Vermont Legislature SmartTranscripts:

[Rep. Lisa Hango (Vice Chair)]: Fun.

[Rep. Matthew Birong (Chair)]: Right, we're live. All right, everyone. Welcome back. 10:15 on Thursday, May 7. We are picking up some witness testimony, piggybacking off of yesterday's robust discussion on S 64, an act relating to amendments to the scope of practice for optometrists. And we are joined by Kelsey George, senior policy specialist, health programs and CSL. How are you?

[Kelsey George (Senior Policy Specialist, National Conference of State Legislatures)]: I'm doing well. Thank you for having me.

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

[Kelsey George (temporary overlap)]: Fantastic. I will share my slides. Can you see? Yes. Yep.

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

[Kelsey George (Senior Policy Specialist, National Conference of State Legislatures)]: Well, thank you so much, Chair, and thank you committee members for having me. Again, my name is Kelsey George. I'm a senior policy specialist with the National Conference of State Legislatures. And I'm here to provide testimony on Senate Bill 64 and to provide an overview of state regulations of optometrists scope of practice. So a quick roadmap of my remarks today, I'll provide a brief introduction of NCSL, I'll provide a short overview of optometrist licensure and certification requirements across states, And then I'll dive into a variation of state optometrist scope of practice laws and regulations across ophthalmologic procedures, prescriptive authority, and injectable authority. And I'll close with a few additional resources. Now, this is a lot of information to cover in fifteen minutes, so I kindly request that you save your questions for the end of my presentation. I'm more than happy to send information after today's presentation if you have follow-up questions. So, as legislators and legislative staff, NCSL is your membership organization. We serve our members in a variety of ways, as you can see on the slide here, including policy research and testimony, as I'm providing now hosting convenings to facilitate shared and collective learning, like our legislative summit, which is coming up in Chicago in July. And while I'm based in Denver, Colorado, we also have colleagues based in DC who advocate on behalf of states to the federal government. We also have a myriad of legislative databases, publications, podcasts, webinars, all publicly available on our website, which will be linked throughout my presentation. So, important note, NCSL staff, like myself, are nonpartisan, and we do not take position for or against any state policy. So all the information I'm sharing today will provide a snapshot of what trends and recent actions we're seeing across states and does not indicate support or opposition for Senate Bill 64. First, I want to note that health policy is consistently a priority across state legislatures. NCSL created this graphic based on the request that we received from members like you, and this is a reflection of the types of questions that we received from legislators and legislative staff in 2025. No surprise, Medicaid is a well established focus within state health policy as it's a huge part of state budgets. Workforce issues are also front and center. Affordability and access remain hot topics as well, especially when it comes to commercial insurance, prescription drug access, affordability, and health system concentration. And states are focusing on things like maternal and child health, behavioral health, among other issues as well. NCSL maintains a database that tracks about 50 databases across a variety of policy topics. This one in particular tracks enacted health workforce legislation across all 50 states, DC, and the territories, and it includes bills from 2024 through present and is updated biweekly. This slide shows a quick snapshot of the trends in enacted workforce bills that we've seen so far this year. These trends are consistent, albeit with a higher total number of bills so far this year than we've seen in the last two years. So, at least 41 states and DC have enacted at least three forty eight bills addressing health workforce topics so far this year. You can see several professions noted on this slide. No surprise to you all, I'm sure behavioral health, primary care, nursing, and long term care are significant topics across states. I'll note the other professionals category here is also quite large. That includes allied health occupations and other healthcare occupations, including eye care professionals like opticians and optometrists. We saw at least 21 bills enacted across 15 states so far this year on optometrists alone, and these touch on topics like scope of practice, like prescriptive and vaccine authority, licensure and certification, like continuing education requirements or professional liability insurance requirements, and workforce protections, like workers' compensation and regulation of non compete agreements. So, before I jump into how states regulate optometrists specifically, I want to note that these professionals exist within a system of several eye care occupations. Opticians primarily fit customers for lenses prescribed by optometrists or ophthalmologists. Ophthalmologists are physicians specializing in eye care and are generally trained to provide surgical and other procedures. Opticians fall in the middle here. They're required in every state to have a doctor of optometry degree, and generally diagnose, manage, and treat eye and vision related conditions. So, every state sets licensure requirements for optometrists, though they vary greatly in the education and training requirements, examination requirements, continuing education for licensure renewal, and other requirements such age, US citizenship, English language proficiency, liability insurance requirements, or good moral character requirements. Now, I'll touch on these in more detail, but to my knowledge, no states license multiple levels of practice for optometry, though they may require certification to perform certain primary eye care procedures, like surgical or laser privileges, to prescribe medications, or to treat certain conditions, like glaucoma. The Association of Schools and Colleges of Optometry reports that there are at least 25 optometry schools across 16 states. Upon completing the didactic or classroom education requirements of a doctor of optometry or OD degree, graduates may complete clinical residency training to specialize in their particular categories or emphasis areas within optometry listed on the slide here. Residencies generally include specific hours of supervised clinical experience addressing these emphasis areas, like providing pediatric care, diagnosing or treating glaucoma, or focusing on vision and rehabilitation therapy. In addition to the degree requirements of a Doctor of Optometry degree, states may define our requirements for didactic and classroom education, or they may define clinical training requirements that applicants must complete in order to achieve licensure. So, are a lot of examples listed on the slide here. Additional hour requirements, when they're outlined in statute or administrative code, generally range from ten hours in California to one thousand hours in Delaware, and they may include both didactic and classroom education and or supervised clinical experience. Some states like Arkansas, California, and Hawaii specify that supervised experience must be under the supervision of a licensed ophthalmologist, while other states may just state the supervision requirement broadly. States also set the examination requirements required for licensure within the state. So, examinations are used to determine an optometrist licensee applicant competency, and are generally administered by the National Board of Examiners in optometry. Nearly every state requires NBU parts one, two, and three, which cover applied basic science, patient assessment and management, and patient encounters and performance skills. According to MBEO also offers examinations in additional areas of optometrist care, those are shown in the middle of the slide here, which include treatment and management of ocular disease, injection skills, laser and surgical procedures, and advanced competence in medical