ALASKA STATE LEGISLATURE  HOUSE LABOR AND COMMERCE STANDING COMMITTEE  February 18, 2004 3:20 p.m. MEMBERS PRESENT Representative Tom Anderson, Chair Representative Carl Gatto, Vice Chair Representative Nancy Dahlstrom Representative Bob Lynn Representative Norman Rokeberg Representative Harry Crawford Representative David Guttenberg MEMBERS ABSENT  All members present COMMITTEE CALENDAR  HOUSE BILL NO. 434 "An Act relating to the practice of naturopathic medicine; and providing for an effective date." - HEARD AND HELD; ASSIGNED TO SUBCOMMITTEE HOUSE BILL NO. 389 "An Act relating to certain monetary advances in which the deposit or other negotiation of certain instruments to pay the advances is delayed until a later date; and providing for an effective date." - SCHEDULED BUT NOT HEARD PREVIOUS COMMITTEE ACTION BILL: HB 434 SHORT TITLE: NATUROPATHIC MEDICINE SPONSOR(S): REPRESENTATIVE(S) HOLM 02/04/04 (H) READ THE FIRST TIME - REFERRALS 02/04/04 (H) L&C, JUD 02/04/04 (H) HES REFERRAL ADDED AFTER L&C 02/18/04 (H) L&C AT 3:15 PM CAPITOL 17 WITNESS REGISTER    REPRESENTATIVE JIM HOLM Alaska State Legislature Juneau, Alaska POSITION STATEMENT: Testified as the sponsor of HB 434.  SCOTT LUPER, N.D. Fairbanks, Alaska STATEMENT: Testified in support of HB 434 as a naturopathic physician, explaining the bill and sharing his professional experience. CLYDE B. JENSEN, Ph.D. Oregon Health and Science University Portland, Oregon POSITION STATEMENT: Testified in support of HB 434 and offered a comparison of naturopathic physicians with allopathic and osteopathic physicians. DANIEL YOUNG, N.D. Eagle River, Alaska POSITION STATEMENT: Testified in support of HB 434. NANCY THERRELL Fairbanks, Alaska POSITION STATEMENT: Testified in support of HB 434. FRANK THERREL Fairbanks, Alaska POSITION STATEMENT: Testified in support of HB 434. MARY MINOR, N.D. Anchorage, Alaska POSITION STATEMENT: Testified in support of HB 434 and shared her background of 20 years of licensure as a naturopathic physician. ACTION NARRATIVE  TAPE 04-14, SIDE A  Number 0001 CHAIR TOM ANDERSON called the House Labor and Commerce Standing Committee meeting to order at 3:20 p.m. Representatives Anderson, Gatto, Dahlstrom, and Guttenberg were present at the call to order. Representatives Lynn, Crawford, and Rokeberg arrived as the meeting was in progress. HB 434-NATUROPATHIC MEDICINE CHAIR ANDERSON announced that the only order of business would be HOUSE BILL NO. 434, "An Act relating to the practice of naturopathic medicine; and providing for an effective date." Number 0082 REPRESENTATIVE JIM HOLM, Alaska State Legislature, sponsor, explained that HB 434 is offered to ensure professional, safe, naturopathic healthcare for all Alaskans; it brings 17-year-old, outdated statutes up to date and in line with 14 other states. It provides for quality health care through continuing education requirements and improved services in the practice of naturopathic medicine; addresses Alaska's shortage of physicians; provides alternative care and reduces health care costs to "all the rest of Alaska"; places continuing education requirements in statute; says naturopathic physicians may prescribe "legend" or prescriptive drugs based on examining board licensure, and/or controlled substances as registered by the federal Drug Enforcement [Administration]; and specifies that naturopathic physicians may perform minor surgery based on their education, training, and licensure. Number 0260 SCOTT LUPER, N.D., a naturopathic physician who practices and lives in Fairbanks, testified in support of HB 434 and shared his professional experience. He noted that he received his undergraduate degree with honors from Portland State University; graduated with honors in research from the naturopathic college in Portland; opened a practice; moved to Tempe, Arizona, as the department chair of diagnostics; taught and supervised the training of naturopathic physicians for two years; last year became chief medical officer and supervised 22 doctors; and then, after deciding against being an administrator, moved to Alaska and opened up a practice. DR. LUPER turned attention to HB 434, saying the intent of the bill is to allow naturopathic physicians to practice as they are educated. They are trained to function as primary care providers, deciding the appropriate action, investigation, or referral for individual cases. He pointed out a JAMA [Journal of the American Medical Association, 1998] article in the bill packet that says their clinical education, which is entirely outpatient-based, is designed to prepare them to be primary care providers. Number 0487 DR. LUPER focused on Appendix C in the bill packet, "A Comparison of