HOUSE FINANCE COMMITTEE March 22, 2024 1:35 p.m. 1:35:26 PM CALL TO ORDER Co-Chair Foster called the House Finance Committee meeting to order at 1:35 p.m. MEMBERS PRESENT Representative Neal Foster, Co-Chair Representative DeLena Johnson, Co-Chair Representative Julie Coulombe Representative Mike Cronk Representative Alyse Galvin Representative Sara Hannan Representative Andy Josephson Representative Dan Ortiz Representative Frank Tomaszewski MEMBERS ABSENT Representative Bryce Edgmon, Co-Chair Representative Will Stapp ALSO PRESENT Representative Dan Saddler, Sponsor; Representative Mike Prax, Sponsor; Dr. Natalie Wiggins, Alaska Association of Naturopathic Doctors; Representative Justin Ruffridge. PRESENT VIA TELECONFERENCE Melodie Wilterdink, Staff, Representative Saddler, Anchorage; Duane Mayes, Director, Division of Vocational Rehabilitation, Department of Labor and Workforce Development; Mystie Rail, Executive Director, Assistive Technology of Alaska, Anchorage; Dr. Carrie Baldwin-Sayre, Associate Vice President, Advancement and Community Engagement, National University of Natural Medicine, Portland, Oregon; Dr. Sean Higgins, Emergency Room Doctor, Anchorage; Dr. Clyde Jensen, Professor of Pharmacology, College of Osteopathic Medicine, Rocky Vista University, St. George, Utah; Dr. Robert Downey, Family Practice Physician, South Peninsula Hospital, Homer; Dr. Roxanne Jones, Alaska Academy of Family Physicians, Anchorage; Dr. Hillary Johnson-Jahngir, American Society for Dermatologic Surgery, Iowa; Dr. Kristin Mitchell, President Elect, Alaska State Medical Association, Soldotna; Dr. Scott Ferguson, Board of Trustees, American Medical Association, West Memphis, Arkansas; Bruce Campbell, Self, Fairbanks; Bart Grabman, Self, Anchorage; Karen Gonne-Harrell, Self, Anchorage; Dr. Tim Birdsall, Alaska Association of Naturopathic Doctors, Anchorage; Pam Ventgen, Executive Director, Alaska State Medical Association, Anchorage. SUMMARY HB 219 REPEAL ASSISTIVE TECHNOLOGY LOAN PROGRAM HB 219 was HEARD and HELD in committee for further consideration. HB 115 NATUROPATHS: LICENSING; PRACTICE HB 115 was HEARD and HELD in committee for further consideration. Co-Chair Foster reviewed the meeting agenda. HOUSE BILL NO. 219 "An Act repealing the assistive technology loan guarantee and interest subsidy program; and providing for an effective date." 1:38:00 PM REPRESENTATIVE DAN SADDLER, SPONSOR, introduced the bill. He stated that one of the best things about living in Alaska were the great people who had big hearts and a willingness to help every Alaskan enjoy life in the state to the maximum, including individuals experiencing physical or mental disabilities. For example, in 1995 the state sought and received a $500,000 grant aimed at backing loans for individuals with disabilities. He detailed that the loans helped people buy assistive technology (AT) to help them get or keep a job, attend school, or live more independently. He provided examples of AT including wheelchairs, computers, sleep synthesizers, prosthetics, hearing aids, and other communication devices. The legislature had established the Assistive Technology Loan Guarantee Fund intended to guarantee the principal amount of the loans to Alaskans in order to purchase AT. He noted the funds could also be used to subsidize interest rates. He relayed that despite the legislature's good intentions, few people had taken advantage of the program. The intent of HB 219 was to repeal the grant fund and direct the fund balance of approximately $460,000 to the Assistive Technology of Alaska (ATLA), a nonprofit empowered to administer the grants. He explained that the repeal of the underlying statute would only happen if the legislature reappropriated the funds through separate legislation. He believed members' bill packets included the draft language. He elaborated that passing HB 219 to repeal AS 23.15.125 would remove outdated statutory barriers that were keeping Alaskans with disabilities from taking advantage of the funds. He noted his staff was available to review the sectional analysis. Co-Chair Foster asked to hear from Representative Saddler's staff. 1:40:22 PM MELODIE WILTERDINK, STAFF, REPRESENTATIVE SADDLER, ANCHORAGE (via teleconference), offered the sectional analysis of the bill (copy on file): Section 1 Page 1, Line 4 Section 1 repeals AS 23.15.125 the assistive technology loan guarantee and interest subsidy program which established the "assistive technology loan guarantee fund." The fund can be used to guarantee the principal amount or subsidize the interest rate of a loan for purchasing assistive technology that enables an individual to obtain or maintain employment or live more independently. Section 2 Page 1, Lines 5-9 Section 2 adds conditional language to Alaska's uncodified law stipulating that this act only takes effect if the Legislature reappropriates the balance of the assistive technology loan fund for the purpose of improving access to assistive technology. Section 3 Page 1, Line 10 Section 3 provides for an immediate effective date. Co-Chair Foster observed that the law would only take effect if the legislature reappropriated the balance of the AT fund. He asked if the adjustment was something that would happen at the very end of session when bills were rolled into the conference committee. Alternatively, he wondered if the operating budget co-chair needed to do something in the meantime. Ms. Wilterdink responded that there was drafted language and the amendment to the operating budget could happen in the House Finance Committee during the budget amendment process, on the House floor, or at a later time during conference committee. She noted that ideally the change would take place prior to conference committee. 1:43:16 PM Representative Josephson asked how the fund avoided being swept over the past several years. Representative Saddler deferred the question to the Department of Labor and Workforce Development (DLWD). DUANE MAYES, DIRECTOR, DIVISION OF VOCATIONAL REHABILITATION, DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT (via teleconference), replied that he did not have the details to answer the question. He relayed that the funding had been a one-time allocation to the Division of Vocational Rehabilitation (DVR) in 1995. He offered to follow up with the information. Representative Saddler speculated that the fact that the funding was still available 30 years after the establishment of the fund was some indication it had found a niche to be safe from the sweep. Co-Chair Foster suggested a follow-up on the question with the information to be provided at the next hearing on the bill. Representative Hannan asked how much money was available in the fund. She understood the fund had initially been capitalized with federal money and $100,000 had been put in a couple of years later. She remarked that the fiscal note did not address how much money would be reappropriated. She asked if none of the money had ever been spent and if it earned interest in the fund. Representative Saddler deferred to Mr. Mayes. Mr. Mayes responded that the current balance of the fund was $447,000. He estimated that over the 30-year life of the fund, around 10 loans had been provided. He relayed that there had been no loans in the past six years. Representative Saddler added that there had been a period of very low interest rates and because part of the aim of the federal grant money was to subside loans it was rather difficult to find a way in which a subsidy was much of a benefit. He stated it was one of the reasons the loan program had been moribund. Representative Hannan asked if there were any restrictions on reappropriation tied to the initial $291,000 in federal funds. Representative Saddler deferred the question to Mr. Mayes. He believed there were some restrictions. Mr. Mayes answered that ATLA was the implementing agency and store front in terms of technology. There were no restrictions on the funds. The change in statute would enable the state to allocate the funding to ATLA, which was better positioned to promote the program and the funds. The department had been talking with its federal funding partner and there were many other states that had done the same thing because they were experiencing the same thing as Alaska. 1:49:09 PM Representative Hannan provided a hypothetical scenario where the legislature wanted to move the initial amount that was capitalized and to reappropriate $100,000 to senior and disability services technology. She asked if the scenario would be allowed. She noted the reappropriation in the scenario would be a different action from the bill. She wondered whether the legislature could only reappropriate the funds to one thing or if it had carte blanche through its appropriation power to put the funds towards any disability services. Mr. Mayes responded that ATLA was the implementing agency that DLWD worked with. The department's Division of Vocational Rehabilitation had a set of rehabilitation counselors who may use ATLA to assess technology needs. There was no other entity in the state that he was aware of. He explained that ATLA was federally recognized under the 21st Century Assistive Technology Act. Representative Saddler added that it was his understanding that with funds established through law, often the lender specified the fund balance included original appropriation plus earnings. He would look into HB 65, the 1995 vehicle that established the fund. Co-Chair Foster thought it was a good question asked by Representative Hannan about whether $100,000 could be reappropriated to another program. He would be happy with a simple yes or no answer. Representative Galvin thanked Representative Saddler for finding money that was not being spent and was meant to be spent on behalf of individuals who need the funds. She referenced support letters included in members' packets (copy on file). She looked at language specifying that ATLA remained one of the only nonprofits to provide services to all Alaskans regardless of age, location, income, or diagnosis. She stated that the language "one of the only" made her wonder if there were others. She asked if there had been a process in which the department had chosen to focus on ATLA. Representative Saddler asked which letter and location she was referencing. Representative Galvin referred to paragraph three of a letter from the Association of Assistive Technology Act (copy on file). She noted that the sentence was in a couple of the letters. She referenced a letter from Articulate Speech and Language Therapy (copy on file) as another example. Representative Saddler responded that ATLA and DVR had made him aware of the issue and had suggested the bill. He believed ATLA was one of a few nonprofits providing the services, but ATLA was the primary entity with the most experience and efficacy. He thought ATLA was the only agency that had every facilitated the grants. He concluded that ATLA was in the best position and best nonprofit available to deliver the money to people who need it. He deferred to the executive director of ATLA to answer if there were other agencies that may qualify. 