Vermont Legislature SmartTranscripts:

[Chair Matthew Birong]: We're live. Alright, everyone. Good morning. It is about eleven or 10:50 on Thursday, May 21, House Government Operations and Military Affairs. We're doing continued work on ethics for an act relating to amendments to the scope of practice for optometrists. We are taking testimony on Representative Stone's amendment that we went through yesterday. So we've got some folks here to offer insight and opinions on the proposal, and I would like to start as Doctor. McDowell.

[Vice Chair Lisa Hango]: Doctor. McNally will be joining by assuming she canceled the patient but she's finishing up her last patient. Okay,

[Chair Matthew Birong]: I guess we will start with Doctor. Tina then.

[Dr. Tina (Optometrist witness, surname not stated)]: Good morning again. Thanks very much for letting me come back and chat with you on S-sixty four. I did number my pages this time, so you won't have the same issue as last. I think it's important to start by making sure this committee has some foundational information about how our profession is governed. The optometric profession is an independently licensed profession in every state of the country. It has been this way for over a hundred years. Optometry is licensed and regulated by state boards of optometry, united by the American Regulatory Boards of Optometry, and in Vermont, the Board of Optometry falls under the jurisdiction of the Office of Professional Regulations. This setup is similar to the way dentists are governed. There is no state in which a medical board oversees, governs, or grants licensure or endorsements to optometrists. This amendment proposes to fundamentally alter the system and to be the first in the country to do so. It reaches far beyond the subject of scope, access, and safety, and raises concerns that have not begun to be addressed. Fundamentally, optometry has operated for over one hundred years safely without medical oversight. The scope of what this profession does, just like all healthcare professions, has evolved through the years with proper education, training, and guardrails, as evidenced by a proven safety record. This includes the history of optometrists safely performing the procedures in this bill in other states without medical oversight. These studies have been submitted to this committee already, but more will be coming in future years. The fact that malpractice rates have not risen in these states is another indication that optometrists are safely performing these procedures with less guardrails than proposed in F-sixty '4. In Vermont, optometrists already help patients daily by removing foreign bodies from their eyes with delicate tools like needles, lacrimal dilation and irrigation, debridement of the cornea, sorry, managing post ops, and checking the internal drain of the eye and retina with specialized lenses similar to what are used for laser procedures. We treat infections, inflammations, glaucoma, and manage surgical complications. We utilize topical, oral, and sometimes even IV medications while considering the patient's systemic disease and medication interactions. We order labs and imaging and work with other healthcare providers to care for our patients. We do all this without oversight by the Board of Medical Practice. It is possible that those who drop to this amendment do not have a good understanding of what optometrists do. Doctor. Greenberg, President of the Board of Medical Practice himself stated last Thursday, The specifics in optometry scope is outside of my knowledge. His board also did not do the same amount of research on this subject as OPR did. The bottom line is there is no legitimate rationale for implementing oversight for these procedures by the Board of Medical Practice. Redstone's proposed amendment removes all lasers, SLT, LPI, and YAG from the bill. We find it surprising that of all the procedures to remove, it would be these procedures. They are the quickest, cleanest, and already in our wheelhouse. They require no injection, no scalpel, no cutting of tissue, no biopsy or sutures, no drainage, no scalpel, or sorry, and little to no blood. And as I just mentioned, use a microscope and lens that we are already trained to use. Doctors in Oklahoma have been doing these for a few decades. This quite simply makes no sense, and again, perhaps speaks to a general lack of knowledge about what all these procedures entail. I want to quickly touch on a few smaller items in the amendment. The proposed practice agreement directs a plan to have an ophthalmologist available for consultation at all times when the optometrist is performing or preparing to perform these procedures. Yet it does not require the ophthalmologist to be physically present at the time or place when the procedure is performed and relieves them of any liability. This achieves nothing except to create paperwork and to assert control by the Board of Medical Practice on an independent health care profession. To be very clear, we already manage and treat the complications that might arise from these procedures in this bill because we presently co manage them and because the issues that might arise are also present in other ocular conditions that we already treat. We do this now without a practice agreement. Furthermore, we do not do procedures without a plan for how to manage complications because we are healthcare professionals. We do not willy nilly perform procedures without a plan for how to manage adverse events. And to suggest that non MD providers are not capable of acting professionally without a signed agreement with an MD is to be frank, kind of insulted. Optometrists are trained to know their limits. When something is outside their comfort level or scope, they refer to a specialist. That being said, there's a wide overlap of what optometrists and ophthalmologists already do, probably somewhere close to 75 to 80% we kind of co treat. As Doctor. McNally mentioned a couple of weeks ago, the procedures in this bill did not make up the majority of her practice, and it won't make up the majority of ours either. But allowing us to do them will save patients from having an extra exam to confirm the diagnosis and allow them to get care quicker and closer to home. And just touching briefly on access, REP Stone is correct that there is limited data out there to suggest that access will be improved by pass and fill, but that does not mean it's not true. The 2025 Bay and Segout study I shared last time did show improvements in access in rural areas like Vermont. It also showed that those states that adopted scope expansion early showed more improvements than those that adopted it later. This last point is exactly why Vermont needs to pass S-sixty four now. We would be the first in the Northeast to expand scope, which will position us to be very attractive to the kind of optometrists we want in this state. We agree that access to routine care is a problem right now. Making it easier for doctors to want to come here will help. You have received several letters stating so from current optometry students, and we have anecdotally shared with you that optometrists have left the state because they wanted to practice scope and they weren't allowed to practice that far here. Additionally, the procedures in this bill are quick and not every patient that comes in will need them. So there should be no worries that allowing us to do them will reduce their availability for routine care. And although there is not a ton of data showing access has improved, there is no data that shows safety or access has been compromised by scope expansion. What is well documented in the literature is the fact that the ophthalmology workforce is declining and will be even worse in ten years, while eye care demands will only be increasing. Allowing optometrists to practice to the full extent of their training will help fill this void, and starting now will set Vermont up for success. S-sixty four, as passed by the Senate, will improve access to quality eye care. It will implement a thoughtful and careful rollout of expanded scope of practice. It is national, even international, with recent changes to Quebec scope to include these procedures. This is not unique to Vermont. I know it feels like you just got this bill in your hands, but it was started back in 2019 and much work has been done on it. All stakeholders were included along the way, including ophthalmology and the Board of Medicine. Right now, you have the opportunity to pass a bill that has been carefully researched and crafted by OPR, Vermont's regulating body to oversee allied health professions. It sets the highest bar of any of the 16 states that has already safely adopted similar scope expansion. You can lean on the work and expertise of OPR and pass S-sixty four with no amendments, just as House Health Care did just a few short weeks ago. Thank you for your time, and I'd be happy to take any questions.

[Chair Matthew Birong]: Questions for our witness? Yes or no?

