Vermont Legislature SmartTranscripts:

[Rep. Alyssa Black, Chair]: Good morning, it is March 25, this is House Healthcare and we are pivoting back to S163. So if you recall this, no, 163? Yes, 163. So this was the role of advanced practice registered nurses in the hospital setting and the questions were asked when we last took testimony as why is this not being extended to physician assistants who also work in the inpatient setting within our hospital. And we've also received a lot of correspondence from physician assistants. Thank you for all your correspondence. We have seen them all. And so I thought I'd have some people in to kind of talk about the role of physician assistants and how they play into our system of care as advanced practice providers. And this issue came up a lot when we were talking about the emergency evaluations. I don't feel like maybe at that time we explored quite as deeply as we should have, but this is a great opportunity for us. So starting with Doctor. Greenberg from the Board of Medical Practice, did you want to come up?

[Dr. Matt Greenberg, Chair, Vermont Board of Medical Practice; Emergency Physician]: Zooming here. Yes.

[Jennifer (Jen) Carbee, Office of Legislative Counsel]: Good morning.

[Rep. Alyssa Black, Chair]: Good morning. Thank you

[Dr. Matt Greenberg, Chair, Vermont Board of Medical Practice; Emergency Physician]: for having me, Madam Chair, committee members. My name is Matt Greenberg. I am here on behalf of the Vermont Board of Medical Practice and currently the chair of the board. I am an emergency physician. I have twenty five years of experience as an emergency physician. The last fifteen of those have been here in Central Vermont. I've been on the board now for about four years and recently became the chair. I was initially asked to come here today to talk to you about the board's position on this. Unfortunately, this topic came up since our last meeting, and I cannot do that because the board has not had a chance to talk about it. But what I can talk about a little bit is about PAs, which are under our authority for licensing and how they are licensed, a little bit about their training and their scope of practice, and hopefully just answer any questions that you may have. I think I should disclose that in twenty five years, I have seen a lot and worked with a lot of nurse practitioners, PAs, EMTs, paramedics. I've participated in the education of more than several 100 probably at this point. I've been a primary preceptor through the University of North Dakota Physician Assistant Program. I have also been a primary preceptor through the Rocky Mountain University Nurse Practitioner Program. So I have worked both sides of the education system.

[Leah Skypeck, PA-C, Medical Director, ICU, Rutland Regional Medical Center]: Think Sure. That

[Rep. Leslie Goldman, Member (Retired Nurse Practitioner)]: Have you taught medical students too?

[Dr. Matt Greenberg, Chair, Vermont Board of Medical Practice; Emergency Physician]: I have taught lots

[Rep. Leslie Goldman, Member (Retired Nurse Practitioner)]: So of medical you have that whole

[Dr. Matt Greenberg, Chair, Vermont Board of Medical Practice; Emergency Physician]: thing up. Medical students, EMTs, paramedics, nurses. So I've done a lot of education.

[Rep. Alyssa Black, Chair]: I didn't want to interrupt being a preceptor because I know

[Leah Skypeck, PA-C, Medical Director, ICU, Rutland Regional Medical Center]: that's what it's

[Rep. Alyssa Black, Chair]: a challenge.

[Lee Morrisett, PA-C, President, Vermont Academy of Physician Assistants (VAPA)]: Look, I don't