optometry. Some states may require these additional examinations, like Alaska and Louisiana, which require injection skills examination for licensure. Oklahoma requires licensed optometrists to complete laser therapy for anterior segment force that is offered through the Northeastern State University prior to taking examinations. At least 40 states and Washington, D. C, including Vermont, require the treatment and management of ocular disease examination for optometrist licensure. And many states also require licensees to pass a jurisprudence examination, which is basically assessing their understanding of laws and regulations of their profession in that state. Every state also sets continuing education requirements for optometrists, but this may vary in the number of hours they must complete, the topics they must cover, and the licensure cycle they must complete it within. Vermont statute currently sets general requirement for continuing education at forty hours every two years. Some states like Alaska, Florida, Rhode Island, and Mississippi require continuing education hours on pathology, pharmacology, or controlled substances. Mississippi requires at least six hours of continuing education every two years on primary eye care procedures, including authorized surgical and laser procedures. And Pennsylvania includes a course every two years on child abuse recognition and reporting. Now, in addition to our health workforce legislation database, NCSL maintains a Scope of Practice Policy Resource Center, which includes 50 state, DC, and territory information on scope of practice regulations for a variety of occupations. Some of those are captured on the slide here, like licensed professional counselors, nurse midwives, nurse practitioners. We also include information on optometrists. So, the maps that I'll show shortly come from this resource, and one note that I'll make here is that there's a variety of research on the outcomes of state changes to optometrists' scope of practice. There are several studies that find optometrists surgical, laser, and prescriptive authority may expand access to primary eye care services, while other studies find no change after states made some of these changes to these activities. I'm happy to provide links and summaries to these studies after today's meeting, if that would be of interest to you all. So, the first area of scope of practice that I'll touch on is optometrist authority to provide ophthalmologic procedures. This may include things like surgical procedures, removal of lumps and bumps, certain diagnostic testing, and other procedures as shown on the right side of this slide. So several states allow optometrists to perform additional procedures. At least 13 states allow surgical or laser privileges. At least eight states allow the removal of lumps and bumps. And at least four states allow other procedures, like those diagnostic or blood testing, certain therapies, or foreign body removal. I want to note that this map may look, and the other two maps may look slightly different from the handout that was distributed. That handout reflects what is currently on NCSL Scope of Practice policy website. I was able to update some of these state information yesterday, so the maps on my slides are the most accurate, and I will make sure to get you all a copy of those as well. The second area of optometrist scope of practice that states regulate is prescription of controlled substances. This may include schedule two drugs, which are labeled as having a high potential for abuse and severe dependence. Typically, states allow schedule two prescription, they are limited to hydrocodone or hydrocodone combination drugs like Vicodin. Connecticut, Idaho, Iowa, Louisiana, Mississippi, and a few other states allow any Schedule II through V drug. Schedule III through V drugs are considered moderate, low, or lower potential for abuse and severe dependence. Hawaii, Maryland, New York, and DC do not grant optometrists any prescriptive authority, while Indiana and Minnesota allow optometrists to prescribe schedule four and five drugs. Vermont statute currently allows optometrists to prescribe schedule three through five controlled substances, and senate bill 64 would allow optometrists to prescribe or administer hydrocodone in combination with other prescriptions for up to seventy two hours and with no refills. Other states also set limits on the duration and refill authority of prescriptions by optometrists for schedule one through three drugs. For example, Alabama sets us at ninety six hours, and there are several other states that set it at seventy two hours like the proposed bill. According to the knee regulatory research center at West Virginia University, almost every state that allows hydrocodone only schedule three prescribing requires licensees to complete those parts one, two, and three examinations, as well as the TMAD examinations for licensure that focus on those therapeutic pharmaceuticals. Arkansas, California, and Colorado require clinical experience or training hours under the supervision of an ophthalmologist, and also allow that prescriptive authority. Several states offer certification for licensed optometrists to prescribe or administer therapeutic pharmaceutical agents. To my knowledge, these states require certification for all new licensure applicants, or they waive this requirement because the additional education or training requirements have since been incorporated into optometry education programs. So, beyond the classification of drugs, states may also set certain restrictions on the types of medication that an optometrist may prescribe or administer. These generally fall under pharmaceutical therapeutics that are administered topically, orally, or via injection. Topical medications generally include eye drops, but may allow the prescription of antiviral medications to treat certain eye or visual conditions in conjunction with other members of a patient's medical team. Optometrists can generally prescribe oral medications. At least 44 states allow optometrists to administer or prescribe oral steroid medications. And moving on to the last area of scope of practice, among states that authorize injection authority for optometrists, some may also define the specific I jumped ahead. In most states that allow injectable authority for optometrists, they fall under a general authority. But in addition to this, states may also define the specific injection procedures or activities that optometrists are allowed to perform. As you can see on the map here, states in blue may allow optometrists to administer injections by to treat anaphylaxis only, like epinephrine, while states in this green or teal color may administer injections more broadly. So among states that authorize injection authority for optometrists, some may also define the specific procedures or activities they're authorized to provide. Existing Vermont statute authorizes optometrists to administer epinephrine for the treatment of anaphylaxis. While Vermont's senate bill 64 proposed bill lists several different types of injection authority that optometrists would be authorized to provide, including vaccinations under certain circumstances, angiography, local anesthesia, removal of certain lumps and bumps, and therapeutic and pharmaceutical agents. This chart shows several other states that outline specific injection procedures or activities in statute. I want to note that this list isn't exhaustive. It's just a smattering of state examples across the country. So, not all states explicitly grant authority for optometrists to administer vaccinations or conduct angiography. Some states note the removal and treatment of chalazion or stye or bump on the edge of the eyelid. And some states specifically note Botox, which I've included under therapeutic pharmaceutical agents in this particular table, like Minnesota specifically notes Botox under injectable authority. Some states also note needle drainage, which is not included in the Vermont bill to my knowledge. Mississippi is an example of this as well as Tennessee. So with that, I've included some additional resources here for your reference, and I want to thank you again for inviting me to present. Thank you so much, chair and committee members for having me.