1:54:42 PM MYSTIE RAIL, EXECUTIVE DIRECTOR, ASSISTIVE TECHNOLOGY OF ALASKA, ANCHORAGE (via teleconference), answered that ATLA was the only agency in the state dealing with assistive technology and it was the implementing agency of the federal AT Act. Representative Galvin stated that all of her questions were answered if the grant was single sourced toward only one purpose. Co-Chair Foster noted that Mr. Mayes was listed as invited testimony. He asked if Mr. Mayes had additional comments. Mr. Mayes shared that he had worked in the state system for 35 years. He started out in 1989 as the rehabilitation counselor for the deaf and hard of hearing and had worked in the position for nine years. He relayed that ATLA was with him at the time, and he often used the agency to identify technology needs for deaf, blind, or hard of hearing. He relayed that with the exception of senior and disability services and the Governor's Council on Disabilities and Special Education, ATLA was the sole agency the rehabilitation counselors worked for. He relayed that the skill set counselors needed to have was complicated and it was rare to find someone with that level of skill. He stated that ATLA had been around for a long time and was the lifeline for DVR. 1:57:17 PM Representative Hannan remarked that DVR had previously had an assistive program to help deaf individuals, but it no longer existed. She wondered if some of the funding could be used to reinstate such a program. Alternatively, she wondered if the funding was constrained and could not be used for that purpose. Mr. Mayes deferred the question to Ms. Rail. Ms. Rail responded that she was not aware of the specific program that had previously existed under DVR. She relayed that ATLA was a community rehabilitation provider for the division. She explained that the division counselors referred individuals to ATLA for a full assessment and to provide recommendations on the right assistive technology. Representative Hannan shared that she had some active deaf constituents who had repeatedly told her they used to have supports at DVR, but the programs had been cut. She elaborated that they found it very hard to find access to services and supports within state agencies to interact with state agencies. She explained that the individuals continually asked when the positions could be reinstated. She was trying to determine whether the funding could only be directed to individuals or if it could be used to provide a deaf assistance person at the division that deaf Alaskans could contact for a variety of supports. Co-Chair Foster thought it sounded like some research and follow up was needed. Representative Saddler stated that he had some difficulty understanding Ms. Rail possibly due to speakerphone. He believed Ms. Rail had said that if someone was referred to ATLA, the agency would conduct an assessment of the person's disabilities and would be able to help provide assistive technology if a person was deaf or hard of hearing. 2:01:07 PM Ms. Rail agreed. She detailed that ATLA provided AT and the associated services. The agency had additional programs it was able to administer to provide specific types of devices for deaf or hard of hearing individuals and individuals experiencing speech impairment. She speculated that the constituents that Representative Hannan was speaking of were likely looking for services beyond assistive technology and the services provided by ATLA. She explained that ATLA was very focused on providing AT and the surrounding services. Co-Chair Foster asked Ms. Rail to provide any comments as an invited testifier. Ms. Rail shared that ATLA had become a 501(c)(3) in 1994 and the implementing agency of the federal Assistive Technology Act under the direction of DVR. She noted that the federal funds went directly to DVR and were passed on to ATLA. The agency's mission was to enhance the quality of life for Alaskans through assistive technology. She relayed that ATLA was the state's only comprehensive assistive technology resource center that provided services statewide to Alaskans at any age with any disability, injury, or illness. She noted that most other nonprofits were specific to certain ages, disabilities, or areas within the state. She explained that ATLA partnered with all of those agencies. Ms. Rail supported the activities outline in the Assistive Technology Act. She detailed that assistive technology was defined as any item, piece of equipment, software program, or product system used to increase, maintain, or improve the functional capabilities of people with disabilities. She explained that AT could be as simple and low tech as putting rubberized grips on a pen for a person experiencing arthritis or as high tech as a device called Eyegaze that enabled a person to control a computer or iPad using only their eyes. She elaborated that AT could range from solutions made ourselves to specialized equipment from AT manufacturers to everyday off-the-shelf devices like an iPad or Amazon's Alexa. She stressed that AT was not a one size fits all solution. She relayed that devices and services were unique to each person ATLA worked with. She provided examples of individuals receiving assistance through ATLA. She highlighted an elder in rural Alaska who was losing his vision and was now able to read his own mail with the assistance of a digital magnifier. Another example was a non-verbal six-year-old with autism in Ketchikan who had recently told her mom "thank you" for the first time using a symbol-based communication device. Ms. Rail stated that AT devices and services were critical to ensure Alaskans with disabilities were able to live, work, and participate in their communities independently. 2:06:27 PM Ms. Rail continued to provide details about ATLA. She relayed that as the implementing agency of the Assistive Technology Act, ATLA provided demonstrations of the devices to offer opportunities for Alaskans to become familiar with the different types of technology that could help them. She explained that it offered Alaskans a chance to compare and contrast the functions and features of each device through hands-on exploration by an AT professional. The agency also allowed individuals to borrow equipment for two to four weeks to determine whether the item would meet their needs prior to purchase. The agency also supported the reuse of AT in order for multiple people to benefit from a device. The AT Act did not allow ATLA to purchase technology directly for a person, but it allowed ATLA to do state financing activities to administer other initiatives for funding resources that did support the acquisition of the AT for consumers at no cost using dollars from non-AT Act sources. The agency also used AT Act dollars to provide outreach and awareness and to collaborate with partner agencies across the state. The intent of HB 219 would be to support the activities already provided by ATLA through the AT Act. Ms. Rail stressed that technology was rapidly changing as were the needs of Alaskans served by the agency. She stated that the funds received by the agency through the AT Act did not begin to cover the need to purchase more AT for demonstration centers or to be able to provide short-term loans. She stated that the funds [that would result from HB 219] would ensure ATLA could meet the increased urgency for AT and to help improve and continue to improve the quality of life for Alaskans with disabilities. The additional funds would also strengthen and sustain the gaps in services or in devices that were needed to support Alaskans. She thanked the committee for the opportunity to speak. Co-Chair Foster thanked Ms. Rail for her testimony. He asked Representative Saddler for any closing comments. 2:09:30 PM Representative Saddler thanked the committee and was available for questions. Representative Tomaszewski asked if the fund had collected any interest over its 30-year lifespan. Representative Saddler deferred the question to Mr. Mayes. Mr. Mayes confirmed that there was some interest made on the funding, but he did not have the specific numbers on hand. He would follow up with the information. Co-Chair Foster set the amendment deadline for Friday, March 29 at 5:00 p.m. HB 219 was HEARD and HELD for further consideration. HOUSE BILL NO. 115 "An Act relating to the practice of naturopathy; establishing the Naturopathy Advisory Board; relating to the licensure of naturopaths; relating to disciplinary sanctions for naturopaths; relating to the Department of Commerce, Community, and Economic Development; and providing for an effective date." 2:11:21 PM Co-Chair Foster asked for a brief recap of the bill. He relayed that the committee would also hear invited testimony followed by public testimony. REPRESENTATIVE MIKE PRAX, SPONSOR, relayed that HB 115 was designed to allow naturopaths to practice to the full extent of their training including prescription authority and minor in-office surgical procedures. The intent was to reduce the cost of care for those choosing to use a naturopath for medical care. He stated that the bill would benefit Alaska by getting more premier care physicians available to serve. Co-Chair Foster moved to invited testimony. He relayed that of the eight invited testifiers there were four in support and four opposed to the bill. 2:14:38 PM DR. CARRIE BALDWIN-SAYRE, ASSOCIATE VICE PRESIDENT, ADVANCEMENT AND COMMUNITY ENGAGEMENT, NATIONAL UNIVERSITY OF NATURAL MEDICINE, PORTLAND, OREGON (via teleconference), stated that her testimony was intended to highlight the education and training of naturopathic physicians and how the training was overseen by national accreditation organizations. She relayed that naturopathic medical programs were four-year graduate programs. The National University of Natural Medicine (NUNM) programs included 5,047 hours of total education, including 1,254 training hours of direct student involvement in clinical care. The training hours were comparable to the education requirements for other healthcare professions and far exceeded the 1,000 hours required in the two-year family nurse practitioner program at Oregon Health Sciences University (OHSU). Dr. Baldwin-Sayre noted that with less clinical training than naturopathic physicians, nurse practitioners had fully autonomous prescriptive authority including controlled substances and had no post-graduate residency requirements while playing a vital role in the Alaska healthcare system. The first two years of instruction [for naturopathic physicians] consisted of biomedical sciences and diagnostic training, followed by an extensive study in diagnostic methods and procedures. The second two years focused on translating the basic science knowledge into clinical application. The courses developed graduates into primary care physicians and included cardiology, gastroenterology, gynecology, endocrinology, and many other subjects. Students took courses on disease management and prevention using therapeutic modalities such as nutrition, lifestyle medicine, mechanical medicine, pharmaceutical prescribing, and minor surgical in-office procedures. Dr. Baldwin-Sayre emphasized that students received specific instruction in pharmaceutical prescribing throughout 15 different courses in their second two-year block of time in addition to the prescribing done in primary care settings during students' internships. Students received extensive hands-on clinical training in dermatology with minor surgical procedures including surgical techniques and laceration repair. Students' hands- on clinical training included progressively increasing levels of responsibility for patient care. She relayed that students were required to pass three hands-on clinical examinations with the final exam occurring after one year with their own supervised patient load in a state credentialed primary care medical home. After graduation, all naturopathic doctors were required to pass two national board examinations. Dr. Baldwin-Sayre elaborated that licensed naturopaths all attended accredited naturopathic medical schools. She stated that NUNM had a programmatic accreditor and a regional institutional accreditor, both overseen by the U.S. Department of Education. The programmatic accreditor was the Council on Naturopathic Medical Education, and the regional accreditor was the Northwest Commission on Colleges and Universities, which was the same accreditor to oversee OHSU and the University of Alaska. She relayed that naturopathic medical colleges prepared graduates to be competent, safe, effective healthcare providers. She stated that the practice authority requested in HB 115 was a very low-risk addition to their existing scope of practice and was well within the confines of their training. She thanked the committee. 