Vermont Legislature SmartTranscripts:

[Rep. Alyssa Black (Chair)]: Wait, hold on one sec. We just gotta go live, Libby. Hold on. Sorry about that. Hi, welcome everybody. It is April 21, and this is House Healthcare, we are turning back to S64. And we have with us a couple of people today. We're going to start with Doctor. Libby So, thanks for joining us, Libby.

[Dr. Libby Houghton, Ophthalmologist (UVM)]: Thanks for having me, Chair. Members of the committee, thank you for the opportunity to speak with you today. My name is Libby Houghton. I'm a practicing ophthalmologist here in Vermont. I was born right up road in Berlin and grew up in Danville. My father practiced general ophthalmology in St. Johnsbury for over forty years. And part of the reason I went to medical school was so that I too could serve the community where I work and live in the way that he did for so many years. Following medical school and residency, I completed a subspecialty fellowship in ophthalmic plastic surgery, which gave me additional skills and expertise in medical and surgical treatment of diseases of the eyelids, the orbit or the eye socket and the tear drainage system. And then at long last returned to Vermont where I've been happily caring for patients and raising my family since 2015. I'm one of two oculoplastic specialists in our state. As part of my practice, I commonly remove the quote unquote lumps and bumps referred to in this bill. I always send what I remove to pathology for interpretation because although I generally have a very good idea about which lumps and lesions are benign and which are malignant or cancerous, I'm not always correct assessment. And so I put that ultimately in the hands of the experts or the pathologists in this case, because making a mistake about which lesions are benign and which are malignant can have profound implications for patients. I think it's important also to note that although these surgeries are referred to as minor procedures, for the patients on the other end of the scalpel or the laser, these procedures do not feel minor. Patients are often understandably anxious and scared to have an exquisitely sharp instrument millimeters from their eye. Their high level of anxiety is often reflected in their elevated blood pressure, we measure before every procedure to ensure that it's not too high to safely proceed. In my experience, a patient's level of anxiety does really does not correlate with the level of complexity of a surgery. Shepherding scared and anxious patients safely through these procedures takes skill, calmness and confidence on the part of the surgeon and the staff. I counsel my patients honestly about what from each procedure. The injection of lidocaine is uncommon for patients to flinch or move during this injection when the needle is one small cough away from penetrating the eye. When a patient flinches or swears or has a full on panic attack, it is essential that I remain calm and relaxed. I can do this because I have a lot of practice. Throughout my training, I provided direct patient care and performed a wide variety of supervised surgeries on real patients for up to eighty hours a week under the supervision of skilled and experienced ophthalmologists. As I'm sure you've heard, after medical school ophthalmologists spend another four to six years in residency and then sometimes in fellowship training, which is hands on supervised training on real patients. These patients are real people with real disease with whom we build therapeutic relationships and who place their trust in us as doctors and surgeons in training under the close supervision of seasoned and experienced supervising surgeons. These supervising ophthalmologists are there not only to ensure our mastery of the technical aspects of surgery, but they are also there to teach us how to think through whether surgery is the right therapeutic option to ensure that we know how to talk to patients about the purpose of the proposed surgery and the associated risks. These supervising physicians and the patients we care for teach us how to manage complications when they do occur. Learning to do surgery is not just about steady hands and mastering technical nuances and variations. Although these are imperative skills, learning to be a surgeon is about navigating all these decisions and conversations around the surgery itself. I no longer do many of the surgeries I learned as a resident because my practice really focuses on my surgical subspecialty. So a subset of those surgeries, but all the patients I cared for and all the surgery I learned during those seemingly endless days and nights as a resident provide the deep and solid surgical foundation I work from every day. A thirty two hour classroom course is simply no substitute for thousands of hours in the trenches caring for patients. Now I would like to focus on the substance and structure of S-sixty four is introduced, specifically the training and competency framework it creates for the proposed advanced therapeutic procedures specialty. My testimony here is really not about professional turf. It's about competency based training and the implications that has for patient safety, which is my primary motivation for testifying here today. Under S-sixty four, an applicant must complete at least eight hours of didactic and clinical instruction for each therapeutic procedure and perform a minimum of two supervised cases of each procedure, only two cases. In most procedural disciplines, whether surgical or medical competency is not established by exposure to just two cases. Competency is demonstrated through repetition, graduated responsibility, management of complications and formal assessment of skill. S-sixty four does not define how proficiency is evaluated. It does not require objective skill assessment. It does not specify case complexity. It does not require documentation of outcomes. These are all weaknesses of this bill. This two case threshold does not begin to capture the complexity difficulties encountered or proficiency assessment that are integral to surgical training. S64 allows the preceptor to be either an ophthalmologist or an optometrist with quote substantially similar scope end quote for at least three years. It also allows an optometrist who gets the specialty by endorsement to serve as a preceptor in Vermont. This means that a cohort of optometrists with this newly defined minimal specialty could then systematically train subsequent cohorts with no external verification of skill or outcomes. In contrast, most procedural credentialing systems require preceptors with independent validation of expertise. For example, board certification, case volume minimums, complication tracking. The bill requires only five additional hours of continuing education every two years to maintain this specialty. It does not require a minimum number of procedures per year to maintain proficiency. It does not require reevaluation of skills in a small state with limited case volume, maintenance of competency becomes a central question and is not addressed. S-sixty four includes an adverse event reporting requirement within thirty days, but it does not specify standardized definitions of adverse events, independent review, public transparency or enforcement mechanisms. Reporting alone is not the same as a safety system. A reporting duty without auditing or verification can result in these no reported complications narratives. All surgeons who perform surgery unfortunately do have complications. So I'm highly skeptical of any report or study that claims no complications. That is simply not possible. S-sixty four authorizes procedures that include injections and management of anaphylaxis. It does not define facility requirements, emergency readiness standards or transfer protocols. Finally, performing eye surgery requires providing emergency call coverage for our postoperative patients. Failure to provide emergency availability for postoperative patients is considered to be patient abandonment. When a patient starts experiencing eye pain at 1AM after surgery, they are able to pick up the phone, call or page their surgeon who can address potential postoperative emergencies. When you expand procedural authority, you also expand associated risks, complications, and responsibility. Infrastructure must expand as well to anticipate and prepare for the increased risks.

[Unidentified committee member]: This is

[Dr. Libby Houghton, Ophthalmologist (UVM)]: not addressed in this bill. In summary, when a bill authorizes new invasive procedures, the framework must ensure demonstrable competency, durable skill maintenance, transparent outcome tracking and emergency preparedness. S-sixty four lacks all of these. Again, this testimony is not about professional turf. It is about competency based training and the implications for patient safety. In my testimony here, I do not intend to imply that MDs have some innate or intrinsic ability to perform surgery or that well trained surgeons are somehow infallible. Neither is true. What we do have our skills and judgment that have been learned and honed over many years of hands on practical training with graduated responsibility and progressive autonomy based on demonstrated competence. Acquiring these skills takes a lot of practice and a lot of time. It is true that some optometrists and probably some of you have the capacity to do these procedures with the proper training. I have a good friend and colleague who initially trained as an optometrist in her native Canada, and then decided that she wanted to be an ophthalmologist and a surgeon. So she went to medical school and completed residency and fellowship training and is now an accomplished and experienced ophthalmic surgeon. I would gladly send a family member to her if they needed surgery because she has had the training required to make the judgment, perform the surgery and manage any potential complications that ensue. I think that this is an appropriate training pathway for someone who wants to perform eye surgery. This bill contains structural gaps that compromise patient safety, competency verification and regulatory oversight and for what does this bill truly serve the best interest of Vermonters? There has been no demonstrated surgical need. The wide gaps in this bill and lack of adequate standardized training goes to the core of whether Vermonters receive safe and high quality care. Those are the concerns before you. Thank you for your time and your consideration, and thank you for your service to our state.

[Rep. Alyssa Black (Chair)]: Thank you, Doctor. Houghton. Appreciate the testimony. Brian, you have a question?

[Rep. Brian Cina (Member)]: Are you saying that there's no amount of training or requirements that we could require for optometrists to be able to do this, and that if someone wants to do these procedures, they should train in a different profession, or are there things we can actually do to increase the training requirements so that optometrists can do it?

[Dr. Libby Houghton, Ophthalmologist (UVM)]: So I think that, like I mentioned it towards the end of my testimony, I think an appropriate pathway to become a surgeon is to go to medical school and do a surgical residency. There are plenty of examples of optometrists who have done that. The colleague I referred to is not the only one that I know who's done that.

[Rep. Brian Cina (Member)]: Are there any other professions that perform surgery besides MDs?