[Lauren Cooper (Deputy Secretary of State)]: Thank you.

[Rep. Matthew Birong (Chair)]: Questions for our guests from the table? Rep Rep Stone, yeah, Rep Nugent.

[Rep. Mary-Katherine Stone (Member)]: Hi, I was wondering when you looked into some of the education requirements and programming for each state, if you parsed out like which states incorporated the hands on training with surgical procedures into their OD programs. Because I heard you say there's 16 states that have optometry schools, and I was wondering if you looked into the specific program makeup of those schools.

[Kelsey George (Senior Policy Specialist, National Conference of State Legislatures)]: Thank you. I did not look at the specific education requirements of education programs. The purview of my presentation is really to present state legislative and administrative rule regulations, though I'm sure someone from the Association of Colleges of Optometry would be able to provide a more in-depth analysis of what is actually covered in each of those 16 programs.

[Lauren Cooper (Deputy Secretary of State)]: Lujan?

[Rep. Sandra "Sandy" Pinsonault (Member)]: I was wondering if you had any sense of or understanding of what the malpractice laws are in all the states where this expanded scope has been in place. My understanding is Vermont's bar is pretty high to succeed with that. And so I'm just thinking about the accountability factors and where the pressures are and if it's the right level in Vermont and how that compares to other states.

[Kelsey George (Senior Policy Specialist, National Conference of State Legislatures)]: Thank you for your question. I am not familiar with the malpractice insurance requirements of each state, though we do have other staff at NCSL that track that across all 50 states, and I'm happy to provide that information for you in more detail.

[Rep. Lisa Hango (Vice Chair)]: I think we might have some of the answers to that question from our witness yesterday who was sitting behind you in the gallery. We got some handouts.

[Rep. Matthew Birong (Chair)]: Is it

[Rep. Lisa Hango (Vice Chair)]: No, I think it was electronic on malpractice insurance. Okay. It was

[Lauren Cooper (Deputy Secretary of State)]: one? Yeah, think it

[Rep. Lisa Hango (Vice Chair)]: was post online. Yes, thank you very much under Emma Schulbisisi.

[Rep. Matthew Birong (Chair)]: Any other questions from our instruments, yes, at the moment? All right, thank you so much for that. As always, all at your organization are a wonderful resource for us. I wanna thank you.

