Vermont Legislature SmartTranscripts:

[Rep. Matthew Birong (Chair)]: And we are live. Alright, everyone. Welcome back from lunch hour. We left 1PM on March 11. We are having a conversation about our OPR bill h five eight eight, and we are taking a look at a proposal of amendment, and that is being introduced by representative Black. So what I think I would like to do first is just bring up counsel, to discuss the proposal with us through his lens, and then we'll get to our guests.

[Tim Devlin, Legislative Counsel]: Thank you very much for having me today, committee members. For the record, my name is Tim Dublin, legislative counsel. You have draft 1.3 of a individual amendment, although it's from numerous, representatives, as you can see. This will add a single section to the bill having to do with pharmacists to be Section 14A, which will amend 26 BSA twenty twenty three. I should initially note that this same section is being amended in another bill, but doesn't conflict. It's a different subdivision. And so this will retitle, 26 BSA twenty twenty three as counsel. One moment I have my hand. Oh,

[Rep. Sandra "Sandy" Pinsonault]: sure. You said 1.3,

[Rep. Lisa Hango (Vice Chair)]: but I only have 1.2. Could you refresh your opinion? Yes. I

[Tim Devlin, Legislative Counsel]: may not have provided the most up to date version to the committee system. Apologies for that. The difference is the list of sponsors and then one reference to the federal code here on, let's see, line 20, page two. That was it was the wrong federal it was referring to statute and regulation, I think. Yeah.

[Rep. Matthew Birong (Chair)]: So that

[Tim Devlin, Legislative Counsel]: was corrected. That's the only difference between one point two and one point three.

[Rep. V. L. Coffin IV]: So I think we can still work on 1.2

[Tim Devlin, Legislative Counsel]: adequately. So the statute will be retitled clinical pharmacy prescribing and testing. And we'll see our first added language here under A3. So reading them together, it will state in accordance with applicable rules adopted by the board, pharmacists may, a pharmacist may engage the practice of clinical pharmacy, including prescribing as set forth in subsection B of this section, which we'll get to, provided that the pharmacist shall not, three, initiate antibiotic therapy pursuant to a collaborative practice agreement with state protocol. Moving on to aforementioned B. Pharmacists may prescribe in the following context. Two, state protocol. A, pharmacists may prescribe a border or administer in the manner consistent with, in a manner consistent with the valid state protocols that are approved by the Commissioner of Health after consultation with the Director of Professional Regulation and the Board and the ability for the public comment. And then we skip some subdivisions here. Or two, X10, emergency prescribing of albuterol or glucagon while contemporaneously contacting emergency services. That's not changing, but what is following, we're striking what was eleven and twelve here and keeping 13 but renumbering it and adding. Let's see, tests waived under 42 CFR, federal regulation, section 493.15 for COVID nineteen, influenza, streptococcal pharyngitis, maybe garbling that, sorry, and subsequent drug treatment. And then we omit the rest of the subsections and sections here. So, the meat of it is removing, tests for COVID for individuals, etcetera, etcetera, under eleven, twelve, similarly for tests for SARS CoV, and then replacing with tests waived under that federal provision for COVID-nineteen, influenza, etcetera, etcetera.

[Rep. Matthew Birong (Chair)]: All right. Any questions for counsel on that? Thank you, sir. I think next, I would like to shift over to the deputy secretary of state and

[Lauren Hibbert, Deputy Secretary of State]: afternoon. If Jen and I can testify together as we like to do, even though we are not together, that would be great.

[Rep. Matthew Birong (Chair)]: You are in my head. I was actually just gonna tee up the digital to, like, live in three d, like, duet because, hey, why not utilize all the tools to Absolutely.

[Lauren Hibbert, Deputy Secretary of State]: For the record, my name is Lauren Hooper. I'm the deputy secretary of State, and I'm beaming into you from Washington, DC. So thank you for that flexibility. I'm going to let Jen do the bulk of the testimony about the amendment. I just want to say a deep appreciation to the chair and this committee for taking up this amendment. This was something that came to light rather quickly, and it makes sense. It's a relatively easy amendment in many ways. It makes sense to do before it passes out of the House floor, and I just really appreciate the opportunity to do this. So thank you. And I wanted to let the committee know that I know of a potential amendment that is coming on this bill on the Senate side, and I just want to in full transparency, I like to give heads up on these things. We are working with the Board of Medical Practice on an amendment around the FBI background checks for the Interstate Medical Licensing Compact. And this is a great avenue for that, even though they're not part of OPI, they're a strong partner with OPI, and their criminal background check issue impacts our licensees as well. So I do think it's relevant. We're going to argue for that on the Senate side. And I know that, and so I wanted to give you guys a heads up on that as well, since this has been your bill. So with that, unless you have any questions about that potential amendment or anything else related to my gratitude, I'll just say it again. Thank you, and I'll turn it over to Jen.

