BILL ANALYSIS Ó
SB 538
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Date of Hearing: June 30, 2015
ASSEMBLY COMMITTEE ON BUSINESS AND PROFESSIONS
Susan Bonilla, Chair
SB 538(Block) - As Amended April 16, 2015
SENATE VOTE: 21-9
SUBJECT: Naturopathic doctors.
SUMMARY: Expands the scope of practice for Naturopathic Doctors
(NDs) by removing physician supervision for prescribing certain
drugs and permitting NDs to perform minor office procedures, as
specified.
EXISTING LAW:
1)Establishes the Naturopathic Medicine Committee (NMC) within
the Osteopathic Medical Board (OMB) to enforce and administer
the provisions of the Naturopathic Doctors Act (Act).
(Business and Professions Code (BPC) Sections 3610, 3612,
3620)
2)Defines "naturopathic medicine" to mean a distinct and
comprehensive system of primary health care practiced by a ND
for the diagnosis, treatment, and prevention of human health
conditions, injuries, and disease. (BPC Section 3613(c))
3)Defines "naturopathy" to mean a noninvasive system of health
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practice that employs natural health modalities, substances,
and education to promote health. (BPC Section 3613(e))
4)Authorizes a ND to order and perform physical and laboratory
examinations for diagnostic purposes, including, but not
limited to, phlebotomy, clinical laboratory tests, speculum
examinations, orifical examinations, and physiological
function tests. (BPC Section 3640(a))
5)Authorizes a ND to order diagnostic imaging studies, including
X-ray, ultrasound, mammogram, bone densitometry, and others
consistent with naturopathic training as determined by the
NMC, but requires an ND to refer the studies to an
appropriately licensed health care professional to conduct the
study and interpret the results. (BPC Section 3640(b))
6)Authorizes a ND to provide the repair and care incidental to
superficial lacerations and abrasions, except suturing. (BPC
Section 3640(c)(5))
7)Authorizes a ND to remove foreign bodies located in the
superficial tissues. (BPC Section 3640(c)(6))
8)Authorizes a ND to utilize routes of administration that
include oral, nasal, auricular, ocular, rectal, vaginal,
transdermal, intradermal, subcutaneous, intravenous, and
intramuscular. (BPC Section 3640(d))
9)Permits a ND to furnish or order specified drugs when all of
the following apply: (BPC Section 3640.5)
a) The drugs are furnished or ordered by a ND in accordance
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with standardized procedures or protocols developed by the
ND and his or her supervising physician and surgeon;
b) The ND is functioning pursuant to standardized
procedures or protocols, as specified, and the standardized
procedure or protocol is developed and approved by the
supervising physician and surgeon, the ND, and, where
applicable, the facility administrator or his or her
designee;
c) The standardized procedure or protocol covering the
furnishing of drugs must specify which NDs may furnish or
order drugs, which drugs may be furnished or ordered under
what circumstances, the extent of the physician and surgeon
supervision, the method of periodic review of the ND's
competence, including peer review, and review of the
provisions of the standardized procedure;
d) The furnishing or ordering of drugs by a ND occurs under
physician and surgeon supervision, as specified;
e) Drugs furnished or ordered by a ND may include Schedule
III through V controlled substances, as specified, and can
be further limited to those drugs agreed upon by the ND and
the supervising physician and surgeon, as specified; and,
f) The NMC has certified that the ND has satisfactorily
completed adequate coursework in pharmacology covering the
drugs to be furnished or ordered, as specified.
