Vermont Legislature SmartTranscripts:

[Chair Alyssa Black]: Welcome to afternoon Neuros Healthcare, April 15, after tax day. We're going back to S-sixty 4, the optometrist still. And first up, we have Doctor Greenberg again, but we just never get to see you.

[Dr. Greenberg (Chair, Vermont Board of Medical Practice; Emergency Physician)]: Madam Chair, committee, thanks for having me back again. Thanks for being here. It's my pleasure. If I can I thought about this yesterday, and I I hope I can just take a very quick tangent? I thought a little bit about the feedback from yesterday and just a comment that I thought might be helpful both to yesterday's testimony, but also to today's because I think it's relevant. And I think that is understanding the perspective of the board. In order to understand that better, it might be to describe the board a little bit because I'm not sure how familiar everybody is with the board. So I just wanna you know, you've asked me to come and represent the board, and I'm here, but you don't know who's behind. So I thought it might be helpful just to get that perspective out there. So the board of medicine is seven employees, an executive director, two investigators, licensing specialists, and three other assistants that do all of the paperwork, set up all the meetings, gather all the files, etcetera. The heart of the board, though, is the 16 volunteers that work, and they work hard. There's a lot of files that we look at every month. We spend almost all of our time looking at complaints, malpractice settlements and other legal issues. So they're all kind of on the downside. We don't get to hear about the happy things. It's all about the downside. Those 16 volunteers include currently, off the top of my head, eight physicians, one podiatrist, one physician assistant, and six community members. The community members come from all different walks of life. There's lawyers, there's a gentleman who's a retired biotech business leader, We have retired law enforcement officers. So regular people. And the 16 of us meet. We are divided into three committees in the North, Central, and South Region. We divide up all the cases that come to the state. We look over every complaint that anybody in the state makes about any of the licensees that we have. We also have a subcommittee that reviews any licenses that have any marks. A completely clean license doesn't have to go to licensing, but anybody that has anything of concern, anything more than a three month gap in training, any red flags, any prior marks, any legal cases, anything gets reviewed. So I think it's important to know that's who we are. And I think the mission statement on the website is kind of important too to understand. I'm just gonna read it, it says, The Vermont Board of Medical Practice protects and promotes the health and safety of Vermonters by ensuring professional integrity through licensure of health care practitioners and investigation of complaints in a manner that is respectful to all parties. So that's sort of the perspective that we're coming at when we come up with these opinions. You heard my opinion yesterday. I'm gonna have an opinion here today. One thing that isn't in our mission, and other people are going to have different perspective on this, is how much health care costs, accessibility, or any of the larger issues that are in health care right now. We all know, we're all sort of intentionally involved in all of those issues, we know they're very important issues, but it is not necessarily the main focus. It's not the lens that we look at healthcare, this very tight lens of licensure and safety. So when you hear an opinion coming from me that I am reiterating from the board, it's really coming through that lens. So it's not that we don't think that how we finance these things is important, but our role right now is really centered on the quality and the licensure aspect. So I just thought that might help a little bit to explain where we're coming from. Since you brought it up,

[Chair Alyssa Black]: we regulate hundreds of hundreds, dozens, I'm not sure, a lot of professions. What is it that makes specifically MDs keys, why are those outside of Office of Professional Regulation? Because OER actually does that for all the same things you're describing. They do that for all of their professions. Why is the Board of Medical Practice not included in OPR? And one of my more that I've always kind of been perplexed about, why does OPR do DOs and APRNs, and yet you do MDs and PAs.

[Dr. Greenberg (Chair, Vermont Board of Medical Practice; Emergency Physician)]: I do not have a good answer for you. This is I've only been on the board since '22. My understanding is that this was set up many, many, many years ago. I would say that most states have a regulatory board that's for physicians that is separate from other licensures, and that probably has to do with the complexity and the legal cases and stuff that go along with it, and just the complexity of training. And healthcare is treated differently in this country. Mean, so much money goes into healthcare, and I have a feeling, but I can't tell you for certain. It precedes my time on board.

[Chair Alyssa Black]: By that measure, then why wouldn't DOs be part of board of

[Dr. Greenberg (Chair, Vermont Board of Medical Practice; Emergency Physician)]: have I would think that they'd be on the same board. I have a friend who's on the DO board. She would prefer to be on, although I've heard other DOs don't wanna be on the same board. I think it had to do with the way that different people lobbied at the time it was being created, but I don't have a good idea. Sorry.

[Chair Alyssa Black]: I mentioned yesterday, I've been thinking a lot about the hierarchical structure and the systemic things that we have in place and how they sustain the same thought mechanisms and build upon each other and how we've built this structure and we're afraid to change this structure. And so thank you for your insights and your information on what the board actually does. You're welcome.

[Dr. Greenberg (Chair, Vermont Board of Medical Practice; Emergency Physician)]: So I am here to talk more specifically about S-sixty four. This has come up, my understanding, as a number of I've been on the board for a couple of years, and I've heard this come up in years past. This is the first year I've been the chair, so the first time I'm talking on it. Did speak to the senate on the same bill. During my experience, the board first reviewed

[Chair Alyssa Black]: this bill

[Dr. Greenberg (Chair, Vermont Board of Medical Practice; Emergency Physician)]: thoroughly in October 2023 through 2024. That was around the time that OPR issued their revision of their commentary on it. At that time, we spent a lot of time going into the bill at that time, as well as the OPR analysis of the scope of practice for optometrists versus ophthalmologists. And at that time, we were unanimously opposed to the bill as we stood. We have since revisited this. We revisited it in January 2025 and then again in January 2026. And just the short of it is that the board did not feel that there was enough change in the information available to change their opinions. So the board stance is still opposed to the change. And we sort of broke it down into three different categories. The first being access, the second being cost, and the third being quality. And what we looked at was there are a few articles. One was a 2023 study in the Journal of Ophthalmology looking at access. It used drive times as a surrogate marker for availability of access. And this had to do mostly in Oklahoma, I believe, where they had made a similar change and found that there was no improvement in access after they initiated expanded scope of practice to optometrists. So not a lot of data, but what was there did not really show that much improvement. And again, anecdotally, several members of the board mentioned that they themselves have had difficulty getting into their own optometrists with delays anywhere from six to twelve months just to get in for a regular routine eye screening. And so the thought being expanding their tasks available to them is not, in fact, going to improve access. In regards to cost, even the OPR's own analysis could not find any evidence that there would be an improvement in cost. And there are some concerns in a few communities or states that have made this change that although an optometrist may be doing these procedures for less money, that the incidence of the procedures went up. And so, there was a cost shift, but not a decreasing cost. Again, there's just not a lot of data out there to support one way or the other. So what we really stepped back on was quality. And again, that's why I kind of brought up the lens of the board generally being centered on quality. Most traditional optometry programs do not teach surgery. There are now new programs that do, and that's what we're discussing are these procedures. And I am an ER doc. I don't do any of these procedures, to be clear. The rule of ER medicine is don't touch the eyeball. We try not to. It's a very complex structure. Even me having been doing this for twenty five years, I do everything I can not to do anything around the eye. There's a lot of potential risks. So that being said, what we know from medicine in general is that how, for the most part, how well a procedure is done and how good and the quality is directly related to how many times you've done that procedure. And when it comes down to just pure numbers, an ophthalmologist, an eye surgeon who has had a residency, is going to come out of residency having done hundreds of these procedures. Whereas the bill, the last time I looked at it, had a much smaller number, a handful of a couple, that had to be done in order to get qualified for doing these procedures. So essentially, the rationale behind our decision of losing it came down to the fact that there wasn't great data for cost savings, there wasn't great data for access. But ultimately, when it comes down to numbers and the potential risk for quality, that it would favor ophthalmologists and not optometrists. And that is sort of how we made our decision. Does any does that make sense? Does anybody have any question about that?

[Chair Alyssa Black]: I just want to reiterate that. Or if you have a couple of real Do

[Rep. Leslie Goldman]: you have real numbers?

[Dr. Greenberg (Chair, Vermont Board of Medical Practice; Emergency Physician)]: In regards to

[Rep. Leslie Goldman]: How many in one program as opposed to how many there can

[Dr. Greenberg (Chair, Vermont Board of Medical Practice; Emergency Physician)]: We're talking for optometry programs, most of the programs for less than 10 and hundreds for ophthalmologists. You know, the ophthalmology program

[Chair Alyssa Black]: is You're talking about a residency? Residency, yeah.

[Dr. Greenberg (Chair, Vermont Board of Medical Practice; Emergency Physician)]: Four years, maybe five. I'm sure that my will tell you for certain. Don't remember off the top of my head.

[Chair Alyssa Black]: I'm concerned about utilization. I mean, we hear testimony all the time in this committee on various aspects of our healthcare system, and we know that if you build it, you have to fill it. Yes, fill it. And I'm kind of concerned about, has there been any studies on increased utilization in states that have done this?

[Dr. Greenberg (Chair, Vermont Board of Medical Practice; Emergency Physician)]: When there was

[Chair Alyssa Black]: And of further that question, if there's increased utilization, has it led to discernible, like better overall eye health? We know that oftentimes sometimes doing nothing is better than doing what you can do just because you can do it.

[Dr. Greenberg (Chair, Vermont Board of Medical Practice; Emergency Physician)]: I could not find any specific data and the OPR report itself couldn't find any data. I think anecdotally, people will discuss individual cases where somebody has recommended a procedure and then they go and see somebody who has more skills who doesn't recommend that procedure. And I think that's really the only data that we have right now. This is still all kind of new. There's only a few states that have been doing this for any length of time. And that one study I could find from 2023 was most of what I could find. There wasn't a whole lot.

[Chair Alyssa Black]: Any questions? I do

[Dr. Greenberg (Chair, Vermont Board of Medical Practice; Emergency Physician)]: well, someone asked for this yesterday. I Oh,

[Unidentified Committee Member]: I did. Thank you.

[Dr. Greenberg (Chair, Vermont Board of Medical Practice; Emergency Physician)]: This is this is AI.

[Chair Alyssa Black]: I love that. And,

[Dr. Greenberg (Chair, Vermont Board of Medical Practice; Emergency Physician)]: you know, the the question was, well, what's the difference between optometrist and ophthalmologist, a Venn diagram? And and so I asked, and it looked fairly accurate to me. So I just put that on here with the optometrist saying eye exams, vision testing, prescribing glasses in context, diagnose common eye conditions, non surgical eye care, ophthalmologists, medical doctors, perform eye surgery, treat complex eye disease, prescribe all eye medications. So I thought it was interesting that AI pointed out that one of the differences is eye surgery versus not eye surgery. And then in the middle, diagnose eye disease, prescribe eye medications and manage overall health. So I thought it was an interesting perspective on how to look at that.

[Chair Alyssa Black]: Thank you. Appreciate it. Any questions?

[Unidentified Committee Member]: Yeah, go ahead. So I was listening to couple of people today. And one of the things that they said is to get people to get new doctors into the state of Vermont, they want to practice at the top of their license. And a lot of them out that earning their degrees right now, that you do this kind of practice. If we don't let them do it in the state of Vermont, will that stop people from coming into the state of Vermont?

[Dr. Greenberg (Chair, Vermont Board of Medical Practice; Emergency Physician)]: I don't know. I think it's a reasonable question. I think that people The eye is a very important organ. If it was my eyes, I'd want somebody who's done a lot of these doing it, and I think it comes down to numbers. And I don't know that we have the outcomes data to really know a lot right now. But that is a potential concern.

[Chair Alyssa Black]: Any other questions? Go ahead, Val. Thank you. Just because I need to hear things more than once. So if an optometrist went to school before 2019, the process was different. Can you talk more about that? I mean, the differences and

[Dr. Greenberg (Chair, Vermont Board of Medical Practice; Emergency Physician)]: Honestly, I can't. I don't know about optometrist school, and I don't know how the training programs have changed. I know that teaching these surgical procedures is fairly new. My understanding was about the last five to ten years, but I don't know how that has changed in the scope of their core curriculum.

[Rep. Leslie Goldman]: Can I see my Venn diagram? Our Venn diagram. Now in my chat GPT. I

[Chair Alyssa Black]: think I have one question. And I sort of asked the same of OPR this morning. I'm sitting here. And I'm looking at a list of things that I can't even pronounce. I'm a citizen legislator. I can bill for this stuff, but I can't do this stuff. And there's 11 of us in this table. And I don't want to I mean, I don't know about your special skill sets, but none of us should be doing this. We're in a position where we're making medical decisions about people. How do we do that? How do we do that?

[Dr. Greenberg (Chair, Vermont Board of Medical Practice; Emergency Physician)]: I think you're in a very difficult position. You're having me say one thing, and these folks say something else, and these folks say something else, and having to come up with a consensus statement. As a physician, I guide people through difficult decisions all the time, but this is a difficult decision. And I that the data I wish there was more data. I mean, that's what it comes down to, is I wish that there was a more concrete answer to a lot of the questions. And when it comes down to safety data and whatever you're looking at, whether it's taking out gallbladders or whatnot, it really comes down to numbers to be able to do something well. That because there was a lack of data, that's really the basis for our recommendation, is that we would prefer to have the people that have been doing this the longest with the most experience to be the people to do those procedures. I don't do any of those procedures. I don't know what half of them are. I've had them explained to me. I've looked some of them up on videos, but they're complicated eye procedures. And I use my eyes every day. I can't imagine losing my vision. And so I think the stakes are really high when it comes to the eye. And that's sort of the

[Chair Alyssa Black]: You said don't touch the eyeball. Said legislators touching every Vermonter's eyeballs. Yes. I'm trying to ask if somebody is going to make the case for me why we don't just send the people in the room who know how to actually do the procedures on here, let alone pronounce them, why don't we just send you into a room and have you all come out with something? Work it out amongst yourselves. I guess I don't need an answer to that, but I am deeply frustrated. Allen?

