Vermont Legislature SmartTranscripts:

[Rep. Alyssa Black (Chair) – likely diarization fragments]: Good

[Rep. Alyssa Black (Chair)]: morning, everyone. It is Wednesday, March 18, and we are doing a walk through on S-one 163, which is the first bill we've gotten from the Senate this year. So let's wait till Jen is able to screen share, and then we'll do the walkthrough.

[Jennifer Carbee, Office of Legislative Counsel]: Great. Good morning. Jen Carpe from the Office of Legislative Council. We are going to be looking at a Senate bill, S 163, and I thought it was important for you to understand the frame of what we're talking about before you start hearing other testimony. So S 163 is a match relating to the role of advanced practice registered nurses in hospital care. And it is a pretty narrow bill that does not, as I understand it, you'll hear from OPR and others, doesn't expand the scope of practice of APRNs. It updates the statutes to reflect roles that they are permitted under their existing scope of authority to take in hospital settings. And so it very specifically amends two

[Rep. Alyssa Black (Chair)]: parts of

[Jennifer Carbee, Office of Legislative Counsel]: the statutes. One is the hospital patients' bill of rights. And so Title 18, there's a hospital patients' bill of rights. It's a long list of rights that patients have in a hospital and are entitled to around privacy, around rights to information, around having the people they want in the room, all kinds of things. And they are enforceable in that a violation by a provider can be caused for disciplinary action under Board of Medical Practice licensure rules. And so there's actually a couple of things that are happening here. One is an additional in that case. So the existing bill of rights for hospital patients refers a lot to the person who is the attending clinician as the physician. And so this bill is adding advanced practice registered nurses, and it's also defining physician as both MD, medical doctor regulated by the board of medical practice, but also an osteopathic physician regulated by the office of professional regulation. And so these statutes currently don't actually refer to OPR and then either it's just Board of Medical Practice. So the first thing that's happening here is just some definitions in the chapter on the Bill of Rights for Hospital Patients. It's adding a definition of Advanced Practice Registered Nurse or APRN and citing to their licensure provisions in 26 VSA chapter 28, sub chapter two. And then you'll also see throughout there's some updates to language to use non gendered terms or to be specific that we're talking about an individual, because as you may recall through some of our work on the private equity bill, a person under our statutes in Title I can be a person or a corporation or other entity. So we're only talking about individuals or patients. The definitions of APRN, modifying the patient one, just to be clear, it's an individual. And then physician means someone licensed under either of the two statutes, the Board of Medical Practice MD statutes and the OPR, the Osteopathic Physician Statute. Section two is the Patient's Bill of Rights, and it's an existing law as the Bill of Rights for Hospital Patients. And throughout, you'll see, again, some changing from gendered language, his or her, to non gendered language, the patient. But notably, in the Bill of Rights, it currently says patient shall have an attending physician who is responsible for coordinating a patient's care. And what the testimony that Senate Health and Welfare heard and the purpose of this bill coming to legislature, as I understand it, was to reflect that an APRN may be an attending clinician who is responsible for coordinating a patient's care in a hospital setting. That happens now. And so this is reflecting that in the hospital patient's bill of rights. Also, just wherever there are references throughout the bill of rights to the physician, if you have the right to obtain from the physician coordinating their care, this would add or APRN. So really adding, that there may be an attending APRN as permitted under their scope of practice. And as long as that is within the hospital's policy, have to be credentialed at the hospital. I should

[Rep. Allen "Penny" Demar (Member)]: know this, but I'm going to ask. An APRN, how's that different from a PA?

[Jennifer Carbee, Office of Legislative Counsel]: It's just a very different educational path, and they have different scope of practice as far as what they're allowed to do independently under Vermont law. Physician assistants are regulated by the board of medical practice. APRNs are regulated by OBR, but their education is different.

[Rep. Alyssa Black (Chair) – likely diarization fragments]: Okay, thank you. Sure.

[Rep. Leslie Goldman (Member)]: Go ahead. So you just mentioned that each hospital credentials their hospitalists in their own way. It would have to be by hospital by hospital. So this is enabling hospitals to choose to do it. Is that I would say this

[Jennifer Carbee, Office of Legislative Counsel]: is especially in this piece, it's really reflecting that already hospitals may be doing this. And Senhov and Welfare heard testimony from some APRNs who are the attending provider, attending clinician in the hospital setting. So this is reflecting that reality in the Bill of Rights and then also in the hospital licensure. So in order for

[Rep. Leslie Goldman (Member)]: APRN to practice at this level, it has to be part of the bylaws. What would it have to be part of the bylaws of the hospital? I think

[Jennifer Carbee, Office of Legislative Counsel]: it has to be part of the hospital's credentialing policy,

[Jennifer Colón, Director, Office of Professional Regulation]: but you will hear That's it.

[Jennifer Carbee, Office of Legislative Counsel]: May hear more from the hospitals. Okay.

[Rep. Leslie Goldman (Member)]: Because I didn't see any hospital testimony in the senate. I was curious of it.