[Dr. Libby Houghton, Ophthalmologist (UVM)]: Dentists, there are

[Rep. Leslie Goldman (Member)]: dentists too.

[Rep. Brian Cina (Member)]: But only dentists?

[Dr. Libby Houghton, Ophthalmologist (UVM)]: I

[Rep. Brian Cina (Member)]: don't know. I honestly don't know. That's why I'm asking you.

[Rep. Alyssa Black (Chair)]: So either an MD or a DO is what you're asking? Exactly. The other profession, When

[Rep. Brian Cina (Member)]: I was a kid, I punctured my eardrum with a lollipop stick, and I know it's done. My mother had a Q tip and I didn't realize. But the point is, I had surgery done on my ear, but I don't know if it was a doctor or not. I'm trying to think who would be That's the only thing I can think of, maybe that person wasn't a doctor, but I think they were.

[Dr. Libby Houghton, Ophthalmologist (UVM)]: If it was done in this country, that person was

[Rep. Alyssa Black (Chair)]: a doctor.

[Rep. Brian Cina (Member)]: Okay, so then that's not an exception either. I'm just trying to think of any possible exception. And the reason, my motive is just to see if we're creating an anomaly here, with this one protection, that's all. I almost shouted that

[Rep. Alyssa Black (Chair)]: off the barber, but that was

[Rep. Brian Cina (Member)]: In the 1700s. Okay.

[Rep. Alyssa Black (Chair)]: I guess we'd have to think about that.

[Rep. Brian Cina (Member)]: Are dentists, they're not MDs, they're DVs, yes. They're based surgery. But it's a similar level of training, right? For dentists, they go to serious school for a long time.

[Dr. Libby Houghton, Ophthalmologist (UVM)]: They go to dent I mean, I'm not an expert on dental training, but from what I understand they And there was no dental school at my medical school because sometimes there are dental schools and medical schools together and they do some of their coursework together. But from what I understand, they do their, you know, dentistry degree and then they do a residency. And then some of them go on to do more advanced surgeries maxillofacial surgery and they do traditional training in order to do that. That's more invasive surgery.

[Rep. Alyssa Black (Chair)]: Patient surgeons.

[Dr. Libby Houghton, Ophthalmologist (UVM)]: Guess one other example that just occurred to me would be podiatrists. They operate on feet, but I don't know their scope of practice or what their training entails honestly, but they do surgery and they're not medical doctors. Like they haven't gone to medical school or osteopathic medical school.

[Rep. Alyssa Black (Chair)]: Do they do invasives? I mean, like, subcutaneous? Oh, they do. Okay. Are you all set, Brian? Oh, yeah. Okay.

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

[Rep. Alyssa Black (Chair)]: I had a question you reminded me when you were talking about putting a needle millimeters from an eyeball. Thank you for that, by the way. I've only had one eye surgery, and I think that one of the standard protocols was to prescribe Valium beforehand. What schedule is that? It's a benzo, right?

[Dr. Libby Houghton, Ophthalmologist (UVM)]: Yeah, that's a controlled substance. And so, I mean, I do procedures in the office. So the removal of these lumps and lesions and other eyelids, like most of a lot of the eyelid surgery I do is in the office without any anesthesia. And I actually usually don't prescribe benzodiazepine that usually it's what I call verbal anesthesia, like talking the patient through it and really reassuring them because it is true that when people come in, they are very nervous and I think it's totally normal to be nervous because it's nerve wracking having somebody work so close to your eye. And so it really the only time I prescribe a benzodiazepine is if I get an explicit request from a patient prior to the day of, and they've taken for, you know, like elderly patients, for example, not, I don't want to prescribe the benzodiazepine for the first time in an elderly patient because I don't want them to go home and then, you know, fall down the stairs or something like that. So yeah, I usually do all these procedures in my office without any benzodiazepine, but it is possible to prescribe those.

[Rep. Alyssa Black (Chair)]: I was just wondering if optometrists within their current scope would be able to prescribe schedule for Did you have a question, Brian?

[Rep. Brian Cina (Member)]: Yeah, it's in that vein because you said that you don't use anesthesia. Do you use topical anesthesia though or local anesthesia? Yes,

[Dr. Libby Houghton, Ophthalmologist (UVM)]: I use local anesthesia. It's topical than local. Yeah. For really everything, but they feel that. That's the part that really hurts is the injection of the local anesthetic.

[Rep. Brian Cina (Member)]: It's similar to the dentist, how they'll put a topical and then they put the giant needle into your jaw. Are optometrists, are they authorized currently to do anesthesia like that, local and topical?

[Dr. Libby Houghton, Ophthalmologist (UVM)]: Topical, yes, because we use topical drops to numb the skin, but injections, no. And that's the dangerous part, is the injection.

[Rep. Brian Cina (Member)]: And there's no amount of training that we could require that would convince you that it was okay for them to do it without them going to medical school?

[Dr. Libby Houghton, Ophthalmologist (UVM)]: I mean, I think that what is being proposed here is really inadequate. And, you know, I've heard, I've listened to some testimony and so I understand, you know, there are hours of didactics, meaning like classroom instruction about these things. But I think what's really unique about residency training, and it's hard to convey sort of the intensity of residency training is that, I mean, we do a lot of classroom training in medical school and some in residency, but then residency is really, it is taking care of patients almost all the time. And so it's incredibly high volume, high acuity. It's like drinking from a fire hose, honestly. It's like, especially in the beginning, the first six months are quite overwhelming because of, you know, what the, we're learning so much so fast. But I think there is really no substitute for that clinical experience and learning within that context. And as far as I understand from optometry school, that there is not an equivalent to that. And not like a weekend course, it's really patients. Like when I was a resident, we had a resident clinic where we saw, we had our own panel of patients, we saw those patients, we took care of those patients. And so I got to know those patients over the course of my residency and had like a relationship with them and talked to them a lot before, both before and after any procedures they might have had or surgeries they may have had. And I think there's not a substitute for that kind of hands on learning because it's like the real world just introduces all of these variables that are difficult to capture in like a really controlled classroom or simulation setting. Because there are all kinds of people in the world and all kinds of scenarios, and so it really takes a lot of practice to work through those scenarios.

[Rep. Brian Cina (Member)]: I get your point. It's not the same, but I can relate because I'm a clinical social worker. And to get our master's degree, we have to get a certain amount of internship time with clinical supervision. But then to get the license, it's very arduous. It's like two years of full time work supervised with weekly supervision and your supervisor's always around. And I know it's not the same, but I can relate with what you're saying about what you get from a residency versus classroom training. And so I just wanna acknowledge that I hear you.

[Rep. Alyssa Black (Chair)]: I have Dave and then Leslie.

[Unidentified committee member ‘Dave’]: Doctor, is any of the procedures in this field that an optometrist would be able to perform, is every one of them you feel that with training they wouldn't be able to perform?

[Dr. Libby Houghton, Ophthalmologist (UVM)]: I think the current proposed procedures are not appropriate for optometrists perform.

[Unidentified committee member ‘Dave’]: So you don't think no matter what training they have that they would be able to perform these?

[Dr. Libby Houghton, Ophthalmologist (UVM)]: No, I mean, like I said, I think that with appropriate training that many people could. I think some of you could, if you went through the appropriate training avenue. I do. It's like there's no getting around doing that work, is what I would say, in order to do these in a way that is like safe. And so in order to do surgery, you know, it requires certain steps. I mean, this is it's important, it's delicate, it can do real damage. And so I think requiring rigorous training, rigorous and appropriate medical training and surgical training is not too much to ask because I think the stakes are high.

[Unidentified committee member ‘Dave’]: Yeah. I appreciate the confidence in the committee being able to perform these surgeries. But I think an optometrist for the training would be much better off.

[Dr. Libby Houghton, Ophthalmologist (UVM)]: I just mean that I wasn't born knowing how to do surgery, you know, in fact, I didn't even know that I wanted to be a surgeon when I went to medical school, but there's a pathway for that. There's like a pathway to learn how to be a surgeon, and if with the will and the propensity, the hard work, and, you know, people can do it. It's not something that any of us are born with. Certainly some people have steadier hands and the, you know, maybe the stomach for it more than others, but it's like they're learned skills. And I just think that like a pathway does exist for people to become surgeons. And, you know, I would encourage anybody who wants to become a surgeon to follow that path, to follow that dream, you know, that pathway exists.

[Unidentified committee member ‘Dave’]: Thank you.

[Rep. Alyssa Black (Chair)]: Leslie? Thank you, Doctor. Houghton.