[Rep. Allen "Penny" Demar]: My question, other areas of healthcare, we're bringing in doctors from other countries that can practice here. We got a chance to maybe bring optometrists here. That doesn't mean the patients have to go to work. We still have a choice as patients. We don't have to go. We can elect to go to either one we want. So I think it just gives a choice. I understand where you're coming from too. Ultimately have the answer ourselves.

[Dr. Greenberg (Chair, Vermont Board of Medical Practice; Emergency Physician)]: Can I reply to that? Yeah. I totally agree with you. But you also have to have the savvy to know to ask what the difference is between. And so if you go to an eye person who says this is what you need, are you someone or is the average Vermonter someone that's going to say, are you an ophthalmologist or an optometrist? How many of these procedures have you done? And so we just I agree, it's always a choice, and we always can make that choice. But working with patients every day, they often don't ask what I consider the most important questions that if I was going to a doctor, I would ask. And that's just because we don't know. I mean, you don't know what you don't know. You go to the ER and you see me, and I tell you one thing, but maybe you leave and you go see a rheumatologist who actually knows more than I do, who gives you a totally different diagnosis. So it's really complicated and it's a difficult position to be in. But I do worry that if we leave it completely up to the patients, that they are not gonna have enough understanding to be able to delineate the two. And maybe that sounds paternalistic, but it's complicated. It's a really complicated topic.

[Rep. Allen "Penny" Demar]: But I'd like to think that if I went to an optometrist that all of a sudden, a problem that I don't understand, I hope they don't use me as a guinea pig and start doing things. I don't think they would do that. They're professionals.

[Dr. Greenberg (Chair, Vermont Board of Medical Practice; Emergency Physician)]: There are consequences for that. And I don't think anybody would do anything malicious. But is the complication rate higher for somebody that's done three procedures versus somebody that's done a 100? And I don't If somebody asks me, if I'm about to do a procedure, how many of these have you done? I'll tell them. If I've only done two, when I was a trainee, I would say I've only done two. And if they ask me to have someone else do it, that's the way we have to do it.

[Rep. Allen "Penny" Demar]: I don't want to be devil's advocate here, but an entomologist started with one or two or 3,000.

[Dr. Greenberg (Chair, Vermont Board of Medical Practice; Emergency Physician)]: But they did that under the eyes of an attending physician, that's the difference of reds.

[Chair Alyssa Black]: Yep, thank you.

[Unidentified Committee Member]: Doctor, I'm just having a thought. Last time we saw you here, were talking about something that I feel like procedurally might be related, in that the bill

[Dr. Tina Keshava (President, Vermont Optometric Association)]: we were looking at at

[Unidentified Committee Member]: the time, 01/1942, and discussing whether we should put the specifics of a practice into rulemaking so that people more familiar with the specifics could get together, talk about it, do the public process, whatever, which seems like what Chair Black is suggesting. And I'm just wondering, is that something that you considered? And I think, Penny, it sounds like you were also thinking of that bill as well. Is it do you see any parallel with the

[Chair Alyssa Black]: white grievance?

[Dr. Tina Keshava (President, Vermont Optometric Association)]: I

[Dr. Greenberg (Chair, Vermont Board of Medical Practice; Emergency Physician)]: totally hear what you're saying. I worry a little bit that you're gonna get to a point where you're just gonna have two competing opinions that can't agree.

[Unidentified Committee Member]: In this bill? In this bill. And what about 01/1942?

[Dr. Greenberg (Chair, Vermont Board of Medical Practice; Emergency Physician)]: 01/1942, if I didn't come across correctly, I'm very much in favor of the making process for 01/1942. I think that that is the best way to do that bill. And I think that getting other people involved with the board and the Department of Health to roll out that and make the rules is absolutely the better option. It's not in this case. Okay. I'm not saying it can't be done, but I would be concerned that it would come to a loggerhead with no answer, because you have two sides that feel very passionately about that, And ultimately, someone needs to make the decision. Unfortunately, it seems like it's coming up from this committee. Referenced. Right? Referenced. Kind of. And, I mean, you're you're having professional opinions on all sides. And

[Chair Alyssa Black]: Alright. Were you all set? Or did you yeah. I think. Okay. Wanna Steve, I know you're gonna ask.

[Unidentified Committee Member ('Steve')]: How many procedures would an ophthalmologist have to do under a attending or a supervisor before they would be able to do it on their own?

[Dr. Greenberg (Chair, Vermont Board of Medical Practice; Emergency Physician)]: Yeah. I know there are ophthalmologists in the room, and I would defer final judgment to them. But my understanding, most residencies, it's gonna be on the order of about 400.

[Unidentified Committee Member ('Steve')]: 100 operations? Variety of procedures.

[Dr. Greenberg (Chair, Vermont Board of Medical Practice; Emergency Physician)]: Prob at minimum. Probably more than that. But I would if I'm corrected during later testimony,

[Unidentified Committee Member ('Steve')]: I would absolutely defer to that testimony. Absolutely. I did notice that Oklahoma's been doing this since 1988. They've been doing it a while.

[Dr. Greenberg (Chair, Vermont Board of Medical Practice; Emergency Physician)]: But there's not a lot of data other than that one study that I could find at least talking about access.

[Unidentified Committee Member ('Steve')]: There was one for JAMA that came out, and then obviously the ophthalmologist or optometrist association came up with conflicting results. Thank you.

[Rep. Leslie Goldman]: Oh, Leslie, sorry. Yeah, thank you. So I'll do my AI, my chat thing. And a small group of states, Oklahoma, Kentucky, Louisiana, and Arkansas are states that allow more procedures for optometrists. And one of the things we talk about a lot here is virality and access. Talk about access that there's not a lot of data, and I get that. But we also heard this morning that there's 168 optometrists and 32 ophthalmologists in Vermont. And worrying, let's say we felt comfortable about quality. I know you don't, but let's just Yeah, understood. About that for a minute. And how do we think about access for rural patients who don't have access to an ophthalmologist as much as we would like? Yeah. I mean, all those states are rural states. I feel like we're in that bucket.

[Dr. Greenberg (Chair, Vermont Board of Medical Practice; Emergency Physician)]: I would make the analogy that we do this with a lot of different medical procedures, right? They might have a general surgeon, but they don't have a vascular surgeon. So you see the general surgeon, he says, You know what? This is outside my scope. I'm going to send you to UVM, Dartmouth, whatever. There are more ophthalmologists scattered throughout the state than many other specialists.

[Rep. Leslie Goldman]: Me 32 meaning more than vascular Than

[Dr. Greenberg (Chair, Vermont Board of Medical Practice; Emergency Physician)]: vascular surgeons, neurosurgeons, etcetera. So I think that there's already a reasonable I haven't mapped it out on a map, but there's already more ophthalmologists than a lot of other specialists available. This is always a question. I mean, the other question to think about is if you have only so many procedures being done in this state and you add a significant number of people that are doing those procedures, then each individual practitioner is going to get less procedures. And there is a bare minimum number of procedures to stay competent. So then you start competing for procedures just to maintain competency, never mind anything else. I don't know how many of these procedures would be done on an annual basis. Again, I would defer to my optometry and ophthalmology colleagues for that. But it is another consideration.

[Rep. Allen "Penny" Demar]: Yeah. That's kind of interesting.

[Rep. Leslie Goldman]: Yeah. When you do the board of medicine and relicensing, do you look at the number of procedures that an ophthalmologist might do? Or how do you manage that?

[Dr. Greenberg (Chair, Vermont Board of Medical Practice; Emergency Physician)]: That's a great question. We don't. That is typically done by credentialing at a facility.

[Chair Alyssa Black]: I have a question for you, but I'm going to look over and I'm going to ask Stephanie Winters, okay, because you have about 40 different titles underneath your hand. She's like all different again. Is there a Vermont chapter of the American, I don't know, College of Opinologists or whatever they're called? I don't know.

[Dr. Jessica McNally (President, Vermont Ophthalmological Society)]: Stephanie Winter is also the Executive Director of the Vermont Ophthalmological Society. And

[Dr. Tina Keshava (President, Vermont Optometric Association)]: I have Doctor. McNally who's the President. Okay,

[Chair Alyssa Black]: Third okay. Vermont chapter. If there is, Stephanie probably doesn't. I actually wanted to ask you a question because it sort of came up in testimony this morning a little bit and more in your role as an emergency medicine physician. You said you don't touch the eyeball. Try not to touch the eyeball. Try to touch the eyeball. Do not

[Dr. Greenberg (Chair, Vermont Board of Medical Practice; Emergency Physician)]: have to on occasion. Is

[Chair Alyssa Black]: there a system in place, either through various hospitals or health service areas, with What would you do if somebody came into your emergency department with a Yeah, had a hole injury.

[Dr. Greenberg (Chair, Vermont Board of Medical Practice; Emergency Physician)]: I was a little bit of hyperbole. I actually do have to, on occasion, touch eyes. As an ER physician, I am trained in some basic eye care. I can remove foreign bodies, I can treat eye infections. The one surgical procedure that I do near the eye is a lateral canthotomy, which involves releasing the tendons if you have too much pressure in the eye. It's a vision saving emergency procedure. So, there are a few procedures that I can do, but what typically happens is when I'm in the ER, if I see something that looks at all concerning, is I have a list of on call ophthalmologists that I can refer to. There are three in the Central Vermont community that take call regularly and have amazing availability. And often they will either see them same day or next day. I rarely have to wait more than that. Often, if it's really bad, they'll just come to the ER. I had a bad eye trauma about three months ago, and ophthalmologist came in the ER, did a surgical procedure in the ER ER, save this guy's vision. Sometimes they'll take him to the Operating Room right then and there. But the emergency department, I guess, would be the gateway for eye emergencies in most cases, and we refer out to whoever's on our call list.

[Chair Alyssa Black]: Okay. Any other questions, doctor Finger?

[Rep. Leslie Goldman]: Looks like your finger's better.

[Dr. Greenberg (Chair, Vermont Board of Medical Practice; Emergency Physician)]: It's getting there.

[Chair Alyssa Black]: Thank you. What? We have a call that we can bring you back Yeah. Noticed you you you removed your split and put

[Dr. Greenberg (Chair, Vermont Board of Medical Practice; Emergency Physician)]: in a I've been alternating. My mallet finger.

[Chair Alyssa Black]: Glad that we can watch the progression. Thank you. Thank you very much. Thank you. You.

[Unidentified Committee Member ('Steve')]: All

[Chair Alyssa Black]: right. Doctor, am I going to get on Zoom?

[Dr. Tina Keshava (President, Vermont Optometric Association)]: Yes.

[Chair Alyssa Black]: Oh, Keshava. Yes. Okay, I was going to say, I can't pronounce it. Doctor. Keshava, thank you. Thank you for joining us. Thanks for having

[Dr. Tina Keshava (President, Vermont Optometric Association)]: Good afternoon, Madam Chair and members of the committee. My name is Tina Keshava. I'm an optometrist in Rutland and currently the president of the Vermont Optometric Association. Thank you very much for allowing us to demonstrate the need for scope expansion of optometry in Vermont. Not only are current optometrists trained and educated to perform these procedures, it is safe and effective when they do. Modernizing optometric care in Vermont will also improve access while reducing costs for your constituents who are also our patients. I would like to start with the basics of optometry versus ophthalmology, because it does sound like there's

[Chair Alyssa Black]: a little

[Dr. Tina Keshava (President, Vermont Optometric Association)]: confusion when someone off the street says, what is an optometrist? Or they call me an optician or an ophthalmologist, and they don't really know. I like to tell people that an optometrist is basically like a family medical doctor for the eye. We can see a lot and we know what a lot of it is. We can't always treat all of it. So And we know where to refer for what.

[Unidentified (various brief interjections)]: So

[Chair Alyssa Black]: you come in with a

[Dr. Tina Keshava (President, Vermont Optometric Association)]: retinal detachment, we send you to retina. You come in with a weird looking lesion on your eyelid, we often send you to an oculoplastics ophthalmologist,

[Dr. Jessica McNally (President, Vermont Ophthalmological Society)]: things like that.

[Dr. Tina Keshava (President, Vermont Optometric Association)]: And then I do have a handout on the education kind of comparing optometry versus ophthalmology. Would you like one? Sure. Okay.

[Chair Alyssa Black]: We'll pass them around. You have multiple. Okay. I'll just wait till everything gets up. I I should do think you get halfway?

[Unidentified Committee Member ('Steve')]: Let's see. If it's one page or two pages.

[Chair Alyssa Black]: There's something stable.

[Dr. Tina Keshava (President, Vermont Optometric Association)]: Some are double sided. Yeah. The other ones yeah. See, these don't have any on the sides.

[Chair Alyssa Black]: Oh, let's see. Stapled. Yeah. One side and the other is two separate.