[Rep. Chea Waters Evans (Ranking Member)]: I'm wondering, we know we're getting a billion emails and letters and phone calls and all kinds of stuff about this from varying perspectives. And your from optometrists in particular, what I'm hearing for the most part is no amendment whatsoever. And you did just say, like, pass it unamended. Is there any point of compromise that you see as something that would work for optometrists or for your organization or to find a balance between what people's concerns are, which, you know, it's not like we can make a choice and say, you're right and you're wrong, and this is what we're deciding. I think it's more of finding something that feels comfortable for people. So is there a point of compromise? Like you said, said this, it's of all the procedures that we would that you're removing, these aren't the ones I thought you would. Are there some that you think we should? That kind of implies that there are some that maybe you had some doubts about. I don't want to put that on you, but you know what I'm saying.

[Dr. Tina (Optometrist witness, surname not stated)]: Is So there a compromise So, bill is already a compromise. Like I said, OPR spent a ton of time talking to all stakeholders. They did all their research. They talked to all the schools. They spoke with ophthalmologists, the Board of Medicine. They spoke with all of them. And they came up with this bill because this bill will be safe for Vermonters, and it also doesn't create such a high hurdle that no one will do it. What happened with the dental therapist bill a few years ago, they tried to make a pathway for dental hygienists to do more than what their scope was. And they created this program, and it just made it so hard that they didn't get any applicants. This bill is very different than that, but it's the same idea. If you make it impossible to collect all the proctored procedures going up to 12, for instance. It doesn't make any sense. It'll take years in order for someone to be able to do that. And it takes time out of their schedule because we don't work with ophthalmologists. So they'd have to it's very hard logistically. On top of that, our education is baseline foundational for all of the procedures. So we've already done the compromising with this bill. You.

[Chair Matthew Birong]: Can

[Vice Chair Lisa Hango]: you verify you said that this bill would set with the highest standards, but we've heard testimony that many other states have initiated higher standards for incumbency and training and analysis. Even in OPR's summarized report, their recommended legislative language asks for one.

[Dr. Tina (Optometrist witness, surname not stated)]: So initially, their first draft you're talking about, or the first bill? I'm talking about S-sixty four,

[Vice Chair Lisa Hango]: but then also the 2023 revised summaries report. Recommended legislative session?

[Dr. Tina (Optometrist witness, surname not stated)]: So it recommended more. And then after the bill, just the first draft of this bill, I think it was 02/23 in the Senate, it was just put on a wall. And that legislative session ended. And then between then and this legislative session started, we talked with OPR and showed them documentation of what the other states require, which is why they cut back a little bit on some of it so that the hurdle wasn't so high. Because it still is thus most stringent of all the states. If you take into the thirty two hour course, the two extra boards, the 12 proctored procedures, and the preceptorship. It took all of it. If you take all of that together, it is the most stringent of all the states that have already passed it.

[Chair Matthew Birong]: Questions? You so much. We'll Thank have no questions, of course, but thank you. All right, up next, Doctor. McNally, good to see you.

[Dr. Jessica McNally, MD (President, Vermont Ophthalmological Society)]: Morning, everyone. Can you hear me okay?

[Chair Matthew Birong]: Yes.

