Vermont Legislature SmartTranscripts:

[Rep. Alyssa Black (Chair)]: Welcome back after a very, very short break. And we are flipping back to H573. I thought we should get some last bit of testimony. As we heard, I don't know, was it yesterday or the day before, sometime this week, that we have this system that has been developed for this multi step process. And one of the within the development of this, whether right or wrong, it is the way it is, is that this first initial certification after a warrant is being done in emergency departments. And as we learned, we have many emergency departments throughout our state that are staffed by physician assistants. And we're trying to clear bottleneck to get people to the right care as quickly as possible. So I wanted the hospitals to come in and just talk about maybe your thoughts on the bill as well as the role that physician assistants play in our emergency departments.

[Devin Green (Vermont Association of Hospitals and Health Systems)]: Yeah, happy to do it. And Devin Green from Vaz. And, Cherry, you mentioned bottleneck, and I do want to say I appreciate the work that this committee has done in the past. We've actually made a lot of great strides in this area between some of the things like the urgent mental health care facilities and the mobile crisis units and some of your other initiatives. That's been a huge help. But I will say that waiting in the emergency department continues to be a big concern for our providers. That is because an emergency department is in no place to stay for a very long time. I think there is a perception of you bring someone to an emergency department and everything will be okay. But in fact, it's a pretty chaotic place. Research has shown that emergency department wait times longer than two hours for patients in need of hospitalization is associated with mortality, morbidity, and patient harms. And in fact, a long wait in the emergency department can actually be, when we talk about preserving someone's freedom, can actually be counterproductive. And that's because as one researcher pointed out, it's not hard to imagine that an individual in psychiatric crisis forced to wait alone for many hours in a small unfurnished room, which is sometimes locked or on a narrow gurney, might lose the control that he or she possessed upon arrival at the ED. That loss of control, in turn, will result in the use of force, and that individual who arrived at the ED with no need for inpatient admission has been transformed by the ED experience into someone who needs an inpatient bed. So our providers are very concerned with eliminating all barriers and really reducing those wait times. Vas had extensive conversation with our chief medical officers, our emergency department directors, and ED nurse managers on this issue. And they all brought forward this desire to have PAs have the ability to do these emergency exams, the first certification. They were unanimous about it, and they all spoke to the professionalism and qualification of physician assistants to do these things. A physician assistant, if you go in there for chest pain, they are going to be the one who stabilizes you and transfer you and assess you and everything else. So we are looking for parity with this bill so that people do not need to wait for a physician to come in and sign a piece of paper. Additionally, the role of the physician assistant has changed. So previously it was physicians supervise the physician assistant. In 2020, Act 123 was passed, and that changed the relationship from the supervisory role to just one of consulting, which physicians do with each other all the time. And so we really support this bill and would ask that you pass it going forward. Happy to answer any questions.

[Rep. Alyssa Black (Chair)]: I see Brian's hand, but to that point, can I clarify something? Yes. So do you know when this

[Rep. Daisy Berbeco (Ranking Member)]: process

[Rep. Alyssa Black (Chair)]: put in place before 2020? Yes. When, So at the time that this was created, made sense because physician assistants had to have supervision and now they just have to have consultation. But this wasn't addressed. This came before, I guess what I'm saying, which came first?

[Devin Green (Vermont Association of Hospitals and Health Systems)]: The emergency examination first certification piece came before Act 123 in 2020. Okay.

[Rep. Alyssa Black (Chair)]: It was created in a different world in which we currently live and practice. Correct. Okay. You for that. Brian, go ahead. I

[Rep. Brian Cina (Member)]: have three questions. I was trying to map them out to make

[Devin Green (Vermont Association of Hospitals and Health Systems)]: it Right. Excised. Me get my eye out. Hold on. First.

[Rep. Brian Cina (Member)]: Do you know, if you don't, it's okay, but do you know or have an estimate of the average wait time for a first certification currently?

[Devin Green (Vermont Association of Hospitals and Health Systems)]: I don't. I heard that in testimony from yesterday, And while we do measure the time from when a person comes in to the time that they leave, we don't have that granular detail in our data.

[Rep. Brian Cina (Member)]: The next question is unlikely to be answerable, but I'm going to ask it, which is, do you have the average wait time for the next step? Between the current verification

[Devin Green (Vermont Association of Hospitals and Health Systems)]: Well, is supposed to be within twenty four hours.

[Rep. Brian Cina (Member)]: And if not, what happens? Can you remind us for the record? I know, but I

[Devin Green (Vermont Association of Hospitals and Health Systems)]: So you may need to correct me on this, but I believe it sort of starts all over again. Right.