[Jennifer Carbee, Office of Legislative Counsel]: I think some of this I I don't recall or any other. As you know, Devin Green is often in the room and may have been asked to provide information more informally. But there were some representatives, APRNs from the Vermont Society who testified as to their experience. Thank you.

[Rep. Alyssa Black (Chair) – likely diarization fragments]: Back

[Rep. Alyssa Black (Chair)]: to Allen's question. So APRNs are able to practice on their own without supervision, a supervising physician, but PAs still need a relationship. That still largely?

[Jennifer Carbee, Office of Legislative Counsel]: Yes. The APRNs have, I think there's a three year transition to independent practice and I'm going to defer to OPR on that as well. But there is when they're first getting licensed, there is that required relationship with a physician. But after that, they can do independent practice. The PA still has to have an ongoing consulting relationship with a physician. Great.

[Rep. Alyssa Black (Chair) – likely diarization fragments]: Okay. Just

[Rep. Alyssa Black (Chair)]: want to make sure that was still in place.

[Rep. Leslie Goldman (Member)]: Another question about that. We got a letter from a PA asking to be added to this. Is that a doable thing or just from your point

[Jennifer Carbee, Office of Legislative Counsel]: of view? I think you would need to hear from the board of medical practice. I think the issues that I understood this bill was trying to address were really having the statutes reflect reality of the practice within the scope of practice that is already authorized for APRNs and the way care is provided in hospitals. I don't know if the same is true for physician assistants simply because we did not take testimony on that MSN. Thank you. All right. So then again, throughout these, every reference to physician, it also includes APRN. I think probably the most sort of notable ones have to do with the attending physician or APRN responsible for coordinating the patient's care, receiving information, again changes from his or her to the patient. Then in this existing language around patient has the right to know the identity and professional status of individuals providing services to the patient and know which physician APRN or other practitioner. So that can be either physician assistant or other practitioner primarily responsible for the patient's care. But I don't know whether the Board of Medical Practice would deem it appropriate for them to be the attending clinician of record. And then again, adding APRN throughout. And then as I mentioned at the outset, failure to comply with this Tail of Rights for Hospital patients can have disciplinary consequences for the provider. And under existing law that just says it can be the basis for disciplinary action against a physician under the 26 BSA Chapter 23. That's the MDs. It doesn't mention the DO. So this would add or 33 for the osteopathic physicians or, and it was at against an APRN under the nursing statutes. And a complaint may be filed again, not just with the Board of Medical Practice, but this bill specifies for the OP OPR as applicable based on the license held by the practitioner. And then where there's language about Board of Medical Practice, I added in OPR. Section three is the other context that this bill is adding, specifically adding APRNs to, and this is in the license requirements for a hospital. And so under existing law, the licensing agency, which is the Department of Health, issues a license when it determines the applicant and hospital facilities meet certain minimum standards. And one of those is that all patients admitted to the hospital shall be under the care of, and under existing law, it's a state registered and licensed practicing physician as defined by the laws of the state of Vermont. This would update that language both to specifically reference the two types of physicians, but also to add an APRN. So all patients admitted to the hospital must be under the care of a physician licensed under either of our physician licensure chapters or an APRN. And then there's language a little bit about that Uniform Credentialing Application. It's an existing law. And then similarly in the requirement that professional case records must be compiled for all patients and signed by the attending physician, recognizing that that could be an advanced practice registered nurse, sees the attending clinician as well, and still kept on file for ten years. And the act will take effect on passage.

[Rep. Alyssa Black (Chair)]: Questions for Jen? Let's let her go to the center. We

[Jennifer Carbee, Office of Legislative Counsel]: will see you in an hour.

[Rep. Alyssa Black (Chair)]: I'm sorry, I don't Oh, I do have one. Would you come on up?

[Jennifer Colón, Director, Office of Professional Regulation]: Good morning. Thank you so much for having me. I'm Jennifer Colon. I'm the director of the Office of Professional Regulation. Good to see you all again. Just want to come right out of the gate and say the Office of Professional Regulation supports this bill. APRNs do have an independent scope of practice, and we can talk a little bit more about that. Hopefully, I can answer your questions. So you know that the Office of Professional Regulation regulates over 50 professions. We oversee over 80,000 licensees. And a lot of those are related to health care. And we do regulate nurses as part of our regulatory programs. And advanced practice registered nurses are a group that we regulate. APRN scope of practice in Vermont is a full practice authority as a medical provider under Vermont law. And their practice authority is listed in 26 VSA fifteen seventy two. And that defines an APRN as a licensed registered nurse authorized to practice in this state who, because of specialized education and experience, is licensed and authorized to perform acts of medical diagnosis and to prescribe medical, therapeutic, or corrective measures under administrative rules adopted by the board. So this means that they have extensive training that stacks on top of a registered nurse license, and they can diagnose, treat patients, order and interpret diagnostics, prescribe medications, give verbal or written orders to other health care providers, manage and evaluate care, or order therapeutic treatment. So it's a full scope, full practice authority with no supervision. They are autonomous across settings, so it doesn't matter which setting they are in, and that includes hospitals. And Ms. Jen Carby testified a minute ago. She did mention that this bill really reflects what's already happening in hospitals. APRNs are primary providers in hospitals. So this is just catching up the law to what's happening on the ground. To become a licensed as an APRN, a nurse must have a graduate degree from an accredited US graduate degree program. It's got to meet educational standards set by the National Accrediting Board and Certifying Board. They have to complete a supervised clinical rotation and they have to successfully complete graduate courses in advanced pharmacotherapeutics, I'm sure I said that wrong, advanced patient assessment and advanced pathophysiology. APRNs also can specialize in certain roles. We have certified nurse practitioners, certified nurse midwives, clinical nurse specialists, psychiatric mental health nurse practitioner. So they have national board certifications similar to physicians that they have to maintain in their roles. Let So me see if there's anything else. An APRN's relationship with their patient is also the same as a physician. So it's a provider patient relationship and an APRN, again, who's a certified nurse practitioner providing primary care, can be the primary care provider of record for the patient. So this bill includes not only APRNs, but osteopathic physicians who we also regulate as primary it identifies them as primary providers and hospitals, essentially. So we support that language. Initially, when the bill was introduced, it had some kind of limiting language with respect to APRN scope of practice. But on the Senate side, that language was removed. So as it was passed, OPR supports.