2:18:24 PM Representative Josephson stated that the committee had been told that naturopaths wanted to practice medicine that overlapped in its primary care purpose with physicians and osteopaths. He asked if naturopaths should be held to the same standard of care as traditional primary care physicians. Dr. Baldwin-Sayre responded that naturopaths were held to the standard of care for naturopathic physicians. For instance, in states where naturopaths were licensed as primary care physicians (e.g., Oregon), naturopaths were held to the standard of naturopathic medicine. She stated it was based on "our" board of naturopathic medicine, which included a variety of naturopathic physicians and public members and determined how the standard of care was upheld in the state. She believed the bill included a naturopathic advisory board, which would determine the same. Representative Josephson stated there was an emphasis in the presentation that the pharmacological training and training in laceration repair and minor surgery was of the same quality as allopathic medical care. However, Dr. Baldwin-Sayre's suggested that naturopaths would establish their own standard of care. He thought in some ways it seemed that naturopaths were saying they wanted to be on the same playing field as allopathic medicine, yet they were going to operate under a different standard of care. He asked how to reconcile those two things. Dr. Baldwin-Sayre responded that in areas where there were overlaps in scope such as pharmacology, if naturopaths were to prescribe a medication, they would be expected to prescribe the medication exactly as it was intended to be prescribed. She stated it was the same with laceration repair or suturing. Naturopaths would not have a different way of suturing up a wound than a nurse practitioner or a medical doctor. She explained that when it came to discipline within the State of Oregon, the Board of Naturopathic Medicine determined how a naturopathic doctor was disciplined versus the Board of Medicine, which determined how medical doctors and osteopathic doctors were disciplined. 2:22:05 PM DR. SEAN HIGGINS, EMERGENCY ROOM DOCTOR, ANCHORAGE (via teleconference), shared that prior to becoming an Alaskan he had worked in several medical communities in Washington State where licensed naturopaths were permitted to work with a broad scope of practice. He relayed that as an emergency room doctor, he was seeing an increasing number of things that should be managed by primary care providers including medication refills, antibiotics for urinary tract infections, contraception, management of chronic conditions such as diabetes and high blood pressure, and procedures such as laceration repair. He estimated that during a typical shift around 30 percent of the patients who visited the emergency room were there for primary care related medical concerns. He stated it equated to expensive bills for patients and was a significant strain on emergency room staff. Wait times and patient volume had increased substantially with patients coming in for primary care, which put a strain on people showing up with true emergencies. Dr. Higgins continued that shortage of primary care providers forced emergency room doctors to practice on the fringes and even outside of their expertise. Patients receiving primary care in the emergency room by providers who were not trained in primary care received a disservice due to a lack of consistency and follow-up care. He believed allowing naturopathic doctors to practice to the extent of their training would increase the number of primary care providers in Alaska and would give more patients access to primary care, which would keep emergency rooms free for emergencies. He had many working relationships with naturopathic providers from Alaska and Washington and the curriculum and training for naturopathic medical school was comparable to the courses he took at allopathic medical school. He stated that the providers had used the same textbooks and study programs he had used for the licensing exams. He previously witnessed naturopathic colleagues manage prescriptive medications and perform minor in office procedures safely and effectively in Washington State. He was somewhat baffled that naturopathic doctors in Alaska needed to refer their patients to physician's assistant or nurse practitioner colleagues for medication management and minor office procedures when he knew that naturopathic doctors had more rigorous and lengthy training. In his experience, naturopathic doctors were more deliberate and forward thinking. He stated that allowing naturopathic doctors to practice to the full extent of their training would help Alaskans receive the primary care needed to keep them healthier and out of the emergency room. Co-Chair Foster recognized Representative Justin Ruffridge in the audience. Representative Josephson stated he had read the Food and Drug Administration (FDA) had proposed a ban on curcumin being compounded with naturopathic drugs. He asked if it was a source of concern if naturopaths chose to compound the drugs notwithstanding the prohibition or if the prohibition existed and they should not do it. Dr. Higgins replied that he could not speak directly to the subject. He was unaware of a ban on curcumin, which was an over the counter supplement. He did not know of many dangers with curcumin, but he would defer to a naturopathic colleague as he did not have experience with curcumin. Representative Josephson asked if he had heard of a colleague who was not a naturopath using ozone therapy. Dr. Higgins responded that he had heard of medical doctors using ozone therapy, but it he had not used it in his practice. Representative Josephson asked if Dr. Higgins had any concerns with the treatment. Dr. Higgins responded that he was not up to date with the literature on ozone therapy, but he was aware of medical practitioners, physician's assistants, and medical doctors utilizing that treatment modality. As an emergency room physician, it was not something he was familiar with. 2:26:55 PM Representative Galvin shared that she had various concerned constituents. She highlighted a constituent was a paramedic and now a physician with 9,000 hours of direct clinical care. The individual relayed that he was still unable to practice independently because his knowledge base was not sufficient. She added that the individual was just about to complete a three-year residency. She asked whether Dr. Higgins thought an individual with the education similar to his should have the ability to prescribe medications sooner. Dr. Higgins responded that once a person finished four years of medical school there were not restrictions for prescribing and practicing primary care. He was not sure what sort of residency program Representative Galvin's constituent was in. He believed the individual could practice independently. He stated that an individual could moonlight while in residency and practice independently. He challenged the individual's initial concern about the issue. He believed the individual could practice independently at present in a primary care center. Representative Galvin understood that the bill would give naturopathic doctors the authority to prescribe medications immediately after completion of a program whose focus was avoiding the very medications that could be prescribed. She stated her constituent had concern that part of the program may be in conflict with the treatment they may have to use. Additionally, her constituent thought there would be very limited training for naturopathic doctors related to minor surgical procedures. She stated that the individual was suggesting that he spent years learning to be comfortable with minor procedures that were less invasive than what was proposed in the bill. She asked if Dr. Higgins had any concerns about the procedures. Dr. Higgins responded that it depended on the specifics of the procedure. He relayed that naturopaths were trained on simple laceration repair. He stated that in terms of motivations for prescribing medicines, he believed naturopaths' ethos was to avoid pharmacology until absolutely necessary, but that for conditions such as diabetes, patients needed insulin. He elaborated that lifestyle and naturopathic interventions could be used up to a certain point, but at some point, when things like antibiotics, traditional blood pressure medication, and insulin needed to be prescribed, it was well within a naturopathic doctor's training. Representative Galvin had heard concern around the removal of a mole for example and whether a naturopath had enough of a background to catch something. She stated that according to a letter she had received, primary care doctors conferred with dermatologists routinely because there were many complicated procedures. Dr. Higgins responded that just as he had been trained in medical school, part of a naturopath's training was to recognize when they were in over their head. For example, if a naturopathic doctor saw a mole, skin lesion, or wart that needed to be frozen, removed, or biopsied, they would apply the same judgement he would use. He relayed that if something looked cancerous, those patients were typically referred to specialists such as dermatologists. He stated that as far as he knew, ensuring an individual was practicing within the standard of care was emphasized in a naturopathic doctor's training. Theoretically everyone was trained to make decisions and to not perform procedures outside of their scope that would be against the standard of care. 2:33:23 PM DR. CLYDE JENSEN, PROFESSOR OF PHARMACOLOGY, COLLEGE OF OSTEOPATHIC MEDICINE, ROCKY VISTA UNIVERSITY, ST. GEORGE, UTAH (via teleconference), shared that he had a Ph.D. in pharmacology and had taught in MD, DO, naturopathic, PA, nursing, and other colleges. He relayed that the pharmacology training given to naturopathic students was not only similar, but probably identical to the training given to MD and DO students