[Rep. Leslie Goldman (Member)]: I appreciate it. So I'm looking at the list of sort of permitted procedures and also the list of not permitted procedures. And the list of not permitted procedures has 23 items, which is pretty long of sort of containing or guardrails, let's say, on what can be done. So, of the list that can be done, You're still saying that you don't feel like that's reasonable Can given the you help me understand, in your training, you became a surgeon. My idea of that training is you did some general surgery and then went on to ophthalmology. So how much was focused specifically on ophthalmology?

[Dr. Libby Houghton, Ophthalmologist (UVM)]: So I did four years, I actually took an extra year in medical school to do research. So I did five years in medical school and then I did a year of internship and my internship actually was not a surgical internship, but it's different now. So I took care of all kinds of patients in the ICU, there were procedures involved in my internship. Now they're more tailored to ophthalmology. And then I did three years of ophthalmology residency and I did one year of subspecialty fellowship training in my particular area of expertise.

[Rep. Leslie Goldman (Member)]: Okay, so it sounds like four years, that's great.

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

[Rep. Leslie Goldman (Member)]: the things I think that is partly driving this bill was the concerns about access. So we learned that there are one and sixty hundred eight optometrists and 32 ophthalmologists in Vermont. And the rural areas particularly have difficulty having access. So that's a concern. And just wondering what your thoughts are about access in the rural areas.

[Dr. Libby Houghton, Ophthalmologist (UVM)]: Yeah, I mean, I grew up in a rural area of Vermont. And so I am very sensitive to those concerns. And I really like where I work because I can serve Vermonters from all parts of Vermont and feel like I do. You know, our state is not very big. So I think that peopleI think that there was alike part of the OPR study actually, I think, showed that there's ophthalmologists within a reasonable drive of most communities in Vermont and whether that, you know, that probably includes Dartmouth too, kind of East of the greens. And I can tell you, you know, I review referrals all the time about these lumps and lesions so that I can expedite anyone who needs expedited treatment in terms of removal of lesions. So I don't necessarily think there's an access issue when it comes to ophthalmic surgery in Vermont. And I also, it disturbs me in some ways to use that as a rationale, because then it means that people who are in these more rural places who don't have as much access in general to services that it's okay for them to have, you know, surgery done by people who are not as well trained. And I don't agree. I really believe that all Vermonters deserve access to well trained surgeons.

[Rep. Alyssa Black (Chair)]: Thanks. Speaking of access, because I've been thinking about this with a little bit of the a couple of the people that we've had testify. And I'm only going from experience from years ago. You're an ophthalmologist at UVM, correct?

[Dr. Libby Houghton, Ophthalmologist (UVM)]: Correct. Yes.

[Rep. Alyssa Black (Chair)]: And I don't know if other parts of the state have this, but like when Doctor. Greenberg said, we were always taught, don't touch the eyes, basically don't touch the eyes. Isn't there like an on call ophthalmologist group that pretty much sees anybody

[Rep. Leslie Goldman (Member)]: kind of

[Rep. Alyssa Black (Chair)]: in an emergency? Just always remember there was some special number that you just called the eye people.

[Dr. Libby Houghton, Ophthalmologist (UVM)]: Well, I mean, do take call. I would say that most ophthalmologists in private practice, they take call for their own patient. So if you're a patient in that practice and you have an emergency, you can call their paging operator, their call service, and they'll page whoever's on call for that practice. If somebody is not an established patient somewhere, then they're having an eye problem, then they need to go through the emergency room. A lot of those emergency rooms don't have ophthalmologists on call. So that falls to the five of us at UVM who take general call. So we cover a very wide range of hospitals in Vermont and New York, patients who have emergencies. It's different when somebody's had a surgery and that it's not necessarily the person on call who covers that, it's the person who did the surgery. For example, like one of my postoperative patients was having trouble over the weekend. And so the paging operator calls me directly, even though I'm not on call. And I want them to do that because that's my patient. I know the surgery they've had. I know them, and so I then arranged to see that patient. So there are nuances to the call system and it is really not, that's what I meant by call coverage. Like if you've done surgery on a patient, then it's your responsibility to that patient. You can't just say, Oh, I did surgery on this patient, if that's having problems and now I'm not available, go to UVM. Like that's what's, that would be considered patient abandonment. Once you've operated on a patient, you have an obligation to care for

[Rep. Leslie Goldman (Member)]: them. Thank

[Rep. Alyssa Black (Chair)]: you. Any other questions? I'm realizing I'm probably pronouncing your name. Is it Houghton? Doctor. Houghton? Yeah, that's right. Okay. I think I might have done Howell earlier.

[Dr. Libby Houghton, Ophthalmologist (UVM)]: That's okay. I didn't notice. Thank you so much for joining

[Rep. Alyssa Black (Chair)]: us, Doctor. Houghton, now that I have it correct. Thank you. Really appreciate your time.

[Dr. Libby Houghton, Ophthalmologist (UVM)]: Thanks for having me.

[Rep. Alyssa Black (Chair)]: Great. And I really have to get better with my enunciation of things. Nate? Leitheizer? My Leitheizer?

[Dr. Nate Lighthizer, Oklahoma College of Optometry (Dean)]: That is correct, Leitheizer. But I'm known as Doctor. Nate at our College of Optometry because Leitheizer is just too difficult. You can call me Nate or Doctor. Nate.

[Rep. Alyssa Black (Chair)]: Hi, Doctor. Nate. Thank you for joining us today.

[Dr. Nate Lighthizer, Oklahoma College of Optometry (Dean)]: Yeah, thank you for having me. Appreciate the committee taking some time to hear this important bill. So my name is, doctor Nate Lueders. I am an optometrist, and faculty member, at the Oklahoma College of Optometry down here in, in Tahlequah, Oklahoma, about an hour to the East of Tulsa. I have been here for approximately seventeen years. I'm actually a North Dakota boy, born and raised in North Dakota. Did my optometry school training, my four years of optometry school in Oregon. That's where I did my four years of optometry school. And then I did my residency in Oklahoma back in 02/2010, where I was trained in a variety of things, laser procedures and surgical procedures. So I've been down here since 2009, served in a variety of roles and I currently serve as the Dean of our College of Optometry. So I've been asked to give my perspective. I sit in it as a unique perspective, obviously being at a College of optometry for the last seventeen years, being very familiar with what is taught in curriculums across optometry schools. But as you guys all know, education does not stop the day you graduate. We are lifelong learners. We continue to learn after you graduate. So there is education that continues post graduation. We have to get continuing medical education or continuing education called CME or CE after you graduate. I've been fortunate, I have lectured in 49 of the 50 states on laser procedures and surgical procedures for doctors after they graduate. So they're done with their formal training. They're done with their four years of optometry school and they have to get continuing education. And again, laser procedures, surgical procedures are a And big part of I had what's called the advanced procedures course or the laser and surgical procedures course. You heard doctor Houghton mention that, you know, a thirty two hour course, the advanced procedures course is the thirty two hour course that has been part of the training to train every optometrist in Oklahoma, Kentucky, Louisiana, Arkansas, Mississippi, Wyoming. I'll show you the states that current authorize laser procedures and injections into the eyelids here in just a second. So I have a lot of knowledge for education while in optometry school and a lot of experience in educating doctors after optometry school through continuing medical education and through training courses for laser and surgical procedures. I'm gonna share my screen, is that okay? Sure. Can I share my slides? Yep. Alright. I'm gonna send a request, and we'll see here. Perfect. Can you guys see my slides here?

[Rep. Brian Cina (Member)]: Now we can. We saw your beach for a second.

[Dr. Nate Lighthizer, Oklahoma College of Optometry (Dean)]: No. Don't the beach will be the next presentation. Does that sound okay?

[Rep. Alyssa Black (Chair)]: Thank you.

