Legislative Alchemy

Legislative Alchemy

Via the magic of Legislative Alchemy, U.S. naturopaths are again seeking legitimization of their quack practices via licensing and practice expansion bills filed in the state legislatures, over half of which are now in session. Naturopaths are looking for licensing or expansion in at least 16 states this year, with over two dozen bills filed. (This doesn’t even include bills mandating insurance coverage of naturopathic services.) In Oregon alone, where the legislature has already declared, ipso facto, that naturopaths are primary care physicians, six pro-naturopath bills have been filed. Today, we’ll take a closer look at pending bills, with an emphasis on practice expansion.

The recent death of 30-year-old patient Jade Erick at the hands of a licensed California naturopath and Bastyr grad is already having an impact on legislative deliberations. (And this on the heels of the highly publicized death of a Canadian toddler from meningitis last year after his parents purchased a herbal remedy from a naturopathic doctor’s office.) As Steve Novella explained yesterday, Erick died after receiving an IV infusion of curcumin, an ingredient in the spice turmeric, from licensed California naturopathic doctor Kim Kelly, who prescribed it for her eczema. Former naturopath and SBM guest blogger Britt Hermes reported on the Forbes blog that the San Diego medical examiner ruled her death was caused by

severe anoxic brain injury secondary to cardiopulmonary arrest, most likely due to turmeric infusion.

Typical of naturopathic practice, which rejects evidence-based medicine, the fatal infusion was prescribed despite the lack of evidence that curcumin is effective for, well, anything, after having been extensively studied. Nevertheless, it is touted as a near cure-all by naturopaths.

This tragedy is the direct result of Legislative Alchemy, the California legislature having foolishly decided, in 2013, to add IV administration to the naturopathic scope of practice. All that’s required is a paltry 25 classroom hours in IV administration, including a whopping 10 IV setups, and getting a 70% on a 50-question exam. Approved course providers include none other than Kelly’s alma mater, Bastyr, where naturopath Paul Anderson, a proselytizer for curcumin infusions and campaigner against recent FDA efforts to improve the safety of compounded drugs, teaches courses on IV infusions. As both Britt Hermes and our good friend Orac reported, Anderson and the American Association of Naturopathic Physicians have been busy with damage control, including the obligatory digs at “conventional” medicine.

Obviously mindful that California’s naturopathic licensing act is about to sunset, David Field, the head of the California Naturopathic Medicine Committee, which will be charged with investigating any complaint filed against Kelly, was busy with his own tu quoque efforts. Orac uncovered this SOS from Field:

I am in great need of statistics, with references/citations if possible, regarding iatrogenic harm from MDs/DOs, DCs, LAcs, etc. As SOON as POSSIBLE please! ANY and ALL types!

That he needed this information it in his official capacity was made clear by the way he signed off:

David Field, ND, LAc
Chair, Naturopathic Medical Committee (i.e. Board) of California
Santa Rosa, CA

(Note to Field: No, the Committee is a Committee, not a Board. It operates under the auspices of the California Osteopathic Medicine Board.)

Field might want to reconsider his strategy of comparing the relative safety of “conventional” and naturopathic medicine in light of a revealing statistic from the 2016 Annual Report of the California Department of Consumer Affairs. California’s physicians and surgeons perform far riskier procedures on a far greater number of far sicker patients than naturopaths, yet the percentage of complaints received against medical doctors relative to their numbers was actually slightly lower than complaints against naturopaths (5.8% vs. 6.3%).

California law currently provides that the Naturopathic Doctors Act, which legalizes naturopathic practice, permits licensing of naturopaths, and establishes the Naturopathic Medicine Committee within the Osteopathic Medical Board, is repealed on January 1, 2018, and subjects the Committee to “review by the appropriate policy committees of the Legislature.” Senate Bill 796, now pending in the California legislature, simply kicks the can down the road for five years by changing the date for review and repeal to 2022. The bill is set for a hearing before the Senate Business, Professions and Economic Development Committee on April 24, about a month after Erick’s tragic death. And this after a bruising legislative battle last year when naturopaths unsuccessfully tried to get rid of physician supervision over their prescribing drugs.

