CSHB 113(HES)-OPTOMETRISTS' USE OF PHARMACEUTICALS  2:22:08 PM CHAIR ELLIS announced CSHB 113(HES) to be up for consideration. REPRESENTATIVE RALPH SAMUELS, sponsor of HB 113, said this bill attempts to open access to health care for more Alaskans. Forty- five other states let optometrists do more than they do here. If there is any one state that probably needs it, it's Alaska because of its geographic size and small population. We have more problems with access than any other state. CHAIR ELLIS asked how many states allow exactly what is proposed in the current version of this bill. REPRESENTATIVE SAMUELS replied that he didn't have the exact numbers. CHAIR ELLIS mentioned that he had drafted some amendments as options that could be offered later. SENATOR STEVENS said he thought that ophthalmologists can do what he is asking optometrists to be able to do. He asked how many ophthalmologists are in Alaska. REPRESENTATIVE SAMUELS replied roughly 20 ophthalmologists. 2:27:24 PM CHAIR ELLIS brought up Amendment 1, labeled 25-LS0411\V.1, emphasizing that he wasn't moving to adopt any of them at this time. AMENDMENT 1 OFFERED IN THE SENATE TO: SCS CSHB 113(HES) Page 2, line 30: Delete "and" Page 3, line 1, following "eye": Insert "; and  (E) has been reviewed and approved by the  State Medical Board for prescription and use by  optometrists" Page 3, line 22: Delete "and" Page 3, line 25, following "eye": Insert "; and (E) has been reviewed and approved by the State Medical Board for prescription and use by optometrists" CHAIR ELLIS explained this amendment would provide that any pharmaceutical allowed to be prescribed by an optometrist would first have to be approved for that use by the State Medical Board. He said this is a big point of contention from the two sides of this argument. The argument is made that some people don't think the State Medical Board would approve of any of these being prescribed by optometrists because of their interpretation of the public interest. He said this is one option. Another option is Amendment 2, labeled 25-LS0411\V.2. AMENDMENT 2 OFFERED IN THE SENATE TO: SCS CSHB 113(HES) Page 2, line 15, following "agents;": Insert "and" Page 2, lines 16 - 17: Delete all material. Renumber the following paragraph accordingly. Page 2, line 31, through page 3, line 1: Delete "injected, unless the injection is for emergency  anaphylaxis and is not injected into the ocular globe of the  eye" Insert "administered by injection" Page 3, line 13, through page 4, line 1: Delete all material. Renumber the following bill sections accordingly. Page 4, lines 17 - 18: Delete "secs. 1 - 3, 5, and 6" Insert "secs. 1 - 5" Page 4, line 22: Delete all material. He explained that Amendment 3, labeled 25-LS0411\V.3, would prohibit all injections by optometrists and this also seemed to be a point of contention. The third option would prohibit the injection of botox by optometrists. AMENDMENT 3 OFFERED IN THE SENATE TO: SCS CSHB 113(HES) Page 2, line 30: Delete "and" Page 3, line 1, following "eye": Insert "; and (E) is not a derivative of clostridium  botulinum" Page 3, line 22: Delete "and" Page 3, line 25, following "eye": Insert "; and (E) is not a derivative of clostridium botulinum" CHAIR ELLIS said he has heard that optometrists don't want to be in the cosmetic procedure business. 2:29:25 PM REPRESENTATIVE SAMUELS said he opposed the first amendment. SENATOR STEVENS asked if he might support giving this authority to a board other than the State Medical Board. REPRESENTATIVE SAMUELS replied that the conflict between the two groups would make it impractical and using the Board of Optometry would be a good idea. SENATOR DAVIS asked if they had talked to the Medical Board because she didn't think they would agree with this. CHAIR ELLIS said he hadn't talked to them. SENATOR BUNDE asked if it would be fair to characterize discussion about this bill as turf battles. REPRESENTATIVE SAMUELS replied that he would characterize it that way, but others wouldn't. He said Amendment 3 sounded pretty reasonable. The debate on Amendment 2 on the House floor and in the House HESS committee was about injections into an eyelid and centered around an optometrist could spend his entire career every day all day dealing with the eyes, but could not do something that a general practitioner could do. He said the optometrists and ophthalmologists could clarify the risks and how often they are taken. The idea is to open access to the health care system by allowing a larger number of doctors to provide a little bit more service. So, if he could vote, he would vote against Amendments 1 and 2. 