[Dr. Tina Keshava (President, Vermont Optometric Association)]: On the first page, it just talks a little bit about how optometrists are really primary eye care providers. We're basically primary care for the eye. We see about two thirds of primary eye health care in America. It talks a little bit about our education and training at the bottom. And in the middle, it talks a little bit more about what we do. I think it's a little bit more complex than what that AI Venn diagram was. That made me think about maybe in 1980 or 1990. On the backside, if you have a one-sided copy or on the second page, this page just kind of goes through a little bit more about what our schooling is like. So basically, optometrists and ophthalmologists all do about a four year bachelor's degree before we enter school. So we're all starting as postgraduates. Optometrists know they want to deal with the eye. They know they wanna be an optometrist. So they go to a focused school for optometry. And there are about 26 or so throughout The US. In the first two years, optometry education and medical education are very similar. We go through a lot of just primary biochemistry, anatomy, physiology, optometry focuses a little bit more and visual science, binocular vision, and medicine talks a little bit more about death and dying, healthcare quality improvement, and a little bit more maybe focused on the full body versus optometry is focused on parts of the body that really affect the eye, including a lot of the body. But it's not as heavily focused as maybe medical school is, because we're also getting optics and starting to learn, getting into the clinic even in the first couple of years. Year three and four are very different between optometry and medicine. In optometry school, we're doing a lot of hands on in years three and four, but we're also getting other education on surgeries that we are allowed to do, ocular disease, contacts, infant and child care and pediatric vision. In medicine, they are doing rotations where they're getting a lot of hands on in different areas that are the core of what medicine is. They might have a little bit of ophthalmology if they choose it as an elective, and they can certainly choose a little bit more time in their fourth year if they know that that's really where they want to specialize. But for all intents and purposes, they really don't get a lot of ophthalmology education during the first four years of medical school. They really get that when they graduate and they go into their residency. Our residency isn't really called a residency, but it's kind of built into our curriculum. We do a lot of training. We have a really strong foundation for a lot of these procedures that are in S-sixty four, just built into what we do in our four years. There is an option to go into a residency afterwards. I would equate our residency with a fellowship. So once an ophthalmologist finishes their residency, if they want to specialize in retina or oculoplastics or glaucoma, then they could do another year or two after residency and really hone in on that. And we have that availability in our system as well as a pathway. Are there any questions on that before I move on?

[Chair Alyssa Black]: Any questions? I don't have my glasses on so I can't see anything. I

[Dr. Jessica McNally (President, Vermont Ophthalmological Society)]: have a question if I may.

[Rep. Leslie Goldman]: Doctor. Greenberg talked a lot about the different numbers of exposure that you have in your, well, optometrists have in training as opposed to an ophthalmologist. I was wondering if you could address that.

[Dr. Tina Keshava (President, Vermont Optometric Association)]: So we have about ten thousand hours of education and about 2,000 patient encounters before we graduate. When he said that number of about four hundred surgical cases that residents are finished with, I do think that number varies depending where the residency is. And it also is not all in these procedures. Do a large range of procedures. So they're trying to get really good at cataract surgery, which is a very delicate procedure. They're aiming to get at least 100 cases there. And they're doing some of the procedures that are in here, but they're doing more than what we can do, the emergency trauma, things like that. I believe and I don't have the paper in front of me, but I believe that their hope to have completed for some of the procedures in here are closer to like four or five cases for each of the procedures that they want to have at least done some of those completely by themselves or at least done 50% of their own with maybe 50% help. And so they have to complete, I believe it's about four or five for each of the procedures. One of the reasons that ours is a little lower is because we do have a lot of foundational skills that we gained through our four years. Plus we have the extra training. We have two extra boards that are above and beyond what we do for our regular optometry license. We will be spending time, eight hours at least, with a preceptor to kind of watch these procedures. And then two, after all of our knowledge, and I think if you actually saw some of the skills that we already have, and then how that is almost there to where these procedures are, you would agree that two would be enough to show that we have some competency in that. Anybody else?

[Chair Alyssa Black]: Yeah, go ahead. Okay, sorry.

[Unidentified Committee Member ('Steve')]: On here in year three, you have ophthalmic lasers for this.

[Dr. Tina Keshava (President, Vermont Optometric Association)]: So I graduated in 2,005. When I was in school, we did have a little laser course where we learned about the lasers, the differences. We practiced with a Model I. And that was way before we were doing it in most states. I think Oklahoma was the only state at that time that allowed it. But because Oklahoma allowed it, they taught it to us. And over time, that's just increased in all the optometry schools. And in 2019 is when it was standardized in all of the schools. So all of the schools have that thirty two hour curriculum or more in their curriculum so that all fourth years when they graduate will have had that.

[Unidentified Committee Member ('Steve')]: You think it's gonna be difficult to find ophthalmologists who will be, what is the term? Receptor. Receptor.

[Dr. Tina Keshava (President, Vermont Optometric Association)]: Potentially. I think it depends where you work and how close you are to an ophthalmologist. I think that once this passes, I do think that they might see a benefit of allowing it. I have heard that there are some that I sorry, from the ophthalmologist at the Rutland Hospital that once this passes, the hospital would be happy to allow optometrists to do these procedures because it would increase access and make it easier for their patients to not have to travel outside of Rutland.

[Unidentified Committee Member ('Steve')]: I did notice that most of the ophthalmologists in the state are centered around Burlington, South Burlington, Rotland, perhaps fortunately some here in Barrie as

[Unidentified (various brief interjections)]: well. You.

[Chair Alyssa Black]: May I ask just because I'm on your website, do you have a practicing ophthalmologist in your practice?

[Dr. Tina Keshava (President, Vermont Optometric Association)]: Yes, my husband actually is the ophthalmologist. So now you know where the name came from.

[Chair Alyssa Black]: You might have a preceptor.

[Dr. Tina Keshava (President, Vermont Optometric Association)]: I might have one. Yes. But like you were talking about doing these skills enough times to get good at them. I only work part time right now, so I'm not really sure I'm going to get this specialization. If I start working more, I might want to. But we do have a full time optometrist where we are, And Rutland is in dire need of some new optometrists. We have two retiring and almost all of them are not able to schedule new patients anytime soon. So being able to get another one or two that are ready to go, it would be really helpful for our community.

[Chair Alyssa Black]: Can I ask you a question about that? I know that a lot of the argument for having this is that it would attract new optometrists to Vermont so that they would be able to practice at the top of their license or practicing since they've been trained through optometry schools. But we actually have an access of just general optometry.

[Dr. Tina Keshava (President, Vermont Optometric Association)]: Exactly. That's exactly what I'm talking about. They want to come here to be able to do it. And if they come here, we'll have more access for routine. Part of the reason we feel that they're not coming here is because they're able to go to other states. I know of an optometrist that was up in the Newport area or St. Johnsbury, and she was frustrated because she wanted to be able to do all these procedures. And so she left and she moved to Kentucky where she can.

[Chair Alyssa Black]: My concern is though that the procedures will start to take precedence over, you know, general eye care and that it will then become more about doing the procedures rather than general eye care?

[Dr. Tina Keshava (President, Vermont Optometric Association)]: I'm not worried about that happening because most of what we do is two thirds at least in primary eye care. It's seeing patients treating You do a SLT on a glaucoma patient, which is one of the trabeculoplasties. It's a treatment to lower eye pressure. It's a short laser procedure done right in the office. It is becoming first line care over drops. And it's kind of up and coming. You do that once and then you follow them to make sure it's working throughout the year. That's important. We need people to be able to do that. And right now, getting patients into the ophthalmologist is taking a long time. So it takes the patient a long time to see us, and then it takes them a long time to see the ophthalmologist.

[Chair Alyssa Black]: Do you do follow-up care for ophthalmologists?

[Dr. Tina Keshava (President, Vermont Optometric Association)]: Yes. And we also take the emergency room patients that are seen the next day in our office.

[Chair Alyssa Black]: Any other questions? I do have more. Oh, yes. Keep going. I'm sorry. Alright. Oh, that's right. We didn't meet we just got through the education then. Sorry.

[Dr. Tina Keshava (President, Vermont Optometric Association)]: No worries. Our profession in Vermont has evolved over the past century from providing glasses and checking vision to dilating patients in the early eighties to monitor eye health and to treating eye diseases like glaucoma and uveitis in the early 2000s. Our education evolved before those changes were enacted, and it's time again for scope to match what optometry is allowed to do. These doctors today must complete standardized national education and competency based training culminating in ten thousand hours of education and 2,000 patient encounters before they graduate, in addition to taking three sets of boards. By allowing this expansion, patients will be able to have greater continuity of care with their local eye doctor and save on extra transportation, time and co pays of unnecessary referrals. And I think your guiding principle up there about addressing barriers to accessibility, affordability, sustainability and efficiency across the healthcare system is exactly what this field is all about. Take for example, a patient comes in to see an optometrist with a cyst on their conjunctiva, the clear tissue over the white part of the eye and the inside of the eyelids. So you've probably heard of conjunctivitis, pink eye, sometimes little fluid cysts develop on that area, and it can be very uncomfortable. Patient feels that every time they blink, it's really frustrating and it can be simply drained right in the office within a minute or two. The problem is they had to wait two months to come in, but with scope expansion, this doctor can drain the cyst on the same day. Without scope expansion, the patient must be referred to an ophthalmologist who likely won't get them in for another one to three months, and depending on where they live, maybe another thirty to sixty minutes away. This patient will have to pay for an extra copay, extra gas, and possibly take more time off work, all while continuing to be bothered by the cyst. Plus their insurance will have to pay for an extra exam. In Brattleboro, the closest ophthalmologist for most of the procedure in this bill are either in New Hampshire or Massachusetts, which is taking money out of our economy. Let's talk about one of Doctor. Dan Phillips patients up in St. Albans. Doctor. Dan Phillips did testify for the Senate Health and Welfare Committee. Once Doctor. Phillips determines a patient to be a candidate for SLT, which is the laser treatment for glaucoma, you must refer them to a doctor in Burlington for a quicker care because the ophthalmologist above his office has a longer wait time of at least three months. This patient and possibly his caregiver then has to drive forty five minutes back and forth at least three to four times to treat both eyes, once to have a repeat exam of what Doctor. Phillips already did, and then the other times for the treatment. Doctor. Phillips was able to perform this procedure less than a year ago when he practiced in Oklahoma. But now he lives in Vermont and he can't. And it's the patient who suffers, waiting longer for care, spending more time away from work, more money on gas, and an extra copay for a redundant exam. Plus, if the ophthalmologist the patient sees works at a hospital like UVM, Rutland Regional or Dartmouth, they'll have to pay a hospital facility fee for those visits, increasing healthcare costs to the patient and the system. And I have a little graph here. I don't have copies for everyone. So this kind of shows a little bit about how the price increases. Over here, you have the patient seeing an optometrist with scope expansion doing the procedure. It's about $315 And these are based on the 2025 Medicare costs. In here, the patient had to have an extra exam with the ophthalmologist who may or may not decide to do the procedure. If they decide to do the procedure, then the total cost would then be about $425 So it increased for an exam fee really was a basic difference there. It's about a 33% difference. And then if the ophthalmologist that the patient was sent to is actually in a hospital, the hospital facility fee majorly increases the price to about $2.75 percent for getting that procedure done. And I

[Chair Alyssa Black]: can leave this with Rasha. That would be great.

[Dr. Tina Keshava (President, Vermont Optometric Association)]: And that's you said that's Medicare? This is based on the Medicare reimbursements or cost for the procedure, sorry, based in 2025. Okay, thank you. Doctor. Phillips is excited and ready to obtain this specialty so that he can provide more efficient local care to his patients. But not every optometrist in Vermont will actually apply for this license. Only those who have the desire to perform these skills will pursue it. That's like not every ophthalmology, sorry, every ophthalmologist performs the procedures that are in our bill. So for instance, the ophthalmologist that's in Brattleboro, he doesn't do the SLT or the YAG lasers. And that's why those patients have to go to New Hampshire and Massachusetts, even though there is an ophthalmologist there. I would also like to address concerns regarding complication management. Most of the common complications from these procedures are already managed by optometrists in our offices. If a complication requires additional specialties such as retina, for example, it would need to be referred out just like when an ophthalmologist does it. I would also like to speak for a few minutes on the issue of access. We agree with ophthalmology that access for routine eye care is an issue throughout the state. Wait times for a new patient exams vary greatly across Vermont with some getting them in within a few weeks and many booking out six months or more. When we see someone that needs one of the treatments from this bill, wait times to get into an ophthalmologist vary as well, depending on what the patient needs and where they live. I'm kind of lucky because I have an ophthalmologist right in my same building. Patients in Rutland can often get in for an SLT or YAG within about a month, but it will take three to six months to get them in for a Toulazian or another eyelid lesion. And for that, they would have to travel up to Burlington about 90 miles away because my husband does not do Toulousean surgery. In Chittenden County, SLT and YAG procedures are about two to three months out and benign lid lesions are about three to six months. In Brattleboro, SLT and YAG are about three to six month wait with patients traveling an extra 25 miles out of state to either New Hampshire, like I mentioned before. But LID lesions can actually be addressed sooner in about one to two months, but these patients have to travel 60 miles to Springfield, Mass for that. And one of our optometrists from St. Albans, Doctor. St. Marie, who's right over here, he had his staff go through recently and look at how long, once they were referred, how long it took for them to get in. And it varied, but I'd say it was anywhere from one month, which was minimal, to more like two to eight months to get in for different procedures. So I can leave this with your committee as well to look at. I don't have copies for everyone because I just got it. But these patients' names, they all agreed and signed to have their name put in here too. And if we think that's bad now, Doctor. Edlow's article and an article from the Review of Ophthalmology on Ophthalmology Workforce Projections, which I can share with the committee later, They both show that there will be a shortage of ophthalmologists across the country within the next ten years as demand soars. Not a great combination. Thankfully, another study by Bay and others, which just came out in 2025, provides suggestive evidence that optometric scope expansion impacts are larger in rural areas than in urban areas, implying that populations with the most severe access points may benefit most. So Doctor. Greenberg had said there wasn't really any data to show that scope expansion improved access in some of those other states where they already do it. This study just came out recently and it shows that it does help. Another fact that I feel is important to mention, SLT is becoming first line treatment for glaucoma, which I kind of mentioned before. And I think I already handled that, so I'm just gonna skip that part. We believe passing this bill, especially being the first in the Northeast to do so, will help Vermont meet this impending surge in demand by strengthening our workforce. I can personally tell you that one of the first questions fourth year optometry students ask when considering where to work is what is the scope in your state? I heard that over and over again when I was at the National Optometric Conference last year. These new optometrists do not want to be limited in what they can do based on where they live. They want to be caring for their patients with the skills and tools they were trained to use. We hope that by increasing the scope to this degree, these new grads and other highly trained optometrists will want to come to Vermont to work, helping to fill the gaps in coverage we have now or will have as some retire. And if optometrists are able to work to their full training, it will save the ophthalmologist's chair time for patients with more complex needs, like those that need cataract surgery or injections for macular degeneration. This bill is about working as a team to help deliver the best and most efficient eye care possible to Vermonters. Given the requirements in the bill and the rulemaking process, it will take a while to get the advanced procedure specialty license up and running. Passing S-sixty four now will ensure that there will be a time for this bill to be implemented thoughtfully and safely. As more states expand their optometric scope, Vermont will become a less desirable place to practice. Our state already has an uphill battle including providers as the cost of living is so steep here. We don't need more barriers like the limited scope keeping these skilled optometrists away. Let's be proactive and lead the way in New England by modernizing optometric care so that we can continue to attract highly qualified optometrists. Our population is aging, their eye care demands are increasing, and we must make sure Vermont is in a position to continue to provide excellent eye care now and in the future. Lastly, OPR supports this bill after months of exhaustive research. As you heard this morning, it contains high standards for doctors seeking a specialty license, including extra training, board exams, a preceptorship, proctored procedures, and adverse event reporting. It also requires more continuing education to renew the license than the traditional one, ensuring continued competency in these skills. Additionally, the Oliver Wyman report shows that allowing providers to practice to the full extent of their education and training is a way to reduce healthcare costs and improve patient access. That is what S-sixty four is all about. Instead of being the forty ninth state, like we were for allowing optometrists to treat glaucoma, which I will say again, we are now the primary care for glaucoma in this state. Please help us join the other now 16 states. Was 14, now there are 16 states that allow this scope and become one of the first in the Northeast to fully expand scope by voting yes on this bill. Vermonters are asking for increased access and reduced barriers and costs. You have an opportunity to implement a plan to give them that, one that is supported and proven to be safe for patients. Thank you again for your time, and I'm happy to answer any questions you have now, or I'll be happy to answer after.

