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SUMMARY
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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