[Dr. Jessica McNally, MD (President, Vermont Ophthalmological Society)]: Okay. Of course, I wanna thank you for having me back on behalf of the Vermont Ophthalmological Society and the Vermont Medical Society. For the record, my name is Jessica McNally, and I'm a comprehensive ophthalmologist here at Central Vermont Medical Center. I also happen to be the president of the Vermont Ophthalmological Society and a member of VMS, and I'm here today to support Representative Stone's proposed amendment to S-sixty four. While we have consistently maintained deep concerns about the underlying bill's expansion of optometric scope into surgical domains, we acknowledge that this amendment represents a meaningful and significant effort to incorporate patient safety standards that were absent from earlier versions of S-sixty four. We urge the committee to adopt this amendment and to examine the remaining concerns we described below. To evaluate the adequacy of any safety framework for this bill, it is important again to understand what optometrists would be authorized to perform under this amendment. The surgeries that remain authorized are two categories of in office surgery, eyelid and advective surgeries and injections. Each carries clinical risk that warrants the oversight oversight structures the amendment puts in place. The amendment authorizes Chelizian excision, and this is under eyelid and adnexa surgeries. So it authorizes Chelazian excision, excision and biopsy of non recurrent lesions of the adnexa, closure of wounds resulting from lesion removal, and repair of eyelid lacerations not larger than 2.5 centimeters and not involving the eyelid margin or lacrimal drainage structures. As described in my previous testimony and in other testimonies, these are not minor procedures. The eyelid is a structurally complex, highly vascularized tissue, only measuring about two millimeters thick. Surgical complications from any of these surgeries can include bleeding, scarring, infection, and eyeball perforation, which can require further surgery or result in blindness. Eyelid lesions cannot truly be identified as benign without pathology, which requires biopsy, tissue transport, and coordination with a pathologist, typically at a hospital. Steroid injections, which would be a therapeutic pharmaceutical agent under this legislation, into the chalazia carries a risk of blood vessel occlusion, skin discoloration, and vision loss. Patients can experience vasovagal responses to ocular surgery, which we have discussed before. This can result in loss of consciousness and even seizures. And it's definitely worth noting that most family physicians, general surgeons, and dermatologists routinely refer eyelid surgeries to ophthalmologists precisely because of the anatomical complexity and the proximity to the eyeball itself. The ability to manage adverse events is essential for any provider performing these surgeries. For injections, the amendment authorizes injections of therapeutic pharmaceutical agents into the eyelid or its adnexa, including into the subconjunctival space, injections to administer local anesthesia, injections to perform fluorescein angiography, and injections of epinephrine for anaphylactic shock. Subconjunctival injections, specifically deposit medication using a needle directly against the white wall of the eyeball, that's called the sclera. Risks include bleeding, infection, misplacement of that medication, perforation of the sclera, and sustained elevation of eye pressure and glaucoma if that medication is a steroid. This clinical complexity described above makes clear why the safety structures introduced by the amendment are not simply procedural, they are clinically essential. We specifically commend the following provisions. Removal of laser surgeries from the authorized scope. A critical safety improvement in the proposed amendment is the removal of all three laser surgeries from the authorized scope of optometric practice. Laser capsulotomy, laser peripheral iridotomy, and laser trabeculoplasty are highly specialized intraocular surgeries that use focused laser energy to target precise structures inside the eye. Surgical risks include retinal detachment, intraocular hemorrhage, intraocular pressure spikes, and permanent vision disturbance or vision loss. The amendment removes all three from the authorized scope by adding them to the prohibited procedures list. Board of medical practice oversight. The amendment appropriately places the advanced therapeutic procedure specialty under the jurisdiction under the Board of Medical Practice rather than the Board of Ophthalmetry alone. This is not a technical detail. It is one of the bill's most important patient safety provisions and deserves particular attention. Just to be clear and for everybody to know, in case you don't know, the Vermont Board of Optometry is a five member board administered through the Secretary of State's Office of Professional Regulation. I'm sure you know that. As of today, one of the two public member seats is vacant, leaving the board with three optometrists and a single public member. The board has no physicians on it, no surgeons, and no members with appropriate training or experience in the surgeries this bill would authorize. It lacks a dedicated investigative staff and has no institutional experience evaluating surgical credentialing, reviewing operative outcomes, or adjudicating complaints arising from eyelid surgery or injections. Asking the Board of Optometry to credential and oversee surgical practice would be asking it to regulate a domain entirely outside its expertise and infrastructure. The Vermont Board of Medical Practice is fundamentally different body. As you heard from Doctor. Greenberg the other day, it is composed of 17 members, nine licensed physicians, one physical assistant, physician assistant rather, one podiatrist, and six public members. It is housed within the Department of Health. It meets monthly and is supported by an administrative staff, professional investigators who receive ongoing training and licensing case investigation and access to legal counsel. It has decades of experience of evaluating the competency, credentialing, and conduct of practitioners performing complex medical and surgical procedures. It is in short built exactly for this type of oversight. When the surgeries at issue include eyelid incisions that are millimeters from the eyeball and subconjunctival injections that can perforate the eyewall, the regulatory body responsible for credentialing practitioners and investigating adverse events must be able to understand what went wrong and why. The amendments requirement that the advanced therapeutic procedure specialty be granted and overseen by the Board of Medical Practice in consultation with the Board of Optometry reflects a sound and evidence based allocation of regulatory responsibility. Section 1724E requires a written practice agreement with a licensed ophthalmologist or Vermont based ophthalmology practice. The agreement must include processes for communication, availability, and joint evaluation, and it must ensure that an ophthalmologist is available for consultation whenever an advanced procedure is being performed or prepared. This is one of the amendment's most clinically important provisions. Ophthalmology training equips ophthalmologists not only to perform surgeries, but also to recognize and manage the unexpected. Optometrists whose doctoral training is focused on primary eye care and does not include a surgical residency are not trained to the same depth in recognizing or managing these intraoperative and postoperative complications. The difference in patient outcome may depend on whether the treating provider recognizes what they are seeing, knows what to do next, and has a qualified specialist immediately available. This is precisely why the collaborative practice agreement is not merely a formality. It is the primary ongoing safety mechanism for patients treated under this expanded scope. When an optometrist encounters something outside their training or experience during a surgery, the agreement ensures that there is a named accessible ophthalmologist who has already reviewed the practice's protocols, understands the patient population, and can be reached immediately. That relationship established in advance, documented in writing, and subject to board review helps ensure that optometric surgical practice does not become isolated from the physician level expertise that complications may require. The practice agreement also creates accountability beyond individual patient encounters. Section seventeen twenty four requires processes for joint evaluation of services rendered. In other words, the ophthalmologist is not simply a passive on call resource, but an active participant in reviewing the quality and appropriateness of the surgeries performed under the specialty. This is a model Vermont already uses and other collaborative practice settings, and it is proven as being effective in identifying problems early, supporting professional development, and maintaining standards of care over time. Section seventeen twenty four requires a written plan for transferring a patient to a hospital or a qualified provider in the event of an adverse event. Complications from eyelid surgery or injections, including ocular hemorrhage and eyewall perforation, may require urgent operating room intervention. A pre established transfer plan is a basic requirement that any responsible surgical framework should include. Adverse event reporting. Section seventeen twenty five establishes a thirty day adverse reporting requirement to both boards and a biennial procedure volume report. Systematic reporting is essential for identifying patterns, detecting problems, and supporting evidence based future oversight of this expanded scope. The amendment significantly increases hands on training requirements prior to independent practice. Minimum supervised clinical hours are raised from eight to eighteen, required chalazion excisions from two to twelve, chalazion intralesional injections from two to twelve, and authorized lesion excisions from two to twelve. These thresholds are more consistent with the clinical complexity and patient safety stakes of the authorized surgeries. The safety framework introduced in this amendment is not novel. It mirrors the approach this legislature has already applied when expanding other non physician professions into a domain that has traditionally required medical training. Earlier this session, the House passed H237, which would authorize doctoral level psychologists to provide psychotropic medications. As passed by the full House, that bill included strikingly similar, and in some respects even more robust, structural safeguards, a mandatory practice agreement with the supervising physician psychiatrist, continuing medical education requirements, two years of training in psychopharmacology, a fourteen month specific clinical rotation, and explicit limits on what could be prescribed. The parallel is instructive. In both cases, the legislature confronted the same fundamental question. How do you expand a non physician profession scope into clinical territory that carries meaningful patient risk without undermining the safety standards Vermonters expect. The answer the House reached in H237, additional education, training, collaborative practice agreements, and reporting requirements, is the same approach the amendment before you applies to S64. We urge the committee to recognize that consistency. If the house determined that psychologists prescribing psychotropic medications warranted these safeguards, it follows that optometrists performing eyelid surgeries and injections should at the very least warrant them as well. Adopting this amendment would bring S64 into alignment with the patient safety framework the legislature has already endorsed for scope of practice expansion this session. While we support the amendment proposed by representative Stone as an improvement to S64, our organizations continue to have some concerns about the underlying scope of expansion that the committee should consider. First, optometrists graduating in 2019 or later are exempt from additional postgraduate coursework on the assumption that their curricula incorporated relevant training. The committee should verify that current accreditation standards for optometry schools adequately prepare graduates for all the specific surgeries authorized here before relying on this exemption. Eyelid lesions require pathology analysis to truly determine whether they are benign or malignant. The amendment authorizes excision and biopsy of recurrent lesions that are, quote, without characteristics or obvious signs of malignancy, end quote. But the committee should satisfy itself that optometrists are adequately trained to make that threshold of determination safely in a non hospital clinical setting with no access to pathology potentially. There is a significant mismatch between the surgeries authorized and those required to have a preceptorship. The preceptorship mandates demonstrated competency only in chalazion excisions, chalazion intralesional injections, and excisions or drainages of authorized lesions. But the advanced therapeutic procedure specialty would also authorize wound closure following lesion removal, repair of eyelid lacerations up to 2.5 centimeters, corneal cross linking, subconjunctival injections, injections for fluorescein angiography, and epinephrine injections for anaphylaxis, none of which appear in the preceptorship requirement. The committee should require that the preceptorship cover the full authorized scope or alternatively limit the authorized scope to what the preceptorship actually trains for. The Medicaid parity provision should be accompanied by data collection requirements to assess whether access outcomes for underserved populations are genuinely improved, as has been spoken about by the optometrist during testimony. Vermont patients deserve both access to care and assurance that those providing that care are appropriately trained, credentialed, accountable. The proposed amendments removal of laser surgeries from the authorized scope, combined with its practice agreements, Board of Medical Practice oversight, reporting requirements, and strengthened preceptor standards moves S-sixty four meaningfully closer to a framework that takes patient safety seriously. We urge the committee to adopt this amendment. We appreciate the committee's time and the careful work that has gone into improving this legislation. We certainly remain available to answer any questions and to continue working toward a final product that keeps Vermont patients safe. Thank you.