[Dr. Jessica McNally (President, Vermont Ophthalmological Society)]: I'll be here.

[Chair Alyssa Black]: You had mentioned Medicare. Does Medicare cover this expanded scope of procedures for optometrists? Medicare

[Dr. Tina Keshava (President, Vermont Optometric Association)]: and Medicaid pay optometrists and ophthalmologists the same for our work.

[Chair Alyssa Black]: So with Vermont Medicaid? Medicaid?

[Dr. Tina Keshava (President, Vermont Optometric Association)]: You didn't know that yet, they're for Medicaid. Yes, they would

[Rep. Allen "Penny" Demar]: correct. For surgery?

[Dr. Tina Keshava (President, Vermont Optometric Association)]: If it's allowed in the state, they would, yeah.

[Chair Alyssa Black]: Would we need a waiver for that, Jen? No. I don't require waiver study council. Not that I'm aware of,

[Unidentified Committee Member]: but the providers are already

[Chair Alyssa Black]: credentialed by geneticists participating in Joint Cave.

[Rep. Leslie Goldman]: Well, that would be an expansion of practice?

[Chair Alyssa Black]: They could expand their scope.

[Unidentified Committee Member]: You would want to hear from

[Rep. Leslie Goldman]: scope of practice, we are

[Chair Alyssa Black]: a good indicator for the city provider. I

[Dr. Tina Keshava (President, Vermont Optometric Association)]: also have a letter that shows that in the states where optometrists do this procedure, that malpractice rates have not gone up.

[Chair Alyssa Black]: Is that okay to pass out? Yeah, anything you pass out, happy to take.

[Dr. Tina Keshava (President, Vermont Optometric Association)]: Well, then this one this way and this one this way.

[Chair Alyssa Black]: Any questions? Or I have one, and then I completely lost it.

[Dr. Tina Keshava (President, Vermont Optometric Association)]: It's locked in optometry rates. Are so the other letter will, explain I that, but they are a malpractice insurer. 103,000,000. Okay,

[Chair Alyssa Black]: good. You had mentioned other states. So other states have done different types of procedures. Some have allowed a full scope of practice, some have limited. Because I have no idea what any of the things in this bill are, does this bill, Is this a comprehensive listing of the most expanded Yes. That any states have just

[Dr. Tina Keshava (President, Vermont Optometric Association)]: This is what I believe matches 16 other states at this time. There are about maybe eight to nine other states that have more scope than we do, but not up to the level that's in this bill. So this bill matches the 16 states, and then there's kind of some in the middle that they might allow injections. So they might be able to help that patient with that kind of type of cyst. But we are not one of those states right now.

[Chair Alyssa Black]: But I guess I don't really know my question because I wouldn't even know how to weed out some of these. Is room for expanded scope but not fully? What's the difference? I guess, what are the difference between the types of things in here?

[Dr. Tina Keshava (President, Vermont Optometric Association)]: What we do now? Well, no. I mean,

[Chair Alyssa Black]: are there some that are injections? Are there some that are lasers? Are there some that are more invasive than others?

[Dr. Tina Keshava (President, Vermont Optometric Association)]: So I believe I might be wrong, but all the procedures in the bill are pretty much five minutes or less in office space. They're more superficial. The lasers do go into the front part of the eye. They do not go to the back part of the eye. So it's all kind of from the middle forward. And none of the lid lesions, those are all superficial, it's directed at what size they're allowed to be in the bill. Injections are just on the front part of the eye. One of the prohibited procedures is an injection in the back of the eye, which is done for patients with diabetic complications and for macular degeneration, some other things.

[Chair Alyssa Black]: Are there injections that are allowed to actually inject some sort of pharmaceutical into?

[Dr. Tina Keshava (President, Vermont Optometric Association)]: So this bill does allow for fluorescein angiography. When this was started back in 2019, that was much more of a common thing. I was taught how to do it when I was in school. I know Doctor. Dean Barcelo was doing it himself when he was working at the VA. Optometrists were allowed to do it then. And it's not really used much today. I think it's really reserved more for retinal surgeons. And they barely use it either because we have some more noninvasive ways to help get the same information. But it was just left in the bill because we have been able to do it forever. It's not like we're probably going to start doing them because we have easier ways to get the information now. Which is why I made the comment earlier today that this probably won't even be affected.

[Chair Alyssa Black]: It'll probably have all changed by July 1 because things change so quickly.

[Dr. Tina Keshava (President, Vermont Optometric Association)]: Right. And even the SLT that is potentially becoming something that doesn't really it's like a machine that does it all at once. So it's a very different procedure. I believe it's a non contact SLT. It's very cool. When that machine is going to come to Vermont is another story. But you're right, things do change. And that's why twenty years ago, we were talking about glaucoma. Now we're the primary eye care providers for glaucoma in the state.

[Chair Alyssa Black]: Which is why I worry about putting things like this in statute, because Will they even have meaning five years from now? Will it not be best practice? Will these procedures not even be done because some new technology has come out?

[Dr. Tina Keshava (President, Vermont Optometric Association)]: It. Well, I mean, I think there are a lot of laws being antiquated over time. Right. So it's, yeah, we, you know, maybe we'll come back when there's something new, but there's nothing that I know of on the horizon. I know OPR has fully vetted this and they'd like us to pass it this year.

[Chair Alyssa Black]: Please don't come back.

[Dr. Tina Keshava (President, Vermont Optometric Association)]: That's what they said. No, I'm

[Chair Alyssa Black]: going say it against anybody.

[Rep. Leslie Goldman]: Go ahead. So you handed out this insurance grid, and I'm just

[Unidentified Committee Member]: looking at it quickly.

[Rep. Leslie Goldman]: And we know that Louisiana is one of the small group of states that And it also looks like the Louisiana rates are more than double Vermont rates. But we also know that Louisiana is doing a lot more invasive or surgical or whatever. I was just wondering if you could Oh, of course. Think about

[Dr. Tina Keshava (President, Vermont Optometric Association)]: that for a minute and help me. So what this was showing was really how it changed over time. So Louisiana, it has changed a little bit over time. And it's probably one of the more expensive. But if you look at Connecticut and DC, where scope is not expanded, it's even more expensive. So I think it just has to do with the state. It doesn't have to do necessarily anything. Yeah, because

[Unidentified Committee Member]: I see what you're saying.

[Rep. Leslie Goldman]: It started out higher, it ended up higher. Thank

[Rep. Allen "Penny" Demar]: you. Thank you very much.

[Chair Alyssa Black]: Thank you for having me.

[Unidentified Committee Member]: And since Gus goes to the floor, are you going to be here to tutor us on how to say all these words?

[Chair Alyssa Black]: Oh my god. What would be great is if you said, I could be taking the salt of Ledged Counsel and then Jen would go. So that's great to hear. Let's see, I'm sorry, where are we? Doctor McNally. Hi, how are you? I'm doing okay, how are you all? I'm doing okay. I