[Kelsey George (Senior Policy Specialist, National Conference of State Legislatures)]: Thank you so much for having me.

[Rep. Matthew Birong (Chair)]: And up next, Tina Kshiva, President of Autonomous Research Association, thank you for your patience and spilling over today's testimony from yesterday.

[Dr. Tina Keshava (Optometrist, Rutland; President, Vermont Optometric Association)]: I will send all of the journal articles and anything I refer to during my speech right now later. But I will hold up what it looks like so you'll know what to look for in your emails. Good morning, Chair Birong and members of this committee. My name is Tina Keshava. I'm an optometrist in Rutland and currently the president of the Vermont Optometric Association. Thank you very much for allowing me to speak today on the need for scope expansion of optometry in Vermont. Not only are current optometrists trained and educated to perform these procedures, but it's also safe and effective when they do. Modernizing optometric care in Vermont will also improve access while reducing costs for your constituents who are our patients. Optometry as a profession has progressed over the past century, expanding scope to dilating patients in the early 80s and to treating eye diseases like glaucoma and uveitis in the early 2000s by increasing our prescribing authority. This 2023 article by Bay, Timmons and Mandy shows that there was an average twelve percent reduction in visual impairment in the fifteen years following the last scope expansion. So that was when we were able to start treating with oral medicines and more eye drops. Another 2025 study by Bay and Sabud, looks like this one, examined laser scope expansion and showed that improved access was noted in rural areas more than urban and that greater benefits were seen in earlier adopting states than later ones, likely because it takes a while for the doctors to get up and running and get used to doing these procedures, and also because it just takes a little while for the benefits to show. And this gives us another reason why we should pass the bill now so we can kind of start the ball rolling. Our education evolved before those changes were enacted, and it is time again for our scope to match what optometry graduates are trained to do. As you heard from Drs. Feiss and Leitheiser yesterday, these student doctors are getting close to ten thousand hours of education and 2,000 patient encounters before they graduate. With scope expansion, patients will be able to have greater continuity of care with their local eye doctor and save on extra transportation, time, and unnecessary co pays because they won't have to be referred out all the time and because this bill will give optometrists more tools in their tool belt to treat these common conditions. I would like to demonstrate how this works by introducing you to Doctor. Dan Phillips from St. Albans, who unfortunately could not be here today.

[Rep. Lisa Hango (Vice Chair)]: Sorry. What happened in my page?