[Rep. Matthew Birong (Chair)]: Yeah, thank you. And thank you for the awareness on that. And I'm sure we'll have questions once that starts to evolve, but let's stay near term right now unless somebody has a question on that one.

[Jennifer Colón, Director, Office of Professional Regulation]: Great. All right to you. Thank you so much, Jennifer Colon, Director of the Office of Professional Regulation. Good to see you all. So just coming today to fully support the amendment to H588. Thank you so much for this amendment. It allows tests to treat in pharmacies for limited conditions, such as, namely, COVID-nineteen, influenza, and strep as a way to increase access to care. So, this came about as part of the Rural Health Transformation Program grant, which it's our understanding that grant funds were recently approved for the fiscal year and Test to Treat was one of the initiatives that was included in the grant process as a way to increase access to treatment for these limited conditions. It's quick to go into your local pharmacy if you have or you think you may have strep, COVID-nineteen or flu, to be able to test and get treatment at that point of care is a way to streamline care and in a lot of cases much easier than making an appointment with your primary care provider. So, for these conditions where timing in treatment is critical, it's good to be able to have an easier access to this treatment. So the proposed language allows testing and treatment of COVID-nineteen, influenza, and strep by pharmacists in the practice of clinical pharmacy via a state protocol that would be approved by the Commissioner of Health, and as the result of collaboration between the Commissioner of Health, OPR, and the public. It's something that would go out for public comment as well. These are, again, limited conditions with fairly straightforward treatment. And from OPR's public protection lens, which that is our mandate, public protection, Pharmacists have the training and education to be able to safely and effectively provide this service, particularly under the guidance of, and in accordance with, a protocol developed by the Department of Health, which would have additional procedures for pharmacists to follow when doing the testing and treating. Also, just important to note that quite a few other states do allow tests to treat via state protocols, as well as collaborative practice agreements. So this is something that's done in other states, and we fully support this effort.

[Rep. Matthew Birong (Chair)]: Any questions for Jen?

[Jennifer Colón, Director, Office of Professional Regulation]: Thank you.

[Rep. Sandra "Sandy" Pinsonault]: Madam Chair. Welcome.

[Rep. Lori Houghton (Chair, House Health Care Committee)]: Thank you. I admonish my committee every single year about the importance of being on time because everyone's time is valuable. And I apologize for few sleep. You kept the train moving. Got single-minded in thinking about AI and mental health. So So I understand that you've already had a walkthrough of the amendment from legislative council. I will just say that we have met with Agency of Human Services even before the session began around the Rural Health Transformation grant that I know that all of you know about, because I think you guys are working on an EMS bill also that might, pertain to that. And one of the grant proposals in the application, which was approved, was this test to treat. And we always intended to do this. It was very small statutory changes that needed to be made to the licensure around pharmacists and, enabling them to do this. So this legislation is necessary in order for us to move forward with the RHT money that has been allocated to this. So that's why this proposal is before you. We took testimony from, Department of Health, agents well, not Agency of Human Services, but Office of Professional Regulation, as well as the Vermont Medical Society. This is treating after testing is within the scope of practice for a pharmacist. So we not expanding their licensure at all for something that they are unqualified for. They are trained. They are licensed to do this. This is an access issue. Imagine we talk about access a lot. We talk about primary care a lot in our committee. And just the ability to be able to get a visit with your primary care physician, oftentimes you can't get in for a couple of days. Which if you have the flu, let's say, you can go to your pharmacy. They can test you because there are instant tests for influenza now. And this is now allowing that pharmacist to prescribe you with Tamiflu, which needs to be given at the beginning of your flu rather than later. And it can shorten the course and it can make much less complications from the flu. Same thing with COVID. Why am I blinking on the medication?

[Rep. Sandra "Sandy" Pinsonault]: Paxlovid? Paxlovid, thank you.

[Rep. Matthew Birong (Chair)]: I got you.