2:33:17 PM DR. DONALD CINOTTI, Chairman, State Governmental Relations Committee, American Academy of Ophthalmology, said his expertise is in scope of practice and ophthalmology. He said his main concern is when an optometric degree becomes an ophthalmologist degree. In every state bills continue to pop up to increase the scope of practice of optometry and this bill is by far one of the most liberal. It essentially makes an optometrist an ophthalmologist who doesn't do surgery. He went over some of the myths that are heard is that the main reason for expansion of practice always comes down to access to care and this is a turf battle. In every state optometrists say they have to refer some patients to an ophthalmologist to get care. He said probably the only time they hear from constituents about access to care is when bills like this are in committee. DR. CINOTTI stated that rural communities have taken care of access in all fields of medicine for time immemorial by the physicians, the optometrists, the emergency rooms having friendly ophthalmologists who they call and will guide them through the care of the patient and be told which patients need to be referred in and for which patients a prescription can be called in. "So, there really is no access problem in any state in this country." 2:36:14 PM Second, he said training is an issue. He has been training for 26 years and small ophthalmology programs have been ended; the majority of programs are very highly supervised and standardized. The average three-year ophthalmology residence program would have five residents per year or 15 residents. The average residency is about 10 to 15 patients per day. So, taking the small number, that would be 15 times 10 or 150 patients a day would have to be seen in the clinic to qualify for the set standards - plus the patients that are seen on nights and weekends. An average optometric program has many more students - 60 per year for four years and that would result in 240 students times 10 patients or 2,400 patients a day to be equivalent to the experience that an ophthalmology resident has during his training. DR. CINOTTI said that ophthalmology residency programs see a tremendous amount of pathology every day. They are supervised from medical school through residency by another ophthalmologist or someone who has more training. All of their prescriptions are looked at before they are written. So, in medicine, we have always learned and been trained before we were given the right to prescribe. What this bill and all of the expansion bills around the country do is they get the right to prescribe and then we worry about how they are going to be trained - whether it's going to be a weekend course or how much training do they need to take. 2:38:21 PM Specifically, Dr. Cinotti said he was concerned about the oral medications part of the bill - especially with off-label use. He said that many diseases now, especially Uvitis, which is an inflammation inside the eye, are now being treated with anti- cancer drugs. He asked if an optometrist is trained to be prescribing anti-cancer drugs and would they know the side effects. Would they require medical consultations and would all of their patients be seen by medical doctors. He was also very concerned about the use of medications in the pediatric population. There is no equivalent between a child and a baby and a new born to an adult; the doses are completely different and the danger is extremely high. This bill allows an optometrist to treat a baby who is one hour old and up through adult life. He was concerned about what he has seen happen in other states where optometrists were found writing prescriptions for Viagra and birth control - things they are not entitled to. He was also concerned that these prescriptions would be given unwittingly to drug addicts. Ophthalmologist and medical doctor graduates have training in psychiatry and recognizing when a patient is in the office complaining about something so they can get drugs. He asked where the optometrist would get the training to prescribe the narcotics and would they recognize if a patient is a drug addict. He also said that people who prescribe narcotics have a much higher incidence of addiction to them. The highest addiction rate in medicine is in anesthesiology. He asked if optometrists who prescribe narcotics would have an increase in rate of addictions and said that in general ophthalmologists don't write narcotics. They manage pain with topical drops. He concluded saying: We in medicine feel that these bills and this bill, in particular, is creating a medical graduate from an optometrist without the education. We understand the difficulty that you have in Alaska with the rural population, but we know that those people have been taken care of. And I think it's difficult for you to talk to your constituents and really say to them 'Hey, today we did a good job. We got you second best.' 2:42:02 PM BOB LOSHER, Juneau consumer of health care services, said he opposed this legislation. He said he is legally blind as a result of diabetes and a kidney transplant. He has spent a lot of money and has a lot of experience with both ophthalmologists and optometrists having had nine eye surgeries and many other treatments. MR. LOSHER said he had traveled extensively through Alaska and helped many people with their health, jobs, energy and other things including building medical clinics in rural communities. He was concerned that legislators should not diminish the quality or safety of health care and delivery to any Alaskan whether they live in an urban or rural area; and that is one of the main premises he is hearing. He said this is a consumer protection issue and he is more concerned that people have qualified people providing their health care services. He believed the legislature should protect consumers in these areas. 