10)Permits a ND to independently prescribe and administer
epinephrine to treat anaphylaxis, natural and synthetic
hormones, vitamins, minerals, amino acids, glutathione,
botanicals and their extracts, homeopathic medicines,
electrolytes, sugars, and diluents, as specified. (BPC
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Section 3640.7)
11)Prohibits a ND from prescribing, dispensing or administering
a controlled substance, as specified; administering
therapeutic ionizing radiation or radioactive substances;
practicing or claiming to practice any other system or method
of treatment beyond what is authorized under the Act;
administering general or spinal anesthesia; performing an
abortion; performing any surgical procedure; or performing
acupuncture or traditional Chinese and Asian Medicine,
including Chinese herbal medicine unless licensed as an
Acupuncturist. (BPC Section 3642)
12)Specifies that physician and surgeon supervision, for the
purpose of furnishing or ordering drugs, does not require the
physical presence of the physician, but does include: (BPC
3640.5(d))
a) Collaboration on the development of the standardized
procedure;
b) Approval of the standardized procedure; and,
c) Availability by telephonic contact at the time of
patient examination by the ND.
13)Prohibits a physician and surgeon from supervising more than
four NDs at one time.
THIS BILL:
14)Permits a ND to order diagnostic imaging studies consistent
with the practice of naturopathic medicine instead of as
determined by the NMC.
15)Clarifies that a ND may provide, in addition to dispense,
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administer, order, or furnish, specified extracts,
hydrotherapies and devices consistent with the naturopathic
training as determined by the NMC.
16)Authorizes a ND to utilize a cervical route of administration
only for the purpose of administering barrier contraception.
17)Authorizes a ND to perform "parenteral therapy" and perform
"minor procedures" instead of only performing repair and care
incidental to superficial lacerations and abrasions and the
removal of foreign bodies located in the superficial tissue.
18)Defines "minor procedures" to mean care and operative
procedures relative to superficial lacerations, superficial
clinically benign lesions less than one centimeter and not
located on the face, and superficial abrasions, and the
removal of foreign bodies located in superficial structures
and the topical and parenteral use of substances consistent
with rules established by the NMC.
19)Authorizes a ND to obtain samples of superficial human tissue
by means of shave, punch, or excisional biopsy consistent with
the practice of naturopathic medicine.
20)Specifies that "minor procedures" do not include general or
spinal anesthesia, sclerotherapy, or procedures involving the
eye.
21)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.
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22)Authorizes a ND to administer, furnish, order, or prescribe
Schedule IV through V controlled substances, as specified,
without the supervision of a physician and surgeon, except
chemotherapeutics.
23)Maintains the requirement that in order to administer,
prescribe, furnish, or order Schedule III drugs, a ND must act
under the supervision of a physician and surgeon.
24)States that when Schedule III controlled substances are
administered, furnished, ordered, or prescribed by a ND, the
controlled substances must be administered, furnished, ordered
or prescribed in accordance with a patient-specific protocol
approved by the treating or supervising physician and a copy
of the section of the ND's standardized procedure or protocol
relating to controlled substances must be provided, upon
request, to a licensed pharmacist who dispenses drugs when
there is uncertainty about the ND furnishing the order.
25)Requires a ND to be subject to peer review reporting
provisions, as specified.
FISCAL EFFECT: According to the Senate Appropriations Committee
Analysis dated May 26, 2015, this bill will result in "unknown
additional enforcement costs to the [NMC]. 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
[NMC] from patients that will require investigation and
potential disciplinary action. The extent to which this will
occur is not known."
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COMMENTS:
Purpose. This bill is sponsored by the California Naturopathic
Doctors Association . According to the author, "[NDs] are
primary care doctors who attend four-year post-graduate
accredited naturopathic medical schools recognized by the U.S.
Department of Education. As a part of their education, they
complete a minimum of 1,200 hours in clinical rotations, and a
thorough curriculum in basic and clinical science that includes
biochemistry, pharmacology, lab diagnosis, epidemiology,
pathology, neuroscience, and clinical physical diagnosis.
Like other primary care doctors, NDs diagnose, prevent, and
treat disease. [NDs] are licensed to perform physical exams,
order laboratory tests and imaging (x-rays, MRIs, mammograms,
etc.), draw blood, and perform CLIA-waived laboratory testing
in-office, administer IVs and injections, and prescribe drugs
(including most controlled substances). NDs are licensed in 16
other states, some dating back to 1919, with no malpractice
claims filed nationally according to both Verdictsearch and the
National Practitioner Databank, maintained by the U.S.