There’s also a bill pending to allow naturopaths and chiropractors to perform physicals required for participation in school athletics.

For its part, rather than protecting the public from naturopaths, California Naturopathic Medicine Committee is proposing a scope of practice expansion along the lines of the bill defeated last year, including controlled substances in the scope of practice and removing physician supervision over prescribing. No bill based on this proposal has been introduced.

I’ve argued that the California legislature should allow the Act to sunset and stop further licensing of naturopaths altogether, reluctantly allowing the 600 or so naturopaths currently licensed to keep practicing due to the political difficulties of total delicensing. (Although Idaho did just that in 2015.) This is the approach taken by Florida when it delicensed naturopaths in the 1950s.

The NPLEX Pharmacology Exam debuts

Last year, the North American Board of Naturopathic Examiners (NABNE), which administers the NPLEX exam, admitted that naturopathic education and training was insufficient for prescribing privileges, claims to the contrary made by the American Association of Naturopathic Physicians notwithstanding. The NPLEX, according to the NABNE, tested only a naturopath’s knowledge of drugs commonly prescribed by other practitioners, not whether the naturopath herself could safely and effectively prescribe drugs. No word on whether the NABNE went back to the states that already allowed prescribing privileges with this startling news and warned them to amend their practice acts accordingly. Somehow, I doubt it.

Now, the NABNE has quietly debuted the new NPLEX Elective Pharmacology Examination “comprised of 75 stand-alone items” to be completed in 90 minutes. Presumably, this new exam is meant to be the PR tool the NABNE envisioned:

a legitimate way to test pharmacological knowledge will give further credibility to the profession, and may make legislators more likely to consider expanded scope of practice.

Legitimate? Here’s how a representative of the NABNE described the process for creating the exam in an email:

NPLEX has completed the practice analysis to determine which drugs NDs are most likely to encounter in practice. The focus of the examination will be on the knowledge an ND needs to have about those drugs to be able to take their patients off drugs (which is a common patient request) or to safely prescribe drugs when pharmacotherapeutics are warranted.

In other words, they did this back ass-ward. First, they did a practice analysis to determine what drugs naturopaths already encounter in practice. Then they made up a test to see if naturopaths knew what they were doing when they advised a patient to stop using a drug his physician had prescribed or prescribed a drug themselves. (Know what they are doing in theory, at least. Only the naturopaths are privy to the actual exam contents, although you can find some information here.)

One state has already taken the bait via administrative action. A few years ago, Vermont passed a law allowing naturopaths to prescribe drugs (not just substances on their formulary) if they passed a pharmacology exam. The legislature left it up to the Director of the Office of Professional Regulation (OPR) to establish the rules and make up the exam. Those rules require naturopaths to take the National Board of Medical Examiners subject matter exam in pharmacology, the exam given in the Medical Pharmacology course taught through the Department of Pharmacology at the University of Vermont College of Medicine, “or a substantially equivalent” exam approved by the Director. However, without ever amending the rules (that I can find) the Director has decided to replace the real pharmacology exams with the NPLEX pharmacology exam. I have never been able to determine whether a single Vermont naturopath was able to pass the medical pharmacology exams (I’ve asked the OPR twice), giving rise to a suspicion that a new, easier exam had to be substituted if any Vermont naturopaths were going to gain independent prescription rights.

In any event, in spite of the NABNE’s admission, bills seeking expanded prescription privileges are pending in seven states. Two of these have already failed.