Licensed Medical Professions in the State of Alaska," which compares levels of education of all health care providers in Alaska and shows those for naturopathic physicians to be among the highest. Appendix D compares Alaska with other states in the document entitled "Comparison of Naturopathic Governance in Licensed States." This points out that Alaska is unique in not allowing naturopathic physicians to practice up to the full scope of their licenses. He specifically mentioned the areas of minor surgery and some prescription rights. DR. LUPER reported that malpractice costs for naturopathic physicians are among the lowest of all the professions; he personally pays $3,000 a year. He turned to Appendix E, "Comparison of Naturopathic and Major Medical Schools," in which three leading naturopathic colleges, National, Bastyr, and Southwest, are compared with three leading allopathic colleges, Johns Hopkins, Yale, and Stanford; the comparison is further broken into basic and clinical sciences, clerkships, and allopathic therapeutics. He explained that the first two years of medical education are devoted to basic sciences, and the last two years to therapeutics and practical applications. He said the hours of education are comparable, though not identical, within the six colleges. DR. LUPER referred to the next supporting document, "Comparison of Pharmacology Training," and explained: What we did was gather information from over 100 colleges and pull them all together. Under the pharmacology list you see that for allopathic, osteopathic and naturopathic colleges, ... the amount of hours in pharmacology training is about 100 hours, ... again comparable. DR. LUPER pointed out that the teachers for all types of physicians in the area of pharmacology are the same. The second table looks at the numbers of hours involved in clerkships and clinical therapeutics, with the hours for all types of physicians being comparable. Number 0720 DR. LUPER related that a naturopathic education includes learning how to use nutrition, botanicals, and a wide variety of therapeutic agents to help patients. He said N.D.s get special training on the interactions between drugs and nutrients, and are recognized experts in that field. He gave an example of a Fairbanks hospital that brought up an N.D. from Washington State to consult in its oncology program on the interactions between nutrients and chemotherapeutic agents. He said patient care is the motivating factor for pursuing an expanded scope of practice in Alaska for naturopathic physicians; it is inconvenient and expensive for his patients to go to another physician to get an antibiotic or hormone prescription when he, as a naturopathic physician, is well trained to perform these functions. Number 0891 REPRESENTATIVE LYNN noted that he'll soon be 71 years of age, with aches and pains. He asked how he should choose a health care provider. DR. LUPER shared that most patients come to his practice by word of mouth when they want to find the cause of a particular problem. They generally experience an hour-long initial intake process in order to find out what predisposes them to a particular problem, such as diet, sleep habits, genetics, or motor patterns. He added, "You'd have to be willing to spend the time, and you'd also have to be willing and open-minded enough to perhaps change something about your lifestyle, something about your diet, something about the things that you take, for example. You'd have to be willing to be coached." DR. LUPER, in further response, said state insurance provides coverage, but Medicare and Tricare insurance don't. He explained that Alaska has an insurance-equality law that requires recoverage in state group policies for naturopathic services. The federal government doesn't have this requirement. He noted that currently he has to go to an M.D. to get prescriptions written for his patients, and those prescriptions are covered by state and federal insurance programs. In response to a question from Representative Dahlstrom, he said legend drugs are sold by prescription only; schedule drugs are drugs with an abuse or addictive potential. Legend drugs comprise a wide category of drugs, whereas schedule drugs are a subcategory of legend drugs. Number 1120 REPRESENTATIVE GATTO referred to Appendix E and asked Dr. Luper what the Johns Hopkins, Yale, and Stanford medical schools are doing "that you are not doing." DR. LUPER replied that the Johns Hopkins, Yale, and Stanford students are doing specialty rotations such as oncology, neurology, or nephrology, while naturopathic physicians in training are learning naturopathic modalities such as homeopathy and hydrotherapy. The basic knowledge - what it takes to become a doctor, how to listen to people, how to run lab tests, and how to do a differential diagnosis - is similar for both groups. He informed the committee, "The therapeutics are where the differences begin to multiply." Number 1145 REPRESENTATIVE GATTO asked for clarification with regard to residency requirements. DR. LUPER replied that there was no requirement to do residency for naturopathic physicians. He further explained that the profession experiences a scarcity of residency placements. He gave the example of a residency program that he directed at Southwest College. He had three residency positions and eleven well-qualified applicants. A further difference between the naturopathic profession and the allopathic profession is that the federal government subsidizes residencies so that each and every allopathic physician has the ability to get a residency. Number 1199 REPRESENTATIVE GATTO gave an example of someone suffering from cancer. He asked whether [naturopathic physicians] will say something is out of their league if that's the case. DR. LUPER replied that many of his patients have cancer and come to him looking for alternatives; he is trained to let them know the best treatment for their particular problem. For example, the treatment for testicular cancer is actually quite good, with a success rate higher than 85 percent; thus he'll tell such a patient, "The best treatment available for you is to go and get chemotherapy." For pancreatic cancer, though, the effectiveness of chemotherapy is less than 2 percent. He explained: I know of a treatment where the average lifespan increases from two months to nineteen months. So I let him know, "There's an alternative for you. There's a ... program ... that's been put together by a doctor in New York City by the name of Gonzales. Here's his results from the published research. This is what it takes to do this. Frankly, I think this is a good option for you." DR. LUPER added that he never tells his patients what to do, but instead tells them what he knows. He pointed out that some people do "wacky things" in any profession. In his role as a teacher, he noted, he trained naturopathic doctors to know the boundaries of their expertise. He felt that experience played an important role in confidence building and that many naturopathic doctors go on to become experts in a particular field such as cancer. Number 1255 REPRESENTATIVE GATTO asked what Dr. Luper thought of PC SPES [a dietary supplement marketed for "prostate health"]. DR. LUPER replied: PC SPES is a substance that was touted to treat [prostate] cancer, and the results of the initial research looked quite good. I was suspicious of it ... and did not use it with any patients. It turns out that PC SPES was adulterated with a hormone, and that's why it worked. Once that came out, it was like, forget it. If we wanted to use hormones, we'd refer for hormone treatment. There are things in the world which are new and unproven. And, frankly, I stay away from those. ... I'm willing to look at new things as long as there's a reasonable approach and some research behind it. Number 1525 CHAIR ANDERSON read from a letter submitted to the committee by Alex Malter, M.D., president of the Alaska State Medical Association, which read in part [original punctuation provided]: The Alaska State Medical Association (ASMA) represents physicians statewide and is primarily concerned that Alaskans receive high quality healthcare. The Association urges you and your committee to not support HB 434. The expansions of the scope of practice for naturopaths through the bill would not enhance patient care nor would it improve access to care. Medical treatments fall into three broad categories: 1) Those that have been proven to work; 2) Those that have been proven not to work; and 3) Those that have not yet been adequately studied to know whether or not they work. Unfortunately, naturopathic treatments often fall into the third category, being based on anecdote as opposed to scientific proof. Training for naturopaths is significantly less rigorous than that for physicians, in both length and depth of study. Its emphasis on natural healing does not allow adequate opportunity for its students to fully learn the accepted pathology, physiology, and pharmacology necessary to safely treat most medical conditions. Yet HB 434 would allow naturopaths to practice many aspects of medicine heretofore (and appropriately) limited to physicians and those other with training based in proven medical science. This could be unsafe for Alaskan patients. Additionally, expanding the scope of practice for the 35 naturopaths in Alaska will not realistically improve