ARIZONA STATE LEGISLATURE
Forty-ninth Legislature – Second Regular Session
SENATE HEALTHCARE AND MEDICAL LIABILITY REFORM AND
HOUSE OF REPRESENTATIVES HEALTH AND HUMAN SERVICES
COMMITTEE OF REFERENCE FOR THE SUNRISE APPLICATIONS OF:
THE AMERICAN MEDICAL COLLEGE OF HOMEOPATHY
THE ARIZONA PHARMACY ALLIANCE AND
THE ARIZONA COMMUNITY PHARMACY COMMITTEE
THE ARIZONA STATE ASSOCIATION OF PHYSICIAN ASSISTANTS
THE ARIZONA NON-MEDICAL HOME CARE LICENSURE COALITION
THE ARIZONA NATUROPATHIC MEDICAL ASSOCIATION
AND THE SUNSET REVIEWS OF:
BOARD OF EXAMINERS OF NURSING CARE INSTITUTION ADMINISTRATORS AND ASSISTED LIVING FACILITY MANAGERS
BOARD OF MEDICAL STUDENT LOANS
STATE OF ARIZONA BOARD OF PODIATRY EXAMINERS
Minutes of Interim Meeting
House Hearing Room 3 -- 9:30 a.m.
Chairman Barto called the meeting to order at 9:42 a.m. and attendance was noted by the secretary.
Members Present
Senator Barbara Leff Representative David Bradley
Senator Linda Lopez Representative Steve Court
Senator Thayer Verschoor Representative Nancy Barto, Co-Chairman
Senator John Nelson
Members Absent
Senator Amanda Aguirre Representative Doris Goodale
Representative Phil Lopes
Board of Medical Student Loans
Ingrid Garvey, Majority Research Analyst, related that the Board of Medical Student Loans was created in 1977 to provide educational loans to medical students who agree to serve in rural and medically underserved areas of Arizona. In addition to granting loans, the Board collects and maintains data on loan recipients. The Board’s eight members serve four-year terms. For the students, each year of eligible service as a physician results in one academic year of loan forgiveness, and there is a minimum two-year service commitment requirement. The Board serves with no compensation and receives no funding for administrative support, which is provided by the University of Arizona (UA), Midwestern University and A.T. Still University. The Board is funded through an annual General Fund appropriation and the Medical Student Loan Fund.
Carol Galper, Chair, Board of Medical Student Loans, gave a presentation about the medical student loan program, including the following recommendations (Attachment 1):
In response to questions, she advised that there are currently eight students in the program; seven will graduate in 2011 or 2012 and one will graduate in 2013; however, the program should not sunset until 2017 because the residency placement needs to be monitored to make sure the students fulfill their service obligations to the state. She advised that there is oversight by the UA College of Medicine, which pays the majority of administrative costs, but in the last few years, A.T. Still and Midwestern University provided funds to offset costs.
Co-Chairman Nelson moved that the Board of Medical Student Loans be continued for six years until July 1, 2017 and authorize staff to draft conforming legislation.
Senator Leff questioned whether the motion should include the requested language change to statute, which Ms. Galper acknowledged would be helpful in funding the last student.
Co-Chairman Nelson withdrew the motion that the Board of Medical Student Loans be continued for six years until July 1, 2017 and authorize staff to draft conforming legislation.
Co-Chairman Nelson moved that the Board of Medical Student Loans be continued for six years until July 1, 2017 and authorize staff to draft conforming legislation, including the waiver provisions. The motion carried.
State of Arizona Board of Podiatry Examiners
Ingrid Garvey, Majority Research Analyst, related that the purpose of the Board is to protect the health, safety and welfare of Arizona citizens by regulating and maintaining standards of practice in the field of podiatric medicine. The Board issues and renews licenses to qualified persons, conducts investigations and hearings concerning unprofessional conduct or other statutory violations, disciplines violators and provides consumer information to the public. Its five members serve five-year terms. In 2008 the Committee of Reference (COR) recommended that the Board be continued for two years. She directed the Members’ attention to letters from the Board to the Arizona Ombudsman’s Office and from the Ombudsman’s Office to the Board stating that the concerns in the Ombudsman’s final report have been resolved (Attachment 2).
Sarah Penttinen, Executive Director, Arizona Board of Podiatry Examiners, reviewed a handout highlighting major points of the written response submitted for the sunset review inquiry, including requested changes to the Board’s enabling statutes (Attachment 3):
Ms. Penttinen asked that the Board be continued for 10 years.
