing the members of an advisory board. MR. BULLARD advised that it was a drafting request; it did not have to work that way. CHAIR DAVIS asked if there was any reason that all appointments should not be made by one entity. MR. BULLARD replied that it was not unusual for the commissioner to appoint the members of an advisory board or council, or for the board or council to have no regulatory authority. 6:03:13 PM SENATOR ELTON was struggling with the notion of adding a council that would have no authorities or whose authorities could be "trumped" by the department. Instead of adding advisory groups he opined, they might want to subtract some if they had no real powers. 6:04:04 PM DR. JOHN RASTER, Alaska State Medical Association, testified that, although they appreciated the changes in the CS, the Alaska State Medical Association still felt it was somewhat unregulated and had misgivings about it. The Naturopathic Council could potentially allow all drugs to be in formulary; that could include narcotics, OxyContin, Schedule 2 drugs or chemotherapy. Although the Department of Commerce was given oversight of the list, he did not believe they had a physician or pharmacist on staff who could sign off on those drugs; so the council would essentially decide the formulary. In addition, the bill allowed in-office minor surgeries [Sec. 6 AS 08.45.200 (4)(A) and (B)] but did not allow surgeries "... involving tendons, ligaments, nerves or blood vessels;" even one millimeter beneath the skin there were nerves. With the medications that could potentially be prescribed along with the surgery, this would give naturopaths the most broad prescription and surgical authorities in the country. He noted also that it was not clear who would handle patient complaints. CHAIR DAVIS said she did not agree with some of Mr. Raster's comments; other states were already allowing naturopaths to do what this bill was proposing. She reproved him for opposing the bill without offering any practical suggestions, and reminded him that she had asked repeatedly for the Medical Association's assistance in this process. DR. RASTER responded that he would definitely discuss it with their board of trustees the following day and would come up with some suggestions. SENATOR ELTON offered his understanding that the council could not do the formulary; that power was reserved for the Department, which "may approve," not "shall approve" the list. Also, at the bottom of page 4, line 30-31, it stated that "(c) An endorsement issued under (a) of this section is valid for two years unless revoked or suspended by the department." That would seem to give the department the ability to suspend the privilege. 6:10:56 PM IRMA NORLAND, representing herself, supported CSSB 107. She said that her primary medical provider was Emily Kane, a naturopath, and it would be helpful to her if naturopathic doctors were empowered to use all the skills they were trained for, including prescribing medication and performing minor surgery. She currently had to contact an MD for those services; because General Practitioners were not readily available, she often had to go to the Emergency Room, which was more time-consuming and costly to both her and the medical insurance industry. MS. NORLAND related an incident that occurred in 2006, when Dr. Kane diagnosed her as having a life threatening deep vein thrombosis (DVT) or blood clot, and recommended the proper treatment. The problem had not been correctly diagnosed by the MD at the emergency room, which nearly caused her to travel without the necessary medication to thin her blood. What is more, Dr. Kane was the only doctor who had worked with her to reduce the clot. MS. NORLAND was a nurse for 30 years and it was her opinion that naturopathic medicine was not only legitimate, but preferable in many cases to conventional treatments. She was currently being treated for hypertension, which might require medication, and it would be less expensive and more convenient if Dr. Kane could prescribe those medications for her. 6:13:48 PM DR. SCOTT LUPER, President, Alaska Association Of Naturopathic Physicians (AKANP), supported CSSB 107. He appreciated the testimony and wanted to speak to the essence of the bill, which was that it allowed naturopathic physicians to practice as they were educated. Naturopaths came into the practice after 4 years of college, an additional 4 years of medical education, and testing by a national board in a wide variety of competencies including minor surgeries and the use of pharmaceuticals. Most states that licensed Naturopathic Doctors did allow some degree of prescription authority; Alaska was one of the places that did not. DR. LUPER stressed that he wanted to provide the care to his patients that he was trained to provide. He said he had seen a patient that week, a 43 year old woman with 3 children, who complained of fatigue, menstrual problems and headache. He gathered history, performed a number of tests and examinations, and came back with a diagnosis of hypothyroidism. Because he could not prescribe the necessary medication, she had to endure the added time and expense and the delay in treatment required to see an MD. He said he would be happy to answer any questions the committee might have. SENATOR THOMAS noted that they had heard previous testimony that the difference in education [between MD's and naturopaths] was the residency served by MD's that required them to work under licensed physicians in a hospital environment for a period of time. He asked if Dr. Luper could explain why he thought that was not valid, or if in fact the residency was also required of naturopaths. DR. LUPER said he was in charge of the residency program at Southwest School of Naturopathic Medicine and he did think residency was a good idea; residency was the place that doctors got to hone their skills. He felt it was unfortunate that the residency positions available to naturopathic physicians were fewer than the physicians themselves. The reason was that naturopathy was not subsidized by the federal government as was medical or osteopathic practice. The AKANP was trying to correct that, but it would take some time. He said that the bottom line however, was that Naturopathic Doctors were trained well enough after 4 years of medical school and the thousands of hours of patient contact they had while in school, to diagnose, treat, prescribe and perform minor surgical procedures. He pointed out that naturopaths were all trained under licensed physicians. 6:20:06 PM EMILY KANE, Naturopathic Physician, Juneau, AK, wanted to make a point that might alleviate Dr. Raster's concerns and those of his board. She said her understanding was that one version of this bill specifically excluded narcotics and chemotherapy from the potential list of legend drugs; she was not personally interested in either narcotics or chemotherapeutics and would guess that she spoke for most naturopaths in that regard. She asked if her understanding was correct. CHAIR DAVIS agreed that it was still written that way as far as she knew and asked Mr. Bullard to speak to that. DR. KANE asked why then, Dr. Raster was concerned about those categories. CHAIR DAVIS said that although Dr. Raster spoke to them, they were never in the bill. 6:22:03 PM DR. RASTER said he could not find those exclusions in the current version of the bill. SENATOR THOMAS questioned whether on page 2, [line 28], the verbiage "except as authorized under AS 08.45.056" would cover that. MR. BULLARD advised that the exclusions were not in the current bill. CHAIR DAVIS wondered why they had been removed. She said they were running out of time, but the bill was clearly not in the shape they thought it was; those exclusions should not have come out. MR. BULLARD referred Chair Davis to Version \A where the exclusions did appear on page 2, lines 30-31. MR. OBERMEYER said he believed that Section 08.45.050 had not changed except under AS 08.45.056 and that the current restrictions on controlled substances would cover narcotics. Chemotherapy was not addressed. If they determined that this profession should be regulated by the Alaska State Medical Board, then the law would have to be changed. SENATOR ELTON asked Mr. Bullard about a possible anomaly on page 4, line 3 and lines 27-29. Line 3 provided that the council would create a list that the department "may" approve for use by naturopaths; beginning on line 27 it said that "(b) An endorsement issued under (a) of this section authorizes the licensee to prescribe and administer prescription drugs and medical devices that are on the formulary approved by the Alaska Naturopathic Council under AS 08.45.054." He asked if line 29 should say approved by the Department rather than by the Naturopathic Council. MR. BULLARD agreed with Senator Elton that the verbiage as written was incorrect. CHAIR DAVIS announced her intention to close public comment on the bill until corrections could be made. She held SB 107 in committee.