Except for a few items listed on their formulary (hormones, for example), Maine naturopaths cannot prescribe drugs. House Bill 393 would have allowed naturopaths to prescribe “certain naturally occurring medications.” Like curcumin and turmeric, perhaps? Fortunately, the Maine Medical Association, unlike some other state medical groups, did its job, showed up at a hearing on the bill and testified against it. The first committee to hear the bill listened and quite sensibly voted it down.

No fewer than three separate bills were filed in Connecticut expanding naturopathic prescribing privileges. (Senate Bills 125 and 314; House Bill 6250). All failed to meet the deadline for further consideration. Connecticut naturopaths lobbied for prescription privileges in 2014, when the state “modernized” their scope of practice, but didn’t get them. Their attempts are no doubt weighed down by a 2014 report from the state’s Department of Public Health, which found their education and training insufficient.

Prescription privileges are at the heart of a battle between the Colorado Senate and House over Senate Bill 106. Colorado’s naturopathic registration law, passed in 2013, required a sunset review by the state’s Department of Regulatory Affairs (DORA) last year. DORA issued a report consisting solely of boilerplate about the review process and regurgitation of naturopathic talking points, reaching the conclusion that “the laws that govern naturopathic doctors ensure competent and qualified practitioners” and, with minor amendments adding naturopaths as mandatory reporters of abuse and requiring reporting of information on malpractice claims, recommended the naturopathic registration law be continued until 2022.

DORA’s report completely ignored the criticisms of naturopathy (insufficient education and training, quack practices, anti-vaccination ideology, for starters) made during a conference call with DORA set up by the Colorado Citizens for Science in Medicine and featuring noted ethicist Arthur Caplan, Ph.D., immunization expert Paul Offit, M.D., and former naturopath Britt Hermes, among others, whose well-founded complaints fell on deaf bureaucratic ears.

So SB 106 was filed, dutifully extending the next sunset date and making the minor modifications to the statute DORA recommended, except that 2 years were shaved off by the Senate, sunsetting the law in 2020. The Senate also amended the bill to clarify that naturopaths are only registered, not licensed (DORA’s report explains the difference). Once the bill got to the House, egged on by naturopaths, the bill turned into something quite different: a major practice expansion, adding, among other substances, chelating agents and hormones to the naturopathic formulary, both of which could be administered IV. (According to DORA’s report, naturopaths lust after hormones: 75% said prescribing hormones was “very important” or “important” to their practice, outranking antibiotics, antivirals, antifungals, and nutrients.) Sunset was bumped back up to 2022 and the registration/licensing clarification unclarified. The Senate refused to concur in the House’s amendments and the bill went to the Conference Committee. The significance of Erick’s death was not lost on Colorado Sen. Irene Aguilar, a physician, who mentioned it in Monday’s Conference Committee hearing. Unfortunately, it appears the House version of SB 106 won the most votes in the Committee, although its fate at this point is uncertain.

Bills adding or expanding prescription privileges are also pending in Hawaii (hormones again), Minnesota (Senate Bill 1514, House Bill 1138, which also include, among other privileges, the right to perform minor surgery), North Dakota (along with office surgery and “natural childbirth attendance”) and Washington (all Schedule III, IV and V controlled substances).

Leave it to the Beaver State

Oregon has declared that naturopaths are primary care physicians and given them privileges to match. Apparently unsatisfied with this state of affairs, naturopaths have managed to get six bills introduced in the legislature further insinuating themselves into Oregon healthcare.

Senate Bill 217; House Bill 2390: Allows naturopathic “physicians” and chiropractic “physicians” to return student athletes to play after a concussion. Sort of like punishing the entire class when a few misbehave, the bill was amended to make all healthcare providers obtain a certificate before they will be allowed to sign off on a return to play. Even a pediatric neurologist would have to get a certificate, just to make sure DCs and NDs learn the basics.

Senate Bill 22: Repeals peer review of naturopaths.