Co-Chairman Barto announced the names of those who signed up in support but did not speak:
Joseph Abate, Arizona Podiatric Medical Association
Co-Chairman Nelson moved that the Arizona Board of Podiatry Examiners be continued for 10 years until July 1, 2017 and authorize staff to draft conforming legislation.
Co-Chairman Nelson withdrew the motion that the Arizona Board of Podiatry Examiners be continued for 10 years until July 1, 2017 and authorize staff to draft conforming legislation.
Co-Chairman Nelson moved that the Arizona Board of Podiatry Examiners be continued for 10 years until July 1, 2021 and authorize staff to draft conforming legislation.
Co-Chairman Barto commended the Board for making so many changes within a short time and addressing all of the problems during the couple of years it was closely examined.
Question was called on the motion that the Arizona Board of Podiatry Examiners be continued for 10 years until July 1, 2021 and authorize staff to draft conforming legislation. The motion carried by a roll call vote of 7-0-0-3 (Attachment 4).
Arizona Pharmacy Alliance and Arizona Community Pharmacy Committee
Ingrid Garvey, Majority Research Analyst, related that a sunrise application was submitted by the Arizona Pharmacy Alliance and the Arizona Community Pharmacy Committee requesting the following:
Gregory Lewis, President-Elect, Arizona Academy of Family Physicians (AZAFP), representing self, opposed the sunrise application. He stated that the AZAFP Board supports allowing pharmacists to immunize children ages six and older with the flu vaccine without a prescription because the vaccine is annual and there is virtually no risk in most circumstances; however, the Board opposes pharmacists immunizing children with any other vaccination with a prescription for the following reasons:
· Providers other than the child’s Primary Care Physician (PCP) may provide a prescription through different avenues, such as urgent care centers, emergency rooms, etc., which would defeat the purpose of the patient-centered medical home, which encourages patients to use their PCP as the main source of entry into the health care system.
· Family physicians and PCPs would be deprived of an opportunity to interact with families when children are brought in for immunizations, which is sometimes the only opportunity to go over a number of preventative care issues.
In response to questions, Mr. Lewis stated that a proposed law will require the PCP to be notified; however, AZAFP members indicate that PCPs are not currently receiving information from pharmacies about vaccinations given to adults, which was required in legislation passed in 2008 that allowed adult vaccinations to be given in pharmacies. He said a survey of AZAFP members shows that 90 percent of providers involved in clinical care provide vaccinations for children in the office. He does not have information about the percentage of PCPs that do not receive information from pharmacists on adult immunizations.
Senator Verschoor contended that by allowing this, opportunities for children to receive immunizations would be increased since they may not otherwise be immunized because it may not be convenient or possible to access a physician, or it could be cost-prohibitive. Mr. Lewis replied that parents and children need to see a provider in some context to obtain a prescription, but the best environment for that to happen is in a patient-centered medical home.
In response to further questions, Mr. Lewis cited the immunizations given to children over age six and advised that he has not talked to pediatricians, but he believes they are in favor of the concept. He acknowledged that children can currently obtain vaccinations from public and community health centers, which are encouraged to notify the PCP, but that is not the reality, although he does not have a survey or statistics to provide detailed information.
Jeff Gray, Legislative Liaison, Arizona Pharmacy Alliance, testified that a sunrise hearing was held two years ago to request a scope of practice increase for pharmacists to immunize adults without a prescription. Legislation was passed and pharmacists have immunized about 100,000 individuals. The legislation required a report to the PCP, if the patient has one, and the Arizona Department of Health Services’ adult reporting system. Additionally, any adverse reactions must be reported to the federal Vaccine Adverse Events Reporting System. Since passage of that legislation, the Alliance has been asked why immunizations for children were not included. He explained that the intent was to address adults first, and if that is successful, to address children in the future. He added that this is the first time he has heard that reports are not being made to PCPs on adult immunizations.
Mr. Gray stated that meetings have been held with stakeholders since August 2010. Pediatricians were worried about children under 6 years of age not receiving well checks, which is the reason for the 6 to 17-year range for flu vaccines. The flu portion is not controversial at all. In relation to immunizations for children with a prescription, the Alliance supports the idea that the patient should have a center point for care, but there are already opportunities for children to receive prescriptions apart from the PCP, so this application does not create that circumstance.