in their first two years of medical school. The training was provided in naturopathic medical schools for several reasons, wherein educators wanted naturopathic graduates to be able to prescribe medications in the jurisdictions that fell within their scope of practice. Another reason pharmacology was taught to naturopathic medical students was in order for them to understand the potential interactions between drugs, herbs, and nutrients. He elaborated that most patients who were prescribed nutrients or herbs by naturopaths were also taking drugs that in many cases had been prescribed by MDs or DOs. Naturopathic physicians were especially well trained in drug and herb interactions. The third reason naturopathic physicians were trained in pharmacology was because patients were generally using drugs and naturopathic physicians needed to be able to counsel their patients. He opined that as a professor of pharmacology and as the former president of MD, DO, and ND colleges, that naturopathic physicians were capable of confidently and conservatively prescribing medications commonly used in primary care practices. Representative Josephson stated that the bill would delete a prohibition on the use of poison. He asked if Dr. Jensen knew the reason. Dr. Jensen responded that all drugs were poisons, it was simply a matter of what dose was given that enabled their side effects to rise to the level that would be considered poison. He suspected the language may have been entered into the bill to caution the prescribers to use drugs appropriately and to avoid the use of substances that had levels of toxicity that the risk of using the drug exceeded the benefit. Representative Josephson believed he had not received a good answer about why it was okay that naturopathy largely dispensed with a residency program requirement. He noted that a retired emergency room doctor and friend from Juneau was specifically accredited as a family practice physician. He stated that every five years the doctor had to renew his accreditation. He stressed there had been tough requirements even though the individual had been a senior emergency room doctor. He wondered why naturopathy did not require residency programs of any serious level. Dr. Jensen stated it was an excellent question. He believed the reason naturopathic physicians were not required to do residencies was because unlike MD and DO graduates, funded residencies were not available to naturopaths through Medicare. He stated it meant that when naturopaths took residencies, they were taking residencies that were privately funded usually by hospitals or clinics. He stated there were simply not enough residencies to satisfy the aspirations of all naturopathic physicians who may like to take them. He added that it would be desirable for naturopathic physicians to all have access to residencies just like MDs and DOs, but those residencies were funded by the federal government and were not available to naturopathic physicians. He shared that he had testified before Congressional committees about the funding of MD and DO residencies. He highlighted there had been concern about the expenditure of public funds just to provide funding for those residencies. Representative Josephson thought that because [residencies] were not available [to naturopathic physicians] he thought it would support a collaborative agreement law so that something akin to residency could be accomplished. Dr. Jensen thought that a collaborative relationship between a newly prescribing naturopathic physician and a veteran prescribing MD and DO was not a bad idea. He shared that earlier in the day he received a call from the president of an osteopathic medical school who had testified on a naturopathic licensing/prescription bill in another state. The individual had asked him the same question Representative Josephson had just asked. The individual communicated he was going to propose or favor the inclusion of pharmaceuticals in the scope of practice of naturopathic physicians, but he would also feel more comfortable speaking on behalf of that bill if it contained a collaborative requirement. He and the other individual had agreed that if a collaborative relationship were to be established, it should have a finite time period of perhaps one year and the collaborative professional would be a licensed MD or DO (not a PA or NP) with residency training. 2:43:11 PM Representative Coulombe referenced Dr. Jensen's statement that the training [for naturopathic students] was identical to the first two years of MDs. She asked if she had heard him accurately. She asked if residency started two years after an MD started training. Dr. Jensen confirmed that she had heard him correctly. He shared that when he and colleagues had taught pharmacology in naturopathic medical schools, they had given the same number of contact hours and lecture using the same drugs and same content as were used in MD and DO schools. He relayed that most professors used the same textbooks in each of those types of schools. He relayed that pharmacology training was given during the first two years of school. Subsequent to the first two years, naturopathic physicians, MDs, and DOs had another two years of clinical training. He noted that Dr. Baldwin-Sayre had described the number of hours spent in clinical training. He stated that the number of hours for naturopathic physicians was comparable to the number of hours for MDs and DOs. He noted that the difference between the training of naturopaths and MDs and DOs resided in the residency program. He stated that many naturopathic physicians did not have access to residency programs because the funding for naturopathic residencies through the federal government did not exist. Representative Galvin asked if there was any difference in pharmacology versus finding the correct diagnosis and matching it up with the correct selection of medicine. She thought it was an ever evolving science. She remarked that the options for medicines on various diagnoses changed constantly. She wondered if there was continuing prescription education for naturopathic doctors. Dr. Jensen responded that they were approaching the edge of his pharmacology expertise. He turned to some of his expertise as a leader of medical schools to answer the question. He relayed that naturopathic physicians had continuing medical education requirements that were similar to MD and DO continuing education requirements. He stated the requirements were similar in number of hours and to a large extent in content. When there were new developments pertaining to existing drugs or new drugs that had come on the market since a naturopathic physician had graduated, the new discoveries would be taught to naturopathic physicians in the same way they were taught to MD and DO physicians. He noted that Representative Galvin's question touched on standard of care. He relayed that his observation, as a leader of medical schools who attended conferences for all types of medical schools, was that the standard of care for the use of pharmaceuticals was uniform among MDs, DOs, and naturopathic physicians. He stated that it was taught in continuing medical education in all of those professions. 2:48:41 PM Representative Hannan asked about the pharmacological exam. She explained that HB 115 required an individual to pass a pharmacological exam. She asked whether there was one pharmacological exam taken by DOs, MDs, PAs, and naturopathic doctors. Dr. Jensen replied that the MD, DO, and naturopath professions each had their own board examinations. He explained that the pharmacology tested in the examinations was embedded within the exams. He noted that recently graduate medical education requirements and the governance of graduate medical education for MDs and DOs had been combined. The change meant that DOs had a choice to take a standardized DO exam or an exam that MDs also took. He relayed that naturopaths took an exam that was prepared specifically for naturopathic physicians, which included pharmacology. He personally had the opportunity to write questions for the DO and naturopathic board exams in pharmacology. His questions for DOs and naturopathic physicians were the same level of difficulty. Representative Hannan asked Dr. Jensen if it was his conclusion that anyone currently taking a naturopathic doctor exam to practice in a state that allowed them to have a scope of practice including pharmacology was taking an exam that was equivalent to other practitioners with pharmacological authorities. Dr. Jensen agreed. Representative Ortiz referenced a letter of concern from someone in the American Medical Association (AMA). The letter stated that the AMA did not have access to the testing material for naturopathic doctors and did not know whether it was equivalent testing material when it came to pharmaceuticals. He thought it sounded like Dr. Jensen had access to the material and he wondered why the AMA did not. Dr. Jensen replied that he never had access to any of the examinations. He clarified that he had written questions in pharmacology for the examinations. He did not know what would happen if the AMA were to have a bona fide representative ask the testing body for naturopaths if they could have access to some of the questions. He had never requested the information. He shared that when he had written questions for DO and ND exams, the questions he had written in pharmacology were comparable. He believed all writers of examinations were writing questions that test contemporary knowledge that was necessary to prescribe drugs whether a person was an MD, DO, or ND. 2:54:42 PM DR. ROBERT DOWNEY, FAMILY PRACTICE PHYSICIAN, SOUTH PENINSULA HOSPITAL, HOMER (via teleconference), clarified that he was speaking on behalf of himself and not on behalf of the hospital. He shared that he was dual certified in family medicine and functional medicine through the Institute for Functional Medicine. He relayed that in 2006, he met a naturopathic doctor, Hillary Daily, who encouraged him to attend the Institute for Functional Medicine. He relayed that he had worked with Dr. Daily for many years, including in Alaska from 2012 to 2014. He stated that the naturopathic doctors he worked with were well trained. He referenced the prior testimony from Dr. Jensen that his curriculum and instructional content for MDs and DOs was the same for naturopaths. After working in the same room with naturopaths for 17 years and making decisions with them, he had no reservations regarding their training. He referenced data from the Federation of Naturopathic Medicine's regulatory authority showing naturopathic care to be safe, even with the scope of practice as requested in HB 115. Dr. Downey found it puzzling that nurse practitioners in Alaska had less formal education and broader scope of practice then what naturopaths were seeking. He explained that naturopaths could refer patients to a nurse practitioner to receive a prescription and have a laceration sutured even though they both received medical degrees with no post-graduation residency. He stated that some of his colleagues argue that lack of residency training made naturopaths unsafe. He underscored that nurse practitioners had no post-graduation residency, yet they had exercised broad prescriptive rights