SB 175-PRACTICE OF NATUROPATHY  1:40:47 PM CHAIR EGAN announced SB 175 to be up for consideration. SENATOR PASKVAN moved to bring CSSB 175(L&C), version \B, before the committee [labeled 27-LS1230\B]. CHAIR EGAN objected for purposes of public testimony. DANA OWEN, staff to the Senate Labor and Commerce Committee, explained that the committee substitute (CS) inserts Senator Giessel's amendment from the last hearing. The intent is to bring statute in line with its original intent. CHAIR EGAN asked where the amendment was located. MR. OWEN replied in the second section of the bill. SENATOR PASKVAN said his understanding is that section 2 returns the practice to what has historically been done for the last 18 years. MR. OWEN replied the intent of the amendment was to bring into statutes the language that was originally covered in regulation. However, Senator Giessel asked to have several words struck from her original amendment and the final version of the amendment that includes those changes. SENATOR GIESSEL explained that the amendment, on page 2, line 1, says, a "dietetic remedy" but in regulation it says "dietetic substance". She changed "substance" to "remedy", but then all of section (c), lines 3-13, were the amendment. She removed "or other natural substance" that was in regulation because it seemed to be a source of confusion. SENATOR PASKVAN said removing that phrase doesn't change the practice over the last 18 years. SENATOR GIESSEL replied that was her discussion with Dr. Jasper who felt it did not change the practice. 1:45:20 PM At ease from 1:45:20 to 1:46:11 p.m. 1:46:11 PM DR. CAROLYN BROWN, M.D., Douglas, said she practices clinical obstetrics and gynecology, public health and preventive medicine. Naturopaths have indicated that this measure is needed because some pharmacies have recently refused to supply them with natural or herbal medicines and that they are doing so because of instructions from the Alaska Division of Corporations, Business and Professional Licensing. That struck her as a bit unusual and in the spirit of transparency and lack of any stated documentation of facts or other data that she could find, she thought it would be good to find just what the nature of the problem is. She said Senator McGuire indicated that SB 175, would not expand the scope of practice, but rather protect the practice. She asked what needs protection in statute that is not provided in regulatory language that has an 18-year history. DR. BROWN said of the thousands of biopharmaceuticals, many are from concentrates and extracts for which the Food and Drug Administration has authority and it would be very helpful to know which specific drugs, medicines and pharmaceuticals the naturopaths wish to have prescriptive authority for. Do they want prescriptive authority for everything in the Physician Desk Reference (PDR)? Almost everything in the PDR has at one time been a natural drug. She said there is a lack of documentation about why a change in statute or regulation is really needed. 1:53:23 PM DR. BOB URATA, M.D., Juneau, testified against SB 175, because it would expand the scope of practice of naturopathy by giving them prescriptive authority for prescription drugs. Because it isn't specific and could be interpreted broadly, they will be able to prescribe penicillin and cephalosporin antibiotics which are derived from fungus, streptomycin and genomycin, tetracycline antibiotics and the macrolide antibiotic which come from the actinomycetes fungus. He mentioned other FDA-controlled medicines that could be prescribed by naturopathic doctors if this passes, which is not the intent of this bill. DR. URATA said some of his patients go to naturopaths and that is fine with him, but he did have patient once on a strong chemotherapy drug for cancer. During the time when his white blood cell count was at its lowest he was getting colonics from naturopathic doctor to reduce its side effects. This is a dangerous procedure and unfortunately it caused a serious blood infection called Sepsis, requiring the patient to get hospitalized. He has done well, but ever since he asked patients not to get colonics while they are on chemotherapy. Patient safety must be the utmost concern in this bill. This means doctors of any kind must practice within the scope of their education, training and experience, and allowing naturopathic doctors to prescribe prescription drugs controlled by the FDA is a dangerous expansion of their scope of practice. SENATOR PASKVAN said he understands that pharmacies have stopped distributing products to naturopaths in a manner they had done for the prior 18 years and asked if that was his understanding as well. DR. URATA replied that he wasn't familiar with that. SENATOR GIESSEL asked if he was the person prescribing the oncologic drug. DR. URATA replied yes along with the oncologist; family practice doctors work with closely with the specialist in order to provide the care patients need rather than having to move out of town away from their homes, friends and support. SENATOR GIESSEL said access to care is the key. DR. URATA agreed. 