Department of Health and Human Services. Despite their medical
education and safety record, some limitations remain in
California which prevent[s] these healthcare professionals from
performing all of the duties that are typically part of primary
care practice and are important for patient care.
[This bill] removes barriers for patients seeking medical care
from licensed naturopathic doctors, by allowing them to
prescribe medications, such as blood pressure medications and
antibiotics, without a written supervision agreement and to
perform minor procedures, such as applying stitches and removing
warts. These barriers interfere with patient access to
appropriate, timely primary care. For example, if a patient who
regularly sees a naturopathic doctor comes in with strep throat,
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an ND can diagnose them but must send the contagious patient to
a medical doctor (MD) for an antibiotic. Given California's
primary care shortage, it may take weeks for the patient to get
an appointment with an MD, so the patient would likely visit an
emergency room or urgent care for a simple prescription. Delays
in care for simple medical procedures and medications may result
in minor medical conditions becoming major medical problems. For
example, a patient who delays taking antibiotics for strep
throat in a timely manner can experience lifelong complications
to the joints, kidneys, and heart as a result of acute rheumatic
fever or glomerulonephritis. [NDs] are already educated and
trained to perform these minor procedures and independently
prescribe these medications and are already safely performing
these functions of primary care in [nine] other states. [This
bill] will ensure that patients seeking primary care from a
naturopathic doctor can receive appropriate care without the
added time, cost, and health risk of finding another physician
for a routine prescription or procedure."
Naturopathic Medicine Committee. The practice of Naturopathic
Medicine has been formally regulated in California since 2003.
SB 907 (Burton) Chapter 485, Statutes of 2003, established the
regulatory entity, known today as the NMC, which licenses and
regulates NDs and enforces the practice act. The NMC is housed
within the OMB. The NMC is authorized for 2.0 staff positions
and is currently staffed by an Executive Officer (EO) and a
licensing and enforcement analyst. These two staff persons are
responsible for all licensing and disciplinary-related
activities for the NMC and its approximately 500 licensed NDs
practicing in California. The NMC notes that it has one of the
lowest enforcement caseloads within the DCA where the majority
of enforcement related cases pertain to misuse of title and not
violations committed by its licensees.
At the time SB 907 was enacted, California was only the 12th
state to recognize the practice of naturopathic medicine and
regulate NDs. Today, that number has grown to 17 states. As
currently drafted, this bill seeks to expand the scope of
practice of NDs by expanding the types of procedures that can be
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done in an office visit and also removes the physician
supervision requirement for NDs who wish to prescribe Schedule
IV and V drugs. This bill would maintain the supervision
requirements for NDs who wish to prescribe Schedule III drugs.
Naturopathic Medicine. According to the NMC, the practice of
naturopathic medicine is a distinct and comprehensive system of
primary healthcare practiced by a ND for the diagnosis,
treatment, and prevention of human health conditions, injuries
and disease. A ND may be considered as a primary care provider
who uses herbs, supplements, vitamins, homeopathy, nutritional
counseling, some prescription medicines, and other treatments to
help the body. Naturopathic medicine is distinguished by the
six principles on which its practice is based. These principles
include:
1) The Healing Power of Nature: NDs trust in the body's
inherent wisdom to heal itself.
2) Identify and Treat the Cause: Look beyond the symptoms
to effectively address the underlying cause(s) of illness.
3) First Do No Harm: Seek to utilize the most natural,
least invasive and least toxic therapies first.
4) Doctor as Teacher: The primary role of an ND is a
teacher who educates and encourages people to take
responsibility for their own health and to take steps to
achieve and maintain optimal health.
5) Treat the Whole Person: Total health includes physical,
emotional, mental, genetic, environmental, social,
spiritual, and other factors.
6) Prevention: Encourage and emphasize disease prevention
and focus on promoting health and wellness.