Senate Bill 23: Current law allows naturopaths to do minor office surgery like repair of superficial lacerations. This bill would allow any surgery “that poses little risk to the life of the patient and can be safely performed in an office setting” according to rules set by the Oregon Board of Naturopathic Medicine, a group of naturopaths who’ve likely never done a single one of the procedures they’re going to authorize.

Senate Bill 856: Amends a variety of state laws, adding naturopathic “physicians” to various protections afforded to, and privileges allowed, MD and DO physicians and other health care providers. Most frightening, it adds naturopaths to health care practitioners who can participate in the state’s POLST (physician orders for life-sustaining treatment) registry.

House Bill 3400: Oregon forces insurers to cover naturopaths as primary care physicians. To protect themselves and their insureds from substandard naturopathic education and training, some insurers have imposed additional credentialing requirements on naturopaths. Like their previous attempt to quash an insurer’s requirement that they practice (gasp!) evidence-based medicine, the naturopaths are attacking the credentialing rules via their friends in the legislature. This bill would prevent insurers from imposing any requirement not also imposed on MDs or DOs.

The legislature would do well to heed the advice of Hawaii insurer University Health Alliance which actually reviewed three years of clinical documents associated with every claim for naturopathic services (Hawaii has an insurance mandate pending; UHA’s testimony starts on page 9 of the linked document):

UHA’s coders and physicians have studied the claims and clinical records and worked to reconcile these with standard CPT manual criteria and the Hawaii statutory definition of medical necessity. In addition, appropriate use criteria from a variety of sources have been used in determining whether tests or treatments have been safe, timely, efficient, patient centered, effective and equitable.

The result of UHA’s exhaustive review?

In general, our experience with Naturopaths has not been clinically favorable. . . In view of our three years’ worth of evaluation, UHA does not believe that this is safe or effective care and, therefore, does not favor legislation which will serve to embed naturopathic medicine in a standard health insurance plan.

Healthcare giant Kaiser Permanente also opposes Hawaii’s naturopathic insurance mandate bill.

Licensing and practice expansion: What you can do about it

Naturopaths are currently licensed or registered in 17 states and D.C., with practice acts that vary widely. Because of bills passed last year, they will be allowed to register in Massachusetts in September. They will not be allowed to practice primary care or call themselves “physicians” and must refer patients who are not fully vaccinated to a physician. However, they will be regulated by their own board and allowed to diagnose and treat any patient of any age with any disease or condition. In Pennsylvania, they will simply be allowed to register on January 1, 2018. No scope of practice is specified and they will be regulated by the state medical board, which will enact regulations governing their practice.

This year, initial naturopathic licensing or registration bills have been introduced in Illinois, Indiana, Mississippi, New York (for the ninth consecutive time), North Carolina (for the eighth time), and Rhode Island. A New Jersey bill is still pending from 2016. The Mississippi bill has already failed. You can find out more information on these bills, plus the practice expansion bills, including links to state legislative websites, over on the Society for Science-Based Medicine website, under Legislative Updates, which is refreshed weekly.

Commenters to previous posts on naturopathic legislation have asked if there is some ready reference they could use in opposing naturopathic licensing and practice expansion. Thanks to the indefatigable Britt Hermes, now there is. She has both a page on Naturopathic Diaries devoted to legislative action and a handy pdf you can print out or link and send to your state legislators. To find out more about when your state legislature is in session and how to contact your representatives, SFSBM also has an Advocacy FAQs page. For you Oregonians, who, let’s face it, could really use some help in fighting quackery, there’s also Oregonians for Science-Based Medicine.

Now, get on it.

Posted by Jann Bellamy

Jann J. Bellamy is a Florida attorney and lives in Tallahassee. She is one of the founders and Board members of the Society for Science-Based Medicine (SfSBM) dedicated to providing accurate information about CAM and advocating for state and federal laws that incorporate a science-based standard for all health care practitioners. She tracks state and federal bills that would allow pseudoscience in health care for the SfSBM website.  Her posts are archived here.