safely in Alaska for decades. He underscored that the importance of the particular point could not be overstated given how strongly it paralleled the safety the state would see from naturopaths when they should and would receive the prescriptive authority in HB 115. Dr. Downey relayed that naturopathic doctors knew when a patient's blood pressure required immediate care, yet under current restrictions, a patient had to go to a second medical appointment or go to the emergency room to get required medication. He stressed that even one hour between diagnosis and treatment may have dire consequences. He relayed that naturopathic doctors were trained to determine whether lifestyle changes could mitigate underlying health problems. He highlighted the shortage of primary care providers in Alaska, which was placing a burden on emergency room care. He stated there was no factual evidence that a naturopathic doctor who had graduated from a certified four-year medical program and passed required post-graduation exams measuring their pharmaceutical knowledge should not be able to prescribe medications as the bill would allow. He remarked that if the state wanted to get serious about the primary care shortage, [naturopathic] doctors needed to be granted the prescribing authority they had earned. Dr. Downey explained that naturopathic doctors would prescribe the same way he did. He stated they would become familiar with a small group of medications and would know them well and use them safely. He elaborated that individuals who were currently opposed, would subsequently feel the same way they feel about the great care nurse practitioners were currently providing in a safe manner. He stated that curcumin was invoked around FDA prohibitions regarding compounding [earlier in the meeting], which he believed conflated two issues. He relayed that curcumin was an important botanical with the same benefits as prednisone without the downsides or safety concerns. He noted that curcumin was rarely compounded in his 17 years of functional medicine practice and familiarity with NDs. He remarked that it was an excellent example of a professional grade supplement that worked well and safely. He highlighted that he had addressed the safety of supplements in prior testimony. Dr. Downey shared that ozone therapy tended to create free radicals, which disrupted tissue and the therapeutic advantages created by the tissue response. He expounded that it was an aggressive therapy, not favored by many in natural and integrated medicine. He addressed concerns by a constituent [highlighted earlier in the meeting by Representative Galvin] about being able to prescribe sooner. He thought it missed the point that the amount of training naturopaths received regarding procedures and prescribing was very adequate. Additionally, he clarified that naturopaths were not taught to avoid medication, they were taught to choose the right thing, in the right place, at the right time. He highlighted that residency was not necessary to do the work safely. Lastly, he pointed out that part of the issue was a cultural divide. He compared it to a divide between skiers and snowboarders in the past, who were now happily sharing the slopes. He stated that once the legislation passed, over the next five to ten years more Alaskans would be served, and people would not be hearing the same concerns invoked as they were presently. 3:00:40 PM Representative Galvin appreciated the ski analogy and valued working together. Referred to concerns around continuing education. She had asked earlier about continuing education and had been reassured it was taking place, but she was considering the difference between the number of hours required. She understood that MDs spent 50 hours every two years. She looked at line 9 on page 5 of the bill and highlighted a requirement for 15 hours of continuing education over a five-year period. She noted a couple of other references in the bill related to continuing education that amounted to about 10 hours. She observed that the difference was substantial. She wanted to ensure there was an equal playing field in terms of medical providers understanding what to prescribe when. Dr. Downey responded that he felt very comfortable commenting based on his 17 years of working daily with NDs. Additionally, the ND community of professionals were all extremely rigorous and concerned about this. He shared that the naturopathic community took the power of the prescriber's pen just as seriously as the conventional allopathic community. He stated that any "of us" who value the power also had an immense respect for what could go wrong if the prescriber's pen was wielded improperly. There was no difference between the two camps. Second, there was already prescribing happening safely in the U.S. akin to nurse practitioner's prescribing in Alaska. Lastly, many providers of conventional medicine, particularly in primary care, had a small handful of medicines they used safely over and over again. Some of his favorite and most effective medications were medications he became familiar with in medical school and residency. He was certainly excited when new medications came out. For example, when biologics came out to treat autoimmune conditions like rheumatoid arthritis, which had revolutionized the ability to serve people, he was still conservative and looked at when and how to refer for those medications. He noted he currently did not prescribe those medications and had a specialist prescribe them. He explained that newer was not always better. He stated there were separate issues around the pharmaceutical industry wanting providers to feel that way, but most medical providers with prescription authority had a sturdy toolkit of excellent pharmacological education that they were exceedingly familiar with in order to be safe. Co-Chair Foster noted that the meeting would likely go longer than anticipated. He continued with the remaining four invited testifiers. 3:06:26 PM DR. ROXANNE JONES, ALASKA ACADEMY OF FAMILY PHYSICIANS, ANCHORAGE (via teleconference), testified in opposition to the bill as written. She shared that she had previously lived and practiced in the Norton Sound region of Alaska for five years and had served as the lead physician for four villages including Elim, White Mountain, Golovin, and Little Diomede. She currently worked in Anchorage as an assistant program director for a family medicine residency program and as a medical director of one of Anchorage's two safety net clinics. She detailed that she had worked in a primary care clinic that accepted Medicare, Medicaid, and self-pay. She had intimate knowledge of the complexity of primary care needs in Alaska and of the training physicians undertook to become independent practitioners. The organization opposed the bill because it provided full prescriptive authority and in-office surgical procedures; however, the organization was very supportive of the creation of a regulatory board for naturopaths in order formalize their pathway to licensure in the state. Dr. Jones relayed that she would address the risks associated with prescriptive authority and the claim that the bill would expand the primary care provider pool in the state. She stated that while accreditation was a great tool to create a minimal acceptable standard and more uniformity across schools, it was accreditation for naturopathic standards. She argued that naturopathic standards were not equivalent to the standards for physicians. She understood that other testifiers had used NPs and PAs as examples, but she would specifically compare the standard of care and training for naturopaths to those of family physicians because the Council on Naturopathic Medical Education Standards specifically noted that the goal of the accredited institutions was to train "primary care/general practice physicians/doctors." She pointed out that having the same accreditor as another institution had no bearing on the scope of practice of those trained under accredited programs. She highlighted that her family medicine residency was accredited by the same accrediting agency as neurosurgeon residency. She noted they were certainly not training neurosurgeons in her form of medicine. Dr. Jones stated that the Council on Naturopathic Medical Education (CNME) standards included pharmacology as one of the required academic components. She elaborated that sometimes the exact same lecture was delivered to naturopath students and first or second year medical students. However, first or second year medical students should not be given licenses for full prescriptive authority because they sat through a lecture. She stated it was combination of the lectures and thousands of hours of supervised clinical practice that made a physician competent to safely prescribe pharmaceuticals. As a faculty member at a residency, she saw residents training and growing daily. She relayed that it was not until they were close to their third year of clinical supervised practice in a residency that they were ready to competently and safely prescribe pharmaceuticals. Dr. Jones shared that naturopath students had 850 hours involved in patient care. She knew that another testifier had spoken to 1,254 hours at their school. She pointed out that the minimum requirement according to accreditation was 850 hours. She stated it was a minimum of 225 patients for whom a naturopath acted as the primary student clinician prior to graduation. She noted there was no residency requirement. She relayed that medical students completed 3,000 to 5,000 hours of supervised clinical practice by the time they graduated medical school. She stated that the additional supervised practice was needed to fully learn and appreciate the complexity of medicine and how to safely diagnose and treat patients. She highlighted that family physicians had an additional three years or approximately 10,000 to 12,000 hours of supervised practice prior to becoming an independent practitioner. She detailed that the 10,000 hours included minimum standards of over 2,000 patient encounters for which they were the primary care provider. She stressed that the residents were not ready right out of the gate and were not ready until they had thousands of hours under their belts. She corrected earlier testimony and relayed that in Alaska if a person graduated medical school after 1995, they were required to have a minimum of two years of post-graduate residency training before they could be independently licensed to practice medicine. Dr. Jones hoped the committee could see that the comparison being made was between apples and oranges. The organization believed it was too risky to give prescription authority to naturopaths. She addressed earlier comments about increasing the pool of primary care providers in Alaska. She did not feel that naturopaths were the equivalent to be primary care physicians. She argued that naturopaths would not meet the need within the community because the biggest need was for Medicare patients. She emphasized that Alaska was desperate for more Medicare primary care providers. She relayed that Medicare, Tricare, and the Veterans Administration did not recognize naturopaths as medical providers. She thanked the committee for its time. 3:14:08 PM DR. HILLARY