[Dr. Jessica McNally (President, Vermont Ophthalmological Society)]: have a few things that I brought with me today. I'm not gonna pass them around just yet. I do have a video to show. I know we might be running a little bit short on time at the end. I think it's really important that you guys see this video. That is what I'm hearing over and over again from the committee, is that you don't know what these things are, you've never seen them, you don't know what it takes to actually do them. And the video will show you what they are and describe what they are, and maybe help you judge a little bit better what you think the severity of potential complication or how scary they are, just by looking at some of the pictures. I'd like to introduce myself. My name is Jessica McNally. I'm an ophthalmologist and I'm the current president of the Vermont Ophthalmological Society and a member of the Vermont Medical Society. Chair Black, I'd like to thank you for allowing me to testify on behalf of the Vermont ophthalmologist to voice our concerns about S-sixty four, a bill that would expand the scope of practice of Vermont optometrists to include eye surgery. To be very clear, the singular goal of Vermont ophthalmologists is to ensure that Vermonters receive safe, high quality surgical eye care. With that in mind, we have grave concerns about this bill and its implications. In the close to twenty years I've been in practice, I have seen firsthand the confusion about the difference between an ophthalmologist and an optometrist, as Doctor. Keshiva mentioned. Just last week, for example, I was referred a patient who was diagnosed with one of the most visually threatening diseases that we ever deal with, who did not obtain timely and appropriate referral because the PCP, unlikely the patient, thought that the patient had been seen by an ophthalmologist when, in fact, the diagnosis and initial treatment had been initiated by the optometrist, and the PCP did not realize that. The lapse in time between the suspected diagnosis and the appropriate referral may have serious consequences for this patient in the coming years. In fact, a 2018 survey conducted by the American Medical Association found that over half of respondents either did not know or were not sure if an optometrist was a physician. I can bet you that the data would not be any different now. All ophthalmologists are physicians and surgeons. Ophthalmologists complete a four year undergraduate bachelor's degree program, as Doctor. Keshiva mentioned, after which we complete four years of medical school identical to other physicians and surgeons. After completing medical school, we move on to obtain four to six more years of residency and fellowship training. Our first year of residency training incorporates inpatient and outpatient care involving surgery, internal medicine, emergency medicine and critical care. Then residents complete three more years of focused training on advanced medical disease and surgery of the eye. The three year ophthalmology residency is standardized in all programs across the country and must meet rigorous national accreditation council for graduate medical education requirements. I want to add in here that I feel like sometimes the four years of training that we get in medical school is minimized by our optometric colleagues when we're discussing this issue with legislators. And I want to be clear that throughout medical school, we may not be focused on eyes, but we are learning surgery. We start at the very beginning with our anatomy labs cutting into cadavers. We complete our OBGYN rotations. We complete emergency medicine rotations. We complete dermatology rotations. And in every single one of those rotations, we learn how to cut and sew skin. Not on the eye, the eye comes way later because it's such a delicate part of the body. We start on the arm, the leg, we start on parts of the body where scar tissue doesn't matter so much. So I would say that it is extremely important for us to go through our four years of medical school and first learn surgical technique there before we even get to our residency training on the eyes. The majority of ophthalmology trainees then follow-up their residency with another one to two year fellowship in a subspecialty such as cornea, retina, or glaucoma, thus giving them more surgical experience and of course, totaling hundreds of cases, as was mentioned earlier. As in all surgical residencies, ophthalmologists are held to the highest standard and do not graduate from their program until they have proven competency, not simply by numbers, which I've heard is a major question, how many numbers of surgeries do ophthalmologists and do optometrists do, but more on the meticulous formal assessments by our mentors, our surgeon mentors who've been doing this for many, many years. These include elements such as working cohesively with colleagues, professionalism, patient relationships, and surgical skills and progression. All ophthalmology residency programs have clinical competency committees that have to all agree, every member of these committees have to agree that each resident has attained these surgical skills and these qualifications to gain graduation from a residency. Doesn't have to do so much with numbers. Numbers are important, yes, as Doctor. Greenberg said. But a lot of it has to do with just assessments from our mentors and whether or not we are ready to graduate and are safe to graduate. Optometrists, as Doctor. Techevun noted, complete a four year undergraduate bachelor's degree program and then attend a four year optometric program. They have the option of completing additional training, but this is not required. In the materials that optometry gave OPR in the second report, examples of such additional training include low vision, contact lenses, and ocular disease. To my knowledge, there is no such further training that is standardized for optometry trainees for surgery. What we and what OPR found is that in optometric programs, as Doctor. Keshavar mentioned, there are didactics such as lectures and videos, and that has changed and expanded over the years, along with laboratory simulations and surgeries on model eyes and model skin. However, when I reviewed the different curricula, the standardization of numbers of hours of didactics and numbers of simulations performed is not clear from one optometry program to another. What is clear and what OPR found is that in the far majority of optometry school, there is no hands on surgical training on live human beings. In fact, there are only two states out of the current 14 states with expanded scope. And when I say expanded scope, I mean partially expanded scope, not the full gamut of what's being asked for in S-sixty four. But there are only two states that can provide training for all of the things that are in S-sixty four, even though 14 states have pieces. Some have lasers, some do injections, and some are Okay with incisional sort of scalpel surgeries, as we call them. We have been told that optometry programs may be able to rotate their students through these schools where they can teach these surgeries, but the amount and type of surgical exposure an optometry student might obtain at one of these schools is completely unclear. We have observed that the system of licensing optometrists to perform advanced procedures is starting to develop some cracks. Recently, it was revealed that Kentucky allowed 21 optometrists to be licensed without passing all of the required exams. A malpractice lawsuit has been filed against one of those optometrists relating to use of a laser, and optometrists all over this country have themselves expressed commitment about the lack of responsibility by the Kentucky Board of Optometric Examiners. A West Virginia court also recently determined that their board overstepped its bounds and they voided a rule that allowed an optometrist to perform eyelid surgeries. The two main arguments that Vermont optometrists have brought forward since beginning their effort to expand scope, and this was years ago, involved access and cost, as you've heard. Optometrists in Vermont have repeatedly asserted that by allowing scope expansion, access to these surgeries will be improved. In Vermont, we are extremely fortunate in that we have enough ophthalmologists to provide all scalpel and laser surgical care in and around the eyes. It has been suggested that the absolute number of ophthalmologists in Vermont does not reflect access because some of subspecialize and don't perform these surgeries. The fact is that there are only a handful of ophthalmologists, typically retina specialists, who don't perform these surgeries. I myself, a comprehensive ophthalmologist, I perform every single one of them, as is my partner, Doctor. Jeff Young. We're both here, Washington County in Berlin. We do them all. Furthermore, a July 2023 article published in the Journal of American Medical Association showed that in Oklahoma, Kentucky, Louisiana, Arkansas and Missouri, all states that have expanded scope to include laser surgeries did not lead to a shorter travel time or improved access at all. A more recent November 2025 article published in the Journal of American Medical Association demonstrated that although there's been a decrease in the number of ophthalmologists, as Doctor. Keshava mentioned, were worried about a shortage of course, they're practicing in a greater number of locations. The article further determined that nationwide driving distances to optometrists and ophthalmologists is similar. Furthermore, there really are no studies that show that optometrists are flocking to states with increased scope. I can talk a little bit about the cost of that as well. We have approximately 33 practicing ophthalmologists in the state. Not every county has an ophthalmologist, that's true. As Doctor. Greenberg said, not every county has a urologist or a dermatologist or a neurosurgeon either. These are highly specialized physicians and surgeons, and expecting to have a provider with that level of training in all counties is unrealistic. I think we can all agree that we would not be comfortable with a family practice doctor performing neurological surgeries to fill the gap in neurological issues. Optometrists provide primary medical eye care. As Doctor. Keshadar mentioned, they should not perform ophthalmic surgery. Our concern, and I think your concern as well, regarding access is that primary eye hearing needs of Vermonters are not being met. All diabetics need yearly annual dilated eye exams. All contact lens wearers need yearly exams. I encourage all of my patients over the age of 50 to have yearly dilated exams. And it is very difficult to understand how expanding the scope is going to make access to these primary eye care services any better. Optometrists are already very busy. Wait times are long. We've also had issues with numerous optometrists not taking vision insurances anymore, which is forcing our patients to have to leave places where they work or places where they live in order to find optometrists in other parts of the state that accept their insurance. That's been a huge deal lately. VSP, one example. Nobody's taking VSP anymore for primary eye exams. Indeed, both the 2020 and the 2023 reports from OPR conclude that OPR is unable to determine whether expanding the optometric scope of practice would improve patient access to care. I can assure the committee that if a patient needs expedited or urgent eye surgery, our optometrists know that they can reach out to us directly. Many of us have each other's phone numbers, email addresses, and can get ahold of us without any problem if there's a concern. With regards to cost, many arguments have been put forward by optometry, insisting that scope expansion will decrease cost. One argument is that the patient could simply be brought to another room on the day of diagnosis and have the scalpel or laser surgery done right then and there. Optometrists argue that this would decrease costs by saving patients a trip to see a surgeon for another evaluation. This argument absolutely does not hold water. All ophthalmologists can cite examples of many patients who were sent to them for the requested surgeries in F24 that after being evaluated were deemed unnecessary or even ill advised. Other patients will often opt out. They will not move forward with whatever surgery or surgical procedure they have been sent to me for once I have a dedicated discussion with them about the risks and benefits. If they don't know about the risks and benefits, then they can't make the decision on whether or not they should have their surgery. And that's where the ophthalmologist comes in. By deciding not to do a surgery or recommending no surgery, that actually decreases the cost. Furthermore, it's almost impossible, really, truly impossible, to do a procedure on the same day of seeing a patient in the office because you have to get reimbursement issues and you have to get prior authorizations, which can sometimes take two to three weeks. And these procedures, which are elective. The laser equipment required to perform the requested laser surgeries can cost anywhere from $40,000 to $60,000 We relate to the Senate Health and Welfare that we are aware of at least two instances of our patients being told recently by their optometrists that either they had the laser already or that they would be able to perform the laser legally in Vermont within a year. This conveys to us that there are some optometrists who assume that this legislation were on the path without being fully evaluated by this legislature. Expanding optometric scope of practice to include surgery will not lower costs. The cost for medical services is set by payment formula created by Medicare and not by traditional supply and demand. Each procedure and service has its own code and a set payment. We all get paid the same. In 1986, federal law established that optometrists would be reimbursed for services by the Centers for Medicare and Medicaid Services, CMS, at the same rate as an ophthalmologist. Private insurers use the same set of codes, and their payments are similar established by Medicare. Private insurers also reimburse ophthalmologists and optometrists, again, the same amount. The topic of facility fees has come up that came up in our previous conversation here. Facility fees are utilized by hospitals. These are office based surgeries. Office based surgeries do not utilize facility fees. There's no cost savings going to happen because of facility fees with these surgeries. I do not have facility fees in my office when I perform any of these lasers or any surgeries. A 2023 report from OPR invalidates optometry's claims by stating that OPR is unable to determine whether scope expansion would have an impact on costs. Optometrists have repeatedly portrayed ophthalmic lasers making safe and easy. We, the Vermont Ophthalmological Society, strenuously object to this characterization. Ophthalmic lasers, as proposed for use inside the eye, are categorically surgical instruments used for altering tissue. Surgical treatment with ophthalmic lasers is not a primary eye care service and should be performed by physicians who are hospital residency trained physicians. Furthermore, the existing and future laser eye care needs of Vermonters do not come close to providing the caseload numbers needed for optometrists to maintain competency. I reviewed the laser surgery data from my practice from September to November 2025 and submitted to SEN Health and Welfare, and it demonstrated relatively low numbers of lasers compared to the number of referrals that I actually get from local optometrists. Optometry scope expansion into the scalpel and injection surgeries listed in S64 would allow optometrists to remove lesions, what some refer to as lumps and bumps on the eyelids and around the eye without characteristics or obvious signs of malignancy. These surgeries have been described by optometrists as chairside procedures. Let me assure you that these surgeries are not chairside procedures. They are done under sterile conditions with specialized lighting and equipment. The oculoplastic specialist at UVM, Doctor. Libby Houghton, has spoken and written at length about how difficult it is to predict a malignant from a non malignant lesion just by looking at it, and how that even she, an expert, has been surprised with biopsy results. Two months ago, I did a biopsy on a patient who was 35 years old. It looked completely normal to me. I was doing it mainly because it was bothering her. It came back because of basal cell carcinoma. Two weeks ago, my partner had the exact same experience. Took off a small lesion, did not think it looked concerning at all. It came back cancer. We send every single thing we take off an eyelid to pathology because of that, because you just don't know. And I'd like to make one reference to what Doctor. Keshava said, in all due respect to her. Her references to taking off cysts, and that being one of the things included in this legislation, is incorrect. When you needle a cyst, it does not necessarily go away. You're putting a needle against an eye, a cyst will close again and recur. That is not the definitive treatment for a conjunctival cyst. And I think that's just another demonstration of you don't know what you don't know. If you haven't done enough of these, if you haven't experienced enough of these, then you just don't know. Other technical challenges in removing lesions from the eyelids, and again, this isn't, if you don't do it, you don't know. Technical challenges involve how large the wound is after you take the lesion. Lesions look small on the skin, you take it off and the wound just expands. There can be unexpected excessive bleeding It can be very anxiety provoking, both for the surgeon who's sitting in the room with an awake patient. S64 would allow repair of traumatic eyelid lacerations. These are patients who show up in the ER who Doctor. Greenberg is even unfamiliar or does not feel firmly that he can do correctly and will call me. When he talked about calling people in the community who are on call, I don't even know where my pager is, but I am on call right now, and they could call me at any moment with something like this. This is an extremely, extremely specialized part of the eye. The eyelid itself requires a lot of understanding of how to close the skin without maintaining a scar. And I think, thinking that closing an eyelid lesion is the same as closing an incision, a surgical incision, and equating those two things is completely wrong and shows a lack of education and understanding on what this is. Other proposed surgeries in the bill include corneal cross linking. There is one ophthalmologist in the state of Vermont who's trained to perform the surgery, just one. And that's because he's a fellowship trained cornea specialist. This surgery is outside the scope of practice of all other Vermont ophthalmologists. It costs thousands of dollars and is the most often performed on a very particular subset of younger patients. Why Vermont Alcoholics Specialist want permission to do this? I have no idea. Our retina surgeons have significant concerns about the inclusion of fluorescein angiography that Doctor. Keshavar mentioned. This is a dye test to look at structures in the back of the eye. The dye is injected into a vein in the arm. It can cause nausea, vomiting, and anaphylaxis. Our retina specialists continue to maintain that the far majority of retina disease can be diagnosed with other equipment that, as Doctor. Keshiva mentioned, is widely available and utilized regularly in almost every single optometric practice in the state. They do not need to be performing angiograms by fluorescein, nor do I. OPR's most recent report basically creates a training program for eye surgery, which is labeled a preceptorship. It incorporates some of that information and some of that model into S-sixty four, but there are even less stringent characteristics in the S-sixty four bill. With all due respect to OPR and to our Vermont legislature, we assert that setting appropriate standards for medical and surgical training should only be done by properly accredited organization. This organization should be comprised of individuals with firsthand knowledge and expertise in eye surgery and developing curricula with proven standardization to ensure competency of surgeons and accountability of the accrediting body. Safe eye surgery for Vermonters can only be provided by physicians who have completed medical school and an ACGME accredited ophthalmology residency program. There are a few things that Doctor. Kaesheva brought up about optometry programs as far as their training, things that OPR has brought up. OPR has looked at the different levels of board certification, the different testing levels that optometrists can get where you can gain the ability to do an injection and then the ability to do incisional, scalpel surgery and lasers. I wanna make sure everyone's clear that these are all based on models, that when these exams are done by optometry students, they are model based. They are not done on people. So although I know OPR has a certain amount of confidence that these board examinations show competency for optometric applicants. In fact, they're just being done on models. They're not being done on people. Real competency has to come from mentors and teachers during our training program. Vermont legislators are not alone in navigating the issue of optometric scope expansion into surgery. We have a map. We'll show you the 14 states of all the different ones. Some of them do lasers. Some of them do incisions. Some of them do injections. There's a reason for that. And the reason is because legislators struggle with this. It is very, very, very difficult to determine what these things are, what they mean, what different providers should be allowed and not allowed to do. And that is why there is such variability from state to state. Within the last two weeks, the governor of New Hampshire vetoed a bill that was even less expansive than S-sixty four, and that was passed by her own party. Both her own party in the House and the Senate passed it and she vetoed it. Yesterday, legislation in Maine failed. Understanding eye surgery and the training it entails is extremely difficult for anyone who does not live in the world of eyes as we do. I will close where I began, that the singular goal of the Vermont Ophthalmological Society is to ensure that Vermonters receive safe, high quality surgical eye care. As legislators, as you've noted, your ultimate responsibility is to protect the safety and well-being of the people of Vermont. And I hope you do so.

[Chair Alyssa Black]: Thank you, Doctor. McNally.

[Dr. Tina Keshava (President, Vermont Optometric Association)]: See Would you like the video?

[Dr. Jessica McNally (President, Vermont Ophthalmological Society)]: The video is about seven minutes.

[Chair Alyssa Black]: Let's put it up and you can ask can we ask questions during it? Sure. Yep.

[Dr. Jessica McNally (President, Vermont Ophthalmological Society)]: I think it's worthwhile. So this is

[Chair Alyssa Black]: the to pinch. Yeah.

[Dr. Jessica McNally (President, Vermont Ophthalmological Society)]: Bending assist. This is not a conjunctiva your eye. This is not doing it.

[Rep. Leslie Goldman]: Nice and relaxed. So this is

[Dr. Jessica McNally (President, Vermont Ophthalmological Society)]: this is an eyelid cyst, not a conjunctiva cyst since doctor Capedonia was referring to. Okay. Okay. These are the instruments that we use. The cup. Breathe in.

[Chair Alyssa Black]: Breathe in. Yeah. There you go.

[Dr. Jessica McNally (President, Vermont Ophthalmological Society)]: Oh, yep. Yep. Good job. Patient's groaning. It hurts. Actually. He's

[Rep. Leslie Goldman]: got another lesion. You be warned. You wanna warn the people about

[Rep. Allen "Penny" Demar]: what's going on?

[Chair Alyssa Black]: Breathe out. Breathe in. They're if they know. They're watching it too.