[Rep. Leslie Goldman, Member (Retired Nurse Practitioner)]: know what that

[Dr. Matt Greenberg, Chair, Vermont Board of Medical Practice; Emergency Physician]: means. So the preceptor in the clinical setting would be the chief medical person that oversees someone education in clinical setting, sort of like the main teacher in classroom setting. So when I work with students, they will go see a patient, they will present it to me, we'll discuss the medical care. It's sort of the process of training a clinical practitioner. Great, thank you. I think what I would say is that and again, this is more me speaking because I can't speak for the board because we have not discussed it. I think the leap under this bill from physician to non physician is probably a much bigger leap, a bigger change than it would be to discuss PA versus APRN. Often in the hospital settings, APRNs and PAs fill the same role. They are seeing inpatients right now. They're doing most of the work that an attending physician would do, usually under well, now, by law, under the authority of that physician for final say, final billing, and those sorts of things. Obviously, this bill would open that up so that that physician role would not be necessary. PA and APRN training is a little bit different. I would say that PA training is a little bit more like physician training. It's typically two years. It is generally contiguous. So it's a two year block. People tend to, you're not working full time or maybe you are, but afterwards, you're doing school full time. There's a set block of clinical, I'm sorry, non clinicals, meaning bookwork, learning your physiology and your pharmacology and whatnot, and that's usually several months, followed by several months of clinical. I will say that physician assistant programs typically are hospital based, meaning a lot more of their clinical work is in the hospital rather than the outpatient setting, although that is variable. I will also say that PA training is probably a little bit more consistent across programs right now, only because there is a single accrediting association for PAs, and it's been around a little bit longer. So I would say that in my experience, there's a lot more variability in APRN training. I'm not saying variability is bad, but the credentialing really limits the way. So somebody coming out of PA school has a certain level of understanding and clinical practice that's expected of them. Typically, that's on the order of about 2,000 of training with an estimate of between 1,002 patient encounters. Just for comparison's sake, everybody's aware, the AMA states that physicians come out of training with about fifteen thousand hours of training and somewhere between 1,403,000 to 4,000 patient encounters. Proceduralists are generally expected to have performed about 1,000 procedures. So there's a fairly big difference between physician and PA. PA and APRN are much more similar. The estimated hours of training for an APRN is about fifteen hundred. So fifteen hundred for an APRN, about two thousand for a physician assistant. Again, these numbers are very variable. Where people come to become a PA is a little bit different. If you think about an APRN, that's somebody who's already become a nurse, already has a graduate degree or has a associate's degree in nursing. And so probably already has a full time job as a nurse, and then is becoming an APRN on top of it. Typically, the pattern of PA training is that it's somebody who's coming from a medical background, whether it's a medical scribe, medical assistant, a technician in the hospital, a paramedic, who basically puts career on hold to do a contiguous two year program, graduate master's level program, and then is going come out with that graduate degree. After that, it is expected that they would pass a national board exam. It's only offered by one organization. APRNs have two separate accreditation, two separate boards that they could take. And then once they pass that, then they would approach a licensing organization such as the Vermont Board to become licensed to then practice. What the board does when we see we take an application, we look at all of their schooling, we make sure that they have completed everything that is a requirement, we make sure that they have passed their exams, make sure that they don't have a criminal record, those sorts of things, similar to what we would do for a physician. And then they can work on getting a license. I think probably the biggest difference, at least in Vermont, it's not the same in every state between PAs and APRNs, is that we require a collaborating physician to sign saying they are available at any time to be involved in patient care with that PA. It doesn't have to be in person, they don't have to be right there in the clinic or in the hospital with them, but they have to be available. Now, the practical sense, what happens, particularly on an inpatient team where a PA is part of that team, is that there'd be one person signed off legally as their primary collaborative physician and then several others that are associate collaborative physicians. So that way that PA can participate in the team. Another portion of that rule as the collaborating physician is that there's some intermittent feedback and evaluation, whether that's just discussing patients, looking at numbers, returns, etcetera. So there's sort of a feedback. That does not currently exist legally with EPRNs. I will say that each hospital can do as they will. I'll use my own hospital, for example, in the ER, I have both PAs and NPs working with me, and we have the exact same requirements for them. In the ER, we do things based on triage level. Anything above a triage level three needs to be discussed with the physician. So hospitals can have their own sort of regulation on top of it. Hospitals will also independently credential practitioners, whether that's physician, PA, or APRN. That credentialing process is yet another step to check on education, background, experience, and it's just one more role of looking at them. So I'll probably just leave it there and hopefully answer any other questions that you might have. But I think, again, my primary point is that the leap going from physician to non physician is probably the big decision. Once you've made that leap, I think PA to APRN, I don't want to say equivalent because they're not exactly the same. They have different philosophies in their education. But I think that the amount of training that they have is similar, The amount of responsibility, the roles that they're currently undertaking in the hospital is essentially the same. So I think that if you're going to give that responsibility to APRNs, it makes logical sense to give that responsibility to PDPs.

[Rep. Alyssa Black, Chair]: That's really helpful. So the big decision is whether or not we do this bill at all rather than who it is that we're identifying.

[Dr. Matt Greenberg, Chair, Vermont Board of Medical Practice; Emergency Physician]: My opinion, that's the question, yes.

[Rep. Leslie Goldman, Member (Retired Nurse Practitioner)]: Thanks for putting the pressure on.

[Rep. Alyssa Black, Chair]: I have a question about the licensure of physicians. And maybe because this has come up in some other topics, and it's not relevant necessarily to this bill. So a physician assistant has to have a collaborating physician. And I've looked up several of their licenses before and their licenses actually list who their collaborating physicians are. There can be multiples. Does the Board of Medical Practice track from a physician standpoint how many collaborative agreements an individual physician has?

[Dr. Matt Greenberg, Chair, Vermont Board of Medical Practice; Emergency Physician]: Not to my knowledge. But we do track and every year some of our interactions have to do with not having an appropriate, that's an important step for the physician assistant to maintain that, an appropriate person that still has a license. We run into not infrequently where a physician moves out of state and their collaborating agreement doesn't get changed. But I don't know, and I probably have to clarify that with David Hurley, the executive director, but I don't think there's back looking to see how many physician assistants are under any single physician license.

[Rep. Alyssa Black, Chair]: Does the nature of the collaboration I know that nurse practitioners, after several years, can practice independently. Could a PA establish their own practice and just have a non affiliated provider be their collaborating provider?

[Dr. Matt Greenberg, Chair, Vermont Board of Medical Practice; Emergency Physician]: Is that Or Yeah. They would still need a collaborating physician that is of reasonable proximity to them. And I don't remember exactly how that's defined in the board, but they have to be a practicing physician at that location. They can't be just a name on paper.

[Rep. Alyssa Black, Chair]: So my understanding of this bill, limited understanding of this bill, is essentially that, I mean, now PAs, APRNs, they can be the attending provider while somebody is in inpatient status, but they cannot do the admitting and they can't do the discharge. I mean, they can, but they've got to have it signed off on.