In order to be licensed as a ND in California, an individual
must meet educational and training requirements including
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possession of a Doctorate Degree of Naturopathic Medicine from
an approved naturopathic school. As part of the program
requirements, a student must have completed a minimum of 4,100
total hours in basic and clinical sciences, naturopathic
philosophy, modalities, and medicine. NDs have limited
abilities to complete hospital residencies, but perform a
minimum of 1,200 hours of supervised clinical training approved
by a naturopathic medical school. In California, there is one
approved school to provide naturopathic education and only eight
total schools nationwide. In addition, to be licensed in
California, NDs are required to take and pass the Naturopathic
Physicians Licensing Examination (NPLEX) or an equivalent
examination approved by the North American Board of Naturopathic
Examiners.
The National Institutes of Health (NIH). According to
information provided by the NIH's National Center for
Complementary and Integrative Health, "?people visit
naturopathic practitioners for various health-related purposes,
including primary care, overall well-being, and complementary
treatment (used in addition to conventional medical treatment)."
In addition, regarding the efficacy and safety of the practice,
the NIH reports that "some of the individual therapies used in
naturopathy have been researched for their efficacy, with
varying results. The complex treatment approaches that
naturopathic physicians often use are challenging to study, and
little scientific evidence is currently available on overall
effectiveness. Related research is under way but is in the early
stages."
Recommendations Based on NMC Subcommittee Reports. As part of
the enabling legislation, the NMC was required to two establish
two specified subcommittees: 1) a naturopathic formulary
advisory committee and 2) a naturopathic childbirth attendance
advisory subcommittee. The function of the formulary advisory
committee was to review the naturopathic education, training,
and practice requirements and make specified recommendations
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regarding the prescribing, ordering, and furnishing authority of
NDs and supervision protocols. The childbirth committee was to
review the practice of naturopathic childbirth attendance. Both
of the subcommittees were required to consult with physician and
surgeons and licensed NDs in developing the findings and
recommendations. As a result of this requirement, the NMC
convened the formulary advisory committee 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 a ND should be allowed
to perform the following four additional procedures without
physician supervision: 1) prescribe and administer local
anesthetic solutions, their adjuncts and diluents; 2) remove
clinically benign skin lesions; 3) repair skin lacerations,
including suturing; and 4) perform incision and drainage of
abscess/trephination of subungual hematoma. This bill seeks to
enact the recommendations made in the NMC's 2007 report to the
Legislature, but specifies that the removal of clinically benign
skin lesions are to be limited to less than one centimeter and
not located on the face.
Minor Procedures. Under the act, NDs are permitted to perform a
range of healthcare related tasks independent of physician
supervision except with respect to prescribing certain Schedule
drugs. Currently, NDs can provide repair and care incidental to
superficial lacerations and abrasions, except suturing. The
sponsor illustrates that a ND would be prepared to clean a wound
but not provide the suture if necessary. NDs are permitted to
remove foreign bodies in the superficial tissues, and have the
authority to order lab tests but cannot study or interpret the
results. In addition, NDs can administer certain vitamins,
netraceuticals, minerals, enzymes and nonprescription drugs as
identified by the federal Food, Drug Cosmetic Act, consistent
with specified routes of administration.
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This bill would authorize NDs to expand their current scope of
practice to include minor office procedures, specifically care
and operative procedures relative to superficial lacerations,
superficial clinically benign lesions less than one centimeter,
excluding the face, and superficial abrasions. This bill also
clarifies that NDs are able to utilize a cervical route of
administration for the purpose of administering barrier
contraception. In addition, a ND would also be permitted to
obtain samples of superficial human tissue by means of shave,
punch, or excisional biopsy consistent with the practice of
naturopathic medicine, which does not include general or spinal
anesthesia, sclerotherapy, or procedures involving the eye. As
currently written, this bill would not require the supervision
of a physician and surgeon to perform any of the procedures
within the proposed new scope of practice.
According to information provided by the California Naturopathic
Doctors Association, naturopathic students receive up to 72
hours of classroom training in minor procedures, which includes
both didactic and lab instruction, and are required to obtain
check-offs from clinical faculty indicating their competency in
performing minor procedures prior to graduation. The California
Naturopathic Doctors Association reports that 13 of the 17
states which license and regulate NDs allow minor procedures to
be included within the scope of practice of NDs.