access to care in the state. Indeed, few naturopaths practice in those rural areas in which access issues are most critical. Finally, anyone not licensed as a physician but seeking to practice in any like manner should be legally held to the same standard of care as a licensed physician. ASMA suggests that if HB 434 is enacted, it should first be amended to keep existing law pertaining to naturopaths in place (AS 08.45.010 - 200), and a subsection should be added to hold naturopaths to the same standard of care as licensed physicians in their treatment of any patient. CHAIR ANDERSON asked Dr. Luper to respond to this letter, particularly in the area of standards. Number 1648 DR. LUPER replied that, to the best of his ability, he'd presented the committee with information about the extent of a naturopathic physician's education. He acknowledged that not all naturopathic students get residencies, but they are all trained as primary care providers; they sit for national board exams, and this indicates a certain level of safety, he suggested. The national board exams include minor surgery and pharmacology. He commented, "You go to school, you learn how to do it, you take a test, then you go do it. That's ... the system. That's how it works." DR. LUPER took issue with Dr. Malter's assertion that this bill would not have a large impact on healthcare in Alaska. He sees approximately 30 patients a week, 1,500 visits annually. He estimated there are about 20 practicing naturopathic doctors in Alaska and, as a result, many people's health is affected. He said his patients would certainly argue that what he does is significant. He said he felt that even if naturopathic doctors helped only a handful of patients improve their health because of this bill, then it would be worthwhile. He explained, "We're asking ... to be able to practice up to the level of our education, to be able to practice up to the level of our training, so that we can provide the best quality care we can for our patients." CHAIR ANDERSON noted, from his discussions with several physicians, that there is fear that this legislation could result in someone getting hurt. Referring to Section 13, page 6, paragraph (6), where minor surgery is defined, he said concerns he'd heard included lack of justification to perform this type of procedure without proper medical training and whether [naturopathic physicians] are prepared to deal with problems that may arise from anesthetics when performing minor surgery. DR. LUPER responded that naturopathic physicians are well trained in this area, since they are trained in the use of sterile technique and local anesthetics, and they have "crash carts" available in case of serious drug reactions or heart problems. Number 1883 CHAIR ANDERSON noted that Section 15, on the last page of the bill, repeals AS 08.45.040, pertaining to required disclosures to a patient. He asked why this should be repealed. DR. LUPER clarified that that section refers to a disclosure, that "we have to say we are not physicians." REPRESENTATIVE ROKEBERG asked Dr. Luper if he could get malpractice insurance and currently has to disclose to patients that he has malpractice insurance. He also asked if medical doctors have to disclose to patients that they have medical malpractice insurance. DR. LUPER replied that he has insurance and has to, at this point, disclose this fact to his patients. He didn't know if this was the case for allopathic doctors. Number 1977 REPRESENTATIVE LYNN asked if naturopathic physicians are admitted to practice in any hospital in Alaska or any of the other 49 states. DR. LUPER replied that they don't have admitting privileges, although in the past they did. He explained: The profession almost died out in the '50s, and it's experienced a resurgence, ... starting in the '70s. ... Fully one-third of the profession ... is in school, learning to be naturopathic physicians. We've had ... a net gain of eight doctors in the state in the last three years. So, in time, we will achieve these goals of ... having hospital privileges. In a way, we are at the position where D.O.s [doctors of osteopathy] were back in the '50s and '60s. Number 2050 REPRESENTATIVE ROKEBERG asked for clarification on the minor- surgery examination that naturopathic doctors take. DR. LUPER responded that it is a national board, multiple-choice exam. He gave some background information: As part of the program, naturopathic ... students have to take a course of study in minor surgery to learn the technique. Then, when they're in the clinic, they have to perform the procedures on a specialty minor- surgery shift where they observe first, and then do with assistance, and then do