In response to questions, he advised that if someone has no PCP, there is no report, but the information is stored at DHS where it can be accessed by physicians. He conveyed that he will conduct research to determine what percentage of pharmacists report to PCPs.
Mr. Gray told the Members that the Alliance is committed to working with stakeholders and most are comfortable with moving forward with that commitment in place. He added that voluntary collaborative practice agreements between physicians and pharmacists to manage patient medications are currently permitted, but only in four particular practice settings. The sunrise application requests removal of the location requirements to allow physicians and pharmacists to enter into the agreements regardless of where the pharmacist practices.
Sandra Leal, Director, Clinical Pharmacy, El Rio Health Center, Tucson, remarked that when a doctor identifies a patient having trouble with uncontrolled diabetes, high blood pressure or high cholesterol, the doctor refers the patient to the clinical pharmacist or the pharmacist staff. She helps the provider and patient maximize the medication regimen so the patient obtains better control, and coordinates care for the patient. Often patients cannot afford the regimen they are on, so she works closely with the provider, patient and pharmacy to develop medication regimens that are affordable. Data collected over nine years shows a significant reduction in blood glucose of patients, increased success in controlling blood pressure and improving things like immunization rates and foot and eye exams. Four sites in the state have these agreements, three of which are at El Rio. She would like to work with other institutions so they can also provide these services.
Arthur Martinez, Chief Medical Officer, El Rio Health Center, Tucson, stated that when the program started at El Rio, many doctors were concerned, so a voluntary system was developed with guidelines for the pharmacists to work within. The pharmacists conduct a very comprehensive assessment and communicate with the doctor, but the major benefit is to the patient by having someone actively working with them to provide education about their disease and engage them in their treatment process. There have been improvements in blood glucose levels that translate into significant savings in the long run. It has been a very successful model and all of the doctors now are supportive of the program.
Co-Chairman Nelson commented that he relies on the pharmacist to advise him on medications and there have been occasions where he has had to go back to the doctor because the pharmacist indicated that something could not be done, so he cannot see the need for specialty.
Mindy Smith, Director, Arizona
Pharmacy Alliance, advised that currently the legislation specifically
lists only four sites where a collaborative practice can occur. The idea is to
eliminate the four sites so the site is defined in the agreement between the
physician and the pharmacist. For example, in a rural community where there is
one pharmacy, services would not be provided at the dispensing counter, but there
would be a sit-down consultation with the patient for 30 to
90 minutes to manage medications for a chronic disease.
Dr. Kelli Ward, President, Arizona Osteopathic Medical Association (AOMA), Lake Havasu City, indicated that AOMA supports the pharmacists’ request to administer flu immunizations without a written prescription for children ages 6 to 17; however, there is still concern that pharmacists administering other immunizations may interrupt continuity of care and prevent families from bringing children in for well checks. Also, if the family is insured, they may not receive reimbursement from the insurance plan for vaccinations given in the pharmacy. She added that she is willing to work with pharmacists to address those concerns.
She related an incident in which a pharmacist made a therapeutic substitution for a regular tetanus shot without her approval. She added that while she realizes immunizations are for the public good, she fears negative public health outcomes that may happen to children without access to a physician’s guidance during crucial years, especially in areas of weight control, nutrition, sexuality, safety and school performance. A yearly physical, including vision, hearing, etc., is very important. She responded to questions concerning the therapeutic substitution made by the pharmacist and patient access.
Ms. Smith answered questions concerning collaborative practice agreements.
Mr. Gray clarified that the example by Dr. Ward relating to a therapeutic substitute occurred in California, but that is not permitted in Arizona. He responded to questions concerning liability. He explained that the last portion of the application is a technical issue dealing with students currently in pharmacy school; the idea is that students, under the direct supervision of an immunization-trained pharmacist approved by the Board of Pharmacy, can administer vaccines so students have that training upon graduation.
Rory Hays, Arizona Nurses’ Association, expressed support for the over six-year-old flu immunizations. She pointed out that nurse practitioners are the medical homes for a growing number of people; therefore, they should be included in the ability to prescribe and enter into collaborative agreements. She added that more work is needed to make sure appropriate communication takes place between all involved parties in collaborating practice agreements.
Amanda Weaver, Executive
Director, Arizona Osteopathic Medical Association, expressed support for
the flu shots, but indicated that there are some problems with the collaborative
practice agreements and other vaccines with prescriptions, but she deferred her
testimony to
Dr. Ward.