[Rep. Lori Houghton (Chair, House Health Care Committee)]: Okay, Paxlovid and Streptococcus antibiotics. These are standard treatments, and the sooner that they are given, the better outcomes for the patient. And oftentimes, if you can't get into your primary care physician, you're you're making people miserable. So this is safe, This is effective. And that's why you have this amendment before you. Thank you. Speaking of access currently, I will just say, if you can't get into your primary care, you are then going maybe to an urgent care if your community even has an urgent care, which we don't have a lot of around the state. Or oftentimes you'll just end up going to the emergency department. Because when you're really sick, you want help and you want help now. So, it really saves on costs. Yeah, time. Time, costs, effective treatments in a timely manner.

[Rep. Matthew Birong (Chair)]: Sounds to me. Any questions?

[Rep. Lisa Hango (Vice Chair)]: You have Hango. Just a quick question. Maybe I missed this somewhere. Is the pharmacist the one who does the actual testing as well? Like you can't bring in a home test and say, here, I have strep, but I have treatment for it.

[Rep. Lori Houghton (Chair, House Health Care Committee)]: Yes, no. They would test there. And there is provision. If you look at existing law, it's around CLIA. You have to have a What does CLIA stand for? Certificate of

[Rep. Matthew Birong (Chair)]: I can't help you on that one.

[Rep. Lori Houghton (Chair, House Health Care Committee)]: Clinical Laboratory Yes. You have to have a CLIA waiver, and that is what allows facilities to provide testing. So no, testing would be done there by pharmacists, and then treatment would be rendered. And once somebody has been treated, that information would then be communicated to their primary care physician so that we're ensuring continuity of care.

[Rep. Lisa Hango (Vice Chair)]: Does it say that in the bill somewhere or is that part of

[Rep. Lori Houghton (Chair, House Health Care Committee)]: the CLIA? It's actually part of the rulemaking that OPR has. Better OPR to speak to that than

[Rep. Lisa Hango (Vice Chair)]: Oh, sorry. It would be part of the state protocol. So that's what's developed with the Commissioner of Health. The state protocol has all those details in it about process and records and that sort of thing. Thank you. I'm just questioning that because in the past, as this committee knows, I've had a disconnect between the pharmacy and the primary care. So I want to make sure that was in there.

[Rep. Sandra "Sandy" Pinsonault]: That will be part of the

[Rep. Lisa Hango (Vice Chair)]: Thank you. So,

[Rep. Sandra "Sandy" Pinsonault]: we only have one pharmacy in a 15 mile circle. It's very, very busy. And so now some of the pharmacist techs are authorized to give shots. So would they fall under that CLIA where they will be able to give the testing as well, or is it just the pharmacist?

[Rep. Lori Houghton (Chair, House Health Care Committee)]: It's just the pharmacist But that can

[Rep. Sandra "Sandy" Pinsonault]: they could do the test and then give the pharmacist the I'm just concerned that we have

[Rep. Matthew Birong (Chair)]: a pharmacy that's so good. That's a valid question for a different different witness. And

[Rep. Lori Houghton (Chair, House Health Care Committee)]: I will say, because that is a concern, this is voluntary for pharmacies. So if pharmacies don't feel as though they have the time or inclination to be doing this, they don't have to do.

[Rep. Sandra "Sandy" Pinsonault]: Just see how a poor pharmacist is just like, I mean, you go there and there's just piles of pillboxes ready for her to go through and glimmerify. I don't want to see a pharmacist become an emergency room for strep and COVID-nineteen or whatever. Just see her throwing her hands up in the air.

[Rep. Lori Houghton (Chair, House Health Care Committee)]: She might choose not to participate.

[Rep. Sandra "Sandy" Pinsonault]: It would be nice if her assistants could at least test and then she would prescribe to help the flow. That was my question. Would they be able to assist? Well, I think that would be a better

[Rep. Matthew Birong (Chair)]: That is our next, our next is the Commissioner Health. Yes. But do we have anything else from Madam Chair? Seeing no hands.

[Rep. Lori Houghton (Chair, House Health Care Committee)]: Thank you. Back to AI. Oh, yeah, I apologize.

[Rep. Matthew Birong (Chair)]: You for

[Rep. Lori Houghton (Chair, House Health Care Committee)]: the heads up, Randy, remember.

[Carrie Phillips, Executive Officer, Vermont Board of Pharmacy]: You're gonna quite welcome anytime, my friend.