[Dr. Tina Keshava (Optometrist, Rutland; President, Vermont Optometric Association)]: But in any case, so Doctor. Phillips would say he sees a patient and he determines that they need selective laser trabeculoplasty, or SLT, which is the laser that's used to treat early glaucoma. And he decides he need it. He would refer to an ophthalmologist. So he has an ophthalmologist above his office in St. Albans. Unfortunately, the wait time to get in to see him is too long. So he refers out to Burlington. So then this patient and maybe their caregiver or driver needs to drive forty five minutes to repeat the exam that Doctor. Phillips already did, forty five minutes home, and then another forty five minutes to get treated for each eye, so two more trips at least. And if Doctor. Phillips, who was able to do this last year in Oklahoma, could treat him, it would have saved all of that extra time, all that delay in waiting to see the doctor. So it just saved a lot of money and time, basically, for the patient. Doctor. Phillips is excited for this pill to pass. But like Senator Morley mentioned yesterday, not every optometrist is actually going to go ahead and get this extra license or advanced license. At our most recent optometry meeting, I asked the room full of doctors, how many of you are going to get this advanced procedure license? And about twenty five percent or so of the doctors in the room raised their hand. And Doctor. Leitheizer, speaking with him, he seems to think that it's closer to fifteen to twenty percent of optometrists in any given state will go forth and do the extra hoops and extra for this procedure. But even fifteen percent to twenty percent more providers in our state that are able to do these procedures, I do believe would make a difference. Let's see here. All right. So I'd also like to address concerns regarding complication management. Most of the common complications from these procedures are already managed by optometrists in their office. And when they can't handle it, they refer out to appropriate specialists. In states where optometrists perform these procedures, complication rates are very low and comparable to ophthalmology. In fact, that's what happened. In this study, Doctor. Leitheiser's study that came out in 2024 showed that of 146,000 patients that had laser procedures done by optometrists, there were only two negative outcomes, which is pretty good, I think, and very comparable to ophthalmology. And then he also highlighted this new study that came out last month. And that was what showed that malpractice rates did not increase for optometry laser procedures, which is why our rates are still really low. And as Representative Hango had mentioned, we received this yesterday. And this is just showing that over the years from 2011 to 2024, that the rates really haven't gone up. And some of the states that scope has changed, such as Colorado, you can see that it barely went up over time. And really, inflation can explain a lot of it. There is some variation between the different states, but the variation, some of the higher states don't even have the scope expansion. I also think that this is why no scope expansion of optometry has ever been reversed. That's been approved in the past. We have also heard concerns that optometrists do not take call. When I recently surveyed 10 optometrists across the state, of the seven that responded, five had 20 call, one had twenty four hour care for high risk patients, and one said that they would extend their call if they started doing these procedures. Next, let's talk access. Access to routine eye care is a problem across the state. Wait times for new patients' exams vary greatly, with some optometrists getting them in within a few weeks and many taking six months or more. When we see someone that needs one of the treatments from this bill, wait times to get into an ophthalmologist vary as well, depending on what they need and where they live. This delays their care even further. In Chittenden County, which is one of the highest concentrations of the 33 or so ophthalmologists in the state, it still takes one to three months for most referrals. In Brattleboro, they actually have to send out of state to New Hampshire or Massachusetts because the local ophthalmologist there doesn't perform many of the procedures in the bill. And I also have a charter patient from Doctor. Philip's office, which is showing how long it took for he and his colleagues' patients to get treated once he referred them. And we'll make sure that this gets submitted as testimony as well. These patients agreed to share their names because they were so frustrated with the process. And if we think that's bad now, the 2024 workforce projections from the American Academy of Ophthalmology shows that there will be a shortage of ophthalmologists over the next ten years by about 12% and demand will be increasing by about 24%. And that's just not a great combination. As Doctor. Leitheizer mentioned, SLT is becoming the first line treatment for glaucoma. This is a study that will show you a little bit more about that. Optometrists are the physicians treating this disease now, first line with drops before sending for surgeries. Studies have shown that compliance with drops can be very difficult. My colleague was just telling me yesterday he had a patient that had been lost to follow-up, that had been treated for drops on glaucoma, stopped using the drops, stopped coming in for follow ups for five years, came back in recently, was almost nearly blind in one eye. And I believe that if this patient had SLT, which does not require drops daily unless it's more advanced and then they need less drops often, that I don't think that the vision would have been so severely affected or impacted. And if SLT continues to become the first line treatment for glaucoma, we have a problem because there is no way ophthalmology can handle seeing all these patients in a timely manner for this quick laser procedure that's done in the office. If optometrists are the primary eye care providers for glaucoma, which we are, we have to be able to use all the tools at our discretion for first line treatment. We believe passing this fill, especially being the first in the Northeast to do so, will help Vermont meet this impending surge in demand by strengthening our workforce. One of the first questions fourth year students ask us when considering where to practice is, what is the scope in your state? These new optometrists do not want to be limited in what they can do based on where they live. They want to be caring for their patients with the skills and tools that they were trained to use, with hope that by increasing the scope to this degree, these new grads and other highly trained optometrists will want to come to work, helping to fill the gaps in coverage we have or will have as some retire. If optometrists are able to work to their full training, it will save the ophthalmologist chair time for more complex needs, you know, such as cataract surgery and macular degeneration injections, things like that, which are outside of the scope that we're asking for. This bill is about working as a team to help deliver the best eye care possible to Vermonters. Given the licensing requirements in the bill and the rulemaking process, it will take a while to get this advanced license up and running. Passing Act 64 now will ensure that there will be time for this bill to be implemented thoughtfully and safely. As more states expand their optometric scope, Vermont might become a less desirable place to practice. Our state already has an uphill battle recruiting providers since the tax burden and cost of living is so steep here. We don't need more barriers like the limited scope keeping these skilled optometrists away. Let's be proactive and lead the way in New England by modernizing optometric care so we can continue to attract highly qualified optometrists. Our population is aging. Their eye care demands are increasing. We must make sure Vermont is in a position to continue to provide excellent eye care now and into the future. Lastly, OPR supports this bill after months exhaustive research with all stakeholders. It contains high standards for doctors seeking the specialty license, including extra training, board exams, preceptorship, proctored procedures, and adverse event reporting. It also requires more continuing education to renew this license than the standard one, ensuring continued competency in these skills, effectively making this bill one of the most stringent in the country, as Deputy Secretary Hibbert mentioned yesterday. Additionally, the Oliver Wyman report shows that allowing providers to practice to the full extent of their education and training reduces health care costs and improves access. That is what S-sixty four is all about. Instead of being the forty ninth state like we were for allowing optometrists to treat glaucoma and the beginning of the eye wars, please help us join the other 16 states that now have laser authority and become one of the first in the Northeast to fully expand the scope by voting yes on this bill. I really appreciate your time. Thank you.

[Rep. Matthew Birong (Chair)]: Questions for the guests? Had firsthand was Rep. Waters Evans a while ago, and then I got Rep.