Co-Chairman Barto announced the names of those who signed up in support but did not speak:
Mark Boesen, Director, Government Affairs, Apothecary Shops
Katie Schiraldi, representing self
Kelly Hampton, Immunization Trained Pharmacist, representing self
Peter Vu, Pharmacy Student, representing self
Nisha Patel, PharmD, El Rio Community Health Center
Andrew Wong, Pharmacy Student, El Rio Community Health Center
Kevin Boesen, Pharmacist, representing self
Lorri Caum, Pharmacist, representing self
Harlan Wand, Executive Director, State Board of Pharmacy
Tara Plese, Arizona Association of Community Health Centers
Mr. Gray remarked that the Members should receive an email from David Landrith, Arizona Medical Association, indicating that he will continue to work with stakeholders on this.
Co-Chairman Nelson moved that the Committee of Reference recommend that a bill be drafted for consideration by the full Legislature containing the items submitted in the sunrise application received from the Arizona Pharmacy Alliance and the Arizona Community Pharmacy Committee. The motion carried by a roll call vote of 7-0-0-3 (Attachment 5).
Board of Examiners of Nursing Care Institution Administrators and Assisted Living Facility Managers
Ingrid Garvey, Majority Research Analyst, stated that a sunset application was submitted for the Board of Examiners of Nursing Care Institution Administrators and Assisted Living Facility Managers. The Board was created in 1975 and consists of 11 members who are appointed by the Governor for two-year terms. The Board is charged with protecting the public health, safety and welfare by licensing and regulating nursing institution administrators and certifying and regulating assisted living facility managers. The Board investigates all complaints, enforces all practice standards of the administrators and managers and approves continuing education courses. In 2006 the Board was continued for five years.
Allen Imig, Executive Director, Nursing Care Board, related that the Board currently licenses 345 nursing care institution administrators and 2,350 assisted living facility managers. A self-audit was conducted in August 2010 as requested by the Joint Legislative Audit Committee. In 2004 a performance audit was conducted by the Auditor General’s Office and all of the recommendations were successfully implemented. A follow-up review by the Auditor General’s Office in 2007 determined that the Board was diligent in implementing the recommendations. The Board is also current on its five-year review requirements with respect to the Governor’s Regulatory Review Council. Regarding performance measures as provided in the self-audit, the agency either meets or exceeds allowable time frames for administrative processing of licenses, applications, Board approval or denial of licenses or certificates, including investigations, resolving complaints, and processing license renewals. The Board also enjoys a strong working relationship with all of its stakeholders.
Co-Chairman Barto announced the names of those who signed up in support but did not speak:
Vicki McAllister, Nursing Care Institution Board of Examiners
Kathleen Pagels, Executive Director, Arizona Health Care Association
Genny Rose, Executive Director, Aging Services of Arizona
Janna Day, Lobbyist, Arizona Assisted Living Federation of America
Karen Barno, President, Arizona Assisted Living Federation of America
Ken Kidder, representing self
Co-Chairman Nelson moved that the Board of Examiners of Nursing Care Institution Administrators and Assisted Living Facility Managers be continued for 10 years until July 1, 2021 and authorize staff to draft conforming legislation. The motion carried by a roll call vote of 7-0-0-3 (Attachment 6).
Arizona Non-Medical Home Care Licensure Coalition
Ingrid Garvey, Majority Research Analyst, stated that the Arizona Non-Medical Home Care Licensure Coalition would like the Committee to consider regulatory oversight of the in-home care industry. Arizona is 1 of approximately 20 states that does not regulate or monitor businesses that provide in-home care support services. The types of services provided by in-home care workers include assistance with the use of a telephone, shopping, food preparation, housekeeping, laundry, use of public transportation, and assisting consumers with dressing, bathing, ambulation, personal hygiene and medication reminders.
Stuart Goodman, Arizona Non-Medical Home Care Licensure Coalition, indicated that when a loved one is placed in an assisted living or nursing care facility there is lots of oversight, which provides a deterrent for bad behavior and a mechanism to families and consumers when things go wrong, and keeps bad actors from repeating offenses. When a loved one is kept at home to maintain their dignity and save money, an individual is brought in to provide assistance with daily living activities, but there is no oversight, yet that person has the same access as an individual in an assisted living or nursing care facility. The population of people age 65 and over is growing, so the need for this service will continue to increase. This proposal is designed to address public safety concerns of an industry that is unregulated while trying to keep the footprint of government as small as possible. He stated that there are three separate business models:
Mr. Goodman said it is difficult to develop a regulatory structure to address all three business models, so the proposal involves a voluntary certification board where agencies and registries have the ability to opt in or out of oversight. The idea is to make the transition to oversight, and over time, move toward licensure. He conveyed that consideration has been given to creating a self-sustaining regulatory board, and there may be an opportunity to co-locate with the Acupuncture Board, so the boards would be separate, but have common administrative staff.