[Chair Matthew Birong]: Thank you. Any questions for our witness? Waters Evans.

[Vice Chair Lisa Hango]: Thank you. Can you speak to

[Rep. Chea Waters Evans (Ranking Member)]: the concern that ophthalmologists won't have the time or the availability for the collaborative practice requirements that would essentially make this a nonstarter for optometrists if they don't have someone to collaborate with? Can you?

[Dr. Jessica McNally, MD (President, Vermont Ophthalmological Society)]: Sure. I mean, my reading of the amendment is that it doesn't have to be someone who's actually standing next to the optometrist at the time. It is an agreement that an optometrist involves an ophthalmologist in that is an agreement that is in writing where there might be phone calls in order to prepare for a surgical procedure that is going to be happening or perhaps some evaluation or discussion beforehand or afterwards, but not necessarily something that's going to take the ophthalmologist out of their clinical responsibilities of taking care of patients during the day.

[Rep. Chea Waters Evans (Ranking Member)]: Okay, and you're confident that ophthalmologists would have the bandwidth to participate in this?

[Dr. Jessica McNally, MD (President, Vermont Ophthalmological Society)]: Absolutely. Okay,

[Rep. Chea Waters Evans (Ranking Member)]: and then I have another question, which is, there is when we've talked to people this whole time, we get feedback from lots of different folks. It's for us. I'll speak for myself. It's hard to when people are saying such vastly different things, I'm coming from two really different points of view. And we are trying to find a middle point or something where we can look out for monitor safety and we can make sure they're getting the care they need and they have the access to it, which I think is the goal of all of this. And I'm assuming the goal of Rapstone's amendment. Something that's come up a lot, but I don't know if we've exactly talked about it on the record, is this concept of turf wars, like Ophthalmologists don't want optometrists pushing in on their territory, or vice versa, and optometrists saying it's being said they don't care about patients, or they want to do this with abandon, just like, Oh, zap everyone's eyeballs with lasers, which I don't think anyone is saying either of those things necessarily, but we're operating or I'm operating under the assumption that all healthcare providers are operating with their patients at the forefront of their mind and that they do want them to be safe and they're not going to do anything that they shouldn't. So can you talk to the maybe political or whatever that element is of this that's kind of protecting one's own turf or financial interests or something like that? Because I think it's important to get it out there because we haven't really discussed it yet, but I think it's kind of an underlying current of this whole conversation.

[Dr. Jessica McNally, MD (President, Vermont Ophthalmological Society)]: Yeah, I think the turf war issue has historically been a problem in probably every scope discussion that your members, that lawmakers, legislators have ever been a part of. It's always been a point that one group is arguing that the other group is keeping them from doing what they are trained and able to do for financial reasons or for reasons of ego or however you wanna define a TERF for. And I think you just kind of have to look at the basics of it all. The basics here are training, as we've said and over and over again. The training of ophthalmologists is comparably much greater than the training of optometrists when it comes to surgeries, and we are certainly not trying to make this a turf war. We are trying to delineate where the limitations of the training is in order to keep everybody safe, certainly not trying to disparage the training of optometrists. We know that the training has changed over the years. You all know that we work closely with optometrists, many of us in the same practice. We work collaboratively with them, taking care of the same patients, but on different levels. And I think that this idea of turf war ends up being more of something that's out in social media and sort of brought about more in a public setting and not necessarily the reality of what is actually really going on when we're talking about trying to take care of patients in the best way possible using the skill set that each group actually has. Thank you.

[Vice Chair Lisa Hango]: Anything else for our guests?

[Chair Matthew Birong]: Nope. Thank you so much. Feel free to stick around in case anything pops up. Appreciate the time. Up next also via Zoom, David, excuse me if I mispronounced this, Herlihy.

[David Herlihy (Executive Director, Vermont Board of Medical Practice)]: Sure. Thank you. It's David Herlihy. And I'm the executive director of the board of medical practice.

[Chair Matthew Birong]: All right. Well, welcome, sir. Thank you for finding the time to come in and share your thoughts on this. So yeah, table is yours sir.

[David Herlihy (Executive Director, Vermont Board of Medical Practice)]: Yeah, sure. So I'm gonna focus mostly on some of the practical aspects of this because I know this came up just yesterday, and I got asked this morning, could could the board do this and can the board give input? Because it seems like the members would wanna have understanding of of the board's ability to meet the additional requirements that would be placed on it if this were to be added to the bill. And, you know, the easy answer is yes, absolutely. You know, that's what we do. We, we license physicians and a number of other professions. And we definitely could establish a process to verify that the optometrists who are interested in gaining the additional authorization for broader scope meet the requirements of the law and any rules that might be developed. And that's not an issue. Can figure out how to do that. I also was a little bit surprised to hear the testimony earlier about how crazy and unusual it is to have the board involved with a profession that gets their base license from OPR, because this is something that physicians deal with all the time. We there's for decades, it's been in law that any MD or PA other podiatrist who wants to use ionizing radiation, so for, you know, x rays, fluoroscopy, other things that use ionizing radiation, need to get an endorsement from OPR. There is an exception radiologists don't need to get the endorsement, but otherwise any of our 7,000 MDs who are licensed need to go to OPR to get an endorsement very similar to to what's proposed here. So that that didn't strike me as odd as a prior witness thought that was. So we we definitely can do this, And I'd be happy to

[Rep. Kate Nugent (Member)]: answer any

[David Herlihy (Executive Director, Vermont Board of Medical Practice)]: questions you have otherwise about the board's position on this.

[Chair Matthew Birong]: Thank you so much for that, sir. Representative Hango has a hand.

[Vice Chair Lisa Hango]: Yeah, thank you. Can you tell me on your board, I haven't looked it up recently, how many medical doctors sit on the board?

[David Herlihy (Executive Director, Vermont Board of Medical Practice)]: Sure, yeah, we have 17 members and nine of them are MDs. We also have a physician assistant and a podiatrist.

[Vice Chair Lisa Hango]: That's right. Thank you. I do recall those figures now. Thank you.

[David Herlihy (Executive Director, Vermont Board of Medical Practice)]: And then we also have six public members.

[Chair Matthew Birong]: Any other questions for this guest? Yes, Repson.

[Rep. Mary-Katherine Stone (Member)]: So I just want to clarify again that you would be willing to take this on and feel like you have the capacity to do so.