[Dr. Matt Greenberg, Chair, Vermont Board of Medical Practice; Emergency Physician]: Yeah, and so in practicality what happened- Allows that to happen. Correct, and that's exactly what happens. In practicality, a PA or an APR may go see the patient, write up the whole H and P, write all the new orders, and then a physician will come in, talk to the patient briefly, and then write an adjunct note with that. I will say that this probably is a bigger issue for the critical access hospitals in Vermont.

[Rep. Alyssa Black, Chair]: Yeah, that's what we've heard. I don't think we were quite aware that being staffed 20 fourseven usually with an advanced practice provider.

[Rep. Leslie Goldman, Member (Retired Nurse Practitioner)]: Leslie? Thank you. Would you be willing to share your testimony so that we can review it? Because a lot of those numbers went bypassed.

[Dr. Matt Greenberg, Chair, Vermont Board of Medical Practice; Emergency Physician]: Absolutely. That was my intent. I, unfortunately, didn't finish this until about 11:00 last night.

[Rep. Leslie Goldman, Member (Retired Nurse Practitioner)]: You're sounds like us, so no worries. Thank you.

[Dr. Matt Greenberg, Chair, Vermont Board of Medical Practice; Emergency Physician]: I will share it. I'll send it to Tasha soon as

[Leah Skypeck, PA-C, Medical Director, ICU, Rutland Regional Medical Center]: I'm about Great.

[Rep. Leslie Goldman, Member (Retired Nurse Practitioner)]: Can you remind me what hospital you where what year are you working in?

[Dr. Matt Greenberg, Chair, Vermont Board of Medical Practice; Emergency Physician]: I work in Central Vermont.

[Rep. Leslie Goldman, Member (Retired Nurse Practitioner)]: Okay. So I'm trying to understand the bill, too, and it looks like the Patient Bill of Rights is what the bill is about. So that's what I'm trying to balance. I actually did a little bit of a dive into why did we need a Patient Bill of Rights, and I'm old enough to have lived through the whole history of that. I'm a nurse practitioner retired, so lived through that, so I understand it. So what I'm understanding is that we're trying to acknowledge what's already happening and that by changing, adding the APPs into the patient bill of rights, which is what I think we're being asked to do, is that we're acknowledging what's already happening. Is that not right? I think that's mostly right.

[Dr. Matt Greenberg, Chair, Vermont Board of Medical Practice; Emergency Physician]: I think that currently, by having that physician oversight still necessary, you are still getting a little bit of physician oversight. I mean, you're getting it on paper, but I think that you're really getting a physician that has looked at the patient and said, I agree with you, or have you considered this? In medicine, the biggest enemy is not knowing what you don't know. You're not going to make a diagnosis if you're unfamiliar with it. And familiarity with diagnoses is really all about experience. How many times have you seen that particular rarity or whatever? There's so many unknowns in medicine. Everybody has different genetics, everybody has different exposures to medicines, toxins, substances, whatever. And so something can look absolutely like something else that's very common and not be it. And if you've never seen that, then you don't even think about it. And I think having the physician oversight, and that's the biggest difference between physicians and APPs is that amount of training.

[Rep. Leslie Goldman, Member (Retired Nurse Practitioner)]: No, I hear you. But isn't this bill, and this is what I'm trying to understand, talking about the interaction between the attending and the patient. And what's going on in that background is not what this bill is about, is what I'm trying to understand. And it's more about telling, like I say, patient bill of rights is telling the patient well who's in charge. And that patient may never see the attending when they're there because the attending is doing their work and then the APP is doing all the work except maybe consulting or whatever, or they're in the critical access hospital and there's no one there anyway. So that's what I'm trying to understand. Is it about the interaction between the patient and the clinician and that the credentialing process that you mentioned is what actually is the underpinning of what goes on in that particular hospital.

[Dr. Matt Greenberg, Chair, Vermont Board of Medical Practice; Emergency Physician]: Yeah, the credentialing is really important. And my understanding after reading the bill, and you've been doing this a lot longer than I have, is that this bill of rights is being used as a surrogate to determine who has the authority to sign off on those patients. And so it is the sign off authority and what has in practical speak been happening with the APRNs and PAs seeing and doing most of the work. But there is still by requiring the physician to sign off and be involved in it, and they're still supposed to be seeing the patients, so there should be patient contact. But the theory behind that is that there is that bit of oversight and that maybe added experience. Now, we could absolutely, and I'll freely admit, run into a situation where you have a brand new physician and an APRN or a PA that's been working for thirty years, and honestly, the roles are kind of reversed. But the law still says that the physician has to sign off. I think that's less, because still, even a brand new physician coming out of four years of medical school and three to seven years of residency is gonna have a much broader experience to drop. But that's my understanding of the bill. I hope I answered your question.

[Rep. Leslie Goldman, Member (Retired Nurse Practitioner)]: Yeah, I mean, I'm getting the surrogate word, and that was a little bit of a Well,

[Dr. Matt Greenberg, Chair, Vermont Board of Medical Practice; Emergency Physician]: that's what surprised me is when I heard briefly about this bill, about what the, Oh, can you talk about a bill that's gonna talk about PAs being able to admit? And then when I actually looked at the bill, it's actually the- Patient bill of The patient bill of rights. Now, what I don't know is, are there other bills out there that describe this relationship of who is the primary attending? And I don't know enough of the legal background to know whether that exists or not. So my impression was that this is the surrogate to define who is your attending when you're an inpatient.