Discussion followed about possible inclusion of independents and certification requirements for individuals employed by agency models and registries. Mr. Goodman indicated that the requirements will be specified in the legislation and include items like background checks, basic cardiopulmonary resuscitation and insurance. More discussion followed about certification requirements and excessive regulation.
Debra Seplow, President, Home Instead Senior Care; Non-Medical Home Care Licensure Coalition, submitted that there are between 350 to 500 agencies in the state, but unfortunately, her agency is one of the minority that conducts background checks, drug testing, fingerprinting, reviews driving records and provides thorough training, which leaves many vulnerable seniors with no one to watch over them and make sure they are safe at home.
Co-Chairman Nelson asked if a
private organization could be created for this purpose.
Ms. Seplow replied that there are trade associations that are voluntary
membership driven and involve a fee to belong. The National Private Duty Home
Care Association requires that members hire their caregiving employees, which
is one of the three models that
Mr. Goodman discussed. A local trade association, the Non-Medical Home Care
Association, operates along the same lines. The industry does not have the infrastructure
in place and does not collect the amount of fees that would be required if
abuses are discovered and punitive action had to be taken, nor does it have the
appropriate level of “teeth” to create a plan of correction for the agency
deemed inappropriate.
Senator Verschoor remarked that it is expensive for agencies to do what her agency does, which does not necessarily mean the agencies are providing unsafe care. He opined that this is a “slippery slope” and he does not believe this should be done now.
Ms. Seplow responded to questions concerning licensure in other states and the Coalition. She noted that stakeholder meetings were held in which this concept was introduced, and she believes from a raising of hands and written documents that the agencies in attendance are in favor of moving forward.
Phil Pangrazio, Executive
Director, Arizona Bridge to Independent Living (ABIL);
Co-Chairman, Arizona In-Home Care Licensure Coalition, advised that ABIL
has provided non-medical home care to thousands of people in Maricopa County for over 20 years through contracts with the Arizona Long-Term Care System
(ALTCS). He understands the value of program oversight because the ALTCS
program is overseen by the program contractors. There is a requirement for
background checks, fingerprinting, training, site visits and constant follow-up
with the worker. There is a contract between the consumer and caregiver, and
the consumer has control over the hiring and firing of that worker.
Senator Leff asked about funding if regulation is voluntary and not everyone has to pay, noting that she does not believe it can be compared to ALTCS. Mr. Pangrazio agreed that the ALTCS model is completely different from the oversight requested. He added that adequate participation by the agencies will be necessary in order for the Board to provide adequate oversight. He expressed the hope to move forward with the process in the upcoming Session so improvements can be made to the sunrise proposal. If there is not adequate participation by agencies willing to pay a fee and become certified, the process probably would not go much further.
Mr. Goodman clarified that the mechanism considered is a delayed effective date to allow certain things to trigger before certification takes place.
Co-Chairman Barto announced the names of those who signed up in support but did not speak:
Diane Logan, AIRES
Wendy Sokol, Soreo In Home Support Services
Carol Leonard, Director of Patient Care Services, Assisted Healthcare Services
Karen Rizzo, Bayada Nurses
Tom Glatt, Chief Executive Officer, Nightingale Homecare
Daniel Fern, Managing Partner, Homewatch Care Givers
Valerie Shaw, Director of Operations, Care Corner Personal Services
Mahnaz Pourian, President, Home Instead Senior Care
Ed Antonowicz, Owner/Managing Partner, ComForcare Senior Services
Cindy McClung, Arizona Non-Medical Home Care Licensure Coalition
David Carey, representing self
Bob Roth, representing self
Donna Kruck, representing self
Co-Chairman Nelson moved that the Committee of Reference not approve the sunrise application received from the Arizona Non-Medical Home Care Licensure Coalition.