[Dr. Nate Lighthizer, Oklahoma College of Optometry (Dean)]: Alright. So you guys can see the in office procedures I just talked about myself there. There are currently 16 states across The United States that authorize optometrists to perform laser procedures. You can see the list of these states right there. Kansas became state 15 and Tennessee is state 16. They just passed their law within the last couple of weeks. So certainly you can see an evolution of optometry doing more and more procedures, more and more surgical procedures across The United States. I would argue there are numerous providers other than surgeons that are doing office based procedures or surgery. How do you define surgery? I'm guessing all of you would agree there's a difference between heart surgery and removing a skin tag in somebody's armpit. Primary care physicians will do surgery. Dentists will do surgery. Podiatrists will do surgery. While Doctor. Houghton was talking, I was looking online. Advanced nurse practitioners will do surgery. Again, are they doing heart surgery? Absolutely not. Or brain surgery? Absolutely not. Optometrists are doing surgical procedures. We have surgical procedures like punctal plugs and removing foreign bodies. Somebody is grinding metal and gets a metallic foreign body in their eye. That is a surgical code. That's an in office procedure and it's defined as a surgical code. So I would argue optometrists are already doing in office procedures or surgical procedures. Again, it all depends on how you define surgery. In terms of laser procedures that are done in the office, which is what one of the main procedures discussed in this bill, yag capsulotomy, selective laser trabeculoplasty, laser procedures like that. There are currently 16 states that authorize optometrists to do these in office procedures. When you talk about local anesthesia or injections, there are currently 22 states that authorize optometrists to do local anesthesia, to do injections of certain medications into the eyelid. I wanna be very clear, these are not injections into the eyeball. These are not what we call intravitreal injections are going into the eyeball. That's not what Vermont Optometry is asking for. This is local injections into the eyelid for a variety of eyelid procedures, whether it comes to eyelid lesions or other types of procedures. There's currently 22 states that authorize optometrists to do local anesthesia injections or steroid injections into the eyelid. So again, optometrists are doing surgical procedures, dentists are doing surgical procedures. I'll talk about my brother-in-law here in just a second there. So Vermont would not be the first, they would not be in the first 10. There is precedent here for optometrists doing these in office procedures across the nation here. So let's talk about training. Education and training, we're gonna start with in optometry school. Again, I work as the Dean of the Oklahoma College of Optometry Training, there's so much of what Doctor. Houghton said that I completely agree with. There are certainly some things that I disagree with respectfully of what she said, but many things that she said were spot on. You certainly learn, you can't learn surgery from a textbook. There's no ifs, ands, or buts. I have done thousands and thousands and thousands of laser procedures and in office surgical procedures, injections. And certainly I'm better after doing 7,000 of them than I was on my first one. You learn and you get better. I'm fortunate that I get to see a lot of procedures and second procedures and third procedures and fourth procedures in optometry school. So how do you learn these procedures? Well, during optometry school, you're gonna first learn them in the classroom. You're gonna hear professors and experts talk about the procedures, the theory on the procedures. Here's how you do them. Here's the step by step process of doing this procedure. Here are videos that we're gonna watch, dozens of videos to go through these different procedures. That's step number one. And then you're gonna go into the laboratory. Practical hands on laboratory training with model eyes, with models where you can practice injections and you can practice laser procedures and you can practice these surgical procedures again, all on models as we're learning and developing these skills to suture, to do injections, to do procedures. And then our students are, and here's a picture of our students being trained on one of the laser procedures in this bill. You can see no patient there. They've had all of the didactic training, classroom training, and now they're developing their hands on skills to do an SLT, a selective laser trabeculoplasty. You can see these are model eyes. These are model eyes developed by ophthalmology and ophthalmology trains on these model eyes as well. So both ophthalmology and optometroma, you're training on model eyes, developing your skills. And then we test them on it. The third level that we always say, we're gonna test you on this. You're gonna take classroom examinations and we're gonna do proficiencies. I graded a proficiency two hours ago of a student going through procedures and making sure they're doing the things hands on that they should. And then the last level of training is certainly going to be treating patients in clinic, doing procedures on actual patients. Our third year students and fourth year students are doing procedures on actual patients. Now we are very fortunate that we practice in Oklahoma. We have a law that allows us to do this fourth level of training. I want you guys to think about your nearest optometry school. You guys have two of them in the state of Massachusetts. They can get level number I'm gonna go back here. They can get level number one and they do. They can get level number two of training and they do. They can get level number three being tested on it and they are, but the law does not allow them in Massachusetts to do laser procedures. So when you think about it, you can't get that final level of training in clinic because the law doesn't allow that. Well, hear ophthalmology other side again saying, well, can't change the law because you don't have the proper training. Well, we can't get the proper training because the law doesn't allow it. Well, we can't change the law because you don't have the proper training. Well, you can't get the proper training because the law doesn't allow that. Well, in Oklahoma, that's not an issue for us because we have the law that allows us and we do procedures all the time. These are some pictures of our fourth year students doing laser procedures on patients under the supervision of an attending doctor, doing a laser peripheral iridotomy under the supervision of myself, and attending doctor, doing a variety of different laser procedure. You can see these are all, again, showing you the same things here, doing laser procedures, doing YAG capsulotomies, doing SLT, doing laser peripheral iridotomies. I took this photo this morning. Monday, we have laser clinic. Again, third years and fourth years and residents under the supervision of an attending doctor. Monday is laser clinic. Tuesday morning and Tuesday afternoon are OD surgery clinic. After I'm done here, I'm gonna go down to OD surgery clinic and be the attending doctor. These are students doing procedures under the supervision of attending doctors. So getting that hands on training and Doctor. Houghton was exactly right. This is how you learn this. You learn this as you do procedure one and procedure two and procedure three and procedure four and learn this. And optometry students are doing this classroom laboratory tested on it. And in Oklahoma and in the states that allow it, getting the procedures done in the clinic. There's a reason we accept students from the University of Houston and we accept students from Pacific University and we accept students from the University of Waterloo. And we are accepting our first NECO extra New England College of Optometry in May because they want to get So this hands on this picture was taken from this morning. This is Doctor. Dan Phillips. He did his training with us last year and he is a Vermont optometrist. He did dozens and dozens and dozens and dozens. This is him doing a YAG capsulotomy, the main laser procedure that optometry does. He did all kinds of them last year in Oklahoma, and now he moves to Vermont and the law does not allow them to do it. So he is fully trained on all of these levels and ready to go, but the current law does not allow him. You know, and I would respectfully disagree with Doctor. Houghton. Mean, are avenues for training. I've seen them over seventeen years other than medical school. Does Doctor. Phillips after doing, you know, again, sixty, seventy, eighty, ninety different procedures on YAG caps ulotomies and SLT. He needs to go back to eight years of training to be an ophthalmologist. That's four years of medical school, a transition year and three years of residency. That seems like a high hurdle to be able to do a laser procedure that he has done and is very proficient in here in Oklahoma. How about myself? If I moved to Vermont, I've done again, six, seven thousand different procedures. If I go to Vermont, I'm supposed to set my life aside for eight to nine years to do a procedure that I have been proficient in for fifteen, sixteen years. So again, Doctor. Phillips, again, great, great guy who again trained him last year. He's got great training and he practices in Vermont as well. So I heard the mention earlier of dentists. Dentists go to four years of undergraduate, four years of dental school, and then an optional residency after. My sister is married to a dentist who practices in North Dakota. He did four years of undergrad in North Dakota. He did four years of dental school in Oregon. He did a one year residency and dentists do all sorts of in office procedures, injections in their office. They did not go to medical school. They got their judgment, their decision making in dental school. And optometry is doing the same thing. They're getting their judgment, their medical decision making, when to do procedures, when not to do procedures. In optometry school, that is trained thoroughly from first year through second year, third year and fourth year with these procedures there. So it's very, very similar to dentists doing their thing and they didn't go to dental school. So that's in optometry school. So let's ask the question then, well, what if a doctor graduated twenty five years ago? What do they do then? Like how do you get the education never stops? I would ask Doctor. Houghton or her father who any ophthalmologist, well, how did you add a procedure to your arsenal to what you do that came about ten years after you finished ophthalmology residency? How did you add that intravitreal injection? Or how did you add LASIK? And how did these new MIGS procedures, how did you add these procedures that came about after you finished your formal training? And the answer is you go to education and training, continuing medical education, continuing You take certification courses, and you build upon the foundation that you have from medical school, from dental school, from optometry school. You build upon that foundation. You take further training. That's usually four hours, eight hours, twelve hours, sixteen hours, and you add a new skill safely and effectively to what you do for patients here. This is me doing a YAG capsulotomy in a patient a number of years ago. What I'll show you is this is a YAG laser, the most common laser that is done by optometrists. This is incredibly similar to a slit lamp. The skills, you guys have all been had your eyes examined by a slit lamp, that microscope in an optometrist's office that every optometrist has. You put your eyes behind the oculars, your hand on a joystick, you're focusing on tissue that you focus on all the time, and you're adding a new skill of how to do the ag capsulotomy. When do you do it? When do you not do it? What are the potential complications, etcetera, etcetera. So I told you earlier, you know, education continues after graduation, just like MDs and DOs. We already covered this already. And you know, and I had, this is the thirty two hour advanced procedures course. This is the training course that we have delivered in Oklahoma, Kentucky, Louisiana, Alaska, Indiana, Arkansas, Mississippi, Wyoming, Colorado, Wisconsin, Minnesota, Virginia, all those states that I showed you earlier, we have been to every single one of them to provide this laser procedure training and surgical procedures training. And again, this is the like the icing on the cake. They've already got four years of optometry school. They are experts in slit lamp exams. How to look in the trabecular, how to look in the angle at the trabecular meshwork, how to look at the posterior capsule. They've developed all of these skills, and then they fine tune those through courses and training like I'm showing you right here. This is the post graduation training course. You know about that course, from a laser rep that was at one of our courses for the first time and worked extensively, he works extensively, sells lasers to optometry and ophthalmology. He's been in the field for twenty years. He goes, that's the best SL treat see SLT training I've ever seen. We did the course in The United Kingdom, in December 2021, and an ophthalmologist was there. I was a little bit nervous on, man, this is how's this gonna work with an ophthalmologist? Usually, there's, you know, there's a little bit of a a little strife between them. And he goes, man, I wish we had training that this good when I started performing laser procedures. You had better training. You guys provide better training to these optometrists than I ever received before I started doing laser procedures. I was shown the laser and said, there you go. Here's how you do that. Ophthalmology is wonderfully trained and optometry is wonderfully trained as well. I wanna make just a couple last comments in my couple last minutes. SLT is one of the laser procedures. This is a first line procedure for patients with glaucoma, meaning we don't put them on drop one and then drop two and then drop three and then drop four for glaucoma and then consider a laser after that. That's how we did it twenty years ago. There is study after study after study that now says, and this is the big light trial, SLT not could be, it should be offered as first line therapy for glaucoma and elevated eye pressure supporting a change in how we do things. Not could be, should be offered. You know who treats glaucoma first line in Vermont? Optometry does. So when an optometrist sees a patient with early glaucoma, mild glaucoma, moderate glaucoma, they should be able to offer the two wonderful first line options, an SLT or an eye drop to make that decision which is best for Mrs. Jones or best for Mr. Jones. So it's very clear from the data, patients are more likely to progress when they have eye drops versus the laser. In the light trial, twenty seven percent of patients progressed on glaucoma eye drops over six years versus nineteen point five percent with the laser. You're less likely to progress if you have this SLT because patients struggle with drops day after day after day indefinitely. Now we have a laser that can ease the burden and it's a first line treatment for glaucoma. I wanted to show you know just a couple of, this is a ninety second video of a YAG capsulotomy. This is a cloudy membrane, the number one laser procedure that optometry does in those 16 states that authorize. I describe this to patients as a cloudy membrane. You've got like a thin film of wax paper has grown on the back of the lens implant, and we're gonna do a laser procedure that's gonna take between one minute and five minutes right here in the office to clear up this cloudy membrane, this piece of wax paper. It's reduced your vision. It's caused some glare at night. This is an unedited video of our students doing a of a fourth year student recently doing a yag laser capsulotomy. This is ninety seconds from first shot to last shot, and the patient's vision went from twentyforty to twentytwenty. And yeah, you're you're better after your after your third one than you are after your first one. And you're better after your tenth one, just like anything else, just like removing a piece of metal from the eye that optometry can already do in Vermont. You're better after you've moved eight pieces of metal from the eye than you are on your first one. So again, I know I'm out of time here. There's the picture of the membrane before, there's the cleared memory, notice that cloudy sheen is gone, all better. The lumps and bumps, the eyelid lesions, the the picture that I showed you from this morning of them removing an eyelid lesion. This is a different patient, but these are the types of eyelid lesions that we look at. Optometrists are already evaluating which one looks scary, which one does not look scary. I agree with Doctor. Houghton that you should biopsy a lot of things. You you never know for a 100% what something is unless you get a biopsy, but I oftentimes I can go, I'm 99% sure that's benign and there's the before and there's the after. These patients want these very likely benign eyelid lesions, lumps and bumps gone. Again, a before and an after. Can't even tell where it was before. There's a bunch of little seborrheic keratosis and after. Okay, all gone. Again, this one's a more a little bit more advanced one, a great big lesion hanging from the eyelid. I wouldn't make this my first one, but after you have lots of experience removing that, patient was absolutely thrilled. A little sty, a little chalazion before and after a steroid injection into the eyelid to help resolve this bump that the patient does not like, this sty that they are complaining of. Again, there's another one, a chalazion, a sty that we did, We did an incision in curettage. We drained this chalazion. There's the before, and you can see the after on the left, completely gone. Again, these before and after pictures, I've showed enough of these already, but you can just see. Yeah, you see these patients, you follow them, you educate them preoperatively, postoperatively, follow them closely, make sure complications don't develop. This guy hated that cyst on his right lower eyelid. There's the before and there's the one month post op. Okay? And again, choose your patients wisely. You know, you can see most of these when you look, ask any optometrist or any ophthalmologist to look at these, they're gonna look at these lesions. You're gonna ask the patient how long have they been there? If these lesions, they've been there for years, I pick at them. They're bothersome. Likely going to be benign. Ninety nine plus percent chance. So choose your lesions appropriately versus this guy came in or this gal came in a while ago, and she looked at this. Yeah, I'm not touching that one. That one's gonna go off to our oculoplastic specialist or our dermatologist. Now this is an extreme example. But again, we evaluate lesions all the time. This guy was in primary care, they hadn't come down the hall, he's getting an eye exam. This guy comes in. And he shows a picture on his phone. He goes, that's what it looked like a month ago, my nose, and now it looks like this. And that's gonna go right off to dermatology or oculoplastics, whoever's gonna My point is, is you choose your patients wisely. You choose your procedures wisely. Optometrists have that medical judgment and that knowledge to know when to say absolutely not to these. And you know this gentleman where lesions have been there for four or five years, yeah, absolutely. Let's have a local provider with the expertise remove these lesions. And again, perfect outcome, you can't even tell where they were. Okay. So with that, I am going to pause there and any questions for me?