JOHNSON-JAHNGIR, AMERICAN SOCIETY FOR DERMATOLOGIC SURGERY, IOWA (via teleconference), shared that she was board certified in dermatology, micrographic surgery, and other. She frequently worked with medical professional organizations on issues important for patient safety and weighed in on policy impacting dermatology. She was passionate about protecting patients especially in rural areas. She stated that like Iowa, Alaska's incidence of melanoma of the skin was rising more than in the rest of the country, especially in the Native Alaskan population. Her practice covered a broad rural area, and she used physician led team-based care. She elaborated that teamwork focused on patient safety and saving healthcare dollars by avoiding unnecessary testing. For example, when a patient had a skin lesion, they used advanced clinical tools like dermatoscopy, to help determine whether the lesion was benign or needed a costlier skin biopsy to check for cancer. Dr. Johnson-Jahngir relayed that her exposure to naturopathy was through family. She detailed that her parents moved to Iowa from Arizona for better healthcare. She elaborated that her stepmother's Arizona primary care was delivered by a naturopath and unfortunately, she was prescribed thyroid hormone replacement therapy even though her thyroid test results were normal. She expounded that her pre-diabetes had gone unnoticed. She stated there was not a shortcut to being able to safely prescribe prescription drugs. Prior to prescribing, she reviewed a patient's entire medical history including other drugs they were taking, in order to avoid risky interactions or other adverse events. She stated that an advanced clinical training well beyond basic pharmacology was required. Dr. Johnson-Jahngir shared that her older sister currently lived in Arizona and saw a naturopath for primary care. Her sister had a skin lesion that was not diagnosed as skin cancer until she visited a dermatologist. She worried that HB 115 would permit naturopaths to care for skin lesions and perform minor office procedures. She explained it was concerning in terms of getting the most accurate diagnosis and the appropriate management. She noted it was not easy and required extensive education and training. She underscored that there were over 3,000 skin diseases and many mimickers of skin cancer. Dr. Johnson-Jahngir stated that if a potentially cancerous skin lesion was surgically removed before a full medical exam and testing it could render the skin cancer undetectable or lead to a cancer spread or altered pathology so that the diagnosis was delayed or even result in death. She stated that the bill included a broad expansion of office procedures that could be interpreted as practice of medicine that could involve lasers, injection or insertion of foreign or natural substances in or under the skin, liposuction, coagulation and bleeding, grafting skin, or even rotating skin through skin flaps to repair wounds. She relayed that naturopaths did not have the proper qualifications to perform the procedures. Nor would they be able to respond to possible complications that could arise. She summarized that allowing naturopaths to perform tasks beyond their training could have severe consequences for Alaskan patients. 3:18:10 PM DR. KRISTIN MITCHELL, PRESIDENT ELECT, ALASKA STATE MEDICAL ASSOCIATION, SOLDOTNA (via teleconference), was speaking to the committee in her capacity as the president elect of the Alaska State Medical Association. She shared that she was also board certified in internal medicine by the American Board of Internal Medicine. She practiced in Soldotna and had cared for adults with highly complex medical conditions for 25 years. Additionally, she was faculty at Washington, Wyoming, Alaska, Montana, and Idaho (WWAMI) and clinical faculty for the University of Washington School of Medicine. She relayed that her concern was for patient safety, and she believed that Alaskans deserved reliable, safe, excellent medical care. She stated that the care was best provided by teams led by a physician. She quoted from the American College of Physicians, "physicians have extensive education, skills, and training that make them most qualified to exercise advanced clinical responsibilities within teams." She referenced testimony from Dr. Jones about the extent of residency training and how the additional three-year period of supervised practice with an experienced clinician leader helping people make the best possible decisions, double checking their decision making, and providing input was an essential part of what made a medically trained physician qualified and competent to care for patients. Dr. Mitchell highlighted two items she thought would be of particular importance to the finance committee: malpractice implications and insurance coverage. She referenced testimony the committee had received from naturopaths that they had low rates of disciplinary action. She recommended the committee keep in mind that any disciplinary action was reviewed by the board comprised of naturopaths and there was no established standard of care for naturopathic practice with which to compare a complaint. She stated that if naturopaths were to be granted prescription authority that was parallel to those granted by the state for licensed medical physicians, she would expect as a resident of Alaska that naturopaths should be held to the same standard of malpractice liability as medical physicians. Dr. Mitchell referenced testimony heard by the committee that expanding the scope of practice for naturopaths would help address the primary care shortage in the state. She was acutely aware of the primary care shortage challenges. She shared that her clinic in Soldotna had just started an internal medicine residency program where they would train additional physicians. She had great respect for Dr. Jones and her family medicine training program. She elaborated that there were a lot of physicians who were working hard to try to choose the right physicians for Alaska and train physicians who were qualified to take care of Alaskans. She agreed with Dr. Jones that expanding naturopathic practice would not solve the primary care access problems faced by Alaskans because the Centers for Medicare and Medicaid Services (CMS) did not recognize naturopathic practices. She stated it would still leave a tremendous gap in patients who were most vulnerable. Dr. Mitchell addressed the pharmacology aspect of the bill. She shared that she had reviewed the naturopathic study guide. She referred to testimony during the meeting that common drugs and primary care were covered by naturopathic practice and training. She found the study guide surprising. She elaborated that there were a number of oncology drugs that were only given intravenously and would never be given in a primary care office and would only be part of a practice in consultation with an oncology specialist. Additionally, there were extended spectrum antibiotics for treating resistant [indecipherable] infections that were only given intravenously and did not have a role in primary practice due to the crisis with drug resistant bacteria. She was concerned that some of the emphasis on the study guide was not appropriate to primary care practice. She was concerned about ongoing medical education. She highlighted that the newest drugs showing tremendous promise in diabetes were not part of the study guide. She stressed there was so much change in medicine and the expansion of pharmaceuticals required internal medicine providers to stay on top of it annually. She would be very concerned about granting unlimited practice to someone who did not have a clear responsibility to maintain their ongoing education. Dr. Mitchell addressed an earlier question about curcumin. She relayed that curcumin was a supplement and supplements were not regulated by the FDA. She stated that the concern about the drug was due to the death of a patient of a licensed naturopath in California who had been given an IV infusion. She stated that because curcumin was a supplement, the bill would not change the current ability of a naturopath to infuse curcumin or other supplements for patients in Alaska. She stated that the practice of medicine was highly complex. She believed it was difficult for the legislature to understand all of the issues in depth even with the testimony by her colleagues and over the years that the bill had been introduced. She encouraged legislators to look outside of Alaska for examples and guidance. She stated that it was unlawful to practice naturopathy in three states. She elaborated that 28 states did not license naturopaths and only 11 states allowed for any prescriptive authority for pharmaceutical medication. She stated that naturopaths were not equivalent to primary care physicians and should not be granted equivalent prescribing and surgical privileges. She communicated that it was the standard of practice in the U.S. and elsewhere. For example, in the United Kingdom, the National Health Service stopped funding homeopathic remedies in 2017 and Australia's main medical body concluded that homeopathy should not be used to treat chronic, serious, or potentially serious health conditions. Dr. Mitchell provided concluding remarks. She stated that Alaska's current statute regarding restrictions on the practice of naturopathy specified that a practitioner may not give, prescribe, or recommend a prescription drug, a controlled substance, a poison, engage in surgery, or use the word physician in their title. She believed it would be confusing, misleading, and dangerous to pass the bill certifying to Alaskan patients and consumers that naturopath training was sufficient to allow for broad prescription of pharmaceutical medication and the practice of minor surgery. She encouraged members to reject HB 115. 