on their own. Now, to my surprise, I found that I had a talent for this and I liked it. ... Let me remind you, ... every state that licenses naturopathic physicians allows minor surgery, except Alaska. Number 2123 REPRESENTATIVE GATTO requested Dr. Luper's comments on the practice of prescribing naturopathic medications and selling them in the same office. DR. LUPER replied that many of his patients need specialty nutrients that are not sold locally. He orders them, prescribes them, and sells these nutrients. But if there is another local source, his patients will often use them. He gave an example. CHAIR ANDERSON asked if Dr. Luper ever bought these nutrients in bulk to sell to his patients. DR. LUPER replied that, yes, he does this in order to save his patients money. Number 2198 CLYDE B. JENSEN, Ph.D., Oregon Health and Science University, testified in support of HB 434 and offered a comparison of naturopathic physicians with allopathic and osteopathic physicians. He provided some background qualifications, noting that he'd held senior positions in osteopathic, allopathic, and naturopathic medical schools. He said he became the president of the National College of Naturopathic Medicine in 1996 and served in this capacity for five years. DR. JENSEN said he learned several valuable things while teaching and performing administrative responsibilities at the nation's oldest naturopathic medical school. He said the criteria for admission into each of the three types of medical colleges are virtually identical. He found that the people who applied to naturopathic medical school had very strong feelings about the type of care the naturopathic physician can provide. They would have succeeded in conventional medical schools but chose naturopathy because it is a less invasive, more preventive type of medical practice. He reiterated that the admissions criteria is credible and almost identical to those of conventional medical schools. Number 2307 DR. JENSEN stated his second point, that the basic biomedical sciences are taught at generally the same level of intensity and order of magnitude, with the same number of hours of instruction and so forth in each of the three types of medical disciplines. He said he was surprised to find that basic pharmacology is taught in the same way and at the same level as at conventional M.D. medical schools, where the reliance on drugs is greater than in the naturopathic profession. DR. JENSEN said he has learned that naturopathic physicians have some advantages in their training over what allopathic and osteopathic physicians have in areas of nutrition, physical medicine, and, at least in the case of allopathic physicians, herbal medicine and homeopathic medicine. He said he feels these areas of knowledge are effective and useful, and they give naturopathic physicians training in the area of preventive medicine and chronic health care that is, in many ways, superior to that which conventional health care providers receive. TAPE 04-14, SIDE B  Number 2362 DR. JENSEN said instructors of naturopathic physicians realize it is imperative for students to know how and when to refer their patients; he was pleased to see that the curricula of naturopathic medical schools emphasize the responsibility of naturopathic physicians to refer cases that fall beyond their scope of practice. DR. JENSEN listed the advantages of a conventional allopathic and osteopathic medical education, including more training in in-patient facilities where the student has the benefit of seeing the broad scope of pathology. He said conventional medical students receive more and better training in the area of pharmacotherapeutics because the teaching physicians use more of them. Because those medical students see more drugs used, they have an advantage in knowing how to use those pharmaceutical drugs. Dr. JENSEN mentioned that graduate medical education is not as well developed among naturopathic medical education; residencies and fellowships are typically paid for through federal entitlement programs in conventional medicine, and naturopathic physicians do not have access to entitlement programs. Without that federal reimbursement, naturopathic educational programs cannot afford to provide the level of graduate medical education that conventional medical schools provide. Number 2189 CHAIR ANDERSON said he didn't believe opposition to this bill on the part of conventional physicians that he had spoken with was based on competition. He asked Dr. Jensen why there was such opposition to this bill from medical doctors. DR. JENSEN replied: I certainly came from mainstream medical education into a naturopathic medical school, knowing very little