[Rep. Alyssa Black (Chair)]: Any questions for Jen? I was just hoping you could send your, testimony to our call. Happy to do that. So that way we can have it review if Yep. Happy to do that.

[Jennifer Colón, Director, Office of Professional Regulation]: Okay, great. Thank you so much. Thanks

[Rep. Leslie Goldman (Member)]: for your support.

[Rep. Alyssa Black (Chair)]: This is awesome. I was going say, I didn't see Devin at all, but there's a head in my butt. That's not like her not to be here.

[Devin Green, Vermont Association of Hospitals and Health Systems]: Devin Green, Vermont Association of Hospitals and Health Systems. Thanks for having me in today on this bill. And I'll say that our process for this bill, when it came forward, was I reached out to our chief nursing officers, our chief medical officers, and our emergency department medical directors to gather their thoughts. I would say that the majority of folks were in support of this bill, and so as a result, VOS does support this bill. And what we heard is that this does reflect how people practice now and how it works in our hospitals now. If hospitals have concerns, they can always change their credentialing or use their credentialing to reflect that. Overall, people were very supportive of this bill. There were some concerns from some physicians, and you will likely hear this from BMS, around some Medicare regulations in terms of admitting privileges and having a physician sign off. We've heard that this has been done in other states and managed in other states, so we think the bill should move

[Rep. Alyssa Black (Chair)]: forward. So this is currently practice in certain hospitals, I assume. How do they go around it? How are they getting around it? Well, that's a good question.

[Devin Green, Vermont Association of Hospitals and Health Systems]: I wouldn't necessarily say it's currently practiced. I think it reflects what's happening on the ground, which is Vermont has made a shift to APRNs practicing independently. They, for the most part, in hospitals, and it depends on how the hospitals set things up, they can practice largely independently in the hospital. The exception may be the admitting privileges piece. So that may still be done now with physician oversight. I think where we would have to go from here is you know, we would have to figure out the Medicare piece, but we've heard that that has been dealt with. And so, again, we're happy to support the bill.

[Rep. Alyssa Black (Chair)]: Any other?

[Rep. Allen "Penny" Demar (Member)]: You say we've heard that that's been dealt with.

[Devin Green, Vermont Association of Hospitals and Health Systems]: In other states because other states have New it, I believe, and other states.

[Rep. Alyssa Black (Chair) – likely diarization fragments]: We don't have any idea.

[Devin Green, Vermont Association of Hospitals and Health Systems]: We don't have it yet. What's it? So Medicare requires that a physician sign off on admitting a patient in order to get Medicare reimbursement, is my understanding. And so with this bill, there were people concerned about that provision, like how will this work? Because under Medicare law, you need a physician to sign off. And this bill is saying that APRNs can sign off without a physician. And again, I think we can manage around it. So then a physician will sign off on the way out or on the way in. That's what's happening now or not happening now? I'm a little confused, I guess. I know. I'm a little confused about what's happening now, too. It could very well be the physician signing off on the way in or the way out now also. But if this is put into place, what this could do is APRNs can sign off for Medicaid patients, commercial patients with no problem. For Medicare patients, we may need a physician to sign off. But again, like I said, other states have managed this, so I think we can work with it to make it happen. So shouldn't it be happening now?

[Rep. Leslie Goldman (Member)]: I mean, if current state I mean, we're just sort of trying to adapt to current state. So isn't there already a system then to manage this already? Am I misunderstanding?

[Devin Green, Vermont Association of Hospitals and Health Systems]: Yes. I think it's the separating out the Medicare folks from other people. So what a hospital could do is the hospital could say, we're going to have our physicians continue to sign off on the admitted now. Right. Okay. I get it. But the other hospitals could say, actually, what we're going to do is you sign off on the commercial insured, the Medicaid. We'll have a physician do the Medicare. We'll break it down that way. Or again, like I said, there are other states that have done this. So I think that we can look at what they've done to manage this and learn from there.