[Rep. Leslie Goldman, Member (Retired Nurse Practitioner)]: Yeah, don't think there are a lot of bills out there about that, but I think we're learning about the credentialing process of hospitals, and that each hospital may have a different version, and that's appropriate and makes sense. So this to me is about patient, as I say, going through the history of when patients were really excluded from the medical conversation, now is it important for them to understand who is truly taking care of them?

[Dr. Matt Greenberg, Chair, Vermont Board of Medical Practice; Emergency Physician]: Yeah, and I think that's key. I think it is really important. I will just add one point to the credentialing. Credentialing is overseen by CMS, usually through the Joint Commission at most of our hospitals or other organizations. So there are a lot of criteria that are very stringent and dictated. But yes, each hospital does their own convention.

[Rep. Leslie Goldman, Member (Retired Nurse Practitioner)]: Yeah. So maybe the question comes to, what does this bill change in practice?

[Rep. Alyssa Black, Chair]: And maybe not Or does it codify current practice?

[Rep. Leslie Goldman, Member (Retired Nurse Practitioner)]: Yeah, does it codify current practice? Yeah, I think that's right.

[Leah Skypeck, PA-C, Medical Director, ICU, Rutland Regional Medical Center]: At first, your testimony, I really got the impression you were trying to differentiate between positions of defense and APRNs. You said the initial leap of faith was taking away from the doctor itself. Yes. So that's the leap of faith. And then how are you differentiating

[Dr. Matt Greenberg, Chair, Vermont Board of Medical Practice; Emergency Physician]: the two? Yeah, I think that the biggest difference between PAs and APRNs has to do with their training and the philosophy behind them. APRNs are coming from the nursing role and the nursing model, which tends to be a little bit more relationship related, whereas the PA role is modeled under the physician training model, which is a little bit more academic and a little bit more regimented perhaps. I think also the bigger difference right now, and I think this is going to work its way out over the next several years, is I think there's a lot of variability. There are a lot of online training programs to be APRNs, whereas I don't know of any, I could be wrong, but I don't know of any that are PAs. And that sort of delves into the structure of how the training philosophy is. Having been a preceptor on both sides, I would say that they are definitely, the training regimen was a little bit more strict on the PA role. And again, that's just an N of two. So I think that there are distinct differences, but I think overall, particularly after a couple of years, there's not much difference.

[Leah Skypeck, PA-C, Medical Director, ICU, Rutland Regional Medical Center]: And can you just clarify eight? It actually says professional case records have been compiled for all patients and signed by the attending physician

[Rep. Alyssa Black, Chair]: or an APRN. And we're thinking of adding or a physician assistant. Okay. It's not there yet. Okay. Thank you. Thank you very much. All right. We have Lee Morrisett and Leah Skifpec. I think did you guys want to testify together, I had heard, or okay. So, welcome and grab one of the experts. Thank you for coming in.

[Lee Morrisett, PA-C, President, Vermont Academy of Physician Assistants (VAPA)]: Good morning, Madam Chair and distinguished members of the Vermont Health Care Committee. My name is Lee Morrisett. I'm the president of the PAB Association, and I practice emergency medicine at several rural critical access hospitals here in Vermont. We appreciate the opportunity to testify in reference to House Bill 163 amending the Patient Bill of Rights to add APRNs and requesting the inclusion of PAs. As discussed in prior testimonies by OPR, BOS, BMS and the Vermont Nurse Practitioners Association, this bill was intended to reflect current practices of inpatient care within Vermont. Throughout Vermont, APRNs and PAs are integral part of inpatient healthcare teams. In many areas, they are sole provider delivering care to patients from admission throughout the inpatient period to discharge home. As Doctor Greenberg just outlined, medical license for PAs are issued by the Vermont Medical Board of Practice and on the board there is a PA representative. Prior several years when I came to Vermont ten years ago, the chair of the Vermont Medical Board was a PA. Like APRNs, PAs are licensed to conduct physical exams, order interpretation, diagnostic testing, diagnose medical condition, develop and manage treatment plans, prescribe medication, and discharge patients home care plans. Act 123 of 2020 allows PAs to function as admitting providers as well as a clinician of record. Under 26 BSA 1735A, PAs no longer require physician supervisor but now require a practice agreement as Doctor. Greenberg outlined, which is based on the PA's clinical education, training and experience. Thank you, Doctor. Greenberg, for summarizing the PA training. I'm not gonna go into that as I outlined in my brief. But again, we are under the medical model similar to physicians. Many of the prerequisite to be for PAs, actually in 1965, the prerequisite was you were either a Navy corpsman or an Army medic or a nurse. I was a Navy corpsman for twenty five years. And the requirement was for most PA programs, is you have to have between two thousand and four thousand hours of direct patient care experience, as well as your bachelor's degree, similar to applying to medical school. As Doctor. Greenberg outlined, the didactic period, anatomy, physiology, pathophysiology, we also do gross anatomy labs side by side with medical students, clinical medicine, pharmacology, patient assessment, diagnostics and procedures. And then our second year can range anywhere from twelve to fourteen months doing clinical rotations, family medicine, internal medicine, general surgery, emergency medicine, pediatrics, women's health, behavioral health, then there's several electives. As Doctor. Greenberg had mentioned, I've precepted PAs and nurse practitioners in emergency medicine for years. It's very similar at that level. Vermont PAs can serve patients and service clinician of record without independent practice. We know that was referenced in previous testimony, but Vermont law does not require independent practice authority to admit and manage hospitalized patients. Since PAs practice in collaboration, not supervision, hospitals can credential and privilege PAs for admitting and be the clinician of record functions as long as those duties fall within the PA's education, training, experience, and the practice agreement with the hospital. The Vermont Patient Bill of Rights creates a barrier to this by specifying only physicians can be designated as a clinician of record. This prevents PAs from serving in that role even when they are qualified. Instead of excluding PAs, hospitals should decide what each provider is allowed to do based on their training and experience through their bylaws and credentialing process. The Vermont Practice Act 20 six-one 100 seventeen-35A say that PAs, as Doctor. Greenberg outlined, must have a practice agreement for physician availability consultation by phone or some electronic means at all times. Communication decision making process is based on the scope of practice based on the PA's education, training and experience. What this means is PAs do not physically require a physician to be present, nor do they need direct oversight to perform clinical functions, including admitting, rounding, coordinating inpatient care. I'd like to ask that my colleague continue the testimony from him.