3:26:21 PM DR. SCOTT FERGUSON, PHYSICIAN AND BOARD OF TRUSTEES, AMERICAN MEDICAL ASSOCIATION (AMA), WEST MEMPHIS, ARKANSAS (via teleconference), shared that he was a previous legislator, and his wife was currently a legislator in Arkansas. He encouraged committee members to oppose HB 115. He stated that prescribing medication was the practice of medicine. He elaborated that to prescribe safely, a practitioner needed robust clinical training and comprehensive education in pharmacology. He stressed that individuals learned to prescribe in clinical medicine standing side by side when evaluating a patient and talking about the necessary treatment. He urged the committee to recognize that a naturopath's education was distinct from a medical education. The AMA did not believe naturopaths were adequately trained to prescribe. He stated that individuals learned to prescribe during residency. He emphasized that the education students received in pharmacology during their first two years occurred in a lecture hall. He stressed that it did not involve taking care of patients. Dr. Ferguson stated there were crucial gaps in naturopaths' clinical training. He highlighted that naturopaths were required to complete a minimum of 850 patient care hours during their 1,200 hour clinical training. He stressed that physicians were required to have a minimum of 12,000 hours in training. He stated that accreditation standards for naturopathic programs imposed no requirement for students to see patients of any particular age or any illness or condition as part of their training. He relayed that there was no guarantee a naturopathic student would ever see patients who were sick or hospitalized. He elaborated that they may never take care of vulnerable patients like children or the elderly during their training. Dr. Ferguson remarked that if the legislation opened the door for naturopaths to prescribe powerful medications to any patient with any illness, the legislature should not assume a graduate of an accredited naturopathic program received a comprehensive pharmacological education. He elaborated that receiving education on basic sciences in a lecture hall was not where the art of medicine, caring for patients, and prescribing occurred. He stated that the naturopathic curriculum focused largely on non-medical content. He remarked that scientific content was riddled with principles and therapeutics that lacked a foundation in medical evidence. He stressed that it called into question the integrity of the pharmacological content. He relayed that the curriculum in medical schools was rigorous, highly standardized, and had its foundation in evidence based medicine. He elaborated that consequences of prescribing incorrectly could be dire. He asked the committee to take the risk to patients seriously. Dr. Ferguson indicated that workforce maps showed that naturopaths and physicians practice in the same areas of the state and that the number of physicians practicing in Alaska far exceeded the number of practicing naturopaths in the state. He reported that AMA data suggested there were fewer than 50 practicing naturopaths in Alaska. He emphasized that granting naturopaths prescriptive authority would not increase access to care. He urged the committee to oppose the bill. Co-Chair Foster OPENED public testimony. He asked individuals to keep their testimony to two minutes. 3:33:05 PM DR. NATALIE WIGGINS, ALASKA ASSOCIATION OF NATUROPATHIC DOCTORS, JUNEAU, shared that she is a naturopathic doctor in Anchorage. She detailed that she had previously practiced medicine in Arizona as a naturopathic doctor where she had a scope of practice that reflected her level of training, knowledge, and competency. She relayed that the federal government recognized the competency acquired through completion of her program and entrusted her with a DEA number allowing her to prescribe scheduled medications and noncontrolled medications. She had decided she wanted to raise her children in Alaska. Her training, knowledge, and ability to safely practice medicine had not changed when she crossed the state line. Only her residency had changed. Dr. Wiggins addressed comments and areas of concern highlighted during the meeting. When she had practiced in Arizona her continuing education requirement was to complete 30 hours of CMEs [continuing medical education] including 10 hours of pharmaceutical education. She relayed it was the standard of practice of states that had scope of practice including prescriptive authority. She pointed out that the bill was not requesting broad prescriptive authority as the committee had been led to believe. She elaborated that broad prescriptive authority was occurring in Arizona, which was the reason she had a DEA number. She clarified that naturopaths in Alaska were not requesting to prescribe controlled medications. The request was for things like antibiotics and for GLP-1 medications. She agreed that medicine was constantly changing, and it was necessary to stay up to date on changes occurring, which was reflected in CME hours. Dr. Wiggins addressed safety concerns. She pointed out that some of the concerns could be directed to states with scope of practice that reflected naturopath training and the associated safety evidence. She agreed that the committee may hear about particular cases where things had popped up. She noted that likewise there were situations that occurred for medical doctors as well. She highlighted information in members' bill packets that pointed to the safety of naturopaths in states that were licensed, including Oregon. Members' packets also included information about the safety of the practice currently in Alaska. She noted that even in states that were already utilizing broader scope of practice, the safety was well illustrated. Co-Chair Foster asked Dr. Wiggins what position she held with the Alaska Association of Naturopathic Doctors. Dr. Wiggins replied that she is the secretary. Co-Chair Foster asked if Dr. Wiggins lived in Juneau. Dr. Wiggins answered that she lived in Anchorage. Co-Chair Foster noted that Dr. Wiggins had flown all the way to Juneau, and he wanted to take advantage of the opportunity to ask questions. 3:37:28 PM Representative Galvin thanked Dr. Wiggins for being in Juneau and taking the time to come from Anchorage. She referenced a chart provided by Dr. Wiggins related to the number of disciplinary actions related to concerns where patients had somehow been impacted negatively. She remarked that the disciplinary actions pertained to DOs, MDs, and NDs. She asked for more detail. She heard a lot that there was no comparison because people were not unhappy with naturopaths. Dr. Wiggins believed Representative Galvin was asking about the difference in disciplinary action. For example, in Alaska, disciplinary action occurred through licensing. There were other sanctions happening in states with broader scope of practice. She noted that MDs, DOs, and NDs all had their own separate boards. Representative Galvin stated her understanding that in Oregon there were far fewer disciplinary actions (percentage wise) against naturopaths as opposed to DOs and MDs. Dr. Wiggins agreed. She noted that the document illustrated there were far fewer disciplinary actions for NDs than there were for the other provider types. She confirmed that the document pertained to Oregon, where the practice of naturopathic medicine had been broad for many years. 3:40:23 PM Representative Ortiz stated that one of the compelling arguments in support of the legislation was that it would help alleviate the shortage in access to primary care physicians; however, the committee had also heard that Medicaid and Medicare did not cover naturopathic care and it would not help much with the shortage of primary care. He asked for comment. Dr. Wiggins confirmed that naturopaths were not billing services to Medicare and whatnot. She thought it was great that organizations were training primary care doctors to cover that need. She stated that the need was very extensive. For example, she started keeping track of the number of times she was needing to prescribe to her patients and over the past three days there was a need for 19 different prescriptions for 12 patients. She explained that although she was trained and skilled to write the prescriptions, the patients had to go get a separate medical care visit to fulfill the need. She agreed there was a huge need for Medicare and Medicaid access; however, there was still a large need for primary care in all aspects of medicine. Representative Tomaszewski noted that there had been prior testimony that stated that naturopaths were disciplined by naturopaths. He remarked that the inference was that naturopaths were protecting their own. He thought MDs were disciplined by a medical doctor board. He asked for verification that it was a similar comparison. Dr. Wiggins responded in the affirmative. She relayed that each individual board disciplined its own participants. Representative Tomaszewski asked for verification that if Dr. Wiggins was able to fill the prescriptions for her patients, they would not have to go to an MD to further clog up the system and create more need. Dr. Wiggins replied that Representative Tomaszewski was accurate. She shared that two of the patients she saw the previous week had to go to urgent care to get prescriptions. She stressed that the other patients were waiting to get the prescriptions. She explained it was a huge problem because a wait may be difficult for the treatment patients needed, which meant individuals sometimes had to go to the emergency room, further clogging the system. 3:44:06 PM Representative Galvin there had been significant correspondence around the amount of continuing education not having parity. She asked Dr. Wiggins to comment on the issue. She had heard from one physician in particular who stated they were required to have 50 hours every two years and there was nothing that compared. She asked if it was different in different states. Dr. Wiggins responded it was part of the statute in the state of Arizona. Currently, naturopathic doctors did not have any requirements in the state for CMEs. She stated it [taking CME courses] was standard, so she and her colleagues continued to do it. She stated that in other states naturopaths were exceeding the 50 hours every two years. 3:45:36 PM BRUCE CAMPBELL, SELF, FAIRBANKS (via teleconference), testified in support of HB 115. He shared that his family had received primary healthcare from licensed naturopaths for many years and he believed the bill was necessary to update the policy for naturopathic care. He noted that he was on Medicare and his naturopathic provider worked directly with AlaskaCare. He stated that the slate of experts that had spoken to the bill had been impressive. He thought Dr. Jensen's discussion of pharmacology as being much the same was very important. He believed Dr. Baldwin- Sayre's testimony on the comparison of hours with nurse practitioners was also important. He noted that Section 4 of the bill would establish an equivalent pharmacology test, which he believed the state would do well. He had received excellent care from nurse practitioners, but he believed it was illogical for a patient to have to set up a separate appointment. For example, when his daughter's primary care pediatrician retired, his family had been told by a local clinic they would have to sign up for a new doctor because they would face a five to six-week wait to see a pediatrician every time they called. To get prescriptions refilled he and his wife had to go to urgent care where they had to wait for hours and explain the issues. He believed it was an added cost and impediment to care, especially if his naturopathic doctor had already completed labs, explained the current literature, and detailed the evidence based care she was recommending. He stressed that the bottom line was, he determined who he saw, what he did, and what he consumed. He stated it was his responsibility for his medical care. He reiterated his support for the bill. 3:48:28 PM BART GRABMAN, SELF, ANCHORAGE (via teleconference), opposed HB 115. He was currently a resident physician who received his MD degree through the WWAMI program in Alaska and he was in the process of completing his three-year emergency medicine residency. He believed highlighting some of the differences between naturopathic and MD education may be helpful in understanding his opposition to the bill. He stated that according to written testimony provided to the committee by the American Association of Naturopathic Physicians, naturopathic school included about 4,000 hours of training and 1,200 hours of hands on clinical education. He elaborated that according to one