[Rep. Brian Cina (Member)]: I believe that's also the truth. The last one I think you can answer, because I thought you were going be able to answer them all. When you couldn't answer the first one, I'm like, probably don't select the info. But you did refer to statute saying that you have twenty four hours and then you have to do it again. So actually the maximum wait would be twenty four hours because then you have to do the whole thing again. But you mentioned parity.

[Devin Green (Vermont Association of Hospitals and Health Systems)]: Oh no, I think the maximum wait could be longer than that because you're starting the clock, you could be there for a number of days.

[Rep. Brian Cina (Member)]: Oh, I meant till the next.

[Devin Green (Vermont Association of Hospitals and Health Systems)]: Oh, until the next. Yeah, yeah. Okay.

[Rep. Brian Cina (Member)]: Right, because once you're EE'd, you could be waiting for a bed and then they have to recertify, recertify, recertify.

[Devin Green (Vermont Association of Hospitals and Health Systems)]: Right, right, right. And

[Rep. Brian Cina (Member)]: The only answer for that is more places for people to go. But you mentioned parity, and I wanted to end with this one, that we heard some testimony saying that it was gonna create an imparity to allow this. What I heard you, and at least one other witness say, is that this actually increases parity. So we're hearing these conflicting messages. We heard an example from another witness about cardiac care and how there are situations in emergency rooms where PAs will initiate an emergency cardiac procedure or be the first step in the initiation of something that saves people's lives, do you see that as a parallel example to this, that if this could be a lifesaving thing, and so if PAs are allowed to do that, why aren't we allowing them to do this lifesaving thing?

[Devin Green (Vermont Association of Hospitals and Health Systems)]: 100%.

[Rep. Brian Cina (Member)]: I get that now. I'm starting to understand that better now after hearing you in addition to that witness. Can you think of any other examples besides the cardiac wand? It's okay if not, but

[Devin Green (Vermont Association of Hospitals and Health Systems)]: Anything else that you're going into, because yeah, we have PAs. Some emergency departments are staffed only by PAs. So if you go in for anything, any sort of emergency, the PA is the one taking care of you. Here, what we have currently is the PA will interview the person, they'll rule out everything else, and then either they have to wait for the doctor to come in and sign off on trust the PA or the doctor has to go through everything again, which in addition to being in an emergency department, if you're in a mental health crisis and you're getting questioned with the same questions all over again, that doesn't help either.

[Rep. Brian Cina (Member)]: There was another question related to this. You think of any examples where we don't let PAs have equal treatment, I don't know what the word is, scope of practice as doctors in terms of the frontline of a process in the ER. People come in usually, they go to triage with the nurse actually, collecting info, checking them in, and then a doctor examines a person or a PA. Can you think of any other situation where because the person told the triage nurse they were coming in for a condition, that we don't let the PA do it?

[Devin Green (Vermont Association of Hospitals and Health Systems)]: Cannot think of can

[Rep. Alyssa Black (Chair)]: Migrating think of type

[Rep. Brian Cina (Member)]: of Yeah.

[Devin Green (Vermont Association of Hospitals and Health Systems)]: So the other thing is things may be different in other areas, a PA specialist or specialty or something like that. But in the emergency department, everyone is treating that emergency and the PAs are on the levels as the APRNs and as

[Rep. Alyssa Black (Chair)]: the physicians. I've been going through, I'm thinking labs. They can order any lab, any test, they can admit patients, they can get consultations from any, they could transfer the patient. They can do an admission for a voluntary hospitalization. I'm trying to rack my brain in anything where we would say, no, this profession doesn't have the expertise once they've received the training to actually be qualified to do this. And I'm I mean, I'm just from someone who knows an awful lot of physician assistants, I think I found it rather insulting of this really important profession. We rely on our physician assistants, our APRNs. It's not just doctors. I was thinking about the equity piece of it And why should somebody in rural Vermont be subjected to different standards as somebody in Burlington? Just because of how their hospital is. Brian and then Leslie. Sorry, But went off on a

[Rep. Brian Cina (Member)]: I heard you bring up geographic equity, which is important. I want to go back to the I'm really trying to give everyone's perspective in equal say and trying to understand. That's just to be clear, that's why I'm asking these really specific questions. But can you think of any other medical situation where a person's rights get taken away besides this process? Is there any other situation where a person could come into a hospital and present with symptoms and have healthcare providers initiate a process to take away their freedom besides this emergency evaluation process that begins with the first certification that we're looking at?