[Leah Skypeck, PA-C, Medical Director, ICU, Rutland Regional Medical Center]: Good morning, Madam Chair, distinguished members of the

[Rep. Alyssa Black, Chair]: committee, Sometimes.

[Leah Skypeck, PA-C, Medical Director, ICU, Rutland Regional Medical Center]: My name is Leah Skypeck. I'm a critical care physician assistant PA at Rutland Regional Medical Center. I'm also the medical director of the intensive care unit. I've been practicing there for eight years. Prior to that, for five years, I practiced at Dartmouth Hitchcock in the medical ICU there. And before starting my professional career, I did a critical care residency program at Johns Hopkins. So I appreciate Doctor. Greenberg's explanation of PA education. And I just want to point out that more and more often, our PAs going to additional postgraduate training for sub specialty services, as I did. My hope is to describe to you the inpatient service model at Rutland Regional ICU. I hope that will illustrate the role that PAs, APPs, I should say, play on the inpatient service. So Rutland has a 13 bed ICU. About ten years ago, this unit was staffed by one intensivist physician 20 fourseven for a week. That is neither good for the intensivists nor the patients. So in 2018, Doctor. Harvey Reich reached out to me. I was at Dartmouth at the time and said, Hey, I need some help. I can't recruit someone to work these hours. It's not sustainable. What can we do? So at that point, we developed a APP content that is hybrid model to cover the unit twenty fourseven, three sixty five. Better for patient care, better for patient safety, better for provider wellness. So fast forward to today, I have four intensivist physicians and four APPs. Currently, three are nurse practitioners for APRNs and one is a PA, but there have been times where that APP group has been three PAs and one APRN. And the key piece to this is that critical care patients don't schedule a time to get sick. So if it's two in the morning and the PA is on, I am going to provide that patient with the same care, the same quality of care at two p. M. On Friday. And that is up to the hospital's credentialing committee to vet those applicants to make sure that their privileges, that they are trained and qualified to perform those duties so that the quality of the service is the same no matter what day of the week and what time. These are some of the sickest patients in the state. They need timely care. So it is not realistic at two in the morning if I have a patient that needs three procedures, a breathing tube, a central line, a chest tube, that needs to happen. And that the reality is the intensivist that is my resource at home, which I value enormously, is not going to be able to come in and see that patient. I need to do what I need to do. And sometimes that needs transferred to a tertiary care center. So I've admitted the patient, I've managed their inpatient care, done procedures, and I'm transferring them to get lifesaving interventions. That needs to happen on my service, and there is no room in that scenario for me to get on the phone with the attending intensivists and get approval. Now, look, I agree with Doctor. Greenberg. A new grad right out of school, APRN or PA, should not be doing this. And that's the responsibility of the credentialing committee and the bylaws of the hospital. I think we've done a good job talking about the differences between APRNs and PAs, and the reality is they're more alike than different. I know at Rutland, we are working really hard to develop a collaborative relationship between PAs and APRNs. We have an advanced practice provider advisory council on which I sit to develop a really strong relationship. Because the reality is the workforce in Vermont is small. And so I want to staff my ICU with the best providers, whether they're an APRN or a PA. And if this bill includes APRNs and not PAs, that's a real operational workflow barrier that I can't create two systems for two different types of providers that essentially fill interchangeable roles. So I think we've covered a lot. Are there any questions about Rutland specifically, our relationship with our collaborating physician, which, by the way, I personally, I know the APPs at Rutland feel is a bonus. It is a resource. It is better for patients. But it shouldn't be a burden or a barrier to access to care or efficiency.