Senator Lopez
moved a substitute motion that the Committee of Reference approve the sunrise
application received from the Arizona Non-Medical Home Care Licensure
Coalition. The motion carried by a roll call vote of
5-2-0-3 (Attachment 7).
Co-Chairman Nelson moved that the Committee of Reference recommend that a bill be drafted for consideration by the full Legislature containing the items submitted in the sunrise application received from the Arizona Non-Medical Home Care Licensure Coalition. The motion failed by a roll call vote of 3-4-0-3 (Attachment 8).
THE MEETING RECESSED AT 1:07 P.M. UNTIL 1:45 P.M.
THE MEETING RECONVENED AT 1:58 P.M. ALL MEMBERS WERE PRESENT EXCEPT SENATOR AMANDA AGUIRRE, REPRESENTATIVE DORIS GOODALE AND REPRESENTATIVE PHIL LOPES.
American Medical College of Homeopathy
Ingrid Garvey, Majority Research Analyst, stated that in 1980 the Board of Homeopathic and Integrative Medicine Examiners was established and charged with protecting the public health and safety by examining, licensing and regulating homeopathic physicians. Currently, the Board licenses and regulates approximately 100 physicians. The Board consists of six members who are appointed by the Governor. In February 2011 the American College of Homeopathy, which is a nonprofit four-year, full-time homeopathic medical school located in Phoenix, will begin offering a degree entitled Doctor of Homeopathy (DH). Graduates of the school will have completed 4,280 hours of training with 2,130 hours related to basic medical sciences and 2,150 hours related to the homeopathic sciences. The American College of Homeopathy is requesting a new designation of DH. Applicants would be required to pass a homeopathic examination process similar to that which currently exists for a Medical Doctor who specialized in Homeopathy (MDH) and a Doctor of Osteopathy who specialized in Homeopathy (DOH). Additionally, the College is requesting the addition of one professional member on the Board to represent a DH, making it a seven-member board. In response to a question, she related that MDHs and DOHs who already practice homeopathy would be grandfathered in as long as the national certification test is passed.
Todd Rowe, President, American Medical College of Homeopathy; Licensed Homeopathic Physician, stated that the homeopathic medical school is opening in February 2011, and it is anticipated that 60 students per year will graduate with an eventual student body of 240. The scope of practice for the graduates will be limited to classical and complex homeopathy. DHs would not be permitted to prescribe conventional pharmaceutical medicines, perform surgery or practice any of the other modalities allowable under the Arizona Board of Homeopathic and Integrative Medicine. DHs would be regulated by the current Homeopathic Licensing Board and this application would in no way jeopardize or change current licensing laws affecting MDHs, DOHs or those practicing under the current homeopathic exemption. He noted that the only cost to the state would be for a new licensing examination and validation of the examination, and the cost incurred with adding one additional Board member. An analysis shows this cost would be more than compensated by the added income from new license applications and renewals.
In response to questions, he related that this is the first homeopathic medical school in the U.S. but there have been discussions about creating schools in California, Minnesota and New York. There will not be internships and residencies at this time in Arizona, but that is a goal for the future, nor will DHs be recognized in other states at this time. The plan is to begin with one state and move forward gradually. The Board is in conversations with Nevada, which has a homeopathic licensing board that is considering adding this designation.
In response to further questions, Mr. Rowe stated that the amount of medical training the graduates will receive is comparable to any medical school in the country, any naturopathic or chiropractic school, all of which exist at a doctorate level, so he is confident that the graduates will be competent and capable of diagnosing accurately and know when it is appropriate to refer a patient to another health provider.
Mr. Rowe advised that the designation of DH is currently used for this type of practice around the world, as well as in Ontario and many of the Canadian provinces. He noted that he is willing to change the designation to HD (Homeopathic Doctor) if that is the preference of the Committee. He added that he is meeting with family practitioners next week to go over their concerns.
Co-Chairman Barto announced the names of those who signed up in support but did not speak:
Patrick Hesselmann, HMA, American Medical College of Homeopathy
Lesley Hesselmann, representing self
Michelle Kardys, representing self
Alejandra Iniguez, representing self
Mario Fontes, representing self
Thelma Rowe, representing self
Lisa E Platt, Arizona Homeopathic & Integrative Medical Association
Fred Lockhart, Executive Director, Arizona Private School Association
Christine Springer, Executive Director, Homeopathic Board
Bruce Shelton, President, AHIMA; representing self
Joseph Abate, Arizona Homeopathic & Integrative Medical Association; American Medical College
David Landrith, Vice President of Policy & Political Affairs, Arizona Medical Association
Amanda Weaver, Executive Director, Arizona Osteopathic Medical Association
Co-Chairman
Nelson moved that the Committee of Reference recommend that a bill be drafted
for consideration by the full Legislature containing the items submitted in the
sunrise application received from the American Medical College of Homeopathy. The
motion carried by a roll call vote of
7-0-0-3 (Attachment 9).