[Devin Green (Vermont Association of Hospitals and Health Systems)]: So I think intoxication is one thing.

[Rep. Brian Cina (Member)]: You say a little bit about what happened. I don't wanna

[Devin Green (Vermont Association of Hospitals and Health Systems)]: Yeah, loss of consciousness. Yeah, there is a process for intoxication where someone is, and the word is, they don't have their full faculties due to intoxication and-

[Rep. Brian Cina (Member)]: Like incompetent or incompetent.

[Devin Green (Vermont Association of Hospitals and Health Systems)]: Yes, thank you. Thank you.

[Rep. Brian Cina (Member)]: But then the hospital can say, the person tries to leave So here's the thing, if you try to leave and they're detaining you, you can leave against medical advice in many situations, but there's ones where they don't let you leave, like this. If you're competition, if you're trying to leave, they can hold you back.

[Devin Green (Vermont Association of Hospitals and Health Systems)]: They can

[Rep. Brian Cina (Member)]: call the police to come keep you.

[Devin Green (Vermont Association of Hospitals and Health Systems)]: Mean, doesn't at bring you to jail if

[Rep. Brian Cina (Member)]: you try to leave in those situations, but I could be wrong.

[Devin Green (Vermont Association of Hospitals and Health Systems)]: I don't know for sure. I mean, this is definitely a unique this is very much of, like this brings in legal perspective that you don't necessarily see in other areas of the health care world. But I will say that there are times when people they don't necessarily have this process, but they are probably unable to leave due to their incapacity, and it would be unsafe for them.

[Rep. Brian Cina (Member)]: So it sounds like there's some nuance between these different situations, and that this is one of many examples of situations where someone's medical condition could lead to them not having the same rights that they would have otherwise, because their competency, I heard consciousness mentioned, I think that's fair to say, like state of mind or state of consciousness, you don't have the same rights because you're unconscious. People are making decisions for-

[Devin Green (Vermont Association of Hospitals and Health Systems)]: You're not able to make decisions-

[Rep. Brian Cina (Member)]: With the best intention, but they might do something you don't want. That's why people have orders to not resuscitate, so that they can follow your will when you're not there. But I think what we're getting at here is this is a unique medical situation, so the argument we were hearing from others was that because people's rights were being violated, but we're not violated, because it's not a violation. It's more like restricted because of your health condition, and it's really related to safety. Not about harms, it's about safety. So restricting someone's rights due to safety concerns due to a medical condition, this is very unique. But it sounds like there may be other nuanced examples around, like you mentioned, intoxication, or there could be some medical conditions where a person is delirious or something. But they don't have to go before a judge.

[Devin Green (Vermont Association of Hospitals and Health Systems)]: Right, there's not this process for that. But there is according Oh gosh, no. So I would want to go back and look at that. But I think the major concern in this piece is this process creates harmful delay unnecessarily because you have someone who is qualified to do this work available, and we have some law that's saying you need to bring a different person in to do this work.

[Rep. Brian Cina (Member)]: And in those other situations, the PA can do it. And that's why this is not a That's the imperative. I see your point. Thank you for elaborating and giving us some detail.

[Rep. Alyssa Black (Chair)]: And I just want to ground us because I think some of the testimony that we heard yesterday was not relevant to this particular bill. I want to ground us in the chart that Katie began with, that there is a first step in the process, which is a qualified mental health professional or a judge has to secure a warrant just to be able to bring the person to the emergency department. And, you know, we're talking about is there any other level of taking someone's rights away? I want to remind us, this step is not taking the person's rights away. There is a mechanism for that, which is the psychiatric, which we keep hearing concerns about that piece of it, but this bill doesn't address that piece of it. That's right. This is just getting the person to the next step where a qualified psychiatrist can make this determination. This is not a PA in some hospital deciding whether or not somebody is going to be involuntarily admitted. Right. And this is

[Devin Green (Vermont Association of Hospitals and Health Systems)]: a PA determining, does this person need inpatient care? These people that all the time for heart attacks, for voluntary folks, For voluntary psychiatric. Yes.

[Rep. Brian Cina (Member)]: It's even creating an imparity between voluntary and involuntary psychiatric if we don't do it.

[Rep. Daisy Berbeco (Ranking Member)]: That's right.