[Rep. Leslie Goldman (Member)]: Meaning other states have created law to get I mean, can you do that with Medicare? It's federal law.

[Devin Green, Vermont Association of Hospitals and Health Systems]: No, you can't do that with Medicare. That's federal law. But other states have created this law of the admitting privileges thing. And so they manage the Medicare piece in terms of just operational process and flow and everything else.

[Rep. Alyssa Black (Chair)]: This goes through a

[Devin Green, Vermont Association of Hospitals and Health Systems]: Yeah. Okay.

[Rep. Alyssa Black (Chair)]: Thank you. So this bill is if I'm understanding correctly, maybe this was more a question for John. I apologize. Essentially what we're doing is we're making it so that APRNs can be, I don't even know if they use the term attending anymore, but can be the attending physician admissions. Care management during the hospital stay discharge. We're essentially allowing APRNs to be the attending provider.

[Devin Green, Vermont Association of Hospitals and Health Systems]: Yeah, understanding that Medicare has some different requirements.

[Rep. Alyssa Black (Chair)]: So this is kind of current practice, obviously understanding that a physician is signing off.

[Devin Green, Vermont Association of Hospitals and Health Systems]: Following all laws and regulations.

[Rep. Alyssa Black (Chair)]: I don't doubt that you are. Is this practice consistent in hospitals within your association around physician assistants as well. I mean, we did just hear we've got PAs manning the emergency department. Are they also?

[Devin Green, Vermont Association of Hospitals and Health Systems]: They do have a different so APRNs and physicians have had that sort of independence piece for a long time. Back in 2020, we passed the law to take away the supervisory role of physicians for PAs and make it more of a consultation role. So the landscape for PAs is that consultation piece. So it is a little bit different than APRNs currently.

[Rep. Alyssa Black (Chair)]: So they do have they

[Devin Green, Vermont Association of Hospitals and Health Systems]: are

[Rep. Alyssa Black (Chair)]: except for a paper, are they currently acting as the attending? Obviously, have a consulting physician that they're working with, but are they, for all intents and purposes, also acting as an attending physician in hospitals?

[Devin Green, Vermont Association of Hospitals and Health Systems]: I would want to go back and talk to my providers on that to get a finer point on it. My understanding is, the big difference is the consulting piece and having an agreement with a provider.

[Rep. Alyssa Black (Chair)]: None of my line of questioning I want just to say should read into anything that I don't think. I love physician assistants. We do too. Any questions for Kevin? Other questions?

[Rep. Leslie Goldman (Member)]: Did you send anything written?

[Devin Green, Vermont Association of Hospitals and Health Systems]: I did not, but I'm happy to Yeah, that would be helpful.

[Rep. Leslie Goldman (Member)]: Thanks.

[Rep. Alyssa Black (Chair)]: Well, you. Thanks.

[Jessa Barnard, Vermont Medical Society]: Good morning. Thank you for having me. Jessa Barnard with the Vermont Medical Society. I will remind people right off the bat, we represent physicians and physician assistants. So I can talk a little bit about the PA situation as well. Appreciate the opportunity to comment on S163. Our board spent a lot of time talking about this bill, in fact, maybe more than any other bill going into the session to try to wrap our head around. I think some of the questions we're all trying to get to the bottom of in terms of, is this a change of scope of practice? How does it relate to scope of practice? How does it relate to current practice on the ground? How does it relate to other regulations? So it actually, even though the language is pretty simple, took our members and board a little while to get to the bottom of what is this really changing and how does it impact the practice of healthcare here in Vermont? We did a full member survey. We had two board meetings talking about this. Overall, our board took a neutral position. So no, generally neutral position, understand the bill is likely moving forward. And we understand the intent of modernizing the language of the statutes at issue with the goal of ensuring patient access to care. I think how we parse the part in our minds, what the bill is doing is that there's scope of practice statute, which is separate, really. And this is layered on top of that. So both for APRNs and PAs, there's different section of law that talks about, for example, APRNs needing a collaborative practice as they're transitioning into practice for the first two years. For PAs, there's this collaborative practice requirement. That's in law, nothing in this bill changes that, we understand that. And there was a lot of testimony in the Senate about how this does not change scope of practice. On paper, that's correct. And we agree with that analysis. That said, for years, this has been kind of layered on top of that, is that this is a separate section of law, the patient bill of rights and the hospital licensing statutes kind of been like another piece about hospital care layered on top of any other professional scope of practice. So on the ground, would be a change in practice, not scope of practice, but how care is delivered in the hospital, in the way our members and we have sort of understood what the bill is doing. And so our members in general do feel like team based care is the best approach for hospitalized patients. And we did receive, and I wanted to pass along some concerns about that this, again, even though this isn't a scope of practice statute, this has required a physician to be a touch point in a patient's hospitalized care. And our members in general felt like that is a good thing, that for any, just to have somebody having their eyes on the patient record supports patient safety, accountability, and best patient care. And this would be a change saying that a physician no longer has to sign off in some way on that patient's hospitalized care, especially when these are the, we would assume the sickest patients we have in our state with the highest and most complex needs. But we also understand that credentialing the hospital can make that decision. Basically, this is saying that's not a requirement anymore, but a hospital and their credentialing could, or other regulations could continue to require this practice or practice the same. So we understand and appreciate that. The other piece our members did want to point out, or as some of the pieces Devin started to bring up about other regulatory requirements, and is this actually adding complexity in a way rather than streamlining or taking away complexity. So there's the Medicare piece, and I have this in my written testimony, the reference if people are interested, that every Medicare patient must be under the care of an MD or DO, regardless of who admitted the patient. Discharge to home health requires a certification from either a physician or an advanced practice provider under physician collaboration. So that sort of requires a collaborative relationship. And then, so there is gonna have to be some workflows addressing those pieces. And I do wanna address this piece about PAs providing hospital care. What our members shared is that that generally does really look similar on the ground. Again, yes, PAs have a collaborative requirement, but that's not saying That is not a requirement every patient, that the physician is involved in the care of every patient the PA oversees. Is there somebody that they can call if they have questions or consult with as needed? That's really in the PA's discretion. But day to day, a PA also, in our members' perspective, manages hospital care in a very similar way to an APRN and is used in many hospital services. So if this bill is moving forward, we would support addressing them similarly and continue adding PAs in if we are adding APRNs in, our members did not see a distinction in terms of the day to day care of a patient in the hospital. So those are the pieces again, I just wanted to raise for your consideration and share sort of our thought process as we consider the bill.