[David Herlihy (Executive Director, Vermont Board of Medical Practice)]: Yeah, absolutely. We can, we, you know, we overnight we figured out how to do emergency licenses when COVID came on and licensed thousands of people within, you know, a very short time to be added to the Vermont roles to be able to practice here. So I'm sure that we could figure this out with a little bit of of lead time.

[Chair Matthew Birong]: You have any questions for the guests? Thank you so much for the time, sir. And if you wanna stick around, feel free. But if not, that's a

[David Herlihy (Executive Director, Vermont Board of Medical Practice)]: great tag. Sure, great, thanks.

[Chair Matthew Birong]: Finally for this Board of Testimony, Secretary of State's Office, Office of Commercial Regulation. Thank you. Madame Deputy, how are you?

[Vice Chair Lisa Hango]: How are you? Good. Is it okay if Jim Cohen comes up as well?

[David Herlihy (Executive Director, Vermont Board of Medical Practice)]: I

[Chair Matthew Birong]: was expecting it. Thank you for asking.

[Lauren Hibbert (Deputy Secretary of State; former Director, Office of Professional Regulation)]: I'd like to

[Vice Chair Lisa Hango]: turn it over. Is that okay?

[Lauren Hibbert (Deputy Secretary of State; former Director, Office of Professional Regulation)]: Like being short.

[Chair Matthew Birong]: Everybody likes equalized.

[Lauren Hibbert (Deputy Secretary of State; former Director, Office of Professional Regulation)]: You very much for allowing us to testify today and also giving us some time to absorb the amendment. We appreciate the amendment, appreciate the thought that went into the amendment, and do think that while, of course, we stand by our legislative proposal, it's really important to have these conversations. It's a very important role of the legislature to have these conversations. So I would just like to start at a high level again to talk about scope expansion and why we're here, because I think it's really important. The Office of Professional Regulation, we regulate 50 plus professions, the majority of the healthcare professions with the exception of the Board of Medical Practice. I will say that I disagree with the prior witness in that the Board of Medical Practice is more capable of investigating instances of unprofessional conduct than the Office of Professional Regulation. We also have a dedicated team of investigators who are trained in investigating unprofessional conduct in the health care setting. I would say, arguably, we receive over 800 complaints related to our professions. More than half of those are related to health care. And that is the bulk of that team's work. We have nine investigators, six certified law enforcement. We put them through rigorous training, All of the training that's available around occupational licensure investigations, our investigators do. They're very highly trained. We also have four dedicated in house prosecutors who only focus on unlicensed or unprofessional conduct cases. And this is something, again, those prosecutors are trained on these topics. Similarly, OPR is very highly skilled at assessing scope of practice. It is something that we do. It is something that our legislature in prior years has put faith and trust in us to do. It is why we have the Sunrise Review that's set out in Chapter 57 of Title 26. We are designed to do scope review. Why we have to do scope review and why these questions have to come in front of you is culturally the way that the medical profession and, by extension, healthcare professions have evolved over the history of time. You will not see a scope or on what a physician can do. Physicians, because of their training, which is extensive and we should trust and value and we do, are permitted conceptually to have their scope of practice evolve as science evolves, as training evolves, as experience evolves. And fundamental to any health care professional's ability to do a thing, it is not just what the law says, it's what the individual is trained to do. But with physicians, their scope of practice is not constrained in statute. It is assumed that they can do almost anything that they are trained to do, where the science has gone, where the training has gone. And I think this is important because for every other profession, it's a carve out. And that's why the scope discussions are in front of you, because we're carving out what professions can do. And I want to acknowledge that that's complicated, that that's awkward, and that that is worthy of robust conversation. Here, we did a scope review for optometrists. Here, we found after a significant long review that it was safe for optometrists to do these limited procedures. And I will say that this was a compromise. What we found was not what the optometrists were looking for. What we found as requirements for the training was not what the optometrists were looking for. And what we found is not the national standard for what optometrists need to do. We really did a rigorous review and proposed what we felt was safe and appropriate. You, as a body, have seen lots of scope expansions, some in this year, the psychologist is one. Again, that was what we felt safe and was appropriate. But in prior years, you've seen many. Again, this year, you have seen you, as a body, did pharmacists I was blanking on the word pharmacists. These are conversations that are going to come up again and again, and notably don't come up for physicians until there's a space that feels unsafe. So this body has found previously stem cells and conversion therapy. Those were two things where the medical profession had gone beyond where the legislature felt safe and felt like there should be some parameters around it. So it's not that it never happens, but it's very rare. So with that, we stand by the report that we did. We did extensive outreach. We can talk about that more if you'd like us to, to talk about the research that we did and engagement with both of these groups, quite frankly. This has been a lovely conversation for the most part over the course of eight years. So it's been an evolving conversation and one that we've been really engaged in. I know you all have read the Sunrise report, and we could give you the initial application for our sunrises, but this has been a compromise from the time that we proposed it. And then I'll turn to Jen to talk about specifics in the amendment.