about naturopathic medical education and, frankly, being somewhat skeptical of what I was going to encounter there. My guess is that the majority of conventional health care providers have that same skepticism because they have had little experience with the naturopathic profession and are not aware of the intensity and scope of training, ... [and] don't know enough about the profession to know how to interact with it. Number 2110 REPRESENTATIVE GATTO asked whether Dr. Luper would prescribe that his patients take one-a-day vitamins and that those vitamins are ones he sells. DR. LUPER replied that he wants his patients to get what they need, and he went on to discuss the effects of vitamins. He agreed that there could be a conflict of interest if the physician was unscrupulous. REPRESENTATIVE LYNN noted that when he was young, medical doctors sold medicine out of their offices; even today, doctors pass out samples. REPRESENTATIVE GATTO talked about a naturopathic physician's prescribing a medicine that was harmful to him. He ascribed his active interest in patients and their care to his background as a paramedic. DR. LUPER remarked that all physicians make mistakes. Number 1926 REPRESENTATIVE GUTTENBERG referred to Dr. Malter's letter and the statement therein, saying naturopathic treatments fall into the category of "not being adequately studied." He asked Dr. Luper to respond to that statement. DR. LUPER disagreed, citing his experience with reviewing research. He said he is a well-trained physician and uses his knowledge and experience to help patients. He said he depends on the knowledge and experience of other medical people, as reported in the literature. CHAIR ANDERSON gave an example of a conventional prescription of medication for hair loss that he believes is narrow and absolute. DR. LUPER contended that there are alternatives to remedies that are approved by the FDA [Federal Drug Administration]. Number 1813 REPRESENTATIVE CRAWFORD told of his 17-year experience with chronic hives that was not cured by conventional medicine. He said he'd met a naturopathic physician who was able to diagnose and cure him. He offered his belief that many remedies aren't studied because there is no profit motive to do so. REPRESENTATIVE LYNN noted that many over-the-counter medications have a warning that they haven't been tested. He wondered why they had not been tested. DR. LUPER replied that he thought most had been tested and that FDA approval costs hundreds of thousands of dollars. He said he thinks many medicines are not FDA-approved because there isn't a large enough market for them. Number 1565 DANIEL YOUNG, N.D., Eagle River, testified in support of HB 434, noting that he had been practicing in Alaska since 1995 in a practice he shares with his wife, also a naturopathic physician. He provided his educational and professional background. He said his first love is being on the frontline with his patients. Saying he came to represent his patients, he drew the committee's attention to their packets, where there was a list of 700 names, categorized by district, of people who want to be able to access naturopathic medical health care. DR. YOUNG mentioned letters being submitted by medical doctors in Alaska, whom naturopathic physicians work with on a routine or daily basis and who support this legislation because they support naturopathic doctors' ability to practice to the full scope of their training. He noted that naturopathic physician services are requested by medical doctors in medical clinics, specifically, Alaska Regional Medical Park. He continued: The goal of this bill is to bring our scope up to a level that is representative and commensurate with our education. It is not about "us and them." It is about complementary health care. If you're in a car wreck, break an arm, and come into our office, you're going right to the orthopedic doctor because that's where they shine. But if you have arthritis and you've tried every drug in the world and you still have arthritis, you might seek me out, and I might be able to help you a whole lot. Number 1379 DR. YOUNG surmised that a large amount of money is pent on alternative medicine, which isn't naturopathic medicine, where the goal is to teach people to live healthy lifestyles rather than consume supplements. He related that "doctor" in Latin means teacher. Naturopathic doctors teach their patients to make the changes necessary to improve their health. He opined that research is manipulated and that the natural product industry has been bought out by the pharmaceutical industry. He remarked, "They don't care if you're on St. John's wort or Zoloft, because they're marketing both." In