[Rep. Matthew Birong (Chair)]: All right, thank you. And next, we're gonna shift over to Doctor. Hildebrand, commissioner, Department of Health. How are you doing, sir?

[Dr. Rick Hildebrand, Commissioner, Vermont Department of Health]: I'm well, how are you?

[Rep. Matthew Birong (Chair)]: Doing just fine, thank you.

[Dr. Rick Hildebrand, Commissioner, Vermont Department of Health]: Again, for the record, Rick Hildebrand, Commissioner for the Department of Health. This is my first time before you all. Thank you all for having me here. And I'm gonna be a little bit of an echo of what you've heard so far. Access to timely healthcare is an important public health indicator. And that's something we struggle with in Vermont. We've got a number of rural communities. We've got a limited and aging primary care workforce. Stephanie, I know will tell you, listen, if we had as many primary care physicians as we wanted across this entire state, we wouldn't probably be having this conversation, but that's not the real life scenario. We have huge access issues that has been really challenging to provide care to people. I can tell you that I see this all the time. I work in a hospital. I care for folks on the inpatient unit. And when I discharge someone, you'd think I would be able to get people the next day. And I sometimes struggle to get someone as a follow-up appointment for a week or more. There's a real challenge in getting timely appointments for healthcare. When it comes to some infectious diseases, it's really, really important to get timely access. So in this amendment, we're talking about three different things. Two of them are very similar, influenza and COVID, where if we institute treatment that can shorten the duration of illness, the symptoms that people are feeling, and let people get back to work faster and feel better faster and avoid some of the major negative outcomes related to these illnesses. As an example, with influenza, if you're not diagnosed in the first seventy two hours, you're not eligible. It's no longer indicated to give Tamiflu. So I mean, it's a really tight timeframe from when symptoms start. And oftentimes people don't call the moment their symptoms start. So timely access is really important. With strep, I mean, if we don't have timely treatment for strep, we can end up with valvular heart disease. It can really be quite serious. So we were very intentional about windowing this to diagnosis and diseases that are amenable to this process, to this test history process. And we'll be working very closely with our primary care partners and the Vermont Medical Society to make sure that the protocols that we develop and in conjunction with of course, OPR and the pharmacy board is what we all want. It's got tight guardrails. It ensures that we have great inclusion and exclusion criteria. It ensures that we have follow-up as part of it. Everything that we would want collectively as a healthcare system, we wanna have in our protocol. And that's where it's going to be specified. We are in support of this because we know that this can make a big difference in the lives of many folks. I think as you've heard testimony already, this isn't coming from RHDP. So we would like to use the funds from RHDP to get these programs up and running. And that will require some capital investment, which we can get from RHDP. But the other piece is this can give some revenue to pharmacies. I mean, these are revenue generating services and our pharmacies are strapped. I don't think that every pharmacy in the state will avail themselves to this, but I think for some, they can make a good case to actually increase their staffing with programs of this nature. And I do hope that is the case, because we see that where communities have one pharmacy and they're really, really struggling to keep up. They may not be able to operationalize this, and we fully understand that. But this is an option and may be helpful to not only to pharmacies, but certainly to ERs, to primary care offices, to other folks for these three diagnoses. And I welcome any questions.

[Rep. Matthew Birong (Chair)]: Thank you, Commissioner. Ravkov?

[Rep. V. L. Coffin IV]: Oh, I was gonna for I was pointing at Sandy about her question to try to get an would pharm would the assistance at the pharmacies be able to do the testing and then provide the results to the pharmacist? Is that something they could be trained for or is that built in in the rules?

[Dr. Rick Hildebrand, Commissioner, Vermont Department of Health]: So I don't believe it's built in the rules. It's something I would definitely wanna investigate fully and get back to you on. Because you're right, we wanna make sure that we are operating at the top of our licenses, the term we use in healthcare. So that if a pharmacy tech is within their scope of practice to do a thing, we want them to do that thing and not have it go to the pharmacist or to a higher level provider. I don't believe that we have the statutory allowment to do that. But that again, is something I will investigate and get back to you because we certainly would wanna make this make sense for everyone involved. Okay.

[Rep. V. L. Coffin IV]: Thank you. I just because that would help the pharmacist too and help the community if that was something that was possible to

[Dr. Rick Hildebrand, Commissioner, Vermont Department of Health]: do. Agreed.