[Rep. Alyssa Black (Chair)]: I

[Rep. Allen "Penny" Demar (Member)]: guess talked about, a lot of it has been said about Medicare. What about uninsured or other insured?

[Jessa Barnard, Vermont Medical Society]: Right, the requirement is only in federal regulation for Medicare patients. So for other patients, the piece of law that has required that has been this hospital bill of rights, or patient bill

[Rep. Alyssa Black (Chair) – likely diarization fragments]: of rights. So

[Jessa Barnard, Vermont Medical Society]: if that was removed in Vermont statute, there would not be another requirement for patients with other insurance statuses. That's understanding.

[Rep. Alyssa Black (Chair)]: Leslie? So I just want to make

[Rep. Leslie Goldman (Member)]: sure I understand what you're saying, because what I'm hearing you say is that this would be a change, but what I'm hearing from others is that it's already current practice and established just sort of practice so that there wouldn't be a change and maybe hospital to hospital. So that's what I'm a little confused. Yeah,

[Jessa Barnard, Vermont Medical Society]: this is again sort of my lens of piecing together many conversations to try to understand this as well, is that when I think, and I don't want to speak for others, when people say this is current practice, it's more the clinical care that APRNs and PAs are generally independently managing a patient's care in the hospital. However, this regulatory requirement is currently layered on top of that. So you do need a physician to sign off or be the attending of record. And I think there's a bit of a difference of opinion of what does that mean? Is that sort of a needless administrative sign off that doesn't actually mean anything clinically? It's just sort of a piece of paper that somebody is signing saying, yep, even though I didn't see that patient during their stay, I was the attending of record for sort of a regulatory requirement versus does that add some meaningful clinical involvement of another provider in the patient's care? So I don't see any way I don't know how this could be truly fully happening currently because there is this legal requirement. I think it's what people are more saying is in day to day clinical practice, there are situations and departments where APRNs and PAs are generally providing all the day to day care for the patient, even if on paper somebody else has to be the attending of record. That's my interpretation of the current situation.

[Rep. Alyssa Black (Chair)]: So is this still changing that? Yes. Tell me where.

[Jessa Barnard, Vermont Medical Society]: It is added by adding APRNs to where it says that the either attending or admitting provider of record right now that is limited to physicians. This is now adding

[Rep. Leslie Goldman (Member)]: Responsible for coordinating patient care. Yeah. Correct.

[Rep. Alyssa Black (Chair)]: I'm sorry, I swallowed wrong. I just don't even know this. Do your TAs ask admitting rates?

[Jessa Barnard, Vermont Medical Society]: I don't know technically how to I think this law doesn't allow that for APRNs or PAs currently, only physicians. Yet, again, the somebody like somewhere on a piece of paper, it is saying that it is a physician who admitted that patient and is sort of your attending of record and care and feed throughout that hospital stay. That may mean that in practice, you may not actually see that physician. You may actually be seeing APA or APRN day to day. They may be the ones managing your care, ordering your labs or whatever you need during your hospital stay. But on paper, there is a physician who admitted you. That is what this, the patient bill of rights sort of currently requires. And the hospital licensing statute. Oh, I see

[Rep. Alyssa Black (Chair)]: you about really quick. Does remote medical society, do you represent physician assistants as well?

[Jessa Barnard, Vermont Medical Society]: They are our members as well.

[Rep. Alyssa Black (Chair)]: They are our members. Okay. Thank you. Trying to get it.

[Jessa Barnard, Vermont Medical Society]: They're the gay members or something. Go

[Rep. Alyssa Black (Chair)]: ahead, Val.