[Rep. Alyssa Black, Chair]: Is there any requirement that a PA that your collaborating physician actually the I mean, I'm sorry, I'm looking at your license. Doctor. Stingo, I think. Yes.

[Rep. Leslie Goldman, Member (Retired Nurse Practitioner)]: Is there a great guy, by the way.

[Rep. Alyssa Black, Chair]: I bet he is And he doesn't want to be disturbed at 2AM. Is there any requirement that your collaborating physician actually be someone who you're I'm assuming that Doctor. Stingo is also maybe a hospitalist at Rutland Regional or intensive care. So is there a requirement that your collaborating provider be employed and also working in the same environment that you're working where you're collaborating with? Or could you just have, you know, random doc, I'm going to pick on a specialty. Always pick on urologists on this committee for some reason. Could random urologists who practices in Montpelier be your collaborating physician?

[Leah Skypeck, PA-C, Medical Director, ICU, Rutland Regional Medical Center]: I'm unsure if that is permissible, but the bylaws at Rutland require that my collaborating physician have the same privileges in both directions. So my understanding is that's regulated by our Credentials and Privileging Committee and the bylaws, of course.

[Rep. Alyssa Black, Chair]: We don't have the hospitals here today, but I'm assuming that all hospitals in the state have bylaws over credentialing Yes.

[Dr. Matt Greenberg, Chair, Vermont Board of Medical Practice; Emergency Physician]: They have to, as part of their mental practice.

[Rep. Leslie Goldman, Member (Retired Nurse Practitioner)]: Part of their licensed surgery. The Joint Commission, I think, it, yeah.

[Rep. Alyssa Black, Chair]: Tupper, nice question.

[Rep. Francis "Topper" McFaun, Vice Chair]: I'm assuming something. When you transfer the person to the life saving services that they need, is there a physician that does that?

[Leah Skypeck, PA-C, Medical Director, ICU, Rutland Regional Medical Center]: That's me, I'm a PA and I will do that because the patient needs it.

[Rep. Francis "Topper" McFaun, Vice Chair]: Will you actually perform the service with all that stuff you were talking about?

[Rep. Alyssa Black, Chair]: Yes, yes. But you're not able to actually sign off on it. It has to be signed off as somebody else currently. Correct.

[Rep. Leslie Goldman, Member (Retired Nurse Practitioner)]: Okay. Go ahead, Leslie. Thank you. Could you take care of me? You too. It's never been bit about what the patient perceives about who's in charge, because I think this is kind of what the conversation is about from the patient pillow rights, although I'm trying to understand the surrogate thing and I'm not there yet. So if you could talk about patient perception about who's in charge. Great

[Leah Skypeck, PA-C, Medical Director, ICU, Rutland Regional Medical Center]: question. And the short answer is it's confusing. I think for my service, most of my patients are sedated, intubated, not particularly conversant, but it's their families that get confused. And we do our best despite it being sort of high stakes, high stress times to explain, you know, I'm working with, we're a group. And critical care by nature is team based. We don't have turf war. The more brains thinking about a patient, the better. But it is confusing for patients. And I think what matters most is that the provider, no matter who they are, what their title is, treats that patient with dignity, respect, communicates, and that matters so much more.

[Rep. Leslie Goldman, Member (Retired Nurse Practitioner)]: So how do you communicate to the family, let's say, of who's in charge?

[Leah Skypeck, PA-C, Medical Director, ICU, Rutland Regional Medical Center]: Yeah, I say I'm Leah Skypeck. I'm a critical care physician assistant. I'm your provider on service tonight. I'm going to ABCD. And get consent for, and here's the plan. And then at Shift Change, if able, I'll say, Doctor. Singo is on in the morning. We're going to talk about your case, and he's going to take it over from there. I'll see you at seven p. M. Tonight. You try your best to explain that this is a team sport.

[Rep. Leslie Goldman, Member (Retired Nurse Practitioner)]: Does anything change if this bill passes in how you communicate in that case?

[Leah Skypeck, PA-C, Medical Director, ICU, Rutland Regional Medical Center]: No, and it just aligns with what we're doing.

[Rep. Leslie Goldman, Member (Retired Nurse Practitioner)]: Yeah, that was kind of the question. So Doctor. Gueber, we have mentioned that this is a bill for surrogate. And I'm not

[Leah Skypeck, PA-C, Medical Director, ICU, Rutland Regional Medical Center]: sure I understand that. That's what I'm wondering what your thought is about that. I don't know that I understand that either. I think our service provides best practice. The reality is I've been doing this for fifteen years, and three of the intensivists have been doing it for three. We use each other collaboratively. Nobody, those newer intensivists, are not afraid to call and ask for help. Yesterday, one of the newer intensivists was on and was getting overwhelmed. There was a cardiac arrest patient in the ED that needed to come up. He had six other patients, very active. He called me. I came in. I admitted that patient. I talked with the family. I did the whole H and P. I wrote all the orders. I did a procedure.

[Rep. Leslie Goldman, Member (Retired Nurse Practitioner)]: And at all that time, they thought you were kind of in charge.