Arizona State Association of Physician Assistants
Ingrid Garvey, Majority
Research Analyst, stated that the mission of the Arizona State Association
of Physician Assistants (PA) is to promote quality, cost-effective and
accessible health care and the professional and personal development of physician
assistants. The Association is requesting an increase in the scope of practice
to allow PAs to prescribe
Schedule II & Schedule III controlled substances for 30 days instead of the
14 days currently in statute.
Richard Bitner, Arizona State Association of Physician Assistants, introduced Michael Goodwin.
Michael Goodwin, Member, Arizona State Association of Physician Assistants, stated that the prescribing limits of two weeks on Schedule IIs and IIIs has become an inconvenience for the patient, and the profession has amply demonstrated that the complications of a PA prescribing have been very minimal at the Board level. In response to questions, he related that patients have to see the PA in two weeks for refills on these prescriptions as opposed to 30 days for the supervisory doctor. PA colleagues, Nurse Practitioners, expanded to 30-day prescribing privileges on Schedule IIs and IIIs, they have shown great restraint and it has worked well. He added that PAs in Arizona have to have the delegated task by the supervisory doctor to prescribe, and when Schedule IIs and IIIs are prescribed, the statute requires a recordkeeping and data system between the supervisory doctor and the PA.
Dr. Kelli Ward, Arizona Osteopathic Medical Association, testified that the Association supports expanding the length of time a PA can prescribe Schedule III medications to 30 days like Vicodin, anabolic steroids and Marinol for nausea and vomiting associated with chemotherapy; however, there is concern about expanding Schedule II prescribing rights to 30 days because of the fine line between overprescribing and appropriately prescribing, especially for patients with chronic pain. Schedule II medications include Adderall and Ritalin used for attention deficit hyperactivity disorder, but also Methadone, Percocet, Oxycodone and Oxycontin, to name just a few, which are highly abusable, have been sold on the streets and can cause problems for individuals and communities. Physicians have more pharmacology education, training and experience in prescribing these medications and are ultimately responsible for the PA prescribing. There should be excellent coordination and collaboration over the use of these medications to protect the public and the prescriber.
Dr. Ward responded to questions concerning other states that changed from 14 to 30 days, malpractice insurance and PAs practicing in remote areas. She indicated willingness to consider a 14-day initial prescription with 30-day refills after the initial evaluation, as long as there is good physician collaboration.
Discussion followed about physician responsibility and possibly defining what constitutes a 30-day supply.
Amanda Weaver, Executive Director, Arizona Osteopathic Medical Association, acknowledged the importance of the team of MD and PA. She suggested that when a patient is seen initially by the PA and is in need of a Schedule II drug, it should be limited to 14 days in order for the physician to have oversight, and thereafter 30 days ongoing. She responded to questions concerning the patient having to return to the PA for another prescription in 14 days and pay another co-pay, and the practice in other states.
Co-Chairman Barto announced the names of those who signed up in support but did not speak:
Laura Hahn, Executive Vice President, Arizona Academy of Family Physicians
Steve Barclay, Lobbyist, Mayo Clinic Arizona
David Landrith, Vice President of Policy & Political Affairs, Arizona Medical Association
Tara Plese, Arizona Association of Community Health Centers
Co-Chairman Nelson moved that the Committee of Reference recommend that a bill be drafted for consideration by the full Legislature containing the items submitted in the sunrise application received from the Arizona State Association of Physician Assistants. The motion carried by a roll call vote of 7-0-0-3 (Attachment 10).
Arizona Naturopathic Medical Association
Ingrid Garvey, Majority Research Analyst, advised that there are currently 650 licensed naturopathic physicians practicing in Arizona. Naturopathic physicians provide services within the scope of practice of naturopathic medicine, a medical system of diagnosing and treating diseases, injuries, ailments, infirmities and other conditions of the human mind and body including by natural means, drugless methods, drugs, non-surgical methods, devices, physical, electrical, hygienic and sanitary measures and all forms of physical agents and modalities. Currently, naturopathic physicians have the authority to intravenously administer vitamins, chelation therapy and minerals. The Arizona Naturopathic Medical Association is requesting a modification to current law to allow the intravenous (IV) administration of nutrients.