[Rep. Alyssa Black (Chair) – likely diarization fragments]: Okay.

[Jessa Barnard, Vermont Medical Society]: The only part I am not grasping at all is the Medicare piece. Okay, yep. That's another layer on top. Healthcare, you may not be surprised to hear, has many layers of regulation. So on top of state law, on top of hospitals doing their own credentialing, which is a whole separate process where they really look at your experience, your background, your area of practice, say, for our medical staff, we are saying you have privileges to do these sets of procedures, these types of patients, this level of complexity, and they do that for every individual on their medical staff of all their provider types who can be on their medical staff. Then there's your scope of practice, which is through your license, OPR or Board of Medical Practice saying you're licensed to do this. Then we're adding on, in Vermont, we have the hospital licensing statute and patient bill of rights. On top of that are all the billing and coding regulations for every insurer that pays you. So this is a Medicare specific regulation in federal regulations that say for Medicare to pay you, you have to have a MD or DO, a physician, who is not admitting physician. So that means to get paid. It doesn't mean for It's a payment regulation. And Medicare is very tricky about all As we're hearing in all sorts of contexts now, how they're trying to connect policy levers to really payment policy, but this is one of those decisions that is in federal regulation to pay you for that hospital, to pay the hospital for that hospital stay. This has to be in place or else you will not get paid for that visit. And Vermont can't change that. We can't change that. Right. So that will always that will regardless of changing this law, that will remain in place. And that's why Devin was saying the hospitals would basically have to come up with some kind of workflow piece. They can't not comply with that if they want to get paid by Medicare. They'd have to figure out, okay, if we want to change this for other patients, for patients who are being paid by Medicare, we will have to continue to have an MD or DO of record for that patient for their hospital stay, however they figure that out in their workflow. And maybe these hospitals will decide they don't change it for anyone because that's too complex to work out, or they may find a way to change it for some patients.

[Rep. Alyssa Black (Chair)]: I actually have a question. I'm not sure it's a question for you more than it might be a question for Devin that I didn't think about, but I'll ask both of you. I'm just trying to wrap my head around current practice. Is most hospitals hire or contract out as we learn this year in budget. Hospitalists? Are PAs and APRNs hired actually as hospitalists, as individuals? Think you will hear, yes. And I

[Jessa Barnard, Vermont Medical Society]: think actually Michelle may be able to address that as well. I think there are APRN hospitals. I think I know there are some hospitals in Vermont who actually have hired PAs and APRNs for their critical care unit, their intensive care unit. So there are hospital based PAs and APRNs currently practicing in Vermont in different units. Thank you. Any other questions for Jessa?

[Rep. Alyssa Black (Chair)]: Thank you very much. Next we have Jade Kaplan. Jade's on Zoom. Oh, together. Great. Good to see you both.

[Michelle Wade, President, Vermont Nurse Practitioners Association]: Madam Chair, if we could tag team, we'd appreciate that. Absolutely. Thank you. For the record, Michelle Wade, nurse practitioner, currently the president of the Vermont Nurse Practitioners Association. And to directly answer your most recent question, I am a hospitalist. I am the division lead at Gifford in Randolph. And my team consists of three physicians and five APRNs and one recently retired PA. So that is just a sampling of what goes on in a critical access hospital, which as you guys are very aware, Vermont is made up with a large number of critical access hospitals. And I think that you would find many of them are staffed similarly. Let me just pause there. Are you able to hear me okay?

[Rep. Alyssa Black (Chair)]: Very well, thank you.

[Michelle Wade, President, Vermont Nurse Practitioners Association]: Okay, sorry, I didn't do a sound check sooner. And also to concur with what you also just heard, Rutland Regional Medical Center's ICU is staffed primarily by APRNs and PAs with physician collaboration. And I know that to be the case in other larger hospitals as well. So this morning, Jade and I are here together to talk about S163. We also presented this in the Senate, and I thank you for this opportunity. And what I want to emphasize, and I realize we're, if you will, batting cleanup, so you've heard a lot of this already, is that we already have the education, the training and the legal authority within our scope of practice to admit and attend to patients in the hospital setting within our scope of practice. What we're really trying to do is clean up bill language and make sure that we're practicing legally. In the critical access hospitals, it is primarily APRNs, midwives, CRNAs and PAs that do a bulk of the care with physician collaboration. And under Vermont Full Practice Authority framework, we independently evaluate our patients, diagnose their conditions, develop and manage the treatment plans based on whatever diagnostic imaging and results we have access to for our patients. We prescribe the plan of treatment and medications. We then appropriately discharge patients when they're ready to leave the acute care setting, including ordering home health services, thanks to the CARES Act that was passed shortly after COVID. This is all within our scope of practice. And what we're looking to do is just solidify language clarification. Currently, I am the provider that does all of those things at my hospital. And because we're a critical access hospital, the CAH regs say that my physician can retrospectively look at my case. So that's another area how I think we address some of this. But across our states, we're doing this. And so what we're looking to do is have reliable data that shows what we're doing because currently the data's not there because we're not named because of these current issues where it needs to be a physician. And then I'm gonna let Jade speak for a couple minutes, and then I'm gonna wrap it up.