[Rep. Alyssa Black (Chair)]: Thank you. Thank you so much. Brian has a question and I just want to let everyone know that our next witness, Ashley, has a very, very hard stop at 02:15, so we want to got to get to Ashley here.

[Rep. Brian Cina (Member)]: So Did you say 22 states allow this earlier? Is that how many?

[Dr. Nate Lighthizer, Oklahoma College of Optometry (Dean)]: That is a fact.

[Rep. Brian Cina (Member)]: And so 22 states allow it. And do these providers in those states, does their liability insurance cover these procedures?

[Dr. Nate Lighthizer, Oklahoma College of Optometry (Dean)]: That is correct. Their current one may not. You may have to look for a different insurance company. There's numerous of them through the AOA, but absolutely yes, their malpractice insurance covers that. And we always say malpractice insurance has not went up at all for optometrists in these states. Pay $400 year for malpractice insurance, dollars 400 Would per

[Rep. Brian Cina (Member)]: it be fair to say that malpractice insurance wouldn't cover it if they felt that the training wasn't adequate? Because that would okay. And then the last question related to this, because I'm trying to be very focused, is is that the standard in this bill that's being proposed in Vermont equivalent to the standard in the other 22 states? Yes, it is. Thank you.

[Rep. Leslie Goldman (Member)]: We have OPR, Office of Professional Regulation, that manages complaints. I'm wondering about in the states that you've mentioned, have there been complaints? Is quality managed? And I'm not sure if you don't have a hard stop, if we could get back to it, if you want to do that, I'm not really sure. But I am curious about quality and how that's being measured compared to the two different professions.

[Dr. Nate Lighthizer, Oklahoma College of Optometry (Dean)]: Yep. So we looked at this a couple of years ago in 2024, we actually reached out to the state boards. All have to renew, I have to renew my optometry license every single year. Optometrists have to renew their license every single year. That's the governing body in Oklahoma in every state that gives you the authority to be an optometrist, be a dentist, whatever it is. So we contacted the optometry board in the states that are doing laser procedures and injections and said, have there been any formal complaints? Have there been any complaints against any licensed optometrist? We looked at all of those states and there was 146,000 procedures reported because every year when a Louisiana optometrist has to renew their license, they have to report how many procedures they did. In Arkansas, how many procedures you did? Out of the 146,000, there were two registered complaints. Two registered complaints. Now, want to be very clear on that, that that doesn't mean there's only two complications. I mean, completely agree with Doctor. Houghton that if there's any surgeon, is there any optometrist, any dentist, anybody that does procedures that said they've never had a complication, you know what that means? You don't do procedures or you're lying because you're going to have complications, but you manage those complications, and you and they're fortunately very, very rare. And I will I'm gonna share my screen one more time very quickly. Can you guys see this study? Can you see this?