Prescription Authority with Physician Supervision. The use of
physician and surgeon supervision is common for many medical
professions in California. Supervision generally includes the
development of procedures and protocols as determined by the
supervisor and supervisee. Under current law, NDs are permitted
to furnish or order Schedule III-V drugs under the standardized
procedures and protocols developed by the ND and the supervising
physician. This bill would authorize NDs to administer,
furnish, order or prescribe Schedule IV and V drugs and those
drugs that are not on the "schedule" considered "legend" drugs
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without the supervision of a physician or surgeon.
According to the U.S. Drug Enforcement Agency, drugs,
substances, and certain chemicals used to make drugs are
classified into five (5) distinct categories or schedules
depending upon the drug's acceptable medical use and the drug's
abuse or dependency potential. Schedule I drugs have the
highest potential for abuse while Schedule V is the lowest.
Those drugs that are still considered controlled substances but
have even less potential for abuse than Schedule V are part of
the "legend" such as certain antibiotics and some routine
vaccinations. This bill would make it clear that NDs would not
be authorized to prescribe chemotherapeutics regardless of
supervision. NDs report that they are required to obtain 60
hours of continuing education (CE) every license-renewal cycle,
and 20 of those hours are required to be in
pharmacotherapeutics.
Schedule III and IV controlled substances have a currently
accepted medical use in treatment, less potential for abuse
but are known to be mixed in specific ways to achieve a
narcotic-like end product. Examples include drugs Tylenol
with Codeine, Ambien, Xanax, and other anti-anxiety drugs.
Schedule V drugs have a low potential for abuse relative to
substances listed in Schedule IV and consist primarily of
preparations containing limited quantities of certain
narcotics. Examples include Robitussin with Codeine and
Lomotil.
Legend Drugs are controlled substances that are considered to
have a lower potential for abuse than Schedule V drugs, such
as some antibiotics.
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Other States. Currently, there are 17 other states which
license and regulate NDs: Alaska, Arizona, California, Colorado,
Connecticut, District of Columbia, Hawaii, Kansas, Maine,
Maryland, Minnesota, Montana, New Hampshire, North Dakota,
Oregon, Utah, Vermont, and Washington. Although education and
examination requirements appear to be consistent (four-year
post-graduate degree and passage of the national licensing
examination), each state is responsible for determining the
scope of practice for NDs along with establishing the laws and
regulations necessary to oversee the profession. While the
scope of practice for NDs varies across the states, all NDs are
guided by the same six principles. According to information
provided by the California Naturopathic Doctors Association,
only 10 of the 17 states which license NDs have prescribing
privileges, and only California requires supervision. Only 13
of the 17 states permit "minor procedures" which can vary
depending on state statutes and regulations.
Difference Between Naturopathic Medicine and Naturopathy. In
California, there is a distinction between the practice of
"naturopathy" and "naturopathic medicine." An individual does
not need a license to practice "naturopathy" and "homeopathy,"
however; individuals must inform clients that they are providing
unlicensed healing arts services as specified in the BPC.
"Naturopaths" are not prohibited from using the term
"naturopath" but cannot call themselves a ND without the proper
NMC-issued license demonstrating they have met the appropriate
educational and testing requirements. As noted by the NIH, the
traditional educational requirements for naturopaths are
different from the requirements for NDs in that a naturopath's
education ranges from none to specific degrees and coursework.
In addition, the programs vary in length and content and are not
accredited by organizations recognized for accreditation
purposes by the U.S. Department of Education. Further,
traditional naturopaths are not subject to licensing. On the
other hand, NDs are required to obtain a four-year post-graduate
degree, from an accredited institution, take and pass an
examination, and are subject to specified licensure and practice
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acts in 17 states.