[Rep. Matthew Birong (Chair)]: And let me just go out and let the gallery for oh, yes, please. No. Have a Oh, never mind. I will let the gallery do its thing for a moment. Anything else for the Commissioner while the Gallery is doing its

[Rep. Sandra "Sandy" Pinsonault]: thing? Nope.

[Rep. Matthew Birong (Chair)]: All right, so we are on standby.

[Dr. Rick Hildebrand, Commissioner, Vermont Department of Health]: All right, thank you so much.

[Rep. Matthew Birong (Chair)]: Of course.

[Rep. V. L. Coffin IV]: Sorry to steal your thunder.

[Rep. Matthew Birong (Chair)]: No, Yeah. That's

[Jennifer Colón, Director, Office of Professional Regulation]: It's a good question. I know

[Rep. V. L. Coffin IV]: that we have one pharmacy in my area. The pharmacy that was really busy. So if

[Carrie Phillips, Executive Officer, Vermont Board of Pharmacy]: Takes two days to get

[Rep. Sandra "Sandy" Pinsonault]: a pharmacy a prescription built.

[Rep. V. L. Coffin IV]: So, if there's people working with Boardman, we do the testing, help speed up the process, would reduce some of the pressure. And I don't know what the training involved in that, that's not my

[Rep. Sandra "Sandy" Pinsonault]: Oh, I was just I was surprised when I had to get my COVID shot that the the technician could do the job.

[Jennifer Colón, Director, Office of Professional Regulation]: Yes. Jennifer Polin from Office of Commercial Regulation. We were just taking a look at our current statutes. And right now, technicians are authorized by statute to administer COVID-nineteen tests only. So in other words, if pharmacy technicians, if we wanted them to have the authority to be able to administer tests for strep and flu, that would need to be a statutory amendment. So that's the current state of things.

[Rep. Matthew Birong (Chair)]: A much bigger conversation than the conversation we're having right now. Yes, right.

[Rep. Lisa Hango (Vice Chair)]: But is it really a much bigger conversation because COVID-nineteen and flu are very similar? I'm not familiar with the test for strep, if that's any more complicated than flu or COVID-nineteen test. Because it almost makes sense to talk about it here.

[Jennifer Colón, Director, Office of Professional Regulation]: Yep, agreed. It sounds like the flu and the COVID-nineteen tests are the same. They both can are the tests. So it's probably the same procedure. And this is Carrie Phillips, the Executive Officer of the Board of Pharmacy. So she's with us today. So Carrie, did you have something you needed to add?

[Carrie Phillips, Executive Officer, Vermont Board of Pharmacy]: Well, they are frequently the same exact test that's a nasal swab, just like the COVID test. There are combination tests that can test for more than one thing. Test for strep probably is different because it would be a pharyngeal approach. That's not a nasopharyngeal test, probably not terablubulin. But it's certainly, I believe it would be certainly within their skill set to add on to if that was something that the general assembly wished to do. Providing the stakeholders are amenable. And thankfully, Stephanie just showed this to me, so it's certainly something that could be a discussion. Okay.

[Rep. Sandra "Sandy" Pinsonault]: And we

[Rep. Matthew Birong (Chair)]: have a better understanding of what exists. Yes. And how it intersects. Yes. Yeah. Okay. Yes, Representative Engo.

[Rep. Lisa Hango (Vice Chair)]: This may be a question for our next witness, who I think is the pharmacist. But once a pharmacy type administers the COVID-nineteen test, I assume they bring that test result to the pharmacist, and then the pharmacist administers the treatment or dispenses the treatment. So, just thinking along these lines, if flu were also treated the same way in a flu test, and if they were a combination test, would the same protocol happen, same procedure? The pharmacy tech would bring it to the pharmacist and the pharmacist would decide on the treatment and dispense it.

[Rep. Matthew Birong (Chair)]: And were you looking to

[Rep. Lisa Hango (Vice Chair)]: ask that question over the next one? If she's ready to answer

[Rep. Matthew Birong (Chair)]: Yes, please. Join us. Introduce yourself for the record and

[Rep. Lisa Hango (Vice Chair)]: thank you.

[Rep. Matthew Birong (Chair)]: The table is yours.