1:58:19 PM DR. ELIZABETH ROLL, Bethel, said she is a family practice physician and opposed SB 175. She said naturopathic doctors should not be able to prescribe drugs that are regulated by the FDA, because they have not had the training in them. She said the intent of the bill is not to expand their scope of practice, but that is exactly what it does. It doesn't clarify what drugs they could and couldn't prescribe. She had seen several instances where bad things had occurred. SENATOR PASKVAN asked if she was aware that pharmacies stopped distributing products they were distributing for the last 18 years. DR. ROLL replied that she hadn't heard that. 2:01:01 PM JENNIFER YOUNG, representing herself, Chugiak, said she is a cardiac nurse and a patient of Dr. Daniel Young; she said she sees the benefits of both allopathic and naturopathic medicine. Often she thinks having both would make a patient's outcome better than using just one of them. Naturopathic doctors in this state have had rigorous training in order to serve their patients, and she asked that they be allowed to use the tools of their trade to give Alaskans health care choices. Without putting this regulation into law their choices will become severely limited. She said she is married to Dr. Young who is a naturopath and had been helped by naturopathic medicine. What bothers her is that medical doctors don't have the training in natural substances that naturopathic physicians do and that these are very helpful and the choice of many people who need care. That choice should not be taken away because of fear and bias. 2:03:24 PM DANIEL YOUNG, N.D., said he had practiced in Eagle River for 17 years and supported SB 175. He said it is disturbing that another profession can "just dictate" what another profession does. He has 26 years of education and attended a naturopathic medical school that is accredited by the Council of Naturopathic Medical Education that is overseen by the U.S. Department of Education. This is the same body that accredits allopathic and osteopathic medical educations. There is no doubt that naturopathic doctors are the experts in the practice of their naturopathic medicine. MR. YOUNG said naturopaths have practiced in Alaska for 26 years and have an excellent safety record. The current statute is not a good one, but they have made due. On several occasions over the past few years they have tried to make it commensurate with their education only to be stonewalled by the opposition that disseminates misinformation based on opinion, bias, ignorance and fear. This bill does nothing more than preserve the current practice of naturopathic medicine in Alaska and allows the thousands of patients they serve to continue their right to choose their form of medicine. Naturopaths practice from their heart a medicine that they believe in and know will work and improve the lives of their patients. Naturopathic medicine is safe and effective and affordable. They do not wish to write for antiquated natural substances such as penicillin or digitalis, quinine or some anticancer medications because quite frankly they have better things to offer. 2:06:11 PM DR. JOSEPH ROTH, Valley Medical Center, said he is a family doctor in Juneau. He said he was against SB 175 mainly because the prescriptive substance wording is very ambiguous. SENATOR PASKVAN asked if he was aware that pharmacies are not distributing the products they had been distributing for the last 18 years. DR. ROTH replied that he was not aware of that, but wasn't surprised. He knows from some of the committees he sits on at the hospital that there are concerns about "creep" of what naturopaths are starting to prescribe and that their level of education isn't appropriate for, like digitalis and synthroid, a thyroid medication. SENATOR PASKVAN asked if he knew the source of the pushback. DR. ROTH replied that he didn't, but one of his committees had to review a complaint about a naturopath for using a substance; he didn't know if it was from a group or an individual. DR. LAWRENCE SMITH, M.D., Eagle River, said he had served as a physician in the Army and for Alaska Native Health Care and continues to serve in private practice in his community now. He said he didn't hold any animosity toward those practicing naturopathy, but he wanted to urge them to carefully consider the wording of SB 175. The word "prescription" can mean many things. It's generally considered an order or a request to another party to respond by fulfilling that request. It can range from a prescription for eye glasses to recommendations for an exercise or wellness program. DR. SMITH said he believed that the prescribing of drugs and pharmaceutical preparations that require a prescription should be limited to those whose training is designed for such a practice and that allopathic training provides for the prescribing of such medications. He didn't presume to have the knowledge of naturopathic preparations to the same degree as those trained in naturopathic medicine and makes no such claims to his patients. Likewise, if individuals want to prescribe or dispense prescription medications, they should attend medical schools that confirm an M.D. or a D.O. degree. He didn't think that "naturally derived substances" was adequately defined as many drugs that require prescriptive authority have their basis in naturally occurring substances. If the FDA or the DEA requires a prescription to be written in order for a substance to be dispensed, then this should be left in the hands of those trained in allopathic medicine. Ultimately their main concern should be for patient care. Patients make many choices about where to receive care and limitations need to exist on scope of practice and delivery of care for all levels of health care providers. He urged them to not blur the lines of distinction past the point of safety for patients and said that limiting naturopaths to natural substances is a step in the right direction. 