Sunset Review. The NMC was last reviewed by the Senate
Business, Professions and Economic Development (BPED) and
Assembly Business, Professions and Consumer Protection (BPCP)
Committees in 2013. As part of that report, the NMC made
recommendations to alter the formulary and sought expansion of
the scope of practice for ND's. At that time, the BPED
Committee raised several issues in the staff report pertaining
to the NMC's ability to establish disciplinary guidelines as
well as a number of other enforcement related activities. The
Committee report ultimately recommended that the NMC focus on
certain administrative and enforcement issues such as updating
its strategic plan, enhancing data collection, and establishing
disciplinary guidelines rather than changing the scope of
practice of NDs. This bill builds on some of those proposals in
the NMC's last sunset report by expanding the scope of practice
for NDs to perform minor procedures, and remove physician
supervision for the furnishing and ordering of specified drugs.
The NMC will not be up for sunset review until 2017, meaning
that the recommendations made in the sunset review report for
the NMC will not be discussed for another year, potentially
after this legislation would be enacted.
Prior Related Legislation. SB 1446 (McLeod), Chapter 333,
Statutes of 2012, allowed naturopathic doctors to independently
prescribe and administer vitamins, minerals, amino acids,
glutathione, botanicals and their extracts, homeopathic
medicines, electrolytes, sugars, and diluents, as specified. It
also required NDs to demonstrate compliance with specified
requirements, including the successful completion of specified
coursework by a provider approved by the Committee, in order to
qualify for intravenous therapy administration, and clarifies
the types of substances a ND may prescribe and administer.
SB 1246 (McLeod), Chaptered 523, Statutes of 2010, included NDs
in the list of health care practitioners who could perform
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specified clinical laboratory tests, defined a naturopathic
assistant for purposes of the practice act, and specifies
certain functions for naturopathic assistants.
AB X4 20 (Strickland), Chapter 18, Statutes of 2008, abolished
the Bureau of Naturopathic Medicine and created the NMC within
the OMB.
SB 907 (Burton), Chapter 485, Statutes of 2003, established the
Act to be administered by the Bureau of Naturopathic Medicine
within the DCA.
ARGUMENTS IN SUPPORT:
The California Naturopathic Doctors Association writes in
support, "This bill addresses existing limitations in the
Naturopathic Practice Act. Specifically, the legislation will
allow [NDs] to prescribe Schedule III-V and legend drugs without
a written supervision agreement as well as perform minor
procedures with the training of a ND. NDs are licensed primary
care doctors with the broadest independent scope of any medical
profession other than MDs or DOs."
The AARP , writes in support, AARP supports Medicare and Medicaid
policies that result in the efficient delivery of optimal care
for beneficiaries with chronic illness and disabling conditions,
including approaches that encourage an interdisciplinary care
team approach. AARP also acknowledges that the fact that health
care costs must be contained. One of the means to achieve this
objective is reforming [the] delivery of healthcare services to
allow access by beneficiaries to other providers. Passage of
[this bill] will not only eliminate arcane barriers so that
naturopathic doctors may practice fully within their education
and training, it will ensure that restrictions to practice
unfettered from arcane barriers. By eliminating current
barriers faced by naturopathic doctors, access by beneficiaries
to other providers will not be restricted."
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ARGUMENTS IN OPPOSITION:
The Osteopathic Physicians and Surgeons of California (OPSC)
writes in opposition, "OPSC's most significant concern with the
provisions in [this bill] relate to patient safety. [This bill]
would allow NDs to independently prescribe controlled
substances, expand the diagnostic procedures that [NDs] may
order and allow NDs to review and interpret the results of these
procedures. The bill would also allow NDs to conduct parenteral
therapy and conduct "minor procedures. The length and focus of
education and training for NDs is dramatically different than
that of MDs or Dos."
The California Society for Anesthesiologists writes in
opposition, "[This bill] would expand the scope of practice of
[NDs] and erodes provisions in current law that protects
consumers. In particular, this bill deletes the current
requirement that [NDs] furnish controlled substances in
accordance with standardized procedures of protocols developed
by the [ND] and his or her supervising physician. Naturopathic
theory and practice are not based on the body of basic knowledge
related to health, disease, and medical treatment which has been
widely accepted by the scientific community. The scope and
quality of naturopathic education do not prepare its
practitioners to make either adequate diagnosis or provide
appropriate treatment."