[Rep. Alyssa Black (Chair)]: Yep. Yes.

[Dr. Nate Lighthizer, Oklahoma College of Optometry (Dean)]: You know, and this is the state of Oklahoma was the first one in 1988. As of 2024, qualified optometrists in 12 states have been doing these procedures. The outcomes of over 146,000 laser procedures, and there was only two negative outcomes reported to the board, equating to less than zero point zero one percent. So yes, there is data out there from these states that pass legislation like Mississippi and like Louisiana and like Virginia among others that I listed that, yeah, you renew your license, how many lasers did you do and how many complaints were filed against you?

[Rep. Alyssa Black (Chair)]: Thank you. Thank you. Thank you so much for joining us, and we really appreciate your time.

[Unidentified committee member ‘Dave’]: Thank you. And I hope you get that fiftieth state where you can testify.

[Dr. Nate Lighthizer, Oklahoma College of Optometry (Dean)]: You you if you have any connections in Rhode Island, you let me know because I'm trying to get to Rhode Island.

[Unidentified committee member]: I do know some people in Rhode Island. Do.

[Dr. Nate Lighthizer, Oklahoma College of Optometry (Dean)]: There you go. Thank you. Have a good day, everybody.

[Rep. Alyssa Black (Chair)]: Thank you. Thank you. And last but not least on this, we have Ashley Berliner. Hi, So sorry we're running behind. I know you've got a hard stop. Just had asked you to come in. We had asked the question the other day regarding Medicaid, Medicaid coverage, if we need a waiver, and I understand you've done a little research into this for us.

[Ashley Berliner, Director of Medicaid Policy (AHS)]: Yes. So for the record, Ashley Berliner, I'm the director of Medicaid policy for the Agency of Human Services, and we have looked into this. So our current state plan, our Medicaid state plan, which is the contract between CMS and the state of Vermont on what services are covered, currently limits optometrist services to a specific set. It includes visual analysis, diagnostic eye exams, contact lens or specialty lenses, and any other aids to vision. So that is the limitation that is in place in our state plan. Any expansion of that would require a state plan amendment, which means we'd have to do a public notice and we'd have to submit a state plan amendment to CMS for review and approval. We also started to look into what a fiscal might be for the Medicaid program, and we were not able to generate a fiscal that was at all, based in reality. Diva's happy to come back and testify in more detail on this, but what we discovered was that any estimate is going to be really problematic to produce because of the analysis required on the specific codes and procedures like surgery, laser injection treatments. And because we're so far out looking at 2028 for implementation, it would be likely that we'd want to do that analysis closer to implementation to have a real sense of what costs could be. But they're happy to come and provide either written or oral testimony to fill in more details around why that was a challenge to present today.

[Rep. Alyssa Black (Chair)]: Can you remind us what goes into getting a state plan amendment, like what the process is for that?

[Ashley Berliner, Director of Medicaid Policy (AHS)]: Yes, absolutely. A state plan amendment is pretty administrative. I wouldn't imagine that something like this would be a particularly difficult conversation with CMS, but it is a change to our state plan page where we would actually go in and edit to either expand the services of the optometrist to be beyond what's currently stated or provide that coverage somewhere else in the state plan. We would do public notice for thirty days and then it would be submitted to CMS. CMS has to review it within ninety days. They do not have to approve it within ninety days though. Within that ninety day period, they either have to approve it or they have to ask for a conference and provide questions that need additional information to the state. So sometimes SPA approval can be pretty quick, sometimes it can take a year or two, and it is dependent on both the content of the SPA and also just the backlog that CMS has at any given time. So again, I don't think that this would be a particularly controversial SPA. It's pretty bread and butter in terms of the types of changes that CMS would expect the state to make. But the capacity CMS has to review spas right now does seem to be limited. So I wouldn't be able to guess how quickly they would approve it.

[Rep. Alyssa Black (Chair)]: Shall I ask a question regarding, I mean, we have just done a doula bill in the last two years to which there was reluctance to open up our spa and we

[Rep. Leslie Goldman (Member)]: had to delay that.

[Rep. Alyssa Black (Chair)]: Would this not fall under the same category?

[Ashley Berliner, Director of Medicaid Policy (AHS)]: So the reluctance to open up so around the doula bill, there are a couple of things. There was a conversation related to doulas around our waiver, which we're very reluctant to open. And then related to state plan, it is page dependent. So some pages we absolutely don't want to touch at all and some pages are safe. And I'm happy to go into more detail about why that is, but the way it works with our state plan amendment is anything on the page, even if it's irrelevant to what we're asking, is fair game for CMS to review. So if we have a page that has, I don't know, optometry coverage, and it's also on a page with name the really controversial service, we would be really hesitant to open up the optometry coverage page because it means we'd be engaging in the conversation about the other controversial service. So there are some pages in our state plan where we really do get very concerned about opening it up because it puts certain services in the spotlight with CMS and potentially opens it up to changes that CMS wants us to make that the state does not want to make.

[Rep. Alyssa Black (Chair)]: When you say pages, are you literally talking about pages on a piece

[Rep. Brian Cina (Member)]: of paper? How

[Rep. Alyssa Black (Chair)]: many pages long is our SPA?

[Ashley Berliner, Director of Medicaid Policy (AHS)]: Our state plan is over 600 pages and we've been getting a lot more sophisticated with how we structure our state plan amendments so that we don't have this problem going forward. But some of the pages are from the 80s and they have a bunch of stuff on them. And so now what we do when we do state plan amendments is we try to just have a discrete, like one service per page, but we haven't historically done that. So lots of pages have lots of services on them. And as we modernize or make changes, we try to kind of separate and we're of course strategic about when we do those state plan amendments, given what administration we have to work with. But yeah, it's literally paper documentation.

[Rep. Alyssa Black (Chair)]: Can't you just take something off of one page a moment to another? That may be the dumbest question I've ever asked.

[Ashley Berliner, Director of Medicaid Policy (AHS)]: It's not a dumb question at all. It's so frustrating and it's such an administrative burden. But every single page is tracked with a number and we can't make any changes without it going through CMS approval. Like even if we find an edit, like a typo, they won't let us make those changes without going through something. So we have things where we know we need to make changes, even like the name of a department. And they won't let us make administrative changes that are purely technical without going through the process. So they're quite particular about it.

[Rep. Alyssa Black (Chair)]: Thank you, Ashley. Leslie has a question.

[Rep. Leslie Goldman (Member)]: Very quick. I'm just wondering, imagining that if we did this, the state plan amendment page would be one page unto itself in the way you would present it. Is that fair? Yeah.

[Rep. Alyssa Black (Chair)]: Medicaid cover now any sort of care optometrist care? I mean, it doesn't cover routine eye exams. What does it cover?

[Ashley Berliner, Director of Medicaid Policy (AHS)]: It does. So currently, well, for kids, for 21, we cover anything that's medically necessary that an optician can provide within their scope of practice. For adults, we provide coverage for a complete visual analysis, including refraction once every two years, one interim diagnostic eye exam once every two years, contact lenses or special lenses with prior authorization, and other aids to vision, such as closed circuit television when the beneficiary is legally blind and when provided to aid the vision and foster activities of daily living. Those are the four categories of service that are provided under optician care sorry, optometrist care, not optician.

[Rep. Leslie Goldman (Member)]: Great. So I haven't thought about

[Unidentified committee member]: it

[Rep. Alyssa Black (Chair)]: before. Thank you. Anybody else have any questions for Ashley? Thank you so much for short notice joining us and your information and learning something new today. Cannot believe that. Thank you.

[Ashley Berliner, Director of Medicaid Policy (AHS)]: Thanks for having me. Bye.

[Rep. Alyssa Black (Chair)]: Thank you. I was gonna ask for a copy of it, then she said it's 600 pages. When

[Katie McLean, Office of Legislative Counsel]: I looked it up, it's seven sixty seven pages document, and I see what she's saying, that there are, in some cases, multiple services on the same page.

[Rep. Leslie Goldman (Member)]: And that's just the waiver?

[Katie McLean, Office of Legislative Counsel]: No, it's just the same. Oh, yes, it's not that waiver.

[Rep. Alyssa Black (Chair)]: That's 600 other pages. I don't know. It's just really sad that we have to be. Okay. So we are moving on, and I know we haven't had a break, but we are past time. But we only have is Eric coming

[Katie McLean, Office of Legislative Counsel]: in He's coming at 02:30, and he'd lose me at 02:30.

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

[Rep. Leslie Goldman (Member)]: let's have Katie come on up.