[Rep. Leslie Goldman]: Yeah. That's what I'm saying. You may wanna not watch the- So

[Dr. Jessica McNally (President, Vermont Ophthalmological Society)]: this is how we start. We start with an excision, a slow process to take a cyst off an eyelid. Very, very carefully, you wanna try to preserve as much skin as possible because when you suture it up, you don't want a big scar. These are the same size lesions that are allowable in x s sixty four. That's what it looks like when it comes off. And now there's a hole.

[Chair Alyssa Black]: No. It's

[Dr. Jessica McNally (President, Vermont Ophthalmological Society)]: Alright. So you are gonna smell some funny stuff now. Okay? Mhmm. What I'm gonna let you do is just look up into the, left again like you did before. Gotta stop the bleeding with cautery. This smells funny. It's burning flesh. This is the sort of circumstance where you might get unexpected bleeding that you can't stop with cautery. You might be sitting there for fifteen, twenty minutes, half an hour waiting for the bleeding to stop. Patient's wondering, does this person know what they're doing? Why am I here for so long?

[Chair Alyssa Black]: Look up to the left. Alright. Keep looking up to that left.

[Dr. Jessica McNally (President, Vermont Ophthalmological Society)]: Then suturing. Take a look at the suture in here. You'll see how tiny the needles are. They're barely visible. This is the type of skin that we learn how to practice on when we're in medical school. This is the kind of skin that optometrists practice on before they begin doing eyelid surgery. There's absolutely no comparison. You might be able to compare this to a shoulder, me doing surgery on a shoulder, tutoring a shoulder, not the eyelid, and not with the size needle that's going around.

[Chair Alyssa Black]: Right here. K. Look up into the maybe up into the right. Yeah. Go over here to the right.

[Dr. Jessica McNally (President, Vermont Ophthalmological Society)]: You can see how close I'm getting a little.

[Rep. Allen "Penny" Demar]: Sorry. A little bit.

[Dr. Tina Keshava (President, Vermont Optometric Association)]: The patient don't,

[Dr. Jessica McNally (President, Vermont Ophthalmological Society)]: you know what goes into the eye. These are the model eyes that lasers are practiced on and that optometry students may be tested on.

[Dr. Tina Keshava (President, Vermont Optometric Association)]: Alright. You're gonna feel pinch and a burn here.

[Dr. Jessica McNally (President, Vermont Ophthalmological Society)]: This is our Ichoclassic specialist, Libby Houghton at UVM again. Burning. Yep. That's good.

[Chair Alyssa Black]: Less than five minutes left.

[Dr. Tina Keshava (President, Vermont Optometric Association)]: Just keep breathing.

[Chair Alyssa Black]: So should I ask you

[Unidentified Committee Member]: again a question now? Yes.

[Rep. Leslie Goldman]: So I'm curious to know how you think your practice will change should this go past.

[Dr. Jessica McNally (President, Vermont Ophthalmological Society)]: For me, for my practice, I think I'll still be referred some significant medically complicated practice. I'm not honestly sure how many optometrists in the state of Vermont. To do this. We hear in the committee that optometrists in the state of Vermont want to do it. I honestly don't know that that's true. I think that the optometry lobby nationwide is pushing for this. And that's why we've had bills in both New Hampshire and in Maine, especially that have been pushed There so may be optometry students coming out of practice now who are interested in doing these surgeries. There has been no evidence to show that there is any kind of flooding in to rural areas of optometrists As in these I said, no optometrist coming out of practice is gonna be over $40,000 on a laser in rural Vermont to provide the kind of care that we would all like provided within two weeks. It's just not gonna happen.

[Unidentified Committee Member ('Steve')]: They could join a practice that had one currently.

[Dr. Jessica McNally (President, Vermont Ophthalmological Society)]: That is already there, exactly. It's already overwhelmed with primary eye care that can't see their own patients.

[Chair Alyssa Black]: What is the intro? Was this a cyst that we're moving This is

[Dr. Jessica McNally (President, Vermont Ophthalmological Society)]: a Chilean. You evert the eyelid. The states that allow injections are usually the states where optometrists want to inject these steroids. Injecting an eyelid lesion like this with steroids can lead to an arterial occlusion and blindness in the eye. That's one of those complications. Rare but possible.

[Dr. Tina Keshava (President, Vermont Optometric Association)]: So we're having chalazion, chalazion or chalazion? People pronounce it differently.

[Dr. Jessica McNally (President, Vermont Ophthalmological Society)]: Okay, either one is acceptable. Either one is acceptable. The far majority of chalazion excisions I do, I do perhaps one every four months. Patients come in, referred to me, I tell them to go home and do warm compresses, they go away. These are not large volume surgeries.

[Dr. Tina Keshava (President, Vermont Optometric Association)]: You're doing okay.

[Dr. Jessica McNally (President, Vermont Ophthalmological Society)]: Trying to maintain competency with these, it's just, don't see how it's gonna be possible in the state of Vermont, with the numbers that I do in my own practice, with the Luprolol base that

[Dr. Tina Keshava (President, Vermont Optometric Association)]: I have. And

[Dr. Jessica McNally (President, Vermont Ophthalmological Society)]: again, no facility fee, you know? Great. And then there's a couple other slides.

[Dr. Tina Keshava (President, Vermont Optometric Association)]: Can we

[Chair Alyssa Black]: post a video on a testimony? I don't know how. The whole committee page thing just gets silly to me. You go to the next Let's do that. So

[Dr. Jessica McNally (President, Vermont Ophthalmological Society)]: this is one of the laser results, where we clean off the back of the lens implant, it's called a YAG capsulotomy. Go to the next one. This is a peripheral iridotomy where we make a hole in the iris. That's an S64, you can get bleeding, called a hyphema, elevated eye pressure. Next slide. This is an example of an SLT, that's selective laser trabeculoplasty for treatment of glaucoma. It requires an understanding of the anatomy inside the eye. Yes, optometrists do go through that training to understand that anatomy. The judgment on when and when not to do that SLT is extremely important. Here's an injection underneath the conjunctiva. This gets very close to the eye. This exactly is the same sort of use of the needle that Doctor. Keshavolu referred to. This still would allow them to do this. Here's the fluorescein angiogram,

[Rep. Leslie Goldman]: where the dye is put

[Chair Alyssa Black]: into the IV, into the arm of

[Dr. Jessica McNally (President, Vermont Ophthalmological Society)]: the patient. Again, done very rarely and only by retina specialists at this time. This is an example of corneal cross licking, where you have to have specialized equipment in order to do it. Again, thousands of dollars. Have to fight very, very hard with insurance companies to get it covered. Remember that, that's it for them.

[Chair Alyssa Black]: Thank you, thank you so much.

[Dr. Tina Keshava (President, Vermont Optometric Association)]: Anyone have any questions? All

[Chair Alyssa Black]: right, realized my committee was so squeamish.

[Dr. Jessica McNally (President, Vermont Ophthalmological Society)]: I mean, I think it's important for everyone to understand what we're talking about here. I appreciate that.

[Chair Alyssa Black]: I do. Thank you very much.

[Dr. Jessica McNally (President, Vermont Ophthalmological Society)]: Thank you for having me.

[Chair Alyssa Black]: So we are very quickly, because we could only get AHS in today, just wanted an update on hospital transformation and efforts around that. We are working on 01/1989, which is that notice of service reduction, and I thought we should get AHS's take on that. So we're gonna You guys won't be that long, will you? You?

[Rep. Leslie Goldman]: So we don't have any of your slides or anything?

[Chair Alyssa Black]: I did send slides earlier today. We would have finished your slides, but there's also a fucking

[Unidentified (various brief interjections)]: note. The

[Chair Alyssa Black]: slides are on what name? For the next one. For you? Thank

[Rep. Leslie Goldman]: you. I don't know that we've met.

[Chair Alyssa Black]: Thank

[Unidentified (various brief interjections)]: you, by the way, accommodating the schedule.

[Chair Alyssa Black]: Thank you, everyone. Sorry, we're running behind a little bit. We were having very compelling testimony.

[Unidentified (various brief interjections)]: It actually

[Chair Alyssa Black]: was compelling. I'm going to let you all get started. I have to step up for a second and bounce to the tickle. I will be back in two minutes.

[Katie Carroll (Care Transformation Director, AHS Office of Health Care Reform)]: Well, the record, I'm Katie Carroll. I'm the Care Transformation Director in

[Unidentified Committee Member]: the Office of Healthcare Reform.

[Greg Jones (Contractor assisting AHS with transformation efforts)]: Greg Jones, the contractor assisting AHS with transformation efforts. I was here last week with Blueprint discussion.

[Katie Carroll (Care Transformation Director, AHS Office of Health Care Reform)]: We're here to give you an update on health system transformation and where we are with that work. This is really a timeline of where this work started and then where we're heading. So this work is all based in a legislative foundation, starting with Act 167 that really kind of established what the outcomes are intended to be for transformation and started this work moving forward. Then in 2025 with Act 68, that really established transformation and charged AHS with that work. Shortly after that, I started in my role as Career Transformation Director. I've been in this role for about six months. So up to this point, we've been really focused on working with hospitals and how they can contribute to these transformation goals. And so that's what we're mostly going to talk about today is the hospital transformation plans and what kind of work we're seeing from hospitals and moving us towards these goals. The hospital transformation plans are iterative plans that we're working on with hospitals. So the plans that we have currently are encompassing work that hospitals are ready to implement. So we really are moving now into implementation, bringing in TA support, bringing in analytics support to really understand what these changes that hospitals are able to make now are going to impact in the system and then allow us to continue moving forward. TA. Oh, sorry, technical assistance. Thank you. Sorry about that. And so we really feel like where we are in the process right now, along with all the other factors that are at play in the healthcare system are going to set us up to make some really big advancements in transformation of the healthcare system pretty quickly in the coming months and years. So this is really just visualizing everything that is the work of transformation currently. So I mentioned the hospital engagement and we'll get in to some of those themes that have come up from our engagement with hospitals so far. We're also doing convenings regionally. Geographic regions were identified to really think about how hospitals in each geographic region are serving their populations. And each geographic region has worked with HS to come up with poll to really think more broadly about how they're working together to serve the population. And some really strong goals have come out of that work that will expand into our work with the continuum of care partners that we're starting to do at this stage as well. The middle bar here is the implementation bar that I was mentioning. So we're really tracking all of these projects that hospitals are implementing, and we're tracking against affordability, access, quality metrics, equity, all of those goals that have really been established for this work, so that we can really be aware of how those different initiatives are moving us towards where we want to be and be able to change course if we're not moving in the direction that we'd like to be moving with all of the work that hospitals are doing. The continuum of care work has already started. I know you've heard from Doctor. Sorian about the primary care work that's part of this transformation effort with AHS. We also are starting some statewide initiatives around hospice use, which you'll hear more about as we talk about the hospital plans, mental health and substance use disorder, and defining outcome metrics around all of work that we're doing to try to transform those pieces of the healthcare system as well. AHS's role in all of this is really to convene and create collaboration that wasn't already there. Hospitals are already working together, but really getting them to think differently about how they're partnering around, thinking about services, thinking about some back end efficiencies, which we'll get into, and really making sure that we're bringing the right people together to think about some of the bigger topics in health care delivery.

[Greg Jones (Contractor assisting AHS with transformation efforts)]: I was just gonna add in, as we talked about a little bit last week, this is all being done in conjunction with hospitals at the same time as the rural health fund investments are being prepared and considered. So the thinking that is going into this is balancing out the financial pressures, which our hospitals are under right now, particularly the smaller hospitals, the regulatory pressures they're under, but also the investment opportunities that are coming along with some pretty robust statewide projects. So there's a balance of forces at play here that are really driving the work in these various categories.

[Rep. Leslie Goldman]: Leslie? Do want questions now or at the end?

[Dr. Tina Keshava (President, Vermont Optometric Association)]: We can take questions now.

[Rep. Leslie Goldman]: Oh, I'm just curious when I'm seeing continuum of care that you kind of jump from primary care to home and health hospice, there's a

[Dr. Tina Keshava (President, Vermont Optometric Association)]: big leap. So can you talk about that?

[Katie Carroll (Care Transformation Director, AHS Office of Health Care Reform)]: Sure. So those ones that we listed there are ones that we are really already working on. So I mentioned the primary care work you heard about actually from Doctor. Jones and Doctor. Soraya. And then the home health and hospice work is one of the regional goals that came up from our work with hospitals. So that's another one that has come to the surface of really being implemented now. And then the mental health and substance use disorder has also come up as a regional goal. So we are kind of tying what of all the continuum of care partners that we've started engaging with already. That's kind of what you're seeing there for continuum of care partners. But there are certainly plans for us to engage across the board with the entire system as we continue to go forward. What do you

[Rep. Leslie Goldman]: mean by continuum of care?

[Katie Carroll (Care Transformation Director, AHS Office of Health Care Reform)]: So help me understand that. So when we say continuum of care, we just really mean the whole system, system wide expansion of this work. So including every type of provider, community providers, everyone who's really contributing to the care of Vermonters and really thinking about how they each are going to play a role in how we're transforming the system as we move forward.

[Chair Alyssa Black]: Yeah, go ahead. No, I'm sorry.

[Greg Jones (Contractor assisting AHS with transformation efforts)]: I was just going to say, I think, too, what's important here, these categories that you see up there are ones that emerge from hospitals as key priorities among that continuum that need to be enhanced in order for them to be able to operate more efficiently. So for instance, all the people that are in the emergency rooms with mental health problems and there's nowhere to go, there needs to be a focused effort on expanding mental health services outside the hospital so these folks can transition. The underutilization of hospice has been identified by hospitals as a key problem, they see the things that could be done outside the hospital. All of these have to do with expanding care in the community, actually will assist hospitals in delivering the care they need to do, but not having the people that don't need to be in the hospital in there. And moving care out of the hospital. And these are just some of the priorities that emerged in those plans. But this bucket is not meant to represent to your point, the full continuum.