[Dr. Lauren Bode, Legislative Liaison, Vermont Pharmacists Association]: Hi, happy to. I'm Doctor. Lauren Bodie. I'm a pharmacist and the legislative liaison for the Vermont Pharmacists Association. And my my thanks to everyone for taking this up. I'll just say in brief that that really there's not much for me to say because you've already heard all of the reasons why this just makes a lot of sense for us to do. Know, pharmacists, in particular community pharmacists are a part of the primary care infrastructure of our state, and so it does make sense to use our pharmacists as a way of expanding access. So we're accessible, we're knowledgeable, we're trusted and trustworthy. So yes, I think this all makes sense to do. To the specific point of pharmacy technicians, I would highly advocate for, creating a way for the actual administering of the test to be delegated under the supervision of a pharmacist in the same way that it is, for COVID-nineteen. And basically expanding it across the disease states that we're talking about today, because it would work essentially exactly as you're saying. So, you know, the pharmacy technician plays a valuable role in operationalizing any workflow, which in this case, you know, could be facilitating intake and maybe administering the test, but then the clinical activity of evaluating the test results and determining appropriate treatment, if any, or the decision to refer or whatever the case may be that will rely on the clinical decision making of that like a highly trained pharmacist. Any, are there any other direct questions I can, I can answer? I

[Rep. Matthew Birong (Chair)]: do have a hand up here. Yes, representative Coffin. This is actually for doctor Hildebrand.

[Rep. V. L. Coffin IV]: For a strep test, is is it just from what I experienced with my own children, is it just normally a throat swab, just just a swab on the for mucus?

[Dr. Rick Hildebrand, Commissioner, Vermont Department of Health]: Yeah, so a nasopharyngeal or in the nose is for COVID and flu. Oftentimes the same swab used for both. A pharyngeal swab or throat swab is typically used for strep. So swab in the throat in the peritonsillar region around your tonsils, is is typically where the sample is collected for a strep test.

[Rep. V. L. Coffin IV]: Oh, just and I don't know if you can answer this or not, but in your opinion, would it be just as safe for a, assistant at a pharmacy to be able to administer this test if it's a simple swab?

[Dr. Rick Hildebrand, Commissioner, Vermont Department of Health]: I think it's something that we should make sure they're trained to do, it is not incredibly dissimilar from swabbing a nose. It's just a different region of the nasal pharynx that we're swabbing. So, do think if someone can be trained to swab a nose, they could be trained to swab a throat. But again, would wanna make sure that they were adequately trained to do so.

[Rep. V. L. Coffin IV]: Yeah. Oh, definitely. They need to be the training needs to be there. Trying to figure out a way to get this all wrapped up.

[Dr. Rick Hildebrand, Commissioner, Vermont Department of Health]: Fair enough. Thank

[Rep. Matthew Birong (Chair)]: you. And I just saw a deputy secretary show up. So are you jumping on the screen?

[Carrie Phillips, Executive Officer, Vermont Board of Pharmacy]: Yes.

[Rep. Matthew Birong (Chair)]: The table is yours, Madam Deputy Secretary.

[Lauren Hibbert, Deputy Secretary of State]: Laura Hooper, for the record again. If I can recommend what we would like to do is consult and talk about this more with our Department of Health colleagues and make this modification. It's a very good catch by this committee, the pharmacy technician component. This is why the process works so well as we all have good ideas and we work collaboratively. So thank you for that. But we would like to talk through the appropriateness of particularly the strep test for pharmacy technicians and likely, depending on the outcome of that, we'll ask to modify the pharmacy tech language on the Senate side, and would ask to give you a heads up. There will be other amendments to the bill, I'm confident. So we're going to be coming back to you anyway. But this is something that I rather than try and solve it in this hour in this committee at this in this week. If we could just have a little time to talk about it, I promise you that we will, and we'll come back to you on the issue.

[Rep. Matthew Birong (Chair)]: Sounds good. Okay. Reasonable.

[Lauren Hibbert, Deputy Secretary of State]: Thank you very much.

[Rep. Matthew Birong (Chair)]: Okay. With that understanding, we're just gonna refocus to the direct words on the page right now for consideration of this amendment for inclusion of the bill that is getting voted out of appropriations any minute now. So, any other questions for our guests from the Pharmacy Association?

[Dr. Lauren Bode, Legislative Liaison, Vermont Pharmacists Association]: If not, may I, may I echo one other, comment of Doctor. Hildebrandt's?

[Rep. Matthew Birong (Chair)]: Oh, absolutely.