2:45:29 PM Second, Mr. Losher said that the Boards of Optometry and Ophthalmology say two different things and the Medical Board didn't even want to deal with this issue at all. As a consumer, he is concerned that these boards are charged with the responsibility of making sure that Alaskans get qualified practitioners and have qualified facilities and treatment programs. He didn't think they were being well-served by these boards because they can't come forward with a uniform opinion on the subject. 2:47:07 PM Third, he said he was surprised there was no fiscal note and certainly thought there would be costs to the Department of Commerce, Community & Economic Development from, at least, more applications, certifications and testing. This legislation represents an expansion of service that would impact delivery of the state medical programs like Medicaid. 2:48:23 PM He concluded saying that he knows from his own experience with diabetes and a kidney transplant that your eyes' health can't be disassociated from health in the rest of your body. "My experience teaches me that you need a fully qualified medical doctor to deal with your comprehensive health, including your eyes." CHAIR ELLIS thanked him for his testimony and apologized that the committee could not accommodate Dr. Steiner's surgery schedule, but that he had submitted written testimony. 2:50:25 PM DR. MICHAEL BENNETT, President, Alaska Optometric Association, urged the committee to support HB 113. He said it would authorize licensed and trained optometrists to prescribe medications for the treatment of eye and surrounding tissues - not for birth control or other purposes. This is stipulated directly in the bill. The pain medications are somewhat limited and for very brief periods of time - four days. It also provides for the treatment of anaphylactic shock, which can occur in rare instances of topical administration of drugs. This is a critical part of this bill because people can die from anaphylactic shock. Under current law, he would have to treat the person illegally or let them die on the floor. DR. BENNETT reiterated that the bill is quite narrow in scope and does not allow prescription of the most abused controlled substances such as oxycodone and specifically prohibits injections inside the eye. It in no way grants surgical privileges and it mandates continuing education and competency. The course work that is mandated is meant as refresher course work; it is not intended to teach somebody off the street how to prescribe medication for eye care. Supported HB 113. He said the bill stipulates only eye treatment and eye issues, on other purposes, somewhat limited pain medications for a limited amount of time - 4 days. It provides for treatment of anaphylactic shock which is critical. It specifically prohibits injections into the eye and mandates continuing education and competency. The course work is refresher work, not to teach more. 2:53:35 PM DR. BENNETT said optometrists have been well-qualified for these rights for a long time; they are a doctoral level profession - that's four rigorous years beyond a bachelor's degree. Optometry school provides over 200 hours of classroom pharmacology which is comparable to pharmacology training in medical and dental schools. There is greater than 2,000 hours of supervised patient care. These patients are not limited to the young and the health. Elderly people and folks with serious illnesses form the preponderance of most eye care practices. People with debilitating diseases are far more likely to have serious eye health problems and they form the bulk of most practices. DR. BENNETT said that complete medical case history is always taken on every patient he has ever seen. Medications are looked at and interactions are considered. New medications, drops or otherwise, are looked at for interactions. If there are any questions or concerns, he contacts the patient's primary care physician before proceeding. Under current law, when you see a patient who requires an oral antibiotic or an antiviral, or something that is covered in this bill, they must be referred to either an eye surgeon or to their primary care doctor, a nurse practitioner, or a physician's assistant to get the prescriptions covered. Many times it's the end of the day and you try to call the patient's primary care physician and get them to call in the prescription to cover it. That's an awkward position to put the physician in. Or since they have almost no specific eye training, it's difficult for them to