[Rep. Leslie Goldman]: Thank you because it's

[Chair Alyssa Black]: not a continuum.

[Greg Jones (Contractor assisting AHS with transformation efforts)]: No, but the process, and this is, I would say Katie's done an incredible job leading all the hospitals through a very complex These are examples of changes hospitals say need to be made this year, that they're willing to work on this year right now, in order to move people into a more appropriate setting of care. So they had to pick priorities among themselves and groups of hospitals, and these are the ones that merged out of the continuum. Does that help? Okay.

[Katie Carroll (Care Transformation Director, AHS Office of Health Care Reform)]: Okay, great. So we're gonna move into talking about what the hospitals have in their plans based on these themes. So we brought in some themes of shared services, moving care out of hospitals, optimizing care needs and resource allocation, and restructuring service profiles. This does not encompass everything that's in the plan. So we did provide to you all a full list of by hospital, what they have in their current plans and their current thinking. So that is available to you all as well. But we really wanted to make sure that we were talking about those goals and what they're really going to move forward as far as affordability and access and quality as we're thinking about this work and bringing all those pieces together.

[Greg Jones (Contractor assisting AHS with transformation efforts)]: Yeah, thanks. Advanced analytics, and we may have mentioned this last week, but I wanna reinforce it, that emerged from virtually all hospitals as a need that they have in order to understand how to reconfigure their operations, reconfigure their business and administrative strategies, maybe shared business administrative strategies, which Katie will talk to, what clinical services should be prioritized, They need really robust advanced analytics to do that type of optimization and scenario modeling. And that's the work that Kate just buckets referring to up here. So underway is a contracting process for what is an incredibly robust advanced analytics, which every hospital has asked for to assist them in finalizing these plans. I just wanna highlight that bucket. It's a need that especially the smaller hospitals have.

[Katie Carroll (Care Transformation Director, AHS Office of Health Care Reform)]: Thanks Greg. And yeah, moving forward, will really be able to quantify more of this work, which I think will be helpful to all of us as we're talking about it. So our first theme is shared services to create back end efficiencies. So I kind of referenced on the first side some early wins as far as really saving money and leading toward affordability. This is really where we see some of those early wins for hospitals in their budgets and in their efficiencies. So as you can see, many hospitals are engaging in either existing networks or just with agreements between each other and thinking about shared purchasing and shared administrative and non clinical services. So that's really where they can share one insurance pool for their employees and save money there and really realize some savings in the shorter term. There's also opportunities for shared clinical staffing that have started to come up in certain regions, and there's a lot expansion in expanding that as well, where one provider can work across multiple hospital settings and really share that improving access, but also if it's a savings there as well. And shared technology infrastructure, this we've talked about previously, and this is one of those places where there are RHT funding opportunities for us to plug into this. So there are some really good connections there, as Doctor. Joseph mentioned. Pursuing shared electronic health records and that interoperability and all of the opportunities for efficiencies there, like reduction of duplicative imaging, duplicative diagnostic tests that need to happen, really being able to streamline that. There's a lot of opportunities for savings there as well.

[Greg Jones (Contractor assisting AHS with transformation efforts)]: And we just briefly mentioned last week too, New England Collaborative is one example of a shared services purchasing intermediary group that's come together and they are steadily increasing the scope of the shared services that they're offering to the participants across the state. Something to keep an eye on.

[Chair Alyssa Black]: I think I'm gonna ask a question about it. I see you, Allen. We have been talking about this for years and years and years, and it has been in the works for years and years and years. I mean, I don't want to like, I hear representatives McFaun next to me. Why is it in the initiation phase?

[Katie Carroll (Care Transformation Director, AHS Office of Health Care Reform)]: Are you speaking just to the shared I'm just about the infrastructure? Why

[Chair Alyssa Black]: have we not finished this yet?

[Rep. Allen "Penny" Demar]: Can I

[Chair Alyssa Black]: help you? Yes, please.

[Unidentified Committee Member]: Yeah, no, and again, I think

[Greg Jones (Contractor assisting AHS with transformation efforts)]: we did touch on this last week, but I want to really, I can't emphasize it enough. It is the changes that have come into play in the last one to two years that are driving it to fruition in a way that wasn't driven before.

[Rep. Leslie Goldman]: Are you talking about act one sixty seven?

[Greg Jones (Contractor assisting AHS with transformation efforts)]: So guiding legislation, the act one sixty seven, act 68 is one of the levers and it really started and drove this work, but it's not alone. The financial pressures that hospitals are under are causing them to engage in a way that previously wasn't done. Frankly, Vermont's cost of insurance, the highest in the nation and the affordability crisis and the responding increase in regulatory pressures from the Green Mountain Care Board and DFR are another lever. It's different now than it was even a year, let alone two years ago. Leadership changes, UVM, Blue Cross, it's changing, the engagement is different. The hospitals are realizing that the autonomy and the way that things have operated for so long, it's an absolutely fair question, isn't working for them financially anymore, especially with the downward pressure, the regulatory pressure on their budgets. And so they have entered into this transformation work in a different environment than was previously there. You've asked this and it's a good question, why hasn't this all been done before? It's because the pressures today are different than they were even two years ago.

[Chair Alyssa Black]: I guess I'm thinking in my head about Vital and what's Vital been doing for all these years.

[Unidentified Committee Member]: Yeah, no, it's

[Chair Alyssa Black]: I mean, and the warp speed that we have with AI now, this doesn't seem like this is a hard problem to solve.

[Greg Jones (Contractor assisting AHS with transformation efforts)]: It's a really good question on interoperability vital technology front. And I'll tell you literally today, took someone to help somebody with a doctor visit, had surgery a couple of weeks ago. They've been in four different places in the last two weeks, a private GI clinic in Colchester, surgery in St. Albans, UVM primary care, and there was one I forget where none of them, oh, the pathology was, none of them have the complete records of what happened, not one, not one of those sites. So the interoperability environment in Vermont right now is not working well and all but one hospital leader, all but one in a survey that Katie's team put out, answered that the aunt responded that they were extremely interested in interoperability through a common EHR platform because it isn't working today. So redundant tests, delays in getting care, all are being contributed to by our problem, let alone transfer care coordination across hospitals, management of their bed space, all of those things are being influenced because we don't have the interoperability. So these technology platforms, they view the hospital leadership, view as a solution.

[Chair Alyssa Black]: Allen, did you have one?

[Rep. Allen "Penny" Demar]: I have a question, you've got these groups, North Medical Center, but these hospitals, are they part of this transformation now? So they are all aware?

[Katie Carroll (Care Transformation Director, AHS Office of Health Care Reform)]: Yeah, so all of this work is based off work we have done with the hospital, so we are meeting with all the hospital leaders to come up with these goals. So we've got really good engagement from all hospitals.

[Greg Jones (Contractor assisting AHS with transformation efforts)]: And all 14 have submitted. What you're seeing is here a response of what they've actually submitted.

[Rep. Leslie Goldman]: So can I ask you a question? You may not want to answer it.

[Dr. Tina Keshava (President, Vermont Optometric Association)]: So I'm giving you an Do

[Rep. Leslie Goldman]: you think Vermont needs 14 hospitals?

[Greg Jones (Contractor assisting AHS with transformation efforts)]: I'll give you my personal opinion, and it's changing as deeper I get into this work, because I understand the Oliver Wyman report and the push to maybe we don't need 14 hospitals. And what I've come to understand in-depth going through this last process over the year is it's not a matter of whether we need 14 hospitals or not, I'll tell you why. You could have closed all four hospitals that were mentioned in the Oliver Wyman report, and the very next day, every one of those people would have been getting services either at Dartmouth or at UVM and maybe even increase the costs, that wasn't the answer. What comes out is that the configuration of the hospitals needs to be altered. And that is exactly the work that Katie's leading. So maybe we don't need all of the acute inpatient beds at a hospital, maybe we need more geriatric psych, which is in short. There are waiting lines for adult psych inpatient, there's unused beds in adolescent down in the Southeast corner of the state. It's configuration and getting to the optimized profile of what the services are at the hospitals. And that is exactly what this work is driving towards and what the advanced analytics is gonna help.

[Chair Alyssa Black]: Can I ask another question? Yes.

[Rep. Leslie Goldman]: So how do you engage the boards of hospitals, who I think are the drivers of a lot of what happens? They hire the CEOs, which then operationalize their views. Come from the Southeast, just so you know, I come from the Southeast part of

[Chair Alyssa Black]: the state. There's a lot

[Rep. Leslie Goldman]: of supply of hospitals down there. And one we know is practically going bankrupt, and another already did go bankrupt. So that's where I'm coming from. How do we really address that?

[Chair Alyssa Black]: All right. And do you want

[Greg Jones (Contractor assisting AHS with transformation efforts)]: to jump in? You go ahead. So both Los Angeles are part of this program. And they are both undergoing in-depth review of how to optimize their configuration to meet the needs in their community and be financially viable. It's a complex process. They're engaged.

[Rep. Leslie Goldman]: I'm not saying Brattleboro over there.

[Greg Jones (Contractor assisting AHS with transformation efforts)]: There's other Other slides. Yeah. She has other slides. Yeah. She's got but the answer to your question in the Southeast, for example, is there is a robust engagement around considering how to optimize the mental health profile in the whole region. And so beds may change and be used and shifted in a different way. Would it be better to close the facility or would it be better to actually change the services offered? The repurpose was the word that came up. And very that reasonable.

[Rep. Leslie Goldman]: I mean, thoughtful, but I haven't seen it happen in the two years that I mean, I keep hearing the same thing coming from the hospitals in my area.

[Greg Jones (Contractor assisting AHS with transformation efforts)]: They are actively involved now. I will tell you last summer when secretary Samuelson, or actually earlier asked if I would come on, Katie wasn't on yet, and just help the team through this work. That art of repurposing and actually going through the advanced work to do it, not, the hospitals weren't as actively yet engaged in it. There was a different contractor in place trying to lead that. They are now very engaged. And the last six to seven months have seen a completely different energy in this repurposing and restructuring that case.

[Katie Carroll (Care Transformation Director, AHS Office of Health Care Reform)]: Yeah, and a lot of that is the advanced analytics is going to allow us to do some of that scenario modeling of if these beds changed in this way, would that help us solve these problems? What would that mean financially? What would that mean for access? So that's really going to allow us to really push some of those decisions with some data driven insights for them. So I think that'll be really important, especially for those small hospitals that don't have as many resources to really do that themselves.

[Greg Jones (Contractor assisting AHS with transformation efforts)]: And Chair Black's question, you've asked this the two times I've been ignorant, you've asked that question and I appreciate it because why? You

[Chair Alyssa Black]: are absolutely I gotta keep asking.

[Greg Jones (Contractor assisting AHS with transformation efforts)]: No, and I think I mentioned last week, there's a little bit of an eye on the ball problem over the last few years in how this was pushed, the legislation comes passed, the Oliver Wyman report, all these other forces that have come into play have led to a different level of activity now. That's the honest answer to your question, why now?

[Katie Carroll (Care Transformation Director, AHS Office of Health Care Reform)]: Yeah, and I do think we're optimistic that we will be able to move some of these really big things that we've been talking about as a state for a long time forward because of all of those factors that Doctor. Jones mentioned.

[Rep. Leslie Goldman]: You got

[Dr. Tina Keshava (President, Vermont Optometric Association)]: a chunk

[Rep. Leslie Goldman]: of change. Yeah, right.

[Chair Alyssa Black]: I'm not convinced. Yeah.

[Unidentified Committee Member]: Oh, come on. Let's be optimistic. You do that.

[Greg Jones (Contractor assisting AHS with transformation efforts)]: It is an incredible opportunity. It

[Dr. Greenberg (Chair, Vermont Board of Medical Practice; Emergency Physician)]: can be.

[Katie Carroll (Care Transformation Director, AHS Office of Health Care Reform)]: Think there are elements that felt like they came at a good time because this conversation about these specific things were happening prior to that coming into play. So I think there was already some good energy and some good planning around what that would look like. So I think there are some good opportunities amidst maybe some other things that must be more challenging. Some of these other themes, so moving care to more appropriate lower cost settings. Many hospitals, again, are engaging in this and there's many examples we could talk about. I think just for the sake of time, I'll call out the expanded mobile integrated health programs that again overlaps with a funding opportunity, but it's a really great way to move care out of the hospital, especially for patients with COPD or CHF that are using hospital a lot. And there's a big cost savings as well

[Rep. Leslie Goldman]: as big convenience for patients. A question about that, because from what I understand, there's no reimbursement associated with that work. So then what?

[Greg Jones (Contractor assisting AHS with transformation efforts)]: Yeah, I've been in that planning too. What's being done right now is there is active work on a planning process for payment model to sustain mobile integrated health. The rural funds, they're short term, they're viewed as investment upfront that allows operations to be set up that nobody had the money to set them before, but Diva is actively working on a payments model and that can help sustain it because as you probably well know, given your experience, Brattleboro's program has been paid for out of grants and they've been sustained that way, but it's not sustainable. So you're right, and the answer is there is a payment model being worked on to sustain this after the rural fund investments allow the setup of the operations.

[Rep. Leslie Goldman]: So year one, five.

[Greg Jones (Contractor assisting AHS with transformation efforts)]: Yeah, that's under construction. And I would hate to get ahead of the team, but everybody is working off the same timeline of what you know, the rural funds will help with. So I wanna, and by the way, that is a great example of a part of the continuum of care that hasn't received a lot of attention before. Back to your point.