[Jen (Counsel, Office of Professional Regulation)]: So specifically, in the amendment sections one, three, and four, that removes the three laser procedures from the advanced procedures permitted for optometrists with advanced training and puts those procedures on the list of ophthalmic surgeries that are prohibited for optometrists to perform. OPR does oppose those changes. In the context of the scope expansion assessment, OPR found that with appropriate education and training, optometrists can safely perform those laser procedures. And the number of states that agree with us or that agree with that concept is increasing every year. So you've heard testimony that Tennessee was the most recent state that enacted legislation. And some states have allowed optometrists to do these procedures for decades. So this is the trend nationally where optometric practice is going, and OPR supports the laser procedures. The committee's heard extensive testimony that these procedures are critical for first line treatment of glaucoma, more efficient and effective than drops and less expensive over time for patients. The committee also heard extensive testimony about how optometrists begin training on the foundational skills for these laser procedures in the very first semester of optometry school. And they hone those skills throughout their years of optometric study. We're not aware of any data that suggests disparate rates of adverse events, malpractice suits, or unprofessional conduct complaints based upon whether optometrists or ophthalmologists perform laser procedures. So in light of their training, education, and the examinations required in S-sixty four and the additional experience required by S-sixty four, OPR supports keeping those laser procedures in the legislation. Next, in terms of putting the advanced procedure specialty with the Board of Medical Practice and requiring practice agreements to ophthalmologists, OPR poses those measures as well. This scope expansion has been studied and debated for many years, as we all know, since at least 2019, when the Vermont Optometric Association proposed allowing optometrists to perform these procedures. And from the beginning, the primary opponents have been ophthalmologists and physicians who have vehemently opposed and argued that optometrists lack adequate training and education to perform the procedures. This committee has heard testimony from numerous physicians who believe that the expansion poses a threat to patient safety. The Board of Medical Practice has also opposed this expansion effort as recently as in testimony last week. The proposed revisions to Section two and four place oversight of optometrists performing advanced procedures in the hands of the scope expansion's most vocal opponents. Oversight by ophthalmologists and the Board of Medical Practice would create unnecessary barriers that would frustrate the implementation of the expansion. These revisions to the bill impose substantial barriers for optometrists who want to pursue that specialty and perform the procedures. Lots of P's there. OPR is not aware of any data or evidence supporting the necessity of these measures, nor are we aware of any state imposing such limitations or oversight. We have various concerns about these measures, including whether any of Vermont's 33 ophthalmologists would perform this service, whether ophthalmologists could bill for such oversight and whether it would increase costs, whether such oversight would impact availability of services with multiple busy practitioners having to be involved, and how oversight will impact patient care. With respect to having the advanced procedure specialty issued and regulated by the Board of Medical Practice, OPR has concerns about this as well. Having a standard scope of practice regulated by OPR and then a subset of those practitioners who are doing specific procedures to be regulated by the Board of Medical Practice is a complicated regulatory environment. Assessment, diagnosis, treatment, advanced procedures, and management of post procedure care would be a continuum of overlapping actions that would be difficult to parse between two state agencies. Moreover, OKR and BMP have different practices and procedures with respect to licensing and enforcement, such that the administrative redundancy for a specialty that's going to be taken up for less than 100 practitioners would likely cause unnecessary waste of precious resources. We've heard testimony in this committee indicating that ophthalmologists are not aware of the training and education that optometrists have. And even just last week, the chair of the Board of Medical Practice testified that he was not aware of optometrists' training and education. No other state requires oversight by ophthalmologists. There's no evidence suggesting such oversight would be effective or even possible given the acrimony between these professions regarding a scope expansion, nor is there any data suggesting that the outcomes would improve with Board of Medical practice oversight or with practice agreements with ophthalmologists. Just in conclusion, we all know this is a very controversial topic, and we appreciate this committee's consideration of all of these challenging components. However, optometric scope expansion is where this profession is trending nationally, including in small rural states. And in many sectors, Vermont experiences small state problems resulting from our low population density and other rural characteristics. Certainly in health care, with our aging population and workforce shortages, it is and it will continue to be crucial for access to allow practice to the full extent of professionals' training, education, and experience to the full extent that can be safely allowed. So as a state, we're going to continue to bump up against scope expansions. And it appears that we're going to have to do that when it's safe to do so and when practitioners have the training experience and education. OKRs worked very hard to assess this expansion in a comprehensive way to ensure that our conclusions make sense for Vermonters and that they don't pose a risk to the public health safety and welfare. That is our North Star always, what is best for public protection. We concluded that with specialized training, education, examinations, and experience, licensed optometrists who obtain the specialty credential will be able to confidently perform all of the surgical, laser, and injection procedures listed in S-sixty four as passed by the Senate. Thank you.

[Chair Matthew Birong]: Rebecca, can I see your hand? Yes.

[Vice Chair Lisa Hango]: This is for Deputy Secretary Hooper. You spoke about the scope review of optometrists and OPR findings on training, that it was not what optometrists needed and not national standards, and I didn't catch the connections there. Could you talk about that and also talk about how you do your research, please?

[Lauren Hibbert (Deputy Secretary of State; former Director, Office of Professional Regulation)]: Sure. I don't know the first piece. I don't know what I was trying to say. I misspoke or misspoke well, is possible and frequently a problem with communication. What I do know is that we have found that optometrists do have the requisite training experience and education with the additional guardrails in this bill and that the training has evolved. So this committee knows that our first recommendation did not find that, the 2019 finding. And that is because we did not have adequate information from the schools of the training. What we need to assess training and education is curriculum from schools. And we did not have that in our first scope assessment. We then did get it, and we received it from all of the schools in the nation. We also spoke with a lot of the schools. We spoke with the profession itself. We did find that there was a difference between when optometrists were trained, which makes sense because hopefully for all of us, what you're learning is changing. For lawyers, what they're learning is changing. Case law has evolved, medicine evolves, everything evolves, and training and education needs to evolve as well. So it was surprising to us to find that there was this divide, and it did seem to be for graduates before 2019 and graduates after 2019. That being said, even with the advancements in education, our office felt very strongly that there needed to be additional guardrails, specifically the board tests, those two board tests. We thought that that was very important and the preceptorship.

[Vice Chair Lisa Hango]: Between those two reports, what prompted you to do the second report again? You.

[Lauren Hibbert (Deputy Secretary of State; former Director, Office of Professional Regulation)]: Not you specifically, but this month's.

[Vice Chair Lisa Hango]: I just couldn't recall that. And can you also tell us how you do your research?

[Lauren Hibbert (Deputy Secretary of State; former Director, Office of Professional Regulation)]: Sure. And I think now you've met all of them. We have three members of our general counsel team, plus a silent but important member, our policy person, Dylan Bruce. We use that team to work collaboratively with all of the stakeholders in this profession, the educational facilities, with other states. So we reach out to other states who regulate this profession, which is all 50. But in this study, we reached out to the other states that have regulated this profession and have allowed scope expansion and the public.

[Vice Chair Lisa Hango]: And how do you do your public research?

[Lauren Hibbert (Deputy Secretary of State; former Director, Office of Professional Regulation)]: We send out announcements to the public to try and engage in our study. I can't say that it's highly attended representative.

[Dr. Tina (Optometrist witness, surname not stated)]: Like a public A public outreach, yes.

[Vice Chair Lisa Hango]: Period or a specific meeting that one has to attend?

[Lauren Hibbert (Deputy Secretary of State; former Director, Office of Professional Regulation)]: We allow and encourage public comment at all times, but then we have specific meetings at varying times of the day to allow for public feedback. And it's a similar process to how we engage in rulemaking. We want to

[Rep. Mary-Katherine Stone (Member)]: make sure that the public is aware of that. Thank you.

[Chair Matthew Birong]: Nugent?

[Rep. Kate Nugent (Member)]: Thanks. Could you remind us or talk a little bit about the time in the bill that is required for actual procedures on human beings? Because it seems like there's a big difference. Also, would you agree that these procedures are surgical? So if an ophthalmologist is doing them, they're trained in surgery in theory, and so they get a certain number of hours doing it in person. And so I just want to remind myself of the original bill and the number of hours required for that.

[Lauren Hibbert (Deputy Secretary of State; former Director, Office of Professional Regulation)]: So that is that preceptorship time and those eight hours, which is more than the majority of states. But that is the hands on requirement. That is not the only hands on requirement that the majority of optometrists will receive, but that is our fail safe, what we felt comfortable with being absolutely required before someone can practice. So there's

[Rep. Kate Nugent (Member)]: a potential that they would go through schooling. They may or may not get hands on training with the schooling. So the bill, the eight hours, that's the only actual requirement?

[Lauren Hibbert (Deputy Secretary of State; former Director, Office of Professional Regulation)]: Can we say that that's potential? Yes, we have to say that's potential. Is that anticipated? No. The majority of optometrists who are pursuing these procedures are obtaining hands on training.