POLICY ISSUE(S):
Expanded Prescribing Authority. This bill would expand the
scope of practice for NDs by removing physician supervision for
NDs to prescribe Schedule IV and V drugs and those drugs not
listed on the Schedule, commonly known as legend drugs.
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Although the NMC reports a very small caseload related to
enforcement, given the limited size of the NMC and the potential
for new enforcement-related issues to arise as a result of
enhanced prescribing privileges, the Committee may wish to
consider allowing a limited expansion of prescribing authority
to permit NDs to prescribe Schedule V and legend drugs without
supervision, but maintain the restrictions for prescribing
Schedule III and IV, which currently require physician
supervision as defined in current law. With this enhanced
prescribing authority, NDs would be able to prescribe certain
antibiotics and provide certain vaccinations.
Expansion of Scope and Training Limitations. This bill expands
the scope of practice for NDs by allowing NDs to perform "minor
procedures" including care and operative procedures relative to
superficial lacerations, clinically benign lesions less than one
centimeter that are not located on the face, and obtaining
samples of superficial human tissues without the supervision of
a physician and surgeon. While the sponsors of this bill
explain that current law prevents NDs from performing all of the
primary care duties for which they are trained to perform, it is
unclear what this expansion of scope would permit NDs to do, and
how far the reach would be for performing "minor procedures."
In addition, it is unclear which specific "minor procedures" NDs
are trained to perform during their clinical studies and if
there are any potential "minor procedures" which would be
authorized in this bill that are outside of a ND's training. It
may be more beneficial to identify and specify the procedures
that a ND is not able to provide to clients as a result of the
limitations of its current scope of practice and what "minor
procedures" are necessary for the care and treatment of patients
that NDs regularly treat.
It is unknown how many patients see a ND while under the care of
another medical provider such as a physician and surgeon. The
lack of patient-centered data regarding the expected services of
a ND underscores the difficulty in determining the need to
expand the scope of practice of NDs. Although the NMC and the
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subcommittees completed the statutory review and concluded that
an expanded scope of practice is justified, an additional study
encompassing a much broader spectrum of participants, including
education providers and other stakeholders may provide enhanced
information which would further support any need for scope
expansion. Instead of expanding the scope of NDs at this time,
the Committee may wish to request the author to remove the
provisions authorizing NDs to perform "minor procedures."
Residency Requirement. In order to be licensed as a ND in
California, a person must complete a four year, post-graduate
naturopathic medical education program from an institution
accredited by the Council on Naturopathic Education or an
equivalent education program that meets specified requirements.
The program requirements include a minimum of 4,100 total hours.
Of those 4,100 hours, 2,500 must be in academic instruction and
1,200 must consist of supervised clinical training approved by
the naturopathic medical school. Upon completion of
naturopathic medical school, prospective licensees are not
required to complete or attend a residency program which is
common for physicians and surgeons. While some naturopathic
medical institutions provide an optional one-year residency
program, it is not consistent and not required for all NDs
licensed in California.
Increasing the capacity for residency programs for NDs after
completion of naturopathic medical school should be a starting
point for NDs in discussing future scope expansions. Enhanced
residency training would help demonstrate competency for NDs in
performing "minor procedures" and determining what those
necessary procedures would be.
NMC Oversight and Sunset Review. The NMC is responsible for the
licensing and enforcement of NDs in California. Although the
NMC reports it has one of the smallest caseload relative to
enforcement, that could increase given the proposals of this
bill in expanding the scope of practice for NDs. The NMC is
currently staffed by two individuals who are responsible for all
licensing, enforcement and administrative-related duties of the
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NMC. Given the NMC's limited staff capacity, it could be
difficult for the NMC to handle an expanded caseload of
enforcement-related concerns relative to the increase in NDs'
scope.