[Katie Carroll (Care Transformation Director, AHS Office of Health Care Reform)]: So optimizing care needs and resource allocation. This is a topic that came up in our regional convenings early on, and we've been talking about for a while, thinking about statewide bed tracking and transfer coordination is a huge opportunity across the state that also has a technology component that is also part of the RHD funding opportunity. So there's some big opportunities there. I also wanted to just call out that there's many hospitals that are actually making improvements in this already. So improving the process to move patients back to their home hospitals. We're really good at transferring patients that really need care, tertiary care center, but then there wasn't really good processes in place to then move them back when they no longer needed that care but still needed to be in a hospital. So many hospitals have really been working on that for some early wins around really improving where they're getting care, getting patients closer to home and also realizing some cost savings there as well. And this is our last slide, so I'll just go to the last one. It's restructuring service profiles. Oh, go ahead. Sorry. Can I ask

[Chair Alyssa Black]: you a question about the last one, because so somebody would have to make the slide go backwards? I'm sorry. See it.

[Katie Carroll (Care Transformation Director, AHS Office of Health Care Reform)]: There we go. Sorry.

[Chair Alyssa Black]: Moving patients back to their home hospitals lower cost. One of the reasons I asked you to come in to talk about hospital transformation is we are faced with this dilemma, which we are going to have robust committee discussion tomorrow about on 01/1989. And the impetus for 01/1989 was Rutland. And you're working with them. And Rutland is up there as one of the ones of moving patients back and forth to their home hospital or lower cost hospital. So you're doing this work. AHS is doing this work. Aren't you in the best position to

[Greg Jones (Contractor assisting AHS with transformation efforts)]: be

[Chair Alyssa Black]: making this? I know, I'm not trying to put you on the spot, but you're already making these decisions or you're coordinating. If we want this to succeed, if we want hospitals to have a role in their own transformation, and of course we can argue whether or not that's a good idea,

[Rep. Leslie Goldman]: but

[Chair Alyssa Black]: aren't you gonna mess all of this stuff up if you don't have a input on whether or not someone can summarily just pull the rug out from Gifford and VRH and DMH?

[Katie Carroll (Care Transformation Director, AHS Office of Health Care Reform)]: So I think that the way that we view this work is that we would be in a good position to provide the analysis and provide the insight from this work that we're doing. I think that what we have experienced in our conversations with Rutland is that there's a lot more to that process of actually removing a service and bringing in public comment and bringing in all of those additional pieces that we are just as a team not set up to handle. And so I think that's We definitely would want to have a say. We want this advanced analytics informing everyone and for everyone to be able to use it to really think about what our health system should look like and make the decisions. We are using that to help hospitals make decisions and could make sure that information was available. But I think it's just it's a much bigger body of work that I think is not something that we currently would be able to take on, is more how I view it.

[Greg Jones (Contractor assisting AHS with transformation efforts)]: And I can add a little piece onto that. So the interesting thing, as Katie said, when we really dig into the pediatric service profile, was a lot of information that emerges in terms of what's needed, what would be the consequences, the impacts. And there are very different bodies of thought depending as you would imagine, who you would talk to, whether it's hospital leadership or the pediatric providers that are in the community. There are different perceptions about how this came about, there's frankly trust issues. So one of the roles that has emerged in this transformation work with Rutland is to surface those issues and then present it back to the participants and in doing so, try and move them into thinking about a broader pediatric transformation plan. So closing beds is not a transformation plan, could be a hospital optimization plan, it can improve financials, but in and of itself is not a transformation plan for how you're gonna improve pediatric services across a region like in REPL. So there are ways in which right now actively Katie and the team have been involved in trying to move the discussion into development of a broader and more complete pediatric transformation plan. And if you think about what was in Act 68, the language that was in Act 68 last year, it mentioned that hospitals could not have to go to the Green Mountain Care Board as long as their work was part of a transformation plan. So this is right now where both the legislation and the activity of what's going on with AHS are in play. And that is trying to surface information, open the door, bring in insights and analytics, talk to all the players and try and move toward a more complete transformation plan. In this case, it's around pediatric services. That's the state of play right now, given all those elements are in play. Does that make sense to you?

[Chair Alyssa Black]: It does, I didn't mean to derail you. I think let's move on to the, get through the last slide.

[Rep. Leslie Goldman]: And so this actually does get to- If you wanna hold your question, Leslie.

[Greg Jones (Contractor assisting AHS with transformation efforts)]: I'll hold

[Rep. Leslie Goldman]: it, but I wanna ask it. Thank you. So

[Katie Carroll (Care Transformation Director, AHS Office of Health Care Reform)]: I think this is a lot of questions obviously have been asked about hospitals are considering service lines, so exactly related to what you're just asking about. And so, we did just want to call out that is work that we're doing. Many hospitals are assessing service lines and really thinking about what makes sense. Again, referencing advanced analytics and really thinking, trying to be thoughtful about what makes sense for service lines and alignment across the state. So we just wanted to call that out as a body of work. There's not anything that's ready at the implementation phase, but it's a big part of this work that we're considering as we

[Chair Alyssa Black]: move forward. I have a lot

[Rep. Leslie Goldman]: of slides. So understanding that you want to have people move closer to home as they improve out of maybe higher cost places, but what if the quality at the place you want to move them to is good the place that they're at? And is that being addressed? I mean, I'm looking at Medicare ratings and some of them aren't that great. And I'm wondering how in your work you're addressing the low quality perhaps places and asking patients to go to places that are lower quality. And that doesn't seem right to me.

[Katie Carroll (Care Transformation Director, AHS Office of Health Care Reform)]: Yeah, I think that each hospital manages that process in their own way, but there's a very clear process of what types of patients can move out of those settings and what types of needs they might have to ensure their needs would still be met. I don't know if you want to add some more from like more quality perspective.

[Greg Jones (Contractor assisting AHS with transformation efforts)]: Yeah, mean, you're absolutely right. We're not doing very well on our star ratings right now and a number of the CMS safety and patient safety ratings. So that is absolutely a need that needs to be addressed in transformation. And so there are several levels, one is the ability to measure and have more real time or closer to real time information to help guide quality teams. The second is when it comes to payment and through the regulatory process, there could be requirements around safety and quality scores, but from the transformation approach, we absolutely plan as we bring these advanced analytics in one of the layers in these scenario modeling engines are what are the current parameters around quality that includes patient safety and other elements. And what would the impacts be if you made these changes or what was needed to be done to improve these quality and safety. So we will bring it into transformation as part of the advanced analytics to help drive those discussions because right now it's a statewide issue almost. Yeah. Yeah.

[Chair Alyssa Black]: I'm gonna follow-up with you.

[Unidentified Committee Member]: I kind of have the opposite that Leslie did. Like, we had Doctor. Lueders here yesterday, and he said, Oh, we're full. Like, it's almost like they want to be full all the time. I wonder how they would buy into saying, we'll offload a couple of patients, because I think that they want to be full.

[Greg Jones (Contractor assisting AHS with transformation efforts)]: Yeah, it's interesting. So I've had this conversation with Doctor. Leffler and others, and they want to be full and I know him, he would, I'll channel him as I can. He would want to be full with the right patients who are getting the right services.

[Unidentified Committee Member]: And I'm using him as an example, but I know other hospitals feel the same way.

[Greg Jones (Contractor assisting AHS with transformation efforts)]: They do and so when Katie describes the, we talk about our transfer issue here, what we're really talking about is a really complex acuity management process underneath of it And so right now, can we get the patients when they need to go from a smaller hospital to a higher level of care because their acuity requires it, we're having trouble with that right now and a lot of people are having to go down to Albany and hospitals out of state because they're getting nose and Doctor. Leffler or anybody else would say, we'd rather open up the beds that we're in one under utilizing right now, so we can handle that. Well-to-do this type of acuity management, this goes back to the transfer and care coordination center that was the last line on that slide, that has been identified by hospital leadership in every hospital in the state to us as a core need, can we set up a one call, least call process where we can make sure people are being transferred based on acuity to the closest place that's delivering the right level of care. So that's what that's about, it's more about management again, than it is about yes, no.

[Unidentified Committee Member]: Because they do seem siloed this

[Unidentified Committee Member]: will right

[Greg Jones (Contractor assisting AHS with transformation efforts)]: tell you that, in fact, we've had hospital CEOs describe to us nationally, what's called a rural drive by phenomenon. There is a national rural drive by phenomenon where transfer and coordinate, they drive by small hospitals and they go to the big places in our case, Albany or down across the border into Massachusetts, Portsmouth. They'll go there first after calling Dartmouth and UVM. When they drive right by several of our hospitals that have open beds and can handle that level of acuity. So this is really about a complex care coordination, acuity management, and that is one of the rural fun, nobody's been able to create that, Dartmouth does it for its hospitals, UVM does it for its hospitals, We need a center that is doing it across all the hospitals, a little line of sight into what's open, what beds, staffing, what the acuity is, what's available, so you don't drive by three of the hospitals in your region because nobody had the time to call into them.

[Rep. Leslie Goldman]: Oh, you're worried about quality. I'm sorry. No, understand, I understand. Because I hear people say, wouldn't you touch it?

[Greg Jones (Contractor assisting AHS with transformation efforts)]: Yeah, I understand.

[Dr. Jessica McNally (President, Vermont Ophthalmological Society)]: We have to beef them up so they want to go there.

[Chair Alyssa Black]: I mean,

[Dr. Tina Keshava (President, Vermont Optometric Association)]: I think that's

[Greg Jones (Contractor assisting AHS with transformation efforts)]: actually, that's right.

[Rep. Leslie Goldman]: What does that mean to beat them up?

[Greg Jones (Contractor assisting AHS with transformation efforts)]: You know, a focus on the right services at the right place with the right resource management. Technology, it can change a lot very quickly with the right focus. And I would encourage, there was a testimony from a gentleman named Doctor. Peter Pronovos last year at the Green Mountain Care Board from the University of Cleveland Hospital System,

[Chair Alyssa Black]: big system. A lot of us watched that.

[Greg Jones (Contractor assisting AHS with transformation efforts)]: Did you? Okay, well you saw, he described what it took to change the culture and the focus, improve the quality and at the same time do the right acuity management and get people to the right place, it's doable. And we're at that inflection point that we're worried. That is the opportunity.

[Chair Alyssa Black]: Can I just because you're as you're going through these, I'm my spreadsheet, Jill, I don't I I keep looking at this? I'm thinking of all these things, and maybe Jill would be better.

[Unidentified Committee Member]: This is

[Chair Alyssa Black]: the RHT. Do you have updated ones? I love this spreadsheet. So there's this transformation analytics and support. Is that what we're talking about? So we have 15,000,000. This is going to contractors or a contract, right? Have we done the RFP? What's the status of the fund?

[Unidentified Committee Member]: I'm going to say one thing. Joe Olson and the finance director. So how I view that is that that is a way to continue the work that you've already done starting with the procurement process that happened as a result of the access to $80 So the idea and whether or not 15,000,000 is the right number, I think it's not. Remember, we're doing a lot of changing in this document. So that's the question.

[Chair Alyssa Black]: I'm glad you mentioned F-sixty eight. Can you remind us how much money has been appropriated so far to AHS for hospital transformation work? Because we've done a I will, couple yeah, I need

[Unidentified Committee Member]: to look at this. I don't have the numbers right for me, but I will send that.

[Chair Alyssa Black]: We've done a couple of recreations.

[Unidentified Committee Member]: Yes, and we have that report that you get every month that it actually outlines

[Chair Alyssa Black]: what- It'd great, great to go-

[Greg Jones (Contractor assisting AHS with transformation efforts)]: The contract's underway though.

[Unidentified Committee Member]: Yes, we're in negotiations for the analytics contract and they should have some updates on it.

[Greg Jones (Contractor assisting AHS with transformation efforts)]: And that was out of 6x of the eight months?

[Chair Alyssa Black]: Yes, yes.

[Greg Jones (Contractor assisting AHS with transformation efforts)]: Ask us to start

[Unidentified Committee Member]: with those dollars because we can't supplant state funding. So this will allow us to continue that over time, which is I think a really nice compliment to the work that we did in Act 68 and then building on that in rural health transformation, which is sort of how we try to approach rural health transformation as a tool in our toolbox of our larger effort.

[Greg Jones (Contractor assisting AHS with transformation efforts)]: So I'd just like to add onto that because of your concern and questions about the timelines. The way that contract is being worked on right now, we'll have an activity underway that will be delivering insights to these hospitals this year.

[Rep. Leslie Goldman]: What do you mean insights?

[Greg Jones (Contractor assisting AHS with transformation efforts)]: Like modeling about how their profile of services looks, how it's performing, what would happen if certain types of changes would make, if they're considering options, some of the implications be on those options for access, for drive times, for a number of different parameters, including quality. So fairly complex, this is a very advanced analytics contract. It's something the hospitals can't do on that.

[Chair Alyssa Black]: The last question, actually, is for I should have asked you this the other day. I probably should have asked you. So you are not with AHS. You're a contractor. Are you like an independent contractor or Okay. You Okay.

[Greg Jones (Contractor assisting AHS with transformation efforts)]: I retired from the group that I worked with. I was doing, as I mentioned last day, I was doing a lot of support work for centers of Medicare, the innovation center at CMS, actually on data, nationwide data aggregation programs along with their primary care models. I retired from that and then the secretary asked if I'd just help with the teams.

[Chair Alyssa Black]: Okay. So you're a contractor on the hospital transformation or the rural transformation?

[Greg Jones (Contractor assisting AHS with transformation efforts)]: I'm sort of assisting with all of it, including the primary care that we talked about.

[Chair Alyssa Black]: Okay, I was gonna say, keep coming in. Is he consulting? Okay. Thank you. You.

[Unidentified Committee Member]: Thank you

[Chair Alyssa Black]: for coming in.