[Dr. Lauren Bode, Legislative Liaison, Vermont Pharmacists Association]: Thank you. I appreciate it. The thing that I really appreciate and I not for action, you know, in this exact hour today, but in recognition that the full promise of implementation for this is going to rely on there being a sustainable mechanism for reimbursement for pharmacies to implement these services. I just, you know, I'm looking forward to participating in ongoing conversations about how we can support creating those pathways. Because I do absolutely agree with Doctor. Hildebrand that there is a potential there for for this to be a part of helping our community pharmacies remain financially sustainable and therefore present in our communities. But there actually are likely some regulatory changes that would need to be implemented to actually facilitate that. So just hope that we can continue to have those conversations. And I really appreciate this.

[Rep. Matthew Birong (Chair)]: Thank you so much for your time. And if you wanna stick around just in case something else pops up that's relevant to you, that'd be amazing. So let's see. He's us with Stephanie Witters. How are you?

[Carrie Phillips, Executive Officer, Vermont Board of Pharmacy]: I'm just peachy. How are you?

[Rep. Matthew Birong (Chair)]: I'm well. Haven't seen you around here in a while.

[Stephanie Winters, Deputy Director, Vermont Medical Society]: No. I haven't been in this committee room. That shows how long it's been since I've been 10.

[Rep. Matthew Birong (Chair)]: Right? Yeah.

[Carrie Phillips, Executive Officer, Vermont Board of Pharmacy]: Yes. Yes.

[Rep. Matthew Birong (Chair)]: Folk welcome to our new abode.

[Stephanie Winters, Deputy Director, Vermont Medical Society]: Thank you. I like it over here.

[Jennifer Colón, Director, Office of Professional Regulation]: It's all right.

[Rep. Matthew Birong (Chair)]: Yeah. Yeah.

[Stephanie Winters, Deputy Director, Vermont Medical Society]: Stephanie Winters. I am the deputy director of the Vermont Medical Society. And for those that don't know or who are new, the Vermont Medical Society is a physician and physician assistant membership organization representing over two thirds of the licensed physicians in the state. So thank you for allowing me or inviting me to testify today. And Doctor. Hildebrand stole my thunder on the primary care piece. But I will reiterate that as we continue to build our health care system, we have problems in one area, and then we push it to a different area and push it to a different area because they become overwhelmed. And so we threaten overwhelming lots of different systems without really fixing the original problem. So hopefully, if you have bills come across you in the House, hopefully after crossover that will help build primary care, I would ask that you support them. So that's all I will say to that. But on this bill, I want to begin by saying that we explicitly that pharmacists are essential members of the health care team and that we have worked within the Vermont state protocol system that really does work for pharmacist prescribing. And we appreciate that this amendment is tight. It is very medication and condition specific and protocol driven and not open ended. We would be concerned with broad unrestricted testatory authority, and we do appreciate and support that the amendment language is condition or medication specific. Just a little bit about the protocol based approach. We've had a strong history of collaboration between prescribers, pharmacists, and regulators. And in 2020, in fact, this body passed a landmark example of expanding pharmacist prescribing authority safely and deliberately. And that is through these jointly approved protocols by OPR and the Department of Health. And so this model, which has the Board of Pharmacy come up with protocols that then are opened up to the public. I have been able to attend all of those, and we provide comment. We've had really great open discussion and been able to discuss issues and really come to what is best and safest for the patient. So I have appreciated that. And I think I will just end because everything's already been said, but that we support safe collaborative models of pharmacy engagement, those that complement, not replace the patient centered medical home or primary care, and that we support that this language is condition or medication specific and protocol driven. And we look forward to being part of the protocol process, which we hope will address information sharing, coordination with primary care, and notification after prescribing to the primary care so that we make sure the medical records are up to date and everybody knows what is happening with the patient. And then, as you have talked about, include training, oversight, and outcomes to protect both the patients and the pharmacists. So with that, I will conclude and say thank you.

[Rep. Matthew Birong (Chair)]: Any questions for BMS? Alright. Alright.

[Carrie Phillips, Executive Officer, Vermont Board of Pharmacy]: Thank you.

