17 November 2023

Below is my summary of the key discussions and decisions made at today's regular business meeting of the Board of Naturopathy, which regulates the practice of naturopathic medicine. (Please note that this summary does not reflect official meeting minutes of the Board, which is a completely separate entity from the WANP. The reflections and notes below are my own and should not be assumed to represent the Board of Naturopathy in any way.)

Continuing Education Rule-Making
In order to comply with deadlines set forward by the Washington State Legislature, the Board had to advance its rule-making adding a new Health Equity continuing education requirement at today's meeting. Several comments were made by public attendees prior to the Board's discussion. While most of the public comments were supportive of the proposed changes to the "categories" of continuing education implemented in 2021, there were some comments (including from both the WANP and the AANP) expressing concerns about some of the language that had been changed in this rule (for example, improper use of the word "accreditation" and removing the requirement to "pass" an exam to get credit for pre-recorded content).

At the start of the Board's discussion on the rule-making, Board Chair Krystal Richardson, ND, laid out the possible outcomes for the discussion: The Board could obtain a majority vote to adopt all proposed changes; the Board could have a majority vote NOT to adopt all proposed changes (which means the rule-making would fail and would need to be restarted from the beginning); the Board could have a tie vote on adopting all proposed changes (which means the rule-making would fail); or the Board could have a majority vote to separate out and pass the Health Equity portion of the rule-making to remain in compliance with legislative directives and deadlines. Board Vice Chair Joanne Hillary, ND, moved to separate out and advance just the Health Equity portion of this rule-making, and this motion was seconded by Amira Ahdut, ND, LAc. The motion passed by majority vote of Drs. Ahdut, Chad Aschtgen, Hillary, and Richardson; Dr. Elias Kass and public member Brooke Fotheringham voted against. Therefore, the Board complied with its legislative mandate by adopting new Health Equity continuing education rules for Washington-licensed naturopathic physicians. Dr. Kass then moved to separate out and adopt changes to the pharmacology requirements in the CE rules (specifically regarding how pharmacy content is documented), and this motion was seconded by Ms. Fotheringham. This motion was passed by unanimous vote of the Board. The changes will be given an effective date by the Department of Health, at which time the language in WAC 246-836-080 will be changed to reflect them.

Sunrise Review on Senate Bill 5411: Naturopathic Physician scope expansion
WANP Executive Director Angela Ross, ND, gave a brief presentation on the Sunrise Review on SB5411: Addressing a shortage of primary care services by increasing the scope of practice of naturopathic physicians. Dr. Ross provided some context and information on both the bill and the Sunrise Review process and requested that the Board submit supportive comment on the bill to the Department of Health as part of the open public comment period. The majority of the Board (Drs. Ahdut, Aschtgen, Hillary, and Richardson) voted to support this effort to expand the scope of naturopathic physicians in Washington State by submitting a letter of support; Ms. Fotheringham voted against; Dr. Kass abstained. The Board then voted to designate draft writing to Drs. Ahdut and Richardson, with Drs. Ahdut, Aschtgen, Hillary, Kass, and Richardson voting in favor of this designation; Ms. Fotheringham abstained.

[The WANP is grateful for the support of the Board in our effort to advance naturopathic medicine in Washington and to better align our scope of practice with our training and recognition as primary care providers and physicians.]

Second Substitute House Bill 1724: Increasing the trained behavioral health workforce
Brandon Williams, Project Manager, gave a brief presentation on the possible implications of new Section 8 of SSHB 1724 in regards to the Board determining states with "substantially equivalent" training and licensure requirements for naturopathic physicians as Washington. Drs. Aschtgen and Hillary agreed to research which states may meet the "substantial equivalency" requirement and they will report back on this at a future meeting.

