BILL ANALYSIS Ó
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|SENATE RULES COMMITTEE | SB 538|
|Office of Senate Floor Analyses | |
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THIRD READING
Bill No: SB 538
Author: Block (D), et al.
Amended: 4/16/15
Vote: 21
SENATE BUS, PROF. & ECON. DEV. COMMITTEE: 5-2, 4/27/15
AYES: Hill, Block, Galgiani, Hernandez, Wieckowski
NOES: Bates, Berryhill
NO VOTE RECORDED: Jackson, Mendoza
SENATE APPROPRIATIONS COMMITTEE: 5-2, 5/26/15
AYES: Lara, Beall, Hill, Leyva, Mendoza
NOES: Bates, Nielsen
SUBJECT: Naturopathic doctorsNaturopathic doctors.
SOURCE: California Naturopathic Doctors Association
DIGEST: This bill expands the scope of practice for a
naturopathic doctor, including allowing a naturopathic doctor to
prescribe certain drugs without physician supervision and
perform minor procedures.
ANALYSIS:
Existing law:
1) Establishes the Naturopathic Medicine Committee (Committee)
within the Osteopathic Medical Board to enforce and
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administer the Naturopathic Doctors Act. (Business and
Professions Code (BPC) §§ 3612 and 3620)
2) Authorizes a naturopathic doctor (ND) to order and perform
physical and laboratory examinations for diagnostic
purposes, including, but not limited to, phlebotomy,
clinical laboratory tests, orificial examinations, and
physiological function tests. (BPC § 3640 (a))
3) Requires Schedule III drugs to be furnished or ordered by
an ND in accordance with a patient-specific protocol
approved by the treating or supervising physician. (BPC §
3640.5 (f))
This bill:
1) Authorizes an ND to order diagnostic imaging studies
"consistent with the practice of naturopathic medicine,"
rather than only those determined appropriate by the
Committee.
2) Clarifies that an ND may order, provide, or furnish
devices consistent with the naturopathic training as
determined by the Committee.
3) Authorizes an ND to utilize the cervix as a route of
administration.
4) Authorizes an ND to perform operative procedures relative
to superficial lacerations, superficial clinically benign
lesions less than one centimeter and not located on the
face, and superficial abrasions.
5) Authorizes an ND to use topical and parenteral use of
substances consistent with the practice of naturopathic
medicine in accordance with rules established by the
Committee.
6) Authorizes an ND to obtain samples of superficial human
tissue by means of shave, punch, or excisional biopsy
consistent with the practice of naturopathic medicine.
7) Prohibits an ND from any procedures using general or
spinal anesthesia, sclerotherapy, or procedures involving
the eye.
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8) Defines "parenteral therapy" to mean the administration of
substances by means other than through the gastrointestinal
tract, including intravenous, subcutaneous, intramuscular,
and other areas of the body, excluding the ventral and
dorsal body cavities.
9) Authorizes an ND to prescribe, administer, or order
Schedule IV, V, and unclassified drugs labeled "for
prescription only," except chemotherapeutics, without
physician supervision.
10) Requires an ND to be subject to peer review reporting
provisions.
Background
Naturopathic medicine. According to the Committee, naturopathic
medicine is a distinct and comprehensive system of primary
health care that uses natural methods and substances to support
and stimulate the body's self-healing process.
Naturopathic medicine includes the combination of a variety of
natural medicines and treatments. NDs are clinically trained in
both natural and conventional approaches to medicine and can
prescribe all natural and synthetic hormones, epinephrine, and
vitamins, minerals, and amino acids independent of physician
supervision. California NDs complete 72 pharmacology course
hours in school and are required to complete a minimum of 20
hours of pharmacotherapeutic training every two years as part of
their 60-hour continuing education requirement.
NDs attend four year, graduate-level, accredited naturopathic
medical schools, are trained as primary care providers, and take
a national, standardized licensing examination. NDs have
limited opportunities to complete hospital residencies, but
perform at least 1500 hours of clinical rotations at clinics and
private doctors' offices during their education program.
California is one of 17 states that license NDs, and over 500 ND
licenses have been issued to date. There is one naturopathic
medicine school in California, located in San Diego.
Changes to furnishing authority of a ND. Current law allows an
ND to furnish or order legend drugs and Schedule III - V and
drugs in accordance with standardized procedures or protocols
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developed by the naturopathic doctor and his or her supervising
physician and surgeon. A physician may supervise up to four NDs
at a time.
Drug classifications. Drugs, substances, and certain chemicals
used to make drugs are classified into five schedules depending
upon the drug's acceptable medical use and the drug's abuse or
dependency potential. Schedule I is considered the most
dangerous class and Schedule V represents the least concerning
of the scheduled drugs. "Legend" drugs are controlled
substances but have even less potential for abuse than Schedule
V drugs.
Naturopathic Committee recommendation to remove supervision.
Current law establishes a Naturopathic Formulary Advisory
Subcommittee (Subcommittee) to review naturopathic education,
training, and practice and make specific recommendations
regarding prescribing, ordering, furnishing authority, and
appropriate supervision protocols. The Subcommittee is composed
of an equal number of representatives from the clinical and
academic settings of physicians and surgeons, pharmacists, and
naturopathic doctors. The Subcommittee presented its initial
report in 2007.