[Jen (Counsel, Office of Professional Regulation)]: Well, they're obtaining hands on training in other procedures that they're doing throughout their education. So in other words, they've got live patients that they're practicing optometric procedures on throughout their education. But with these specific procedures, right, that was the thing that we were It

[Lauren Hibbert (Deputy Secretary of State; former Director, Office of Professional Regulation)]: is very clear that not every school requires the practice on live patients, although they are doing it in labs and on models. So they are practicing those skills. And it's this crucial problem, is optometry schools are located in states where scope expansion has not happened. So they can't practice what the skills that they're learning in the state that they're learning it in because scope expansion has not happened, but they are learning it and they are learning it on models. And many of them are leaving for fellowships or extended training outside of their optometry school. But that is why we felt strongly that there should be

[Rep. Kate Nugent (Member)]: a preceptorship. So they can potentially show up in Vermont, get that eight hours of hands on treatment only, start practicing here. But there's no requirement to be connected with people who have done that procedure for a long time.

[Lauren Hibbert (Deputy Secretary of State; former Director, Office of Professional Regulation)]: In the bill is drafted? No. In the amendment, yes.

[Jen (Counsel, Office of Professional Regulation)]: I also just would add that I have a professional license. I know some of you have professional licenses. As we're going in our professions, you know, if We all do the phone a friend thing, and I think you've heard testimony from optometrists and ophthalmologists that there's discussion, optometrists consulting with each other or with their physician friends. And so, it's not like anyone's doing this in total and complete isolation, but in terms of what the field requires.

[Rep. Kate Nugent (Member)]: I'm imagining someone in the middle of doing a very precise surgical procedure without saying structure around that. How do you phone a friend in the middle of that and make sure that one tiny movement or one

[Lauren Hibbert (Deputy Secretary of State; former Director, Office of Professional Regulation)]: I think there's two things here. The amendment doesn't allow for that either. There's no requirement that the ophthalmologist would be in the room. That would be a really incredibly burdensome thing, so I respect and appreciate that. Capstone did not put that requirement in the amendment, and that was not anticipation. You got very clear yesterday. But with all of our professions outside of this space, there really is an expectation and requirement that you feel comfortable. Does that go awry sometimes? Absolutely. But that happens across all of our professions. But really, it is the individual professional's responsibility to ensure that they are trained and capable. And that has to remain valued and trusted because that is what the training of all healthcare professions, but really any profession, is doing, is they are training you to use your independent judgment. And the training that you received, plus your independent judgment, to know, am I ready to do this? Is this the right person to do this with? And if the answer is no to either of those questions, then you should not be doing the procedure, whether that is a complex I mean, in cosmetology, just going to something that's more lighthearted and outside of this space, there are cosmetologists who are horrible at dying hair, truly horrible, cannot do it, and should not do it, and have not been kept up to date on where the field is advancing. And you can go to somebody who was trained in cosmetology school and get a hair dyed from them. And a hair dye, it's sort of funny, and I don't mean to equate it to these procedures at all because they're not, but there are risks to hair dye. The reason why the state regulates cosmetologists and beauty establishments is the storage of hair dye, how it's put on a human, all have huge health effects for the people who are engaged in the practice of the profession and for Vermonters who use the service. But even outside of that, the skill sets have evolved and evolved and evolved, and cosmetologists need to continue to advance their training. Now, are there some cosmetologists who think recklessly that they can do the next balage? Yes. But they really should have the training and expertise before they engage in that. And that's built into every profession that we're hearing.

[Chair Matthew Birong]: Other questions for our guests?

[Rep. V. L. Coffin IV (Member)]: All right.

[Chair Matthew Birong]: Thank you so much for the time.

[Vice Chair Lisa Hango]: Thank you. Putting

[Chair Matthew Birong]: the time and effort into reviewing the proposal so very nearly

[Vice Chair Lisa Hango]: Appreciate it.

[Chair Matthew Birong]: All right, we still have a few minutes before lunch hour. I'll open the table up to any committee conversation discussion.

[Rep. Mary-Katherine Stone (Member)]: Before we do that? I just saw

[Chair Matthew Birong]: I actually saw the hand first here. So, I

[Rep. Kate Nugent (Member)]: was just wondering if you could ask what you put the discussion on.

[Chair Matthew Birong]: I mean, the testimony at this point was on the amendment.

[Vice Chair Lisa Hango]: I want

[Rep. Mary-Katherine Stone (Member)]: to say the amendment was my way of trying to have honest conversations. I feel like there's been a lot of mishandling of how this has been I mean, I'm just gonna read this. I wrote down, A good compromise is a mutually agreeable solution where both parties make concessions to resolve a disagreement. It strikes a practical fair balance so that everyone involved feels their core needs are respected, even if neither side gets absolutely everything they originally wanted. My main issue with this is that there is one side who is still very angry. And I know that there has been work to find a compromise, but I don't feel like at this time we're in that place. And so this amendment was me throwing the kitchen sink in to force us to have the hard conversations to find that middle ground. It is very clear from the testimony that we heard today that this issue is still very hot and people feel like they haven't been able to be heard and they're not in a place. And I know that every time I say this, people kind of little girl me, which I don't like, which is, oh, well, Mary-Katherine, you haven't been here that long. This has been going on for years. I recognize that, but you know what? It still may require more time. And I would rather do things with thought and intention. And even if that means that we have to wait another six months, another year, whatever, we have to do another study, I would rather do that and be at a place where I can take something home and be proud of it and feel like everyone walked away feeling good about the product. Maybe they didn't get everything. That's what good compromise is. But right now, I don't feel like that's where we're at. And I know the amendment. I threw it in and I knew I said, this thing's gonna blow up. And you know what? I didn't have a single lobbyist help me. I didn't have anyone help me. Me and Jen Karczfeld wished I did because I was just like, turn my notes that I've written into words that make sense. But it was my way of just pushing the conversation because I feel like we're still not in a middle ground place. It's very evident.

[Chair Matthew Birong]: Our margins.