[Jade Kaplan, Certified Nurse Midwife (NVRH)]: Hi, my name is Jade Kaplan. I am a certified nurse midwife and APRN currently employed at Northeastern Vermont Regional Hospital in St. Johnsbury. I've been there for nine years and I've been a certified nurse midwife APRN for more than thirty five years. So I'm adding just a little bit of lived experience to Michelle's lived experience as an APRN here in Vermont. I work at a hospital that acknowledges through its bylaws my full practice authority. So when I admit a patient in labor, my name is on her bracelet. It provides clarity for the patient that not only am I in front of her caring for her, but my name is on her bracelet and it gives her a sense of continuity of care which we know through research and evidence helps support positive outcomes. I know that nurse midwives are delivering more than thirty percent of the infants in the state of Vermont, but as Michelle was referring to, without admitting, you know, without midwives, and we do have nurse midwives, APRNs, doing deliveries at nine of the 10 open maternity units we have in the state right now. So, that's how we get such high numbers of deliveries because midwives are doing prenatal care and they're doing deliveries of postpartum care and GYN care as well. However, we don't have good records of the midwives activity because the admissions is not consistent across the state. Some of the hospitals allow full practice authority and admitting privileges for the midwives, and some of them are not. So a patient at one of those hospitals will have a physician's name on their bracelet. They will be attended to by the midwife, delivered by the midwife, discharged by the midwife. They will never see that physician because they never needed a physician's scope of practice. They were fully attended to safely by the midwife in her scope of practice. And that data then gets lost. Hospital reporting, admitting records, red cap data, insurance revenues data, even birth certificate data, which doesn't track the admitting provider, but it doesn't track either who did the prenatal care very accurately. So I don't know how a state like ours who is in need of health care reform and rural health transformation projects can actually know what is needed to do if they don't have the data that tells them who's already doing what. So I see that this bill clarifies and supports what's already happening in our state. And I think it would benefit our health care system overall to have this clarity and consistency moving forward. Thank you.

[Rep. Alyssa Black (Chair)]: Jade, can I ask a really ignorant question? I see you You can

[Jade Kaplan, Certified Nurse Midwife (NVRH)]: ask any type of question you would like.

[Rep. Alyssa Black (Chair)]: I well, first of all, I'm sitting here looking at your letter that you both sent. Number one, I'm really happy about the logo that you chose because I think this committee had input in which logo to go with. Number two, I'm astounded by the number of acronyms after both of your names and sounds exhausting to me. Are certified nurse midwives, are all certified nurse midwives APRNs or are you just they are?

[Jade Kaplan, Certified Nurse Midwife (NVRH)]: So, in Vermont, there are two different types of midwives. Nationally, there are actually three types of midwives, but Vermont only recognizes two. One are the APRNs. We are nurses, we're RNs who have gone to school, received additional training as nurse practitioners in the field of midwifery, which is women's health including delivery of normal low risk pregnancies. And in order to be certified as a nurse midwife, you have to pass national boards. So certified nurse midwives are practicing in hospitals in all 50 states who pass these boards and meet the licensure requirements of each individual state. The other type of midwife that we have in the state of Vermont is a licensed midwife. They are covered under a different statute. They are not regulated by the Board of Nursing. They are not nurses. They are people who have gone and gotten a certification as a certified professional midwife or a CPM as opposed to a CNM. And they're practicing in the home only. Or actually now that we have birth centers, eventually they will also be practicing in freestanding birth centers, but they are not credentialed in hospitals.

[Rep. Alyssa Black (Chair)]: Okay, so all APRNs are not CNMs, but all CNNs are APRNs.

[Jade Kaplan, Certified Nurse Midwife (NVRH)]: Correct. You got it. You got it. And there's about 60 of

[Rep. Leslie Goldman (Member)]: us practicing in this day.

[Rep. Alyssa Black (Chair)]: I wouldn't

[Rep. Alyssa Black (Chair) – likely diarization fragments]: even know if they had to be.

[Rep. Alyssa Black (Chair)]: You didn't want to compliment the logo on their thing. Beautiful. Try to load it and see it. We really like it. I'm sorry, any questions? Go ahead, Leslie. Thanks to both of

[Rep. Leslie Goldman (Member)]: you for this information. Michelle, could you speak to the concern about Medicare and how you, in your role, deal with that at Gifford?

[Michelle Wade, President, Vermont Nurse Practitioners Association]: I would love to. Can I just wrap the testimony first and then come

[Jessa Barnard, Vermont Medical Society]: Of back to course? Sure.