of the leading naturopathic schools, National University of Health Sciences, most education on pharmacology was focused on herbal and natural remedies with only three credit hours throughout the entire education specifically focused on medications used in allopathic care. He highlighted that the minor surgery class was 1.5 credit hours total. He noted that naturopaths were not required to do additional advanced residency training. Dr. Grabman shared that during his time at the University of Washington through the WWAMI MD program he had weekly lectures and regular exams on pharmacology. After the first two years he spent the next two years in clinical rotations that included pediatrics, surgery, psychiatry, anesthesia, neurosurgery, and more. He completed more than 5,000 hours of clinical time in addition to classroom time. By the time he completed residency he would complete 8,000 additional hours of direct clinical care. He relayed that even though he had completed more than 10,000 hours to date, he was still not allowed to practice or prescribe independently. He relayed that a primary care resident worked more hours than he did and had the same restrictions. He still consulted dermatologists on questions regarding diagnosis. He stated that conditions were frequently too complex for non-dermatologists to manage. He stated that the bill would give naturopaths prescriptive authority and the ability to perform minor surgical procedures. He stated their training was focused almost entirely on nonpharmacologic and nonallopathic care. He stated that the focus and training between naturopaths and physicians was very different. He urged the committee to not pass the bill. He referenced a review on disciplinary actions taken against naturopaths in Oregon included at least 42 actions since 2018. 3:51:45 PM KAREN GONNE-HARRELL, SELF, ANCHORAGE (via teleconference), shared that she had used a naturopath for 35 years, partly because her son had allergies and his medical doctor would not consider the possibility. She had seen the same naturopathic doctor for 35 years. Her doctor did all of her bloodwork, but she had to make a separate appointment with a nurse practitioner to fill prescriptions who may have less training than a naturopath. She no longer had insurance, but when she did, she received half as many doctor visits because she had to double up on doctors. She thought there was an acceptable solution moving forward that included ways to increase a naturopath's scope of practice, and to allow them to prescribe simple medications like antibiotics and thyroid medications. She stated there were cases where people had abused their licenses on both sides of the fence. She urged support of the bill in a safe manner. 3:54:39 PM DR. TIM BIRDSALL, ALASKA ASSOCIATION OF NATUROPATHIC DOCTORS, ANCHORAGE (via teleconference), shared that he was a practicing naturopath in Anchorage and also held licenses in Arizonia, California, and Washington state. He urged the committee to look at the data and ensure it was comparing apples to apples. He relayed that naturopaths were not asking to be considered the same as MDs and it did not make sense to him to compare their level of training to that of an MD; however, naturopathic doctors were well trained to function in a primary care role to prescribe medications they were comfortable with and to do procedures within their education and training. He stated that the bill increased the scope of practice and the responsibility for naturopaths. He highlighted that the bill clarified the amount of continuing education. He believed it should be equivalent to other licensed states, which would be roughly 30 hours per year including a 10-hour minimum of pharmacology training. The bill also required naturopaths to report communicable diseases, which was not currently a statutory requirement. He noted there were a variety of other things that needed to be added to the naturopathic statute, which was over 35 years old. Dr. Birdsall believed there were many reasons the bill made sense. He underscored that naturopaths were not asking for unlimited prescriptive authority or for the ability to do all types of surgery. He clarified that naturopaths were asking for the ability to do the things that according to statute were within the scope of education, training, and experience of naturopathic doctors. He highlighted that the committee had heard from multiple physicians during the meeting whose MD license would allow them to do brain surgery for example. He knew Dr. Downey and guaranteed that the doctor would never consider doing brain surgery on a patient because he was not trained to do so. He elaborated that those professions were allowed to determine what was appropriate based on the individual's education, training, and experience. He referenced a case study from nurse practitioners in Alaska. He relayed that Alaska was one of the leaders in the nation in granting nurse practitioners independent practice authority 40 years ago and the safety record of nurse practitioners was admirable, and nurse practitioners had a broader scope of practice than what was requested in HB 115. He encouraged committee members to look at the safety record. He stated it was true that no profession was perfect and the purpose of the robust disciplinary section in the bill was to ensure anyone who stepped outside of the limits of a provider's education, their license could be restricted, suspended, or revoked as necessary. He thanked the committee. 3:59:51 PM PAM VENTGEN, EXECUTIVE DIRECTOR, ALASKA STATE MEDICAL ASSOCIATION, ANCHORAGE (via teleconference), relayed that the Alaska State Medical Association supported many sections in HB 115. The association urged an increase in the number of CMEs required. She stated that most of the sections of the naturopath statutes needed to be updated. She noted that the big things were the minor surgery and prescribing authority. There were approximately 1,300 primary care physicians currently practicing in Alaska. The vast majority were in urban areas, with the remainder in rural areas. She stated there were fewer than 50 practicing naturopaths, all essentially in urban areas. She stated that the reported shortage of primary providers was primarily a shortage of providers who accept Medicare patients. She stated that CMS did not recognize naturopathy as a viable medical practice; therefore, they did not cover naturopathic services. She added that there were no federally endorsed residency training programs for naturopaths. She remarked that there was probably a reason for that. Ms. Ventgen stated that the claim that giving surgical privileges and prescribing authority to naturopaths would change primary care availability was a faulty argument. She relayed that most insurance plans only covered what was allowed in state statute. One of drivers of increased healthcare cost was increased availability. She stated it had been seen during the COVID-19 pandemic when mental health services became available via telehealth. She stated that the cost to Medicaid went up dramatically. She remarked that she was not arguing the pros or cons but expanding the scope of practice to include minor surgical procedures and prescribing, would influence insurance plans to cover naturopathic services, which would increase the overall cost of healthcare. She noted that in some cases patients had to go to another provider to get their prescriptions. She had heard testimony that a lot of practices included a naturopath and nurse practitioner. She stated in that case they were in the same office, which seemed to be a minor inconvenience. She urged the committee not to pass 115 as written. She thanked the committee. 4:04:00 PM Co-Chair Foster CLOSED public testimony. He provided the email address for written testimony. Representative Ortiz asked the bill sponsor whether there had been two previous committees of referral prior to the bill's arrival in the House Finance Committee. Representative Prax answered that the bill had also gone through the House Health and Social Services Committee and the House Labor and Commerce Committee. Representative Ortiz asked if there were a number of amendments proposed and adopted by the House Health and Social Services Committee that were not a part of the current version of the bill. Representative Prax responded that there were initially [amendments made to the legislation], but the bill had returned to its original intent. Representative Ortiz asked if amendments had been adopted. He asked for more detail. Representative Prax responded there were a number of amendments proposed in the House Health and Social Services Committee and the first amendment covered a "whole list of things" that took the bill away from its original intent. The committee had rescinded the amendments and sent the bill to the House Labor and Commerce Committee. The only amendment he recalled being adopted that was in the current version of the bill had removed the word "advisory" related to the board. The bill was "pretty much in its original form." Representative Ortiz asked if the amendments that were initially adopted dealt with some of the concerns that had been raised during the current meeting. Representative Prax responded affirmatively. He stated there had been discussion about including a list of drugs that could be administered [by naturopaths]. Another amendment pertained to collegial practice where a naturopath would work under the authority of a doctor. 4:07:38 PM Co-Chair Foster asked Representative Prax for any closing comments. Representative Prax remarked that the discussion during the meeting had been very interesting. He stated that it was difficult to write a statute that covered every situation. He clarified that the bill did not intend to claim that naturopaths were the same as medical doctors. The bill was about a scope of practice and a scope of training. He noted that within the medical doctor community individual physicians focused on their specialty. He elaborated that they may be licensed to do many other things, but they focused on a few of them. Likewise, they may be licensed to prescribe anything, but focused on a handful of drugs. He stated his expectation that the same thing would happen with naturopaths where they would focus on what they knew. He reasoned that it would be impossible to write a statute to cover all situations. He remarked that if a doctor or naturopath were doing something outside of their scope of training they could be exposed to malpractice. He did not see how that could be avoided. He stated that if someone prescribed something beyond their scope of training it would be covered. He provided an example pertaining to certified car mechanics who focused on a select number of car brands, while others focused on other brands. He stated that just because a person knew how to fix cars in general did not mean they would work on just any car; they focused and became proficient at working on specific cars. He stated the market worked itself out and people focused on what they were trained to do. Co-Chair Foster thanked the sponsor. He reviewed the agenda for the following meeting. HB 115 was HEARD and HELD in committee for further consideration. ADJOURNMENT 4:12:00 PM The meeting was adjourned at 4:11 p.m.