2:12:15 PM DR. MARY FOLAND, President, Alaska State Medical Association, said she is a family practitioner and works at Primary Care Associates in Anchorage. She said she is a past president of the Alaska Academy of Family Physicians; both of those have the health of Alaskans as their primary concern. She said not to interpret the lack of calls and letters from physicians and patients as disinterest in this bill that has the potential to have tremendous and irreversible impact on patient safety. It is not an issue of turf protection or competition. DR. FOLAND said the stated goal of this bill to preserve the status quo is not as straight forward as it seems, but its language would actually expand the prescriptive privileges beyond what is currently legal and to a nebulous limit. The phrase "any natural substance" is vague and includes things that were mentioned already. It would be helpful to have a "wish list" of what naturopaths want to prescribe and then doctors could evaluate and research each thing on that list scientifically. She has heard of vitamin B12, Vitamin C, saline and capsaicin in certain percentages, and the general opinion of the doctors she has talked to is that those would be fine. Medications listed by the FDA as prescription drugs, which by definition require a prescription by a licensed physician, would not be okay. It has never been the intent of the State Medical Association or the Academy of Family Physicians to restrict or shut down the practices of naturopaths. They really want to clarify what substances specifically can be used within an appropriate scope of practice for future reference. 2:17:11 PM SENATOR PASKVAN asked if she was aware that other natural substances language had been removed. DR. FOLAND replied yes; but there is still room for clarification. SENATOR PASKVAN asked if she was aware that pharmacists are not distributing products as they have done over the last 18 years with respect to naturopaths. DR. FOLAND replied yes. SENATOR PASKVAN asked what the reason is for pharmacies to stop doing that. DR. FOLAND replied when the Division of Corporations, Business and Professional Licensing was looking into the issue, they found prescriptive practices that made them uncomfortable. SENATOR PASKVAN asked if she was saying the source of the pharmacies ceasing to distribute products is the division. DR. FOLAND replied that was her understanding. SENATOR DAVIS asked her to expand on what the division did. They had the information, and what did they do when they found out? Did they tell her, or did they send letters out to stop the practice? DR. FOLAND replied that she just heard that in the last week's testimony. SENATOR DAVIS said they had asked the division and they denied it and asked Dr. Foland if she had inside information. DR. FOLAND replied that she didn't have inside information. She just listened to the previous hearings on the bill. SENATOR DAVIS said she understood that Dr. Foland was told there was reason why the division had a concern and that something was sent out. Therefore the prescriptions were not filled for naturopaths. DR. FOLAND said the only information she has is from listening to testimony at the previous hearings. 2:20:20 PM JIM JORDAN, Executive Director, Alaska State Medical Association, said he hadn't seen the CS to SB 175, so he didn't want to offer an opinion on it. But he did suggest defining "prescription drug" using the definition found in FDA statutes and regulations, because it would make their application more consistent between the medical community and the pharmacies. 2:22:07 PM SENATOR GIESSEL said the reference to prescription drug occurs in things that a naturopath cannot do and the CS might assuage some of his concerns. MR. JORDAN responded that he also believed that the FDA definitions would apply to other areas of drugs that do not need prescriptive authority. 2:23:21 PM AMY CHADWICK, N.D., Palmer, said a naturopath's education is extensive in human anatomy, physiology, disease and the use of natural medicine and all they are asking for is to maintain the current standard of practice they have had for the last 18 years, not expand their scope of practice. She remarked that many of the examples of medications used here were antiquated and wouldn't be used anyway by a responsible physician. 2:24:28 PM CHRISTIN COX, N.D., Juneau, said she has practiced safely in Juneau for the last 10 years under the current statute and regulations and they are just trying to move current regulations into statute. None of the horror stories have come to pass for the last 18 years, and she did not see why anything would change from moving regulation language into statute. MS. COX said she has served 564 patients in the City of Juneau safely without any problems. It's frustrating that in a day when people need access to safe, affordable, health care that they are fighting to preserve their already limited scope of practice. A Wall Street Journal article said that there will be a shortage of 30,000 general practitioners in the U.S. in the next couple of years. The reason there is a shortage is because general medicine doesn't pay like specialties do. Naturopathic doctors choose to be general practitioners, and they go into this field knowing they will never make the kind of money that medical doctors do, and they provide access to care that patients don't otherwise have and oftentimes can't afford. CHAIR EGAN closed public testimony saying he would hold this bill until Tuesday. SENATOR PASKVAN said he was willing to pass it today, but if they wait until Tuesday, his focus would be on getting some answers from the Division of Corporations. He said: I'll make it even a little more focused. In other words, my perception is that the pharmacies have ceased distributing products to naturopaths as they have done for the last 18 years. If the division hasn't done anything to correct what appears to be a wrong, then the question is how long do they do nothing before they become an active participant in that wrong. That's the first question, and then the second question is how long can the division do nothing before their plausible deniability erodes to nothing. I want to have answers to those questions. CHAIR EGAN said he wanted Mr. Habegar and Ms. Chambers back on Tuesday to answer questions that have been brought up twice. [SB 175 was held in committee.]