[Rep. Chea Waters Evans (Ranking Member)]: As we're talking about this over

[Vice Chair Lisa Hango]: the past few weeks, when did we get the note

[Rep. Mary-Katherine Stone (Member)]: to May

[Rep. Chea Waters Evans (Ranking Member)]: Did you say May 6? So since May 6, and we've been talking about this, I feel like what we hear over and over again from everybody is we have to trust that optometrists don't want to do harm, which I trust. We have to trust that OPR knows what they're talking about and that they're very good at regulating, that they would not do anything that would put Vermonters in harm's way. I also trust that. Trust that ophthalmologists are not just being exclusive and protecting their territory and that they're looking out for patients. And I trust that. So it seems like the common ground, the base agreement for everybody is that we need to look out for patients and people who are getting these procedures. And then that brings me to the thought that what Vermonters trust us to do is make sure that we are allowing people to do procedures that they are trained to do, that is going to keep them safe. Because when I go to a doctor or a specialist or anyone who's regulated by anything, For staff, even when I go to get my hair dyed or when I go to the optometrist, I trust that they have been put in a place where or, you know, they have been given the tools they need and they do have the expertise because I trust state government, which I know some people might say that that is something we shouldn't do. And I really believe that we should. And I believe that the reason that this is such a difficult thing for us is because we do trust the process and we do trust what we do here every day. And I hope that Vermonters can trust that we are not going to say, okay, we're going to have somebody do procedure on your eyeball that they're trained to do or not trained to do in a way that's gonna keep you safe. It's not even a thought when I go to the optometrist. They just assume that they know what they're doing and they're not gonna, you know, cause any harm to my vision. I know that that things happen and that, you know, there we're humans and there are errors. And I don't know where I was going with this whole thing, but I guess I'm just saying that, like, I think as long as we maintain the trust that people have in the process and in the in the system that we've set up for regulation that I think I am really supportive of maybe not everything in Rep Stone's amendment, but I'm supportive of the general idea that, yeah, maybe we do expand. I I like the idea of having the board of medical practice oversee it. I like the idea of the collaborative practice. Is that what it's called? I like the idea of I don't know about the surgeries, but I like the idea of expanding the number of hours of training that they have to have. Like, I think those are all good, solid ideas that aren't going to ruin this. It's not going to make it an unpassable bill. It's something that we really want to do. I and I hope that that compromise is something that we can reach.

[Rep. Mary-Katherine Stone (Member)]: I also want to say the Medicaid piece that I brought up is something that I would really like to talk about. If everyone jumps on me and says, that's a wrong committee. Well, it's in our committee now and it's up to us to make the best decisions that we can. And I do think that that is something that warrants more conversations. If optometrists do this, I wanna make sure that they have the coverage because I worked with, when I am not here, the reason I ran for office is because I'm a healthcare worker and I get to see the underbelly society, the things that y'all don't see because you can't hide from a healthcare worker when you say, how was your day? How are you doing? It's like in your medical chart and you're in a really vulnerable place and I have to figure out how to get you home if you have a home. That's why I ran for office. So I know that people are struggling right now to pay off medical debt. They're working two or three jobs. They can't afford housing and medical debt is crippling. So if we go this path, we need to talk about the Medicaid expansion piece. That is the very least we can do to make sure that we are serving for monitors. And if optometrists want to do that, whatever. We just need to make sure that we're moving forward in a way that does the least amount of harm, and that's something I feel like we have to talk about, and we haven't.

[Chair Matthew Birong]: So in

[Vice Chair Lisa Hango]: an hour. Okay. Yeah. So in the interest of lunch,

[Dr. Tina (Optometrist witness, surname not stated)]: you don't stand between me and lunch.

[Chair Matthew Birong]: That is a lesson learned long ago. Yes.

[Vice Chair Lisa Hango]: Just to bring a little levity to this situation. So I've been sitting and listening and taking in as much as I can. I've also been reading about this bill over the last several years because it's been introduced before. This isn't the first time. So my feelings are, and I know you all have heard me talk about this before, that we're a little bit out of our jurisdiction here when we're talking about medical procedures. And since Rutland has it in her amendment, Medicaid. And those are really in the purview of House health care. I want to remind everybody that our House health care committee voted this bill out 10 to one and sent it to us. And we are the OPR overseers here. So as for GovOps jurisdiction, OPR regulates a number of different professions. And as the deputy secretary mentioned, they vary from cosmetologists and barbers to certain other professions that are not life and death professions. But OPR does regulate some, what I consider to be life and death professions, including pharmacists, who dispense medications that could kill us if they're not in the right format or the right dosage. And I will bring up civil engineers. Civil engineers design and build bridges, roads, and structures that could kill us if they're not done properly. And that's a big responsibility for OPR. So I do want to remind everybody that we're here to talk about what is the jurisdiction of the VOPS and to have trust in both the regulating organization, which is OPR, and trust in our colleagues in the health care committee, because they have been working in this realm for

[Chair Matthew Birong]: a

[Vice Chair Lisa Hango]: little bit longer than I have, and maybe some of you have as well, in terms of legislation for health care. So with that, I moved to go to lunch.

[Chair Matthew Birong]: I see a hand wrap, Coffin.

[Rep. V. L. Coffin IV (Member)]: Could have waited till after lunch, but basically, again, the health care committee floated out ten one. And going back looking at how things were introduced before I got here, OBR has done a lot of research, done years of research on this and has made compromises working with the scope. They have put years of effort into this. And we have to trust that OPR is going to and has done their job. We have to trust that our healthcare committee has done their job. Our job is saying what OPR can do. And I like that there is a comprehensive list of what optometrists cannot do in this bill. Not just what we're expanding their scope, but saying we don't want optometrists doing these items. And it appears that the list for what they cannot do is a lot longer than what they're being added to their scope of what to do. So that is where I stand. I think compromises have been made by OPR and everyone else concerned. And I think this would be good for Vermonters to expand this option because it would bring future optometrists into this state that are choosing not to. I know that when I go to the VA and I have my eyes checked, I go to see the optometrist there, I see a lot of interns there, a lot of people coming in to get practice time at the VA. And when I talk to them and ask them if they're gonna stay keep working in Vermont, am I gonna see them on my next visit? And I hear time and again, I'm going to somewhere they let me do my job. The practicing at the VA to get some time as an intern is just a stepping stone to a state that lets them do their job. I'd like to see these newer optometrists coming in that have got these skills already to be able to help rural Vermonters, help every Vermonter. Okay, and I'll shut up because I see the time.

[Chair Matthew Birong]: Have Rep Waters Evans and then Rep Stone, and then I got a call up

[Vice Chair Lisa Hango]: for I'm good.

[Dr. Tina (Optometrist witness, surname not stated)]: I'm good. Go ahead, Rep Stone.

[Rep. Mary-Katherine Stone (Member)]: I was just saying, I'm not anti OPR. Fun fact, they regulate me and I'm a healthcare worker. So again, this amendment was so that we could have robust conversations instead of side conversations led by lobbyists. No offense to everybody in this room, but we need to hatch it out of the table. And I still feel like there's unresolved business. And the fact that some people feel like there is resolved business and others feel like there's unresolved business, there's a dispute right there. That's all this amendment was. And so I'm sick of getting muzzled again. I'm not attacking OPR at all. Why aren't I shaking her head? I just put in my hours to get recertified as an OT. Like I know they can do their job. That's not what this was about. It was to come up with a a better compromise that I can serve patients. So that's all this was. Thank you very much.

[Rep. V. L. Coffin IV (Member)]: All right. With that, we will be back to

[Chair Matthew Birong]: have