State of Arizona Office of the Auditor General



Naturopathic Physicians Board of Medical Examiners (June 2000, Report No. 00-9)




The Office of the Auditor General has conducted a performance audit and Sunset review of the Arizona Naturopathic Physicians Board of Medical Examiners pursuant to a June 16, 1999, resolution of the Joint Legislative Audit Committee. The audit was conducted as part of the Sunset review set forth in Arizona Revised Statutes (A.R.S.) §§41-2951 through 41-2957.

The Naturopathic Physicians Board of Medical Examiners was established in 1935 to regulate naturopathic physicians through licensure. The 5-member Board is funded primarily through licensing fees and regulates approximately 195 active naturopathic physicians. These naturopaths were once restricted to using natural, drugless, and nonsurgical methods; however, in 1992 the law was changed to allow these physicians to perform many of the same activities performed by allopathic (M.D.) and osteopathic (D.O.) physicians.

Legislative Clarification of
Naturopaths’ Scope of
Practice May Be Needed
(See pages 9 through 15)

The Legislature may wish to consider reviewing the Board’s statutes to more clearly define what services naturopaths can perform. Seemingly minor statutory changes have broadened the naturopathic scope of practice to include practices once limited to allopathic (M.D.) and osteopathic (D.O) physicians. Arizona's board, which has statutory authority to adopt rules for recognizing naturopathic specialties, now proposes recognizing 16 specialties including family medicine and minor surgery, internal medicine, neurology and psychiatry, and ophthalmology. It is not clear if the Legislature intended such an extension of naturopaths’ activities. No other state that regulates naturopaths recognizes such a broad range of specialties.

The Legislature may also wish to consider reviewing the Board’s statutes to determine if increased review should be provided over what prescriptions naturopaths can write. The Board’s statutes require it to develop a list of "natural substances" that naturopaths can prescribe, but the statutes do not define what "natural substances" are. The Board has developed an extensive list, or formulary, that includes not only vitamins and minerals, but also vaccines, antibiotics, oral contraceptives, anabolic steroids, and controlled substances such as morphine and cocaine. The federal Drug Enforcement Administration has recently approved Arizona naturopaths to prescribe controlled substances from the formulary because this appears to be in accordance with state law. Although some other states allow naturopaths to prescribe and dispense drugs, none has a list as extensive as what the Board has developed. Most of these states also have separate oversight bodies to develop or review the list, while Arizona does not. These other states have also established their formularies in rule before allowing naturopaths to begin prescribing drugs; Arizona has not.

Numerous Problems
Exist with Licensing Exam
(See pages 17 through 24)

The Board needs to correct numerous problems with its three-part licensing examination, or adopt a national examination, to ensure that the naturopaths it licenses are competent. Since 1997, the Board has been administering a licensing examination it developed specifically for Arizona. Problems with this examination call into question its validity as a tool for measuring an applicant’s competence to practice naturopathy. For example, the Board has not ensured that the examination tests what a naturopath would need to know to practice safely and has not shown that examination writers possess the necessary expertise and training to develop test questions. Further, the Board has made extensive adjustments to examination scores. For example, one licensure applicant received credit for 90 questions that she had answered incorrectly on one part of the February 1999 exam. As a result of such scoring adjustments, no one has failed the Board’s exam since September 1998.

The Board also has not maintained adequate examination records to show that all licensed naturopaths have taken all required parts of the examination. For 19 of the 32 naturopaths licensed between November 1998 and October 1999, the Official Examination Record did not show that they had taken all examinations required for licensure. If the Board continues to develop and administer its own examination, it needs to take steps to address all of these deficiencies.

The Board Needs to Improve
Complaint Processing
(See pages 25 through 30)

The Board needs to improve complaint processing to ensure that complaints are resolved in a timely and appropriate manner. Although the Board receives only 6 to 13 complaints each year, at the time of this review, it had developed a backlog of cases. Of 13 unresolved complaints, 5 had been open for more than 1,000 days.

After these backlogged cases were brought to the Board’s attention, the Board made an effort to resolve them by placing them on meeting agendas for discussion and by working to hire a complaint investigator. While this is a step in the right direction, some additional improvements are needed. The Board’s complaint records are so limited that the Board probably cannot provide consumers with a complete, or even a recent, history of complaints and disciplinary actions against practitioners. Poor recordkeeping has also resulted in some confusion about which complaints have been resolved.

The Board also needs to separate its complaint investigation and adjudication functions. Currently, the full board participates in investigative interviews with licensees, and then adjudicates the case. Although not illegal, this practice can give the appearance of bias and is inconsistent with the Attorney General’s advice contained in the Arizona Agency Handbook. The process should be changed so that Board members either do not participate in investigations, or, if they do participate, are recused from resolving the case.

Board Needs to Strengthen
Operations and Improve
Oversight of Executive Director
(See pages 31 through 37)

Board operations suffer from numerous problems that either have not been recognized or adequately addressed. In addition to those problems already discussed above, recordkeeping deficiencies exist in a number of other areas, and the Board has had difficulty staying within its personal services budget. In addition, the Board has not responded to a 1992 legislative directive to develop rules for approving naturopathic medical schools and training programs. It has not responded to legislative directive to establish time frames for issuing licenses as required by A.R.S. §41-1073(A), to be in place by December 31, 1998. Many of these problems are compounded by the Board’s failure to adequately oversee its executive director. In addition, the Board has allowed open meeting law violations to occur, and its members have sometimes voted on issues that could carry the appearance of a conflict of interest. For example, a former member voted to approve a training program at an institution where the member was on the faculty. Further, until August 1999, the Board allowed its executive director to also act as a Board member even though this was statutorily prohibited in August 1998.

Sunset Factors
(See pages 39 through 47)

As part of the Sunset review process, this audit also recommends some additional changes to the Board’s practices, rules, and statutes. For example, the Board should take disciplinary actions against naturopaths who do not comply with the requirement to attend continuing education courses. The Board also needs to adopt numerous rules relating to issues such as licensing time frames, as well as the criteria it will use for approving schools, training programs, and specialty designations. Finally, the Legislature should consider amending the Board’s statutes to allow the Board to subpoena medical records as part of complaint investigations, and to allow the Board to keep its examination and examinees’ scores confidential. Currently, at least five other regulatory boards, including those that regulate podiatrists and optometrists, have statutory provisions to keep examinations and scores confidential.

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