[Rep. Alyssa Black (Chair)]: We're switching, by the way, switching off of sixty four. So we're taking a look at a bill right now that has, I believe, judiciary has possession of it. And we're not taking possession of it, but we are reviewing it. There are pieces in here that affect our jurisdiction, and we're being asked to give it a really good look over to make sure we're looking at it from the lens of mental health, which we do, and making any recommendations that we feel need to be made to other committees. Katie, take it away.

[Katie McLean, Office of Legislative Counsel]: Good afternoon. McLean, Office of Legislative Counsel. Eric and I have been staffing this forensic facility bill together, and we're sort

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

[Katie McLean, Office of Legislative Counsel]: order because he usually comes into a committee and tees it up with the judicial process and who is impacted. So you're gonna hear from him afterwards. But I also feel like I can't really explain the second half of the bill, which is sort of the institutional and clinical care pieces around the forensic facility, unless you sort of understand a little bit about what a forensic facility is and who could be impacted by it. Kind of have a chicken and egg issue here. So maybe I'll start by just giving a very high level overview, and then we can look at more of the clinical language. So as folks on this committee may remember, the issue of a forensic facility has come up multiple times, maybe over the past decade. And the concept is a facility for individuals who are criminally justice involved. And there have been different variations of this, but potentially individuals with a mental health condition, developmental disability would be eligible to be in the forensic facility depending on their assessed level of dangerousness. The current iteration you have in front of you is different from what has come to in past years. And that in past years, focus has been forensic facility has been staffed by the Department of Mental Health, possibly the Dale. But this iteration is different in that the forensic facility would be administered operated by the Department of Corrections. So that's one difference. In past years, the scope of who could potentially be eligible for a forensic facility has been much broader. This iteration, in some ways, is narrower because the individual would have had to be a person who has committed a crime that carries a life sentence. They would have had to be assessed to have a higher level of dangerousness to the community. And then there are sort of, if those criteria are met, there are other doors, two doors that sort of bring you to the forensic facility. One is that you've been deemed not competent to stand trial, in which case the forensic facility would have a competency restoration program, meaning that a person at the forensic facility would undergo treatment to become competent to stand trial so that the charges can be brought against them. You'll hear from Eric, but when we're talking about competence to stand trial, this is different than what this committee is typically thinking about, which is competence to make a medical decision. So this type of competence is a legal standard that you can understand the charges being brought against you and you can participate in your defense. So that's sort of one group of individuals. The other group of individuals are individuals who have been deemed not guilty by reason of insanity. So typically, that is a defense. If somebody successfully argues that defense that they're not guilty for a crime on the basis of that they were legally insane at the time that the crime was committed, right now, they would go to the community unless, let's say they have a mental health condition that meets the statutory criteria for clinical need to go into a hospital setting or a community setting. But otherwise, if an individual doesn't meet that clinical need, they'd be released into the community. So this forensic facility could potentially be a placement for those individuals. I know that's really complicated. And I'm hoping that Eric will spend go through sort of the who in a little bit more detail. But I think the important pieces to understand is that in some ways, this proposal is a little bit narrower because the individuals would have had to allegedly have committed one of those serious crimes. On the other hand, it would pick up individuals potentially who have a substance use disorder or a TBI or dementia. So there are lots of different conditions that would give rise to a person potentially being in a forensic facility. So now that I've hopefully not confused you, but teed it up a little bit, I can show you some of the language around the clinical care piece of what is happening at the forensic facility.

[Rep. Leslie Goldman (Member)]: The right document. Okay.

[Katie McLean, Office of Legislative Counsel]: So this is sort of a work in progress because as we're sitting here, house judiciary is also working on this language and refining it. So this is sort of a snapshot of the work in time. I'm going to move us through all of the language I think Eric is going to cover with you about the how, somebody could get to a forensic facility and flag some things for you. So one thing to flag for you is Yeah?

[Rep. Alyssa Black (Chair)]: Just to be clear, this is like setting up all of the stuff at the forensic facility, but we currently do not actually have a forensic facility.

[Katie McLean, Office of Legislative Counsel]: Correct. Doesn't where the forensic facility will be. So there have been a lot of questions as we go to different committees, what is envisioned. The language kind of leaves it open that Corrections is going to be administering this. There's an opportunity for multiple wings to divide the population up. There's the opportunity that it could be sort of a standalone facility, but I don't think that decision has been made yet. And this doesn't lock into a particular option. Ten more minutes. Moving kind of quickly. Well, thinking about No, the questions are great. On page eight, there's language about involuntary medication during the competency restoration process. This is different than this language that is set up in statute right now for involuntary medication for individuals who are perhaps on an order of hospitalization, who meet that clinical standard of need. That standard, one of the components is competency. Can somebody make a competent decision about their health care? This is a different standard, and this is taken from US Supreme Court case law. And this gives different criteria by which involuntary medication could be administered in the context of competency restoration. So the standard is what is listed starting on line five. The involuntary medication is medically appropriate. The involuntary medication serves the important governmental interests of bringing to trial an individual accused of a serious crime and ensuring a fair and timely prosecution. The involuntary medication significantly furthers these important governmental interests by making it substantially likely to render the defendant competent to stand trial. And any alternative, less intrusive treatments are unlikely to achieve the same results. So that's taken almost directly out of case law. And again, setting up a different standard, but this would still be a balancing standard conducted by a judge. Okay, I'm going to keep moving past that.

[Rep. Alyssa Black (Chair)]: You mean a judge in Vermont? Yeah. That get the involuntary medication at the judge's order? Yes. Okay.

[Katie McLean, Office of Legislative Counsel]: So, and then

[Rep. Alyssa Black (Chair)]: it's the same. Remind me, this is just to restore competency. Yes. Okay.

[Katie McLean, Office of Legislative Counsel]: Sorry. I'm trying to find my place here. Okay, so I'm on page 15, section four. This is where we have a definition of a forensic facility. That means a locked facility or placement. That DOC provides secure evaluation, treatment and care of persons involved in the legal system who do not require a hospitalization level of care and is required for the custody control, correctional treatment and rehabilitation of persons who are coming in either because they have that competent, not competent to stand trial or not guilty by reason of insanity. They'd have to have a qualifying condition, meaning any condition, whether mental, congenital, traumatic, however acquired or developed, or any other circumstance that resulted in the person being determined and confident to stand trial or not guilty by reason of insanity. And then there are evaluations that would be conducted to make these determinations. That brings us to subsection B, which I think would be of interest to this committee. And this says that the Commissioner of Corrections shall operate a loft secure forensic facility for secure evaluation, treatment and care of individuals who have been transferred in pursuant to one of those two routes. And then we have lead in language at the top of page 16, the forensic facility shell. And this is a list of different, clinical aspects of what the forensic facility would have. So it would be designed and operated in a manner that supports a therapeutic recovery oriented and trauma informed environment comparable to a community based residential treatment setting while maintaining appropriate levels of safety and security. It would not be able to refuse any persons it is ordered to admit, meaning ordered by the court, and shall not require any clinical or diagnostic prerequisites for admission. Third, it would provide for the safe housing and management of persons, including the ability to separate the population by sex or gender and to otherwise address clinical safety or operational considerations as appropriate, including the possible operation of multiple facilities. So there's language that the Senate added with the idea of being flexible, that this could potentially be administered in different ways. Subdivision four, employing a clinical services director to oversee all forensic clinical and competency restoration services provided to transferred persons. The forensic facility would implement staff, there'd be staff qualifications, licensure, training and supervision requirements that are sufficient to ensure that persons transferred to the forensic facility have access to clinically appropriate treatment services and supports consistent with individual needs and with applicable professional standards.