Mark Barnes, Arizona
Naturopathic Medical Association, noted that Dr. Paul Mittman,
Dr. Christine Girard and Dr. Kimberly Volk are present to testify and passed
out draft legislation that was previously provided to stakeholders (Attachment
11).
Paul Mittman, President, Southwest College of Naturopathic Medicine, stated that this modification was requested to address a slight inconsistency in statute by making the terminology more inclusive as to what is allowed for naturopathic physicians to prescribe, but still limit it to nutrients to make sure patients of naturopathic physicians have the best treatment based on current advances and clinical nutrition. The way nutrient is defined in the proposed statutory language is taken directly from medical textbooks and medical dictionaries. The language stipulates that the nutrient must be manufactured under Food and Drug Administration (FDA) guidelines for IV use and excludes the IV administration of legend drugs except vitamins, minerals and chelating agents. He added that naturopathic medicine has been licensed in Arizona since 1935. The Board functions well and has had very few, if any, complaints in relation to IV therapies.
Christine Girard, Vice President, Academic & Clinic Affairs, Southwest College of Naturopathic Medicine, advised that the College has a four-year naturopathic medical program that includes all the basic sciences, clinical sciences, diagnostic sciences and clinical training at the medical center in Tempe and eight community clinics in the Phoenix Metro area. Students receive 120 hours in training in the classroom setting on nutrition and the clinical training reinforces the classroom training. She related that the request to include the word nutrients is to better treat patients, for example, to reduce the side effects of medication for cancer patients undergoing chemotherapy. She added that the College is committed to coordination of care with other medical practitioners and patient safety. She indicated that she is committed to working with other medical colleagues to achieve resolution to any concerns.
Dr. Kelli Ward, Arizona Osteopathic Medical Association, stated that although the naturopathic scope includes administering vitamins and minerals IV, the Association opposes the administering of nutrients because the term is too broad in the application. She said she is willing to continue meeting with naturopaths to receive information on pharmacology education and explore exclusions from nutrients that need clarification.
Senator Verschoor remarked that new
items are sometimes developed making it necessary to return to the Legislature
for inclusion; the broader definition allows for automatic inclusion, to which Dr.
Ward responded that she would rather err on the side of public safety.
Senator Verschoor assumed that naturopathic physicians would be subject to
medical malpractice but Dr. Ward indicated that the standard of malpractice is somewhat
different than for a MD or DO.
Ms. Girard advised that there is reciprocity in regard to licensure; the term the Board uses is license by endorsement. Anyone licensed in another state must meet a number of criteria to be licensed in Arizona. Also, all of the naturopathic medical schools in the U.S. and Canada have a group that ensures consistency of education in all of those schools.
Dr. Mittman advised that different jurisdictions can have different scopes of practice; however, a naturopathic physician who takes the licensing examination in any state must meet the same educational requirements, so all of the five naturopathic medical schools in the U.S. and two in Canada have to meet the same academic requirements.
Amanda Weaver, Executive Director, Arizona Osteopathic Medical Association, offered to answer questions.
Dr. Kimberly Volk, Director of Clinical Operations, Southwest College of Naturopathic Medicines, conveyed that students are encouraged to know the guidelines for administering IVs, but it is an invasive process that can cause harm, so they are very well trained in what can happen and what to do in case something goes wrong.
Dr. Mittman assured Senator Leff that he is willing to work with the MDs and DOs on the definition of nutrients as he was in 2000 and 2005.
Co-Chairman Barto announced the names of those who signed up in support but did not speak:
Craig Runbeck, Executive Director, Naturopathic Board
Co-Chairman Nelson moved that the Committee of Reference recommend that a bill be drafted for consideration by the full Legislature containing the items submitted in the sunrise application received from the Arizona Naturopathic Medical Association. The motion carried by a roll call vote of 7-0-0-3 (Attachment 12).
Without objection, the meeting adjourned at 3:15 p.m.
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Linda Taylor, Committee Secretary
December 17, 2010
(Original minutes, attachments and audio on file in the Chief Clerk’s Office; video archives available at http://www.azleg.gov)
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COR – SENATE HEALTH & HOUSE HHS
December 9, 2010
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