[Rep. Matthew Birong (Chair)]: So this was good timing. I just was sent a text by Chair of Appropriations that age of five eighty eight was voted out eleven zero. So that is moving. How does everyone feel with the moving parts and the understanding? Anyone have any open questions? No, are we just waiting to hear back from Secretary of State's office now about the pharmacy tech? We just They're going to do that over there. They're going to do this. Yeah, yeah, they want

[Rep. Lori Houghton (Chair, House Health Care Committee)]: us Okay. Focus

[Rep. Matthew Birong (Chair)]: And then that conversation will happen So over we are just really focusing on this.

[Stephanie Winters, Deputy Director, Vermont Medical Society]: On this part. Correct. Just wanted to clarify.

[Rep. Sandra "Sandy" Pinsonault]: Sorry about that.

[Rep. Matthew Birong (Chair)]: No, no, no, not at Totally, that was a lot of moving parts. Valid question.

[Rep. Lisa Hango (Vice Chair)]: Health transformation From the government to the tune of $195,000,000 And that's going to be decided by somebody other than us. They have really specific guidelines for that money.

[Rep. Matthew Birong (Chair)]: Correct. And this here would be funded with those dollars, any cost associated with I like it.

[Rep. Sandra "Sandy" Pinsonault]: They already billed for shots and stuff, so why don't they bill for the time of testing as well? I like it. I don't see the pharmacist over the long term anymore.

[Rep. V. L. Coffin IV]: Right. That's why I like that if the the conversation continues in the senate about getting making sure that the assistants are properly trained, they can do these other tests and let the then the pharmacist can prescribe. Pharmscribe. Yep. And then all in safety, I hope the senate continues on that mode.

[Rep. Matthew Birong (Chair)]: Adam deputy.

[Lauren Hibbert, Deputy Secretary of State]: Yes, for the record, Lauren Hibbard again. I am in no means an expert in medical billing, healthcare billing. But it is a very complicated system. Changes to who's reimbursed and by whom are regulated by DIVA and Medicaid Medicare and the private insurance industry and regulatory rules. So there and it sometimes can be directed by statutes. So it's a multi governed by a lot of different things. And I see that Lauren Bodie, who I always like to testify with just chimed in too. But it's a complicated network and it's not always an easy to change. But what I think this group is committed to is enabling payment to pharmacists and making sure that it is cost effective for pharmacies to be providing these services. I think that's in the mutual goals of everybody who you vote from today.

[Jennifer Colón, Director, Office of Professional Regulation]: Thank you. Anything

[Rep. Matthew Birong (Chair)]: to add?

[Dr. Lauren Bode, Legislative Liaison, Vermont Pharmacists Association]: Lauren Bodie with BPA. Yes, not to minimize the complexity, but these are not insurmountable challenges. These are challenges that many other states, I think now 37, have gone through and have kind of figured out essentially for lack of like a more refined set of set of terms to figure out how to open open up like pathways for pharmacists to be able to do billing. And so by no means. So yes, complex, not impossible. There are some fairly straightforward things that we could start doing from a regulatory side in particular in diva to kind of like start this ball rolling. I also want to note that we actually have precedent. Back in 2021 there was a bill that required commercial insurers operating in the state to provide pathways for pharmacist coverage. So again, complex, but not totally unknown, and definitely not without precedent. And so my purpose in bringing it up is just to, offer support and, ask for help in terms of starting to unravel just elements of the complexity.

[Rep. Matthew Birong (Chair)]: So, any other questions or comments? Alright, so this would be a floor amendment that would be presented by representative Black. So, our position right now would be a stronghold, so we don't have a session to fill. Clear on that one. So, I know other input or questions. Favorable funds for representative blacks amendment. Alright, and that is a thousand 902 on thumbs. Thank you. Alright, I appreciate the time on that. This is an important amendment that came a little late, but, hey, that's what we do here. Right? Yeah. Thank you so much, and please, get back to conferencing, I guess.

[Lauren Hibbert, Deputy Secretary of State]: Probably recognize the hotel drapery. Thank you. I will do so.

[Rep. Matthew Birong (Chair)]: Absolutely. I know. Yes. Yep.

[Rep. Sandra "Sandy" Pinsonault]: The hotel lamp gave it away.

[Rep. Matthew Birong (Chair)]: I think I had that room once. Alright.

[Rep. Sandra "Sandy" Pinsonault]: Actually, the building. No.

[Rep. Matthew Birong (Chair)]: It was yesterday. That was yesterday. Yeah. Alright, folks. Thank you So very much, we will be back in twelve minutes for counsel to just keep mining through, the emergency management bill. So we got a ten minute break until 02:00 with