[Leah Skypeck, PA-C, Medical Director, ICU, Rutland Regional Medical Center]: Yeah, I explained who I was, part of the team, and when I laughed, I said, Doctor. McNinch has got you, I filled him in on everything. But the reality is he couldn't be in two places at once. That's not good for patient care.

[Rep. Alyssa Black, Chair]: Daisy, you had a question, Daisy? No, you heard me thinking really loudly. I'm really good now. Can just like She is really good. I was just sitting here as you were explaining that situation, imagining, okay, so it's like if Doctor. Robbie

[Rep. Leslie Goldman, Member (Retired Nurse Practitioner)]: Yes, and this is just some

[Rep. Alyssa Black, Chair]: of the most helpful testimony. I'm just really grateful for what you all do, and also this is just connecting so many dots and just really appreciate it.

[Leah Skypeck, PA-C, Medical Director, ICU, Rutland Regional Medical Center]: Welcome, my pleasure, truly.

[Rep. Alyssa Black, Chair]: Any other questions? Really helpful, thank you.

[Rep. Leslie Goldman, Member (Retired Nurse Practitioner)]: Thank you. Good morning.

[Rep. Alyssa Black, Chair]: I just wanted to get your message thoughts on, since you all represent physician assistants as well.

[Jessa Barnard, Executive Director, Vermont Medical Society]: Yes, Jessica Barnard, Delmont Medical Society. I don't think I have a lot to add, I will actually say. Thank you for inviting me back. I did testify last week, I think, on the bill. And I will just very briefly, I guess, reiterate the comments I made then and what you just heard. I echo all the testimony you just heard. I really appreciate everybody going before me. We agree with Doctor. Greenberg and the PAs you just heard from that the bigger question is sort of, is the bill moving forward? And then if yes, we agree that it doesn't make a lot of sense philosophically or workflow wise to distinguish between PAs and APRNs in terms of their role in providing inpatient care. So again, we would suggest if the bill is moving forward that they both be included. And I am happy to answer other questions.

[Rep. Alyssa Black, Chair]: Leslie, but I will say that if the bill does move forward, at least we won't have to come back to it in two years and do this.

[Rep. Leslie Goldman, Member (Retired Nurse Practitioner)]: Go ahead, Leslie. So does that mean you're not neutral anymore? Have you changed?

[Jessa Barnard, Executive Director, Vermont Medical Society]: I think on the overall moving forward on the bill, our position is still neutral.

[Rep. Leslie Goldman, Member (Retired Nurse Practitioner)]: Okay. And could you talk about the Joint Commission and let people understand the role they have in hospital credentialing so that we could feel confident that that oversight is happening?

[Jessa Barnard, Executive Director, Vermont Medical Society]: I don't actually know that I can give you specifics, as I am not a hospital regulation expert. I will say I do know that, so the Joint Commission comes in and surveys hospitals. They have 100 probably requirements that each have numbers. Unfortunately, it's proprietary. So I have actually tried at times to look up some of the requirements, and if you don't pay for their service, you can't actually read all of them. But they do require a medical staff, they require medical staff bylaws, they require a credentialing process. That much I do know. So every hospital is required to have medical staff that then does the credentialing, the privileging, and outlines in bylaws, a written document, how they implement that.

[Rep. Leslie Goldman, Member (Retired Nurse Practitioner)]: I don't know, maybe we could ask Devin. Yeah, she might know more about it. I'm just curious if there's any oversight on credentialing, but you might not know that there are some baseline requirements.

[Jessa Barnard, Executive Director, Vermont Medical Society]: Yeah, as of this one, I can't go give you any more detail this morning of what specifically they say. It may be something that Devin has or has access to. I know she does send her regrets this morning. She is, I believe, in a hospital budget meeting with the Green Mountain Care Board.

[Rep. Alyssa Black, Chair]: Speaking of hospital budgets, I'm going to ask an indelicate question, which I don't think you could answer. But I'm wondering if maybe the PAs or even Doctor. Greenberg, I'm always thinking about money. When an attending does an admission and if it's a physician signing off on an APP, the APP has done the work, but there is that element of the physician has to sign off on it. Is the admission I understand that, you know, like sort of the daily inpatient care would be billed under the person doing it, but is it billed under the attending physician, the admission, or the discharge? Or is it billed under the do we still use the term mid level provider? No. Okay, we stopped using that. Okay, I'll stop. I'm going with APPs. Who's the get billed under? Because I'm thinking about reimbursements.

[Leah Skypeck, PA-C, Medical Director, ICU, Rutland Regional Medical Center]: Yep, great question. And I know you touched on Medicare last testimony and we're trying to explore that because of the recent changes with something called an AI modifier, which used to signify who's the consultant, who's primary, and when the consultant code went away, the AI modifiers were being attached to APPs and that triggered what's this. So I think it's evolving, and I'm not an expert on billing, and I think the answer depends, but I think that the hope is that state statute isn't the barrier when federal law touches it.

[Rep. Leslie Goldman, Member (Retired Nurse Practitioner)]: Okay. Go ahead, Capers.

[Rep. Francis "Topper" McFaun, Vice Chair]: The neutral position, does that apply to APRNs as well as the physician assistant?

[Jessa Barnard, Executive Director, Vermont Medical Society]: Yes, correct. Because that was the underlying bill our board was looking at.