[Dr. Tina Keshava (Optometrist, Rutland; President, Vermont Optometric Association)]: So this is,

[Rep. Chea Waters Evans (Ranking Member)]: I'm struggling with this and what you said about, so it's already difficult to get an appointment with an optometrist just to get a routine eye exam. It takes like a few months. My concern is I know it would improve access to certain procedures for people, especially in rural areas. Like, I understand that, that like the far drive and it's an issue and I understand that. But my question is, if you can do a routine eye exam and make X amount of dollars, or you can take the same time out of your day to do some kind of procedure that costs three times X amount of dollars. As a business person, I don't understand why you would choose to do a regular eye exam, let's say, or like a routine appointment. And I worry that it would actually make wait times longer for those things for people who need that regular checkup or, like, you know, you have to go get your prescription renewed every year for your contacts. And I just had to call yesterday, I think, and I got an appointment for August, and it's May. So can you explain to me how adding appointments to the schedule of people who are already booking, like, several months out is going to help access in general for people? Like, I understand that it it it improves access for specific things, but general care seems like it would be more it it would add to the the weight?

[Dr. Tina Keshava (Optometrist, Rutland; President, Vermont Optometric Association)]: So there's two things. One, not every patient needs these procedures done. So that's one thing. A lot of times doctors will stack these type of procedures. Like you heard Doctor. Porto yesterday, how she had a surgical morning. So you just kind of go back to back back to back, and it doesn't take up as much of a slot necessarily as you think this kind of visit would. Not every optometrist is going to do it, but it does make us more pleasing, I think, to newer grads that maybe they don't want to do all of the procedures on the bill, but they want to maybe be able to at some point, or maybe they wanna focus on just the glaucoma part or what have you. It just gets them into Vermont. Attractive. And when I went to the optometry national meeting last year, Vermont had a little booth in The States for all the fourth year students to come around and ask questions. And all I heard was, what's the scope in your state? What's the scope in your state? That's on their mind. They're thinking about that. And I know when I graduated, I did not want to go to a state that did not allow me to do what I was just trained and ready to do. So I really looked at that. And I think that knowing that we have gaps already, as you've noticed, and we have optometrists that are retiring soon, I think making us as attractive as possible would be really helpful.

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

[Rep. Mary-Katherine Stone (Member)]: Okay, I just keep asking questions about educational requirements because from my understanding, not all optometry students are receiving the same level of education or hands on training in laser procedures and surgery. I know that all OD programs teach ocular disease and pharmacology, clinical management, stuff like that. But what I've heard is that training in lasers and surgical procedures varies quite significantly by school and state scope of practice laws. So I know my alma mater of UAB, their school of optometry lists, if you look on their website, laser and surgical procedure courses in their curricula for things that we're discussing like GAG, SLT, LPI, stuff like that. But I just wondered if you could speak to of like parsing out how many programs actually teach hands on training in that, not lectures theory didactic training but hands on because we keep hearing that students are trained but I'm seeing that not every student is. It depends on the school. Could you speak

[Dr. Tina Keshava (Optometrist, Rutland; President, Vermont Optometric Association)]: to that? Sure. So I haven't traveled around to all the schools, so I can't speak with my eyes seeing what they're doing. But from my understanding, from speaking to a lot of experts is that they are teaching as hands on as they can, as their scope allows. I think some of the states, as Doctor. Feiss mentioned yesterday, they have some ophthalmologists on staff. So the students are able to get a little bit more. I don't know what that looks like because I wasn't there, but to dive in a little bit deeper than just using Model I's. And as Doctor. Feis and I well, mostly Doctor. Feis, and I think maybe even Doctor. Porto had mentioned it, that these students, if they are interested in these procedures, they can seek during their fourth year when they have electives or externships, they can seek to go to externships in states where this is allowed so that they can get more hands on training than what was provided at the school. And all students get this foundational training in school. It's up to that particular practitioner that wants to go and actually do it in practice. And so this would allow for those students and those graduates that want to do the next level to be able to do that in Vermont.

[Rep. Mary-Katherine Stone (Member)]: Sorry, I've asked this question a lot and everyone is kind of struggling to answer me. So I'm wondering if would the ASCO you're accrediting,

[Dr. Tina Keshava (Optometrist, Rutland; President, Vermont Optometric Association)]: The ACO?

[Rep. Mary-Katherine Stone (Member)]: The ones who accredit opt the ASCO, the ones who accredit optometry schools. Yeah. Would they be somebody who could shed light on this?

[Dr. Tina Keshava (Optometrist, Rutland; President, Vermont Optometric Association)]: So doctor I just think

[Rep. Mary-Katherine Stone (Member)]: it's really important because there are years put in here of, like, students who are or optometrists who graduated after 2019 and whatnot. But what I'm hearing is that like even if you graduated after 2019, it still doesn't assure me that they've had hands on training in these procedures. Like they may have been doing a fellowship or coursework or whatever the correct terminology is in a state that allows them to do these procedures, but they may not have. So I just wanna

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

[Rep. Mary-Katherine Stone (Member)]: in the right direction.