make that diagnosis if an eye surgeon is not available. Generally, it results in the wait of a day or two for the patient to see them. This results in unnecessary travel and always results in delayed treatment, additional fees and additional lost time at work. He said being allowed to write these prescriptions would result in cost savings; he makes the diagnosis and it doesn't cost any more to write the prescription form. And the patient doesn't have to go to another doctor. SENATOR BUNDE asked if he anticipated getting more patients if this bill passed. DR. BENNETT replied no; patients aren't aware that he can treat their glaucoma and eye infections with topical drops, but that he can't necessarily treat an infection that has spread a little further into the eyelid with an oral antibiotic. The patient comes to his office assuming he can take care of their problem. He said a lot has been made of the idea that the things they are talking about are not run-of-the-mill every day occurrences and that is true. He might not write even one prescription a week and it's very unusual that one would need to prescribe pain medication - especially in Juneau or Anchorage. A good example would be if a battery blows up in someone's face who is in Kotzebue. That person is going need to get to Anchorage and it would be nice to provide them some pain relief for a day or two until they could get there. 2:57:58 PM SENATOR BUNDE asked if an office visit to an optometrist would have a different rate than a visit to an ophthalmologist. He assumed an informed consumer would go the rate is lowest and he would get more business that way. 2:58:29 PM SENATOR STEVENS asked Dr. Bennett about an optometrist writing prescriptions for drugs other than for the eye - specifically Viagra and narcotics. He asked if this bill encompassed more than just medication for the eye. DR. BENNETT replied that this bill specifically states it's for treatment of eye disorders only. SENATOR STEVENS said that the comment that he would be supplying narcotic addicts is not really legitimate. DR. BENNETT replied that is correct and that you couldn't help an addict much with a four-day legal supply anyhow. 2:59:55 PM CHAIR ELLIS said he wanted to turn to the amendment options and brought up Amendment 1. SENATOR STEVENS commented that this might be a more appropriate issue for the Board of Optometry to take up and suggested amending Amendment 1 to that effect. CHAIR ELLIS asked Dr. Matheson if it would be redundant to change to the State Medical Board to the State Optometric Board. 3:01:10 PM DR. JILL MATHESON, President, Board of Optometry, said the statute as written is an optometry statute, which is then automatically regulated by the Optometry Board. So, it would be unprecedented to give the State Medical Board jurisdiction over what optometrists do. That doesn't happen anywhere else and it would be redundant. It would be unprecedented to have the Medical Board have jurisdiction over what another profession does. It would open another can of worms. CHAIR ELLIS said that amendment would be set aside and brought up Amendment 2 that would prohibit all injections by optometrists. SENATOR STEVENS asked if language on page 3, line 25, didn't already say that. CHAIR ELLIS replied that he understands the issue to be the injecting into the eye or around the eye. 3:03:09 PM SIDNEY MORGAN, staff to Representative Samuels, said that the bill specifically says no injections directly into the eyeball. CHAIR ELLIS remarked that this amendment is more expansive in prohibiting all injections by optometrists. MS. MORGAN replied that is correct and that the last committee made some changes regarding injections. It was going to allow immediate injections for anaphylactic shock which makes sense. However, it also took the injections which the original bill allowed and put in an effective date that allowed the Optometry Board to insure that everyone was educated and trained properly for those injections, even though they believe that is already the case. CHAIR ELLIS set that amendment aside and moved to Amendment 3 prohibiting the injection of botox by optometrists. SENATOR DAVIS said that the bill doesn't mention that at all, but the people who wanted the bill didn't object to it. 3:05:31 PM CHAIR ELLIS moved to adopt Amendment 1, labeled 25-LS0411\V.3, [formerly Amendment 3] as follows: AMENDMENT 1 OFFERED IN THE SENATE TO: SCS CSHB 113(HES) Page 2, line 30: Delete "and" Page 3, line 1, following "eye": Insert "; and (E) is not a derivative of clostridium  botulinum" Page 3, line 22: Delete "and" Page 3, line 25, following "eye": Insert "; and (E) is not a derivative of clostridium botulinum" There were no objections and Amendment 1 was adopted. 3:06:49 PM SENATOR DAVIS moved to pass SCS CSHB 113(L&C) from committee with individual recommendations and a zero fiscal note. CHAIR ELLIS said he was personally conflicted about this and deferred to the will of the committee. There were no objections and it was so ordered.