[Michelle Wade, President, Vermont Nurse Practitioners Association]: Yeah, thank you. So just sort of to finish wrapping the testimony, I want to say that this will provide clarification that will support recruitment, retention, and administrative efficiency. Aligning statutory language helps Vermont remain competitive surrounding states. It also will reduce unnecessary administrative burden. It will allow hospitals to streamline care processes. And when a credentialed APRN can function fully within their scope, workflows are simplified, patient handoffs are minimized, and the care is delivered more efficiently without changing safety or credentialing standards. Most hospitals, as you already heard, will continue through their bylaws process and credentialing process to control exactly the scope of the attending physician, and we're Okay with that. We're just looking to fix the language here. That wraps the testimony. There's a little more in the writing. But Leslie, to speak to your question, how is it dealt with at my hospital for the Medicare? What I can tell you that I understand, and I am not the insurance expert, but patients that are not Medicare insured primarily, first of all, it doesn't apply to. Second of all, we are a critical access hospital, so we run by different regulations than UVM, Rutland, all of the other non critical access hospitals. Medicaid patients, private pay patients, and private insurance patients don't have to follow that Medicare rule.

[Rep. Leslie Goldman (Member)]: But does the Medicare rule apply in critical access hospitals? Are you saying it does not?

[Michelle Wade, President, Vermont Nurse Practitioners Association]: It applies, but it's different. Critical access has a different set of regulations. And under the CAH regulations, the physician collaboration does not have to be while the patient is on-site.

[Rep. Leslie Goldman (Member)]: While the patient's on-site? It gets signed off. It's asynchronous, I suppose you could say. Yeah.

[Michelle Wade, President, Vermont Nurse Practitioners Association]: So a physician is signing all of my charts sometime at some point somewhere, but they're often not on service at the same time. They review them. If they have a concern, they discuss it with me, and it's a quality issue.

[Rep. Leslie Goldman (Member)]: But if the person has already been discharged, it's after the fact. So I guess then you go and reconnect with them and follow-up or whatever.

[Michelle Wade, President, Vermont Nurse Practitioners Association]: Make whatever remedial action is necessary. Absolutely. Go ahead, Brian.

[Rep. Brian Cina (Member)]: And part of that review too is for the future patients, right? Like learning from experiences about the flow works in your settings and

[Michelle Wade, President, Vermont Nurse Practitioners Association]: Absolutely, anything that's done through that quality review or through that review would then be applied going forward. I

[Rep. Alyssa Black (Chair)]: have a question that I'm not sure either of you would be able to answer. Is there still insurers, be it either personal Medicaid or Medicare that pay a reduced rate for APRNs?

[Michelle Wade, President, Vermont Nurse Practitioners Association]: So Jade is very special because the Vermont Medicaid regs reimburse them at 100%.

[Rep. Alyssa Black (Chair)]: I

[Michelle Wade, President, Vermont Nurse Practitioners Association]: am reimbursed at 85% and most insurers follow suit with that 85% despite the quality and quantity of work that I do?

[Rep. Alyssa Black (Chair)]: So if you have admitted a patient and it's, you know, the admitting is a physician, Do the patient's claims during inpatient, do they go with you on it so you're getting 85% or are they going with the attending physician on it at 100?

[Michelle Wade, President, Vermont Nurse Practitioners Association]: My hope is they're going out with my name on it. I ran my NPI information two years ago, the claim numbers looked fairly accurate to me. I don't manually track them, but they looked fairly accurate to me.

[Rep. Alyssa Black (Chair) – likely diarization fragments]: Okay, great.

[Rep. Alyssa Black (Chair)]: It came about cost of care, which is how this actually would say about cost of care.

[Rep. Alyssa Black (Chair) – likely diarization fragments]: Correct. All

[Rep. Alyssa Black (Chair)]: right. Any other questions?

[Michelle Wade, President, Vermont Nurse Practitioners Association]: I'd just like to thank you for noting the logo.

[Rep. Alyssa Black (Chair)]: And Michelle, I think you are just as valuable as Jade. You are both equally valuable.

[Michelle Wade, President, Vermont Nurse Practitioners Association]: Thank you, Madam Chair.

[Rep. Alyssa Black (Chair)]: Even if the money doesn't say so. Thank you. Alright. So we don't have Jen until 10:30. So we're going to take a long break. Okay. We have some amendments to here. We have three amendments on our bills. So, yes. We can go off of

[Rep. Alyssa Black (Chair) – likely diarization fragments]: one of

[Rep. Brian Cina (Member)]: Oh, was related to that. Yeah, so I shouldn't say it, I don't want her be opaque about things. One of the amendments I'm offering, so I'll

[Rep. Leslie Goldman (Member)]: have to

[Michelle Wade, President, Vermont Nurse Practitioners Association]: talk about that.

[Rep. Brian Cina (Member)]: One of them is from representative Logan. Are we gonna let her make her pitch? Because I didn't see her on the agenda.

[Rep. Alyssa Black (Chair)]: Was in, and we also invited Ralph North, but we haven't heard from him.

[Rep. Brian Cina (Member)]: Okay. That's the third person.

[Rep. Alyssa Black (Chair)]: That's what

[Rep. Brian Cina (Member)]: I want to ask.

[Rep. Alyssa Black (Chair) – likely diarization fragments]: Thank you.

[Rep. Alyssa Black (Chair)]: Yes. They've all been invited.

[Rep. Leslie Goldman (Member)]: Okay.

[Rep. Brian Cina (Member)]: Mine will be quick.