[Dr. Tina Keshava (Optometrist, Rutland; President, Vermont Optometric Association)]: Sure. So Doctor. Feis is the president of the ASCO. So I think she did cover a lot of what they get, at least in the school. And I think that when OPR did their studies and research, they felt the same as you, that as much as all the schools are teaching it, not everyone is getting some hands on training. I will tell you, we get a ton of hands on training in a lot of foundational skills that are in this bill. Put in punctal plugs, we remove foreign bodies, we do gonioscopy, which is using a little lens like you use during the laser on patient's eyes. We deal with squeamish patients from little kids up to adults that have never had an eye exam and don't know what to expect when they come in and they're 55 or 60. Or someone that just got a little piece of metal in their eye and have never seen an eye exam room before either. So I feel like our training is very foundational for this. OPR agrees that all the schools are training us as much as they can based on their state laws as it stands today. And to make sure that doctors in Vermont can do these procedures, they put in the preceptorship, they put in the proctored procedures, and the extra board exams that are not required in many of the states that have already passed the scope, making this really the most stringent bill out there. And so in Vermont, I feel like you can rest assured that these doctors are going to be very well trained and ready to perform these procedures. No.

[Rep. Lisa Hango (Vice Chair)]: Thinking.

[Lauren Cooper (Deputy Secretary of State)]: Thinking, yes. With my hands.

[Rep. Matthew Birong (Chair)]: It's curbed here. Yeah. And in person. Rep. Pinsonault?

[Rep. Sandra "Sandy" Pinsonault (Member)]: I'd just like to add that throughout my life, when I've had to have procedures done, one of the first things I'd say to a doctor is how often have you done this? How many have you done? What are your complications? Are you comfortable? Mean, those are the questions that the patient should be asking. I don't think anybody, I would hope nobody would just go to a doctor thinking they're going get laser surgery and the doctor had never done laser surgery before. I think that as a patient you would ask, how often have you done this? Are you comfortable? Is this your specialty type of question? Really some of this has to go to the patient responsibility as well and not. I mean, doctor, any profession, any kind of specialty, you wouldn't go to a hand doctor. I mean, like some of those pictures that were shown yesterday. I mean, like, why would you go to an eye doctor? That's definitely a skin problem. I would just say, as a person who has no medical background, why would you go to an eye doctor for that? So I just think that a lot of this is patient responsibility and knowledge as well for Black Europe.

[Rep. Matthew Birong (Chair)]: All that situational awareness. I

[Rep. Lisa Hango (Vice Chair)]: have a question about these procedures that seem to be the most controversial. If they are in the moment that a patient has to make a decision sitting in the doctor's chair that, yes, I need to have this done now, or if it's a process that they can weigh the options of how they're going to get this problem taken care of.

[Dr. Tina Keshava (Optometrist, Rutland; President, Vermont Optometric Association)]: As Doctor. McNally mentioned yesterday, most of these procedures won't be done on the same day. There are small discrepancies, like if a patient came in with a conjunctival cyst, if there's time in the schedule and it allows, if that was a reason they were there, it was bothering them every time they blinked, then that might be able to be done that day or things like that. But most of the time, these procedures are, we see you, we think you need this, these are the risks and the benefits, and let's schedule you when we can.

[Rep. Lisa Hango (Vice Chair)]: That's really helpful for me, having had to have had emergency eye surgery. So if a patient is in a doctor's office, they have the time with the doctor to ask the questions, ask where they would have these procedures done, what the options are for them, and they can make a decision then, barring access problems if there's no other doctor who's available within driving distance or during the timeframe that they need to have it taken care of. That makes me feel a little more comfortable that these emergency situations where a patient has to decide that minute whether they are going to be treated by this particular doctor or not. They do have a choice.

[Dr. Tina Keshava (Optometrist, Rutland; President, Vermont Optometric Association)]: Going back to the eyelid laceration, if a patient comes in with one in Northeast Kingdom, in order to get to an ophthalmologist that can deal with it, it would be nice if one of the optometrists up there was able to do some of these things and just help to ensure that it's not going to get infected. If they can help, having these skills is really great.

[Rep. Lisa Hango (Vice Chair)]: It would almost feel to me, having been in an emergency situation, that I would go to the emergency department rather than an optometrist if I needed my eyelid sewn. I assume eyelids bleed like anything else that's ripped or torn. So I probably would get to the emergency department and they would refer me to whoever needs to do the procedure. In terms of something that's emergent like that, it would feel like that wouldn't be a situation that would happen very often because honestly, in the Northeast Kingdom, how many optometrists are gonna have openings when you rip your eyelid open?

[Dr. Tina Keshava (Optometrist, Rutland; President, Vermont Optometric Association)]: Those are emergencies and optometrists take emergencies every day. I think that it's I'm not saying I would be the one doing it, but

[Rep. Lisa Hango (Vice Chair)]: No, I'm just thinking of the number or the lack of the number, the shortage of optometrists. They may not have openings in their schedules that they keep for emergency situations. We make room for those types of things. If a patient calls with a, they just

[Dr. Tina Keshava (Optometrist, Rutland; President, Vermont Optometric Association)]: got a foreign body in their eye at work, come on in. Our office does that, and I guarantee almost every optometrist's office does that, and ophthalmologists. And you practice where? In Rutland.