This report found that there were a limited number of physicians
who had training in naturopathic philosophy or practice or who
have had the extensive clinical experience in naturopathic
modalities to make them appropriate supervisors for NDs, and the
few physicians who were willing and well-trained for ND
supervision had difficulty getting malpractice coverage for
supervision. The Subcommittee concluded "the supervision
provision is untenable," but at that point did not recommend
independent prescribing privileges. On January 1, 2014, the
Subcommittee reported to the Committee that it unanimously
agreed to support elimination of physician supervision.
This bill is more restrictive than the Subcommittee
recommended, and will allow an ND to furnish only Schedule
IV-V drugs and legend drugs, except chemotherapeutics,
without physician supervision or pursuant to standardized
procedures or protocols.
Expanded minor procedures would be allowed. Current law
authorizes an ND to provide repair and care incidental to
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superficial lacerations and abrasions, except suturing, and
permits an ND to remove foreign bodies located in the
superficial tissues.
The Committee convened an advisory group in 2007 consisting
of two NDs, two physicians, and one attorney to review
whether it would be appropriate to expand the procedures
permitted in current law. After a review of the training,
education, and practice of NDs, the advisory group reached
consensus that an ND should be allowed to perform the
following four additional procedures: 1) prescribe and
administer local anesthetic solutions, their adjuncts and
diluents; 2) removal of clinically benign skin lesions; 3)
repair of skin lacerations, including suturing; and 4)
incision and drainage of abscess/trephination of subungual
hematoma.
This bill largely tracks these recommendations, but puts
greater restrictions on an ND to remove lesions. It also
permits an ND to obtain samples of tissue by shave, punch,
or excisional biopsy, and utilize the cervix as a route of
administration, which will clarify an ND's ability to
administer common birth control devices.
FISCAL EFFECT: Appropriation: No Fiscal
Com.:YesLocal: No
According to the Senate Appropriations Committee, this bill has
unknown additional enforcement costs to the Committee
(Naturopathic Doctors Fund). By expanding the scope of practice
for naturopathic doctors to allow them to prescribe certain
medications without supervision and perform minor procedures,
there may be additional complaints to the Committee from
patients that will require investigation and potential
disciplinary action. The extent to which this will occur is not
known.
SUPPORT: (Verified5/26/15)
California Naturopathic Doctors Association (source)
AARP
Akasha Center for Integrative Medicine
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American Association of Naturopathic Physicians
Arizona Naturopathic Medical Association
Bastyr University
California Chiropractic Association
California Naturopathic Clinic
California Naturopathic Medicine Committee
Center for Health Santa Cruz
Endocrinology Association of Naturopathic Physicians
Integrative Medicine for the Underserved
National College of Natural Medicine
Naturopathic Academy of Primary Care Physicians
Oncology Association of Naturopathic Physicians
Paracelsus Natural Family Health Center
Pediatric Association of Naturopathic Physicians
Santa Cruz Naturopathic Medical Center
Southwest College of Naturopathic Medicine and Health Sciences
Stengler Center for Integrative Medicine
Washington Association of Naturopathic Physicians
Women's View Medical Group, Inc.
Numerous individuals
OPPOSITION: (Verified5/26/15)
American Academy of Pediatrics
American Congress of Obstetricians and Gynecologists
California Academy of Family Physicians
California Chapter of the American College of Cardiology
California Chapter of the American College of Emergency
Physicians
California Medical Association
California Orthopaedic Association
California Radiological Society
California Society of Anesthesiologists
California Society of Dermatology and Dermatologic Surgery
California Society of Plastic Surgeons
Kaiser Permanente
Medical Board of California
Osteopathic Physicians and Surgeons of California
ARGUMENTS IN SUPPORT: The California Naturopathic Doctors
Association writes, "The vast majority of naturopathic doctors
practice primary care medicine. Unfortunately, current law
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creates obstacles for patients who have chosen to see an ND for
their primary care needs. Specifically, these patients must be
referred out for medication management or minor procedures, such
as stitching a cut, despite the fact that their doctor is
trained to do these things. Both of these limitations increase
cost and delay care for patients. This delay in care can result
in patient harm if acute conditions (e.g. strep throat) are not
treated in a timely manner?. It is therefore vital to improve
patient access to licensed primary care doctors who are trained
to independently perform all primary care needs."
ARGUMENTS IN OPPOSITION: The California Medical Association
and the California Academy of Family Physicians were in
opposition to the prior version of this bill and stated the
following: "The distinctive philosophy of naturopathic medicine
and many of its methods of diagnosis and treatment are
unscientific in concept, biologically improbable and clinically
unproven. Moreover, regardless of its theory, the scope and
quality of naturopathic education do not prepare its
practitioners to make either an adequate diagnosis or provide
appropriate treatment independent of medical doctors.
Naturopathic services are not covered by Medicare or most
insurance policies for good reason: a lack of evidence of
appropriate effectiveness. Only 17 states allow the practice of
naturopathic medicine and California is the only large state
among them."
Prepared by:Sarah Huchel / B., P. & E.D. / (916) 651-4104
5/27/15 14:54:35
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