The sunset review process provides a formal mechanism for the
DCA; the Legislature; the regulatory boards, bureaus and
committees; interested parties; and stakeholders to make
recommendations for improvements to the authority of consumer
protection boards and bureaus. The NMC was last reviewed in 2013
and will be reviewed in 2017 by the policy committees of the
Legislature as required by law. At that time, the NMC will have
updated information about enforcement and licensing issues for
the NMC which will include updated data about enforcement cases
as it relates to additional prescribing authority for NDs if
this bill were to pass and permit NDs to have specified
prescribing authority without physician supervision.
AMENDMENTS:
The following amendments will address the policy concerns noted
above by removing the provisions of this bill which authorize a
ND to perform minor office procedures; revise the prescribing
authority to authorize NDs to prescribe Schedule V and "legend"
drugs without physician supervision and restore Schedule IV
prescribing authority as defined in current law; and, remove a
clarifying amendment which authorizes a ND to utilize a cervical
route of administration only for the purpose of administering
barrier contraception in order to avoid confusion with an NDs
current scope of practice related to administering specified
birth control methods.
On page 3, in Section 3640(c), restore former paragraphs 5 and 6
to existing law.
SB 538
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On page 3, strike line 35.
On page 4, strike line 1.
On page 4, strike lines 15-32.
On page 4, line 5, strike A naturopathic doctor may utilize a
cervical route and strike lines 6-7.
On page 5, in line 1, after Schedule III, insert: and Schedule
IV
On page 5, in line 20, after Schedule III, insert: and Schedule
IV
On page 5, in line 22, after III insert: and Schedule IV , and
after III insert: through Schedule IV
On page 5, line 31, after Schedule III insert: and Schedule IV
On page 6, line 18, strike Schedule IV through
On page 7, in line 7, after Schedule III, insert: through
Schedule IV
On page 7, in line 21, after Schedule III insert: through
Schedule IV
SB 538
Page 22
REGISTERED SUPPORT:
California Naturopathic Doctors Association (sponsor)
AARP
Akasha Center for Integrative Medicine
Bastyr University
Berkeley Naturopathic Medical Group
California Naturopathic Clinic
Endocrinology Association of Naturopathic Physicians
LiveWell Center
National College of Natural Medicine
Naturopathic Academy of Primary Care Physicians
Naturopathic Medicine Committee
Oncology Association of Naturopathic Physicians
Oregon Association of Naturopathic Physicians
Paracelsus Natural Family Health Center, Inc.
Pediatric Association of Naturopathic Physicians
San Diego Center for Integrative Medicine
Santa Cruz Naturopathic Medical Center
Stengler Center for Integrative Medicine
Women's View Medical Group
Southwest College of Naturopathic Medicine and Health Sciences
(4/6/15 version)
California Chiropractic Association (4/6/15 version)
Integrative Medicine for the Underserved (4/6/15 version)
Arizona Naturopathic Medical Association (Introduced version)
Center for Health Santa Cruz (Introduced version)
Washington Association of Naturopathic Physicians (Introduced
version)
Hundreds of Individuals
REGISTERED OPPOSITION:
American Osteopathic Association
California Chapter of the American College of Emergency
Physicians
California Society of Anesthesiologists
SB 538
Page 23
California Society of Plastic Surgeons
Medical Board of California
Osteopathic Physicians and Surgeons of California
Union of American Physicians and Dentists
American Congress of Obstetricians and Gynecologists, District
IX (4/6/15 version)
California Society of Dermatology and Dermatologic Surgery
(4/6/15 version)
California Medical Association (4/6/15 version)
California Academy of Family Physicians (4/6/15 version)
Kaiser Permanente (4/6/15 version)
American Academy of Pediatrics (4/6/15 version)
California Chapter of the American College of Cardiology (4/6/15
version)
California Radiological Society (4/6/15 version)
California Orthopedic Association (Introduced version)
Analysis Prepared by:Elissa Silva / B. & P. / (916) 319-3301