[Rep. Lisa Hango (Vice Chair)]: That's what I thought. So, feel like Northern Vermont is a little bit different than that, and people react more by going to an emergency department if they have something. I don't think they're going to choose to go to an optometrist right off, but I could be wrong. Well,

[Dr. Tina Keshava (Optometrist, Rutland; President, Vermont Optometric Association)]: of these procedures are really more routine treatments. That's what I

[Rep. Lisa Hango (Vice Chair)]: was getting So those are the things that people will have time to think about. The optometrist doesn't have an opening until tomorrow morning at 10:00. I can wait for that and see what they say about it, rather than something where they're really in need of care immediately. Thank you.

[Rep. Matthew Birong (Chair)]: Any other questions for this stage of the game? Seeing no hands. Alright. Thank you very kindly for the testimony of the time. Alright, committee. We're gonna take a No, we got a break till 11:30, and we are gonna do an introduction and a walk through on the Williston charter change. We don't have counsel for that, so we're gonna sponsor the bill and the town manager of Williston. So take this time to just read through the language real quick. It's seems to be, STIR focused and reappraisal focused. So, yes, wraps down.

[Rep. Mary-Katherine Stone (Member)]: I just wanted to follow-up and, we don't have to answer this now, but S64 does speak about eyelid lacerations but ones that are not larger than 2.5 centimeters not deeper than the orbicularis muscle and not involving the eyelid margin or lacrimal drainage drainage structures but I'm just pointing that out for patients. I don't think they're going to be measuring their eyelid during that time. Rep Hango's situation may be something that we do want to dig a little bit more into because this bill does talk about expanding OD scope to handle certain types of lacerations.

[Rep. Lisa Hango (Vice Chair)]: Think in that case, thanks for bringing that up. I think in that case, my point is people will probably go to the emergency department to get something like that handled. At least that's my experience with folks at the Northeast Kingdom and Northwestern Vermont on the border.

[Rep. Mary-Katherine Stone (Member)]: Yeah. And I hear what you're saying. I'm just saying in the bill that it does talk about eyelid lacerations and expanding the scope of ODs to handle certain ones. I know personal preference is always something, you know, that's a patient's right. But I do just want to highlight that this bill does talk about eyelid lacerations in particular. So again, not something I think we should dig into right now. I don't want to belabor this and whatnot, but for further conversation later.

[Rep. Lisa Hango (Vice Chair)]: Yeah, I think that's a valid question for an optometrist. Like, do you actually anticipate having to measure the laceration when the patient comes in the office and then send them somewhere else if it's too big of a job to fix? That is a concern, yes. And we have an answer from the gallery.

[Rep. Matthew Birong (Chair)]: Okay, and I got two from the gallery. So we all start left and then we will go right. Please re identify yourself for the record.

[Unidentified optometrist (gallery commenter)]: Honestly, if an optometrist doesn't feel comfortable with the length of the laceration or depth, they're not going to do it. And they're going to say, you should go see the ophthalmologist. I still think it would be better if we could start telling patients, go see your eye doctor first, not the ER. Because when you go to the ER, it costs so much more. And if an optometrist does not feel like they can handle it, they will refer them to an ophthalmologist right away. And if they can handle it, even better. And I think that's what this bill is really about. It's about, you know, we are the primary eye care providers in the state and we will see emergency patients every day.

[Rep. Matthew Birong (Chair)]: Further comment, Madam Deputy?

[Lauren Cooper (Deputy Secretary of State)]: Yes, for the record, Lauren Cooper, Deputy Secretary of State,

[Unidentified optometrist (gallery commenter)]: I just want to tell this committee, if an optometrist were to do a suture on a length or depth that was greater than this bill, they would be charged with unprofessional conduct. I think they will be very mindful and stay within the constraints of what is written in the bill.

[Rep. Lisa Hango (Vice Chair)]: So I just want to say that with regards to the emergency department comment, I do understand the cost of it, but if I have a feeling that I'm gonna be shuttled from one place to the other, I think that would be the first place I would go and feel most comfortable going. But that's just me.

[Rep. Matthew Birong (Chair)]: And representative Stone, is that a fresh hand or a legacy hand? That's fussy.

[Rep. Mary-Katherine Stone (Member)]: No. It's a legacy hand. I had a feeling that was gonna be a hot button issue, but I'm just bringing us back to the language on the page when we bring up these topics, you know, just reflecting that it is language in the bill. So stuff for us to be thinking about.

[Rep. Matthew Birong (Chair)]: Any other questions or comments from the table before we hit pause to