[Rep. Alyssa Black (Chair)]: Leslie, yes, I'm sorry. Wondering

[Rep. Leslie Goldman (Member)]: in all your conversations with the medical directors and all those kind of people, did they comment on the DMH training that was required for people doing EEs, emergency evaluations? DMH initially

[Rep. Alyssa Black (Chair)]: testified that that was required and

[Rep. Leslie Goldman (Member)]: sort of stood behind this as an appropriate

[Devin Green (Vermont Association of Hospitals and Health Systems)]: Yeah, I don't see why the PAs couldn't do the DMH training. I think it is appropriate to have a special training for this. There's a legal component. And so physicians do it, APRNs do it. I think it would make sense to have PAs go through it as well.

[Rep. Leslie Goldman (Member)]: So I understand that there are instances, if the PAs are not allowed to do this, that they may call someone down from the floor, a nurse practitioner or a doc, but maybe neither of them have trained in this particular set of DMH protocols and doing an EE without that training.

[Devin Green (Vermont Association of Hospitals and Health Systems)]: No, you have to have that training to do the EE. Okay, because I was

[Rep. Alyssa Black (Chair)]: I'm sort of not 100%

[Rep. Leslie Goldman (Member)]: sure of that, but It's okay, because if there was a nurse practitioner But I've heard from nurse practitioners that they've had to go down and do it when they work on the floor. So maybe I misunderstood.

[Rep. Alyssa Black (Chair)]: Maybe they've received the training.

[Devin Green (Vermont Association of Hospitals and Health Systems)]: They might have. Well,

[Rep. Leslie Goldman (Member)]: maybe the comment was more they were being taken away from floor work in order to do this thing.

[Devin Green (Vermont Association of Hospitals and Health Systems)]: And we've had doctors or APRNs who have been called in to come in from home, and that adds a bunch of

[Rep. Leslie Goldman (Member)]: time as well. A bunch of thanks.

[Rep. Alyssa Black (Chair)]: Okay. Thank you. Yeah, I think DMH testified the first time that anyone who's qualified for doing this has to receive Okay. The

[Rep. Daisy Berbeco (Ranking Member)]: Thanks. One thing I'd like to put out there is that it's not and I definitely understand the gravity of this situation, that somebody is making a life altering decision for somebody else. But we're talking about the price of care, too. And if you have somebody else come in from outside to do something that seems like a first step. I mean, this is not the final step in anything. It just seems like now you're double billing. It's just That's a lot

[Rep. Alyssa Black (Chair)]: of exercise. That's a compliment. Go ahead, Daisy.

[Rep. Daisy Berbeco (Ranking Member)]: There was one point that came up I don't remember where, and I have a question about UMHTs versus physicians. I don't know if you can answer this, but a line in the bill, I believe it's at the bottom of page one, reads, upon written application by an interested party,

[Devin Green (Vermont Association of Hospitals and Health Systems)]: blah, blah, blah, blah.

[Rep. Daisy Berbeco (Ranking Member)]: That's where everything starts. So we're proposing to scratch interested party and replace it with a qualified mental health professional because that's who's doing Someone noted that actually physicians can also do these, but they are not included as their qualified mental health professionals. Do you want to weigh in on that?

[Devin Green (Vermont Association of Hospitals and Health Systems)]: I think we would need to go and look back at that, because I thought they were included in there, but I would need to look at the definition again just to make sure.

[Rep. Alyssa Black (Chair)]: Oh, we screwed. Katie was here. I think I remember, didn't I feel like I'm going back in my memory that there is a definition of that, that it was in something else that we did, and this very same question was that. Yes, they would be

[Rep. Daisy Berbeco (Ranking Member)]: by virtue of their training.

[Rep. Alyssa Black (Chair)]: Okay, thank you. You. I did want we have reached out a couple of times. I just wanted to make note to the Board of Medical Practice. The Board of Medical Practice is who licenses both physicians and physician assistants just on their thoughts on the bill and as well additionally that maybe they would be able to explain the qualifications and the expertise and training of physician assistants and the role they play, but I just wanted to make a note that they were unable to come in. I did try for that testimony. But I think Devin very capably handled that. All right. I would like to vote on this bill today before we go. Should we take a five minute break?

[Rep. Brian Cina (Member)]: Is that definitely? I'm okay with it, I'm just saying, like, I didn't hear. Okay.

[Rep. Alyssa Black (Chair)]: I know that.

[Rep. Brian Cina (Member)]: That was not on Zoom?

[Rep. Alyssa Black (Chair)]: We're running out of time, people. We are. We have

[Rep. Brian Cina (Member)]: to redo everything. I just was checking. Let's take a

[Rep. Alyssa Black (Chair)]: short break just for