Provider Performed Microscopic Procedures (PPMP) Proposed Rule-making
Jessica Holloway, Program Manager, gave a brief presentation on upcoming rule-making that will remove naturopathic physicians from WAC 246-338-020. The effect of this removal would be to make it technically illegal for naturopathic physicians in Washington to perform any provider performed microscopic procedures (PPMP) in office (e.g. looking for pin worms, doing KOH preps, analyzing urine or semen or vaginal discharge using a microscope, etc.). This proposed change is due to a recent audit by the federal Clinical Laboratory Improvement Amendments (CLIA) program that determined that state law is discrepant from federal law in its inclusion of naturopathic physicians. Ms. Holloway advised that the Department tried to explain to CLIA representatives that we have training and licensure that allows us to do these lab tests in office, but the federal legal team determined that the state is required to remove us from this WAC in order to maintain its "CLIA exempt" status.

Per the presentation: Microscopic procedures are considered “non-waived testing”. Code of Federal Regulations 493.1357 establishes the requirements of a laboratory director AND a provider performing the microscopic procedure. None of the definitions in the federal rules specify or allow naturopathic physicians. CMS CLIA asked why this is in the rule and DOH provided evidence of requirements for the profession. CMS CLIA determined that “naturopaths do not meet the federal definition…” In order to maintain CLIA exemption in Washington, DOH and all labs must comply with federal laws. DOH will conduct rule-making to remove NDs from lab directors and testing personnel. Once rule-making is initiated, there will be a public comment period. NDs will not be able to renew a PPMP license after June 30, 2025.

There were many questions asked during this presentation, including why now - after ND inclusion in this rule since it was written/adopted over 20 years ago. There was also much discussion around which testing would be included and whether NDs would still be able to perform things like rapid Strep tests, COVID testing, and urinalyses via dipsticks. Ms. Holloway assured that nothing other than the 9 PPMP listed in the rule would be impacted by this rule change.

Ms. Holloway did provide some possible advocacy options for the naturopathic community to pursue to try to broaden CLIA's definition of approved providers.

[The WANP has already started exploring multiple avenues to work on this. We are working alongside our national leadership and with both our state lobbyist and AANP's national lobbyist to try to learn more and understand what actions we can take to change this. We will be advocating for our doctors by approaching the rule-making body for CLIA to try to make our case to them, as we fully recognize that our doctors are fully capable and well-trained on the clinical use of microscopic diagnosis and the importance of point of care service - especially for our more remote/rural doctors and their patients.]

2023 Legislative Session Report
Supervising Staff Attorney Bill Kellington provided a recap of the 2023 Legislative Session, including the increase in approved health professions by legislative action. There have been some changes to the Uniform Disciplinary Act (UDA), to include new protections for gender-affirming healthcare and reproductive healthcare and to include a new violation of female genital mutilation to a minor. He also referenced a number of interstate compacts that were proposed or approved during the 2023 Session.

Substantial Equivalency Review | Oregon
The Board briefly considered a request from an Oregon-licensed naturopathic physician to obtain licensure in Washington State through "substantial equivalency" as permitted under SSHB 1724. Given that this bill was just presented to the Board today, the Board opted to postpone a response to this until after they determine whether any other states are "substantially equivalent" to Washington for ND licensure.

FNMRA Requests Comment on Idaho Licensure Issues
The Board unanimously voted to submit a letter of concern to the appropriate authority in Idaho to try to ensure that only "licensable" NDs (i.e. naturopathic physicians who have completed training at an accredited naturopathic medical school and who have successfully passed the naturopathic physicians licensing exam) can become licensed in Idaho. Drs. Kass and Richardson will work on drafting this letter.

Board of Naturopathy Recruitment
Drs. Ahdut and Aschtgen have generously agreed to continue serving on the Board until their successors are appointed by the Office of the Governor. The Board has interviewed several candidates for these two positions and for the open Public Member position, but there is not clarity on when the Governor's Office will make these appointments.

Nonsurgical Cosmetic Procedures Rule-making
The CR-103 was accepted and the rule change allowing Washington-licensed NDs to utilize injectable botulinum toxin for strictly cosmetic purposes will go into effect on 14 December 2023. As of this date, WAC 246-836-212, which spells out training requirements, will be in effect.

As of this meeting, there are 1,630 licensed naturopathic physicians in Washington.

Please direct any questions about this summary to me at executive@wanp.org

~Angela Ross, ND | Executive Director, WANP