contrast, he described the naturopathic approach: We have a hierarchy of therapeutics, and that means we start at the beginning - nutrition and diet and exercise, stress reduction. Then we work up to manipulation or homeopathy or different ways that we can help the body to heal itself. ... It's different than going into a medical primary-care situation where there's a whole cabinet of bright-colored and popular name brands of pharmacological substances. There's lots and lots of fluff in that area. ... We can provide complementary care in Alaska, which is good for Alaskans, and it's what our patients want. Number 1124 REPRESENTATIVE GATTO noted that there is criticism about lack of regulation with regard to natural medicines sold at Wal-Mart and Costco. He asked if Dr. Young exercises a greater control over the quality of the medicines he prescribes and also markets what he prescribes. DR. YOUNG replied that he obtains medicines from reliable sources. He acknowledged that often there are different grades of natural medicines, with associated costs. He said he was against the purchase of medicines from Wal-Mart because he felt "those are an exploitation of the tools that we sometimes rely on in natural medicine." He gave several examples of medicines that he feels are exploited by big business. He added that he prescribes substances that he knows will help; has a one-to-one relationship with his patients; and trusts the people who make the products he uses. He continued: I have a very tight rein on the products that I use in my practice. Those are the tools of our trade. We have that right in naturopathic medicine. Our education is part of that component. We are trained in nutrition. We're Ph.D. levels in nutrition, and we know about botanical medicines. We're the best trained on them. When M.D.s learn of our training, they write us letters of support because they're glad we do what we do, because they don't have time. DR. YOUNG went on to describe patients coming in with shopping bags full of self-selected medications; he described their confusion and vulnerability to marketing. Number 0748 NANCY THERRELL, Fairbanks, testified that she supports HB 434 and works at a naturopathic clinic. She spoke of her improved health and life, and of the importance of having a choice for patients. Number 0704 FRANK THERRELL, Fairbanks, testified in support of HB 434. He provided personal experience with conventional medicine that had had poor outcomes, and then spoke of being cured of his ailment by naturopathic medicine. Number 0635 MARY MINOR, N.D., Anchorage, testified in support of HB 434. She noted that her background included 20 years of licensure as a naturopathic physician and practicing since 1990 in Anchorage. She said patients she sees are in four categories. Probably the most common is already seeing both a conventional provider and her. For the second, she is the primary care provider; if another level of expertise is needed, she refers them to other kinds of providers. Third is a person who, like Mr. Farrell, is suspicious of conventional medicine and doesn't want to see another conventional provider. She remarked, "I can't explain to you why a person with diabetes will accept a prescription from me, but that same prescription, from a conventional provider, they're suspicious of." Noting that the fourth category contains people already on multiple prescriptions, some of which may be interacting in a way that isn't helping their quality of life, she said: I need the flexibility to help them wean down to the least amount that is going to be conducive to a good quality of care. With the web of providers that I have in my community that I refer to, and who also send patients my way, I think I'm in a good position to manage that situation. That's why I think although our licensing law was good for its day, 17 years ago, it's now time that we need to expand it. Number 0366 CHAIR ANDERSON assigned HB 434 to a subcommittee consisting of Representative Gatto, chair; Representative Crawford; and Representative Dahlstrom. He requested that the bill return to the committee by February 25, 2004. He asked subcommittee members to look at a compromise with the Alaska State Medical Association; review Section 13, [paragraph] (6), on minor surgery; review Section 15 to see if that complete repealing is necessary; and determine whether current or proposed revisions relating to the sale of medication from these naturopathic offices are grounded in a question of ethics or potential fraud. [HB 434 was held over.] ADJOURNMENT  There being no further business before the committee, the House Labor and Commerce Standing Committee meeting was adjourned at 4:50 p.m.