[Rep. Francis "Topper" McFaun, Vice Chair]: Why is it neutral?

[Jessa Barnard, Executive Director, Vermont Medical Society]: It's neutral because our board understands the motivation behind the bill and the sort of catching up with day to day practice, but also had some more substantive concerns that it does Even though it's not a scope of practice statute, it's patient bill of rights statute. And I will add, it's actually two sections of statute. The language is kind of repeated into it. It's the patient bill of rights and the hospital licensure statute. So it actually is also a licensing statute for hospitals that is being changed. And that there is or could be, sort of like the testimony you just heard from Doctor. Greenberg, substantive contribution of that admitting physician role. We've heard both opinions, and we kind of balance that with, yes, in some ways it's a paperwork requirement that may not really reflect who's primarily providing the bulk of the care to that patient. However, it is currently, even though it's in kind of weird sections of statute, requiring a physician to have their eyes at some point on what happened in that course of that patient's care. And that could provide some helpful touch points to ensure ideal patient care.

[Rep. Francis "Topper" McFaun, Vice Chair]: And physicians, as we sit here today, are actually doing that now, aren't they?

[Jessa Barnard, Executive Director, Vermont Medical Society]: Correct, they're required to do that now, correct. And so we had some members who felt very strongly that that was a really important aspect of ensuring best patient care in the state. And then we had other members who felt very equally strongly, no, this is more of an administrative paperwork requirement. It's actually a burden on both the APPs and the physicians, and we're supportive of it being eliminated. So we had basically a pretty even split and ended up saying, you know what, we're in the middle, and we leave it to your wisdom of which way you want to go. Distinguished. You're the distinguished committee members that make the decision.

[Rep. Alyssa Black, Chair]: Yeah, I see you, Leslie, but can I ask a point in question? Is this a turf war?

[Rep. Leslie Goldman, Member (Retired Nurse Practitioner)]: Well, that's what surrogate worries me.

[Rep. Alyssa Black, Chair]: No,

[Jessa Barnard, Executive Director, Vermont Medical Society]: I would not say that in that there is more than enough patient care to go around. It's not a we want the work, it's not a we want the billing. I don't see it that way. I see it more of a, is this helping ensure best patient care for the sickest patients in our state who are inpatient?

[Rep. Alyssa Black, Chair]: Is it about the billing, or is it about the financial? Is it about the hierarchy and maintaining the hierarchy?

[Jessa Barnard, Executive Director, Vermont Medical Society]: We received close to 100 comments from our members. They were not hierarchical, but I will say there was, again, a difference of opinion about whether the difference in training and experience matters and how that impacts patient safety. Leslie, did you wanna

[Rep. Alyssa Black, Chair]: And then we gotta get going to

[Rep. Leslie Goldman, Member (Retired Nurse Practitioner)]: the But it's a question for Jen, because I think you just sort of said something about this having impact from other aspects of the law or other parts of the statute. And I just didn't know how that impacts and if at some point we could need to, if we need to think about that. Again, the Office

[Jennifer (Jen) Carbee, Office of Legislative Counsel]: of Legislative Counsel, I think I would need more specificity on which other shall

[Jessa Barnard, Executive Director, Vermont Medical Society]: Yeah, like what you're thinking. I'm curious to know that. I think the reference, the point I was trying to make is just that there are two sections of statute that this bill is amending, the Patient Bill of Rights and the Hospital Licensing Statute. So where is that?

[Rep. Leslie Goldman, Member (Retired Nurse Practitioner)]: And that's what I'm trying to

[Jennifer (Jen) Carbee, Office of Legislative Counsel]: find out. So Section one

[Rep. Leslie Goldman, Member (Retired Nurse Practitioner)]: and two of the bill deal with the Patient

[Jennifer (Jen) Carbee, Office of Legislative Counsel]: Bill of Rights. Section one is just the definitions. And then Section three is amending the hospital licensure chapter. So the license requirements right, that is in hospital licensure.

[Rep. Leslie Goldman, Member (Retired Nurse Practitioner)]: So that adds the APRN or the APP to that? For existing law, all patients admitted at

[Jennifer (Jen) Carbee, Office of Legislative Counsel]: the hospital must be under the care of a, and under current law, registered and licensed practicing physician as defined by the laws of State of Vermont. Physicians under both types of physicians and APRNs and then under inspection potentially physician. And similarly round up case records.

[Rep. Leslie Goldman, Member (Retired Nurse Practitioner)]: Yep. Great.

[Jessa Barnard, Executive Director, Vermont Medical Society]: Thanks, Debra. Thank you very much. Thank you. Yes.

[Rep. Alyssa Black, Chair]: So we'll come back to this at some point. Anybody, if you want to be thinking about whether or not you feel as though there's more people you need to speak to, more testimony you feel needs to be had, and I'm looking for your input on that.

[Rep. Leslie Goldman, Member (Retired Nurse Practitioner)]: So the APRNs testified in the Senate. Don't know if

[Rep. Alyssa Black, Chair]: they testified here yet. They testified the first day. Oh, did I miss it? That's right. That's right. Thank you. Alright, we can go off of live and obviously no more committee.