[Rep. Alyssa Black (Chair)]: Question have

[Unidentified committee member]: on line seven, page 16. Not refuse any persons it is ordered to admit and shall not require any clinical or diagnostic prerequisites Does for that mean that folks who are charged with a criminal offense punishable by life can be co located with someone who is not experiencing a mental illness that are also charged with the crime punishable by life? Are

[Katie McLean, Office of Legislative Counsel]: they both in the forensic facility? Are you asking if the forensic facility population could be mixed? I would say that there is no language that says that the population has to be entirely separate. So potentially. So Okay. We just did staff qualifications. Top of page 17, ensuring a registered nurse or a physician is available to provide care to transferred persons twenty four hours a day, seven days a week. Ensure that persons receive clinically appropriate assessment and treatment planning, including the development of an initial person specific treatment plan within seventy two hours following transfer, which shall be reviewed periodically as clinically indicated. So those are some of the clinical requirements that the Senate put in place. We have some language here that Senate Health and Welfare did not work on. So I'm gonna skip over it, not because it's not important, but just to get us some more of the clinical language. Senate Health and Welfare and Senate institutions sort of worked on certain pieces of this. So they added this Section 4A, which is an annual report about the forensic facility. As you will see, DOC is the lead entity reporting in consultation with the Department of Health who may be implicated because of individuals with substance use disorder. DMH and Dale are all consulting. They're submitting a written report to the various policy committees that addresses the number of persons served at the forensic facility during the previous calendar year and the types of clinical services and treatment provided during the previous calendar year. So this report is taking effect. It's amending the section we just looked at, but it's taking effect later once the forensic facility would be up and running. So there's a year's worth of data before this provision would be effective. And then the last section that they worked on is this rulemaking. Actually, I think there are two more sections. Rulemaking. So again, the Commissioner of Corrections is taking the lead in consultation with the other departments. And specifically, there are items here that would have to be in the rules. So the rules would have to address clinically appropriate standards governing the provision of services at the forensic facility, including requirements related to staffing patterns and ratios, staff qualifications, licensure and training, clinical supervision and the delivery of safe, effective and evidence informed care. Rules would address standards of quality assurance and improvement, clinical oversight, documentation and reporting requirements, safety and risk management protocols, and mechanisms for monitoring compliance. This highlighted language was added by a house judiciary. Victim notification procedures, including which events within the forensic facility will trigger victim notification, who will provide victim notification and by what methods, how victims will be informed of their right to receive notifications, and the process that will permit victims to opt in or opt out of receiving notifications. And then the rules will address any other provisions necessary to ensure safe, effective and clinically appropriate implementation of the forensic facility, including potentially requiring the provision of forensic facility services in a unit that is separate from other correctional populations. So this is just something that has to be considered. It's not a requirement. So including potentially requiring the provision of a forensic facility services in a separate unit, that is for the departments to consider when they're doing rulemaking.

[Unidentified committee member]: We already have some victim notification procedure, right, when someone is released from I

[Katie McLean, Office of Legislative Counsel]: would say that's a better question for Eric when he comes in. Okay. I'm gonna skip over section six. Section seven is an interim report that would come back to you this October. So it's the four departments, and they're required to submit a written interim report to the various policy committees. And though that interim report would contain the draft rules based on the language that we just looked at. And it would also address the status of an anticipated timeline for the adoption of rules under the act. Forensic facility planning, including specific proposed location of our forensic facility, space considerations and design elements necessary to support the provision of therapeutic services and security at the proposed location, and a timeline for any necessary fit up of the forensic facility. It's going to address initial staffing considerations, including anticipated staffing levels, required qualifications, potential contracting needs, and it would also address an anticipated timeline for the development of a forensic facility, including preliminary cost estimates and initial operations. And I think you'll hear from BMH tomorrow, And some of the questions you're asking about what will the forensic facility look like and where will it be? What I've sort of heard them say in testimony is, again, the concept of chicken and an egg. They could make a proposal. But then based on the work the legislature does, that proposal of the location might not exactly fit what the space that they had in mind. So in this case, you're developing the policy of what a forensic facility requirements will be. And this report, October 1, is saying, come back and tell us what location makes sense based on what the legislature has passed.

[Rep. Alyssa Black (Chair)]: Hi. Just because we went through lots of different I'm just trying to think if I'm getting this right. So this envisions a forensic facility. Qualifying conditions in the forensic facilities, and it's resulted in a person being determined incompetent to stand trial or not guilty by reason

[Katie McLean, Office of Legislative Counsel]: of insanity. Which means that they've gone through a legal process. Correct? And it's been determined one of these two things. And now they're all forevermore under the care and custody of the Department of Corrections? Not forevermore. There is a process and a regular check-in that's built into part of the judicial procedures that a person would be at the forensic facility with a court order, and there would be regular check ins with the court. And if the standard is still met, that the person has demonstrated this degree of dangerousness to the public, that they can continue to be held. But they've already been adjudicated through a legal process. And

[Rep. Alyssa Black (Chair)]: I'm not making a judgment in any way on whether or not they still need to be held. I'm just questioning why is it Department of Corrections? At that point, shouldn't Department of Corrections ballot out?

[Katie McLean, Office of Legislative Counsel]: Well, in the case for somebody I mean, that's a policy question. So I think you're That's a good question. That's something that the I'm

[Rep. Alyssa Black (Chair)]: just making sure I'm reading it right.

[Katie McLean, Office of Legislative Counsel]: I think that's something all of the committees are grappling with. In the case of the competency restoration specific piece, that case hasn't been fully adjudicated yet because the person couldn't stand trial. So potentially, if the person regains competence, then that trial could move forward. So at that point in time, it's sort of a paused process.

[Unidentified committee member]: The person can't stand trial, so they're still innocent. Correct? They've just been charged for the crime.

[Katie McLean, Office of Legislative Counsel]: I believe so. You're Alright. That's correct. I know. I know you're starting to get into judiciary.

[Rep. Alyssa Black (Chair)]: Okay. Go

[Unidentified committee member]: ahead. Just a question. Apparently, there's no housing for this. There's no money for this. And just kinda are we putting the car into the horse here or behind the horse? But anyway, do we have any facilities that we could utilize for this? I don't

[Rep. Alyssa Black (Chair)]: think this bill is asking us to come up with the forensic facility. I think it's creating the structure,

[Katie McLean, Office of Legislative Counsel]: right? Creating the process by which somebody could be held in a forensic facility. And it's outlining some clinical protections that would have to be part of a forensic facility.

[Unidentified committee member]: But we don't have a place to put them.

[Rep. Alyssa Black (Chair)]: Yeah.

[Unidentified committee member]: Okay, that's my point.

[Unidentified committee member]: You noted at the top that this space could be holding folks with mental health issues, TBIs, substance use issues, or maybe Alzheimer's. Was DSU ever discussed as a party that Corrections should consult with in their design of audits?

[Katie McLean, Office of Legislative Counsel]: Meaning the Department of

[Rep. Leslie Goldman (Member)]: Health? Yes, you.

[Unidentified committee member]: The Division of Substitutes? I

[Katie McLean, Office of Legislative Counsel]: mean, this doesn't really direct DOC to collaborate with any of the departments about design work.

[Unidentified committee member]: Not just design work, sorry, but of the other about slots where it's referenced that they're supposed to collaborate with DMH, like for the reports?

[Katie McLean, Office of Legislative Counsel]: Well, the health department is listed. Okay.

[Rep. Alyssa Black (Chair)]: So that would include CSU. Yes. Anyone have any other questions for Kate?

[Rep. Leslie Goldman (Member)]: Oh. No, I just Can we go to page 19? Just start at number one. Victim notification procedures.

[Katie McLean, Office of Legislative Counsel]: So I'm sorry, I keep deferring to Eric, but Eric worked on this with House Judiciary. So to the extent you have questions about victim notification procedures, I think he would be better able to answer them.

[Rep. Alyssa Black (Chair)]: Should we take a break till Erin answered?

[Rep. Leslie Goldman (Member)]: Maybe this is for you, I'm not sure. I just want to understand from our healthcare lens, what is in this that we're asking, we're being asked to look at? I think we're being asked to look at this through the lens of

[Rep. Alyssa Black (Chair)]: those with mental health condition that might fall within this scope, and whether or not this aligns with what we feel should be the process that's taken. Down the hall, I know that they're looking at it through the lens of, like, IDD, substance use, you know, dementia, that sort of thing. I think we're just being asked I keep having flashbacks. I feel like every two years, we keep looking at these. And so in this committee, we're just sort of keeping it in We're looking at it through the perspective of the mental health and system of mental health care and whether or not it aligns and fits with what

[Rep. Leslie Goldman (Member)]: Like involuntary medication. I mean, that's what I'm trying to get my head. What am I being asked to think about? And maybe I don't know that answer yet. Don't know.

[Rep. Alyssa Black (Chair)]: I think it's great questions for DMH. Okay.

[Katie McLean, Office of Legislative Counsel]: All right. If you're hearing from DMH, it's also nice to have a reminder of what the current system looks like for individuals who potentially are coming into their system through the criminal justice door because their system of involuntary commitment isn't just treating people coming through the criminal justice door, but it does include those individuals as well.

[Rep. Alyssa Black (Chair)]: Okay, so let's take a break until Eric gets dragged on when that will be.

[Rep. Leslie Goldman (Member)]: Guess he's seen my computer by switching pencils. Oh, he's in

[Rep. Alyssa Black (Chair)]: judiciary right now. Can we take a ten minute break?

[Dr. Nate Lighthizer, Oklahoma College of Optometry (Dean)]: Yes.