Vermont Legislature SmartTranscripts:

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: We are back live. This is Senate Health and Welfare. We're taking up S142 for the first time. It's related to licensure for internationally trained physicians and medical graduates. And the lead sponsor of the bill, Senator Harrison, is here with us. Senator Harrison, give us a quick overview of why you introduced the bill and what it means. You. So I'm Wendy Harrison and I represent the Wyndham District. You very much for having me. The intent of S142 is to increase primary care in Vermont, particularly in rural areas.

[Sen. Wendy Harrison (Windham District) — Bill Sponsor]: It does this through a two step alternative pathway. The process would allow internationally trained physicians who have practiced medicine to become licensed in Vermont. Traditional residencies are expensive and limited. They are also designed to be the next step for recent graduates of medical school. In contrast, the internationally trained physicians, ITPs, have already worked as medical doctors. They've acquired experience and skills, but generally do not have the experience of US processes and procedures, particularly insurance protocols. The challenge is to find a path to licensure that can both assess their skills and provide necessary coaching and training. We found that Vermont hospitals are willing to take on this responsibility. Workforce is a huge problem for healthcare, as you know, and this is a responsible way to generate additional licensed physicians. Diane Walsh, the NAACP of Wyndham, called this to my attention in 2023. That resulted in a workforce bill, S. Two sixty three, in the prior session. That would have created a study committee of a new Tennessee licensing law. So that law was new in 2023. In the two and a half years since then, there's been a significant increase in the number of states licensing ITPs. Neighboring states are taking action. Massachusetts has adopted legislation and policy stage is expected to be complete this July. Legislation has been introduced in New Hampshire and Maine has passed it in both the House and the Senate. New York has had a process since the 1980s. Elsewhere, 11 states are already receiving applications from ITPs, and 16 are in process. Nine more have legislation pending, and two more states expect legislation to be introduced soon, So a total of 41 are in process, and that doesn't include the ones who have already adopted it. You may hear testimony of even more because it's happening all over the country. We've worked with an ever expanding advisory group, including the internationally trained physicians themselves, our local regional development corporation, BDCC, hospital CEOs and financial managers, FQHC's Board of Medical Practice, UBM and others who will testify. Thank you very much for taking up this bill and appreciate your time. Thank you.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Any questions for Senator Harris? No, we're good. Thank you for coming in and introducing the bill. Thank you. It's been a long process for you. I'm glad we're at this stage. Okay. Alright. So, Jen, we probably should walk through the bill and then we'll hear testimony. Great.

[Jennifer (Jen) Garvey (Office of Legislative Counsel)]: Good morning, Jen Garvey from the Office of Legislative Council. I don't know how much detail you want because I know we've gone through this before, but I also want you to be prepared for technical Yeah, I'm

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: thinking a higher and up above level, so we could just remember the individual sections. Yep.

[Jennifer (Jen) Garvey (Office of Legislative Counsel)]: Melissa, can you, let me share. Okay. So this is S 142, and it is an act related to a pathway to licensure for internationally trained physicians and medical graduates. And so as you may recall from the first time we looked at this, this would create a, first, an existing statutory provision allowing the board of medical practice to issue a license to an internationally trained physician or medical graduate who has successfully completed the pathway to licensure, and then it creates that pathway in a new sub chapter. And so it starts out for somebody who is an internationally trained physician or medical graduate, talking about somebody who's received a degree of Doctor of Medicine and has been licensed or otherwise authorized to practice medicine in a country other than The United States. And it allows the Board of Medical Practice to issue a professional, a provisional license to practice with supervision to someone who meets certain criteria as far as having received a medical degree, having been licensed or otherwise authorized to practice in another country for at least three years. They provide sufficient evidence to the board that they are able to have the capacity to practice medicine, a post graduate degree program, and have fairly recently practiced as a medical professional performing the duties of a physician for at least three of the last five years. They have a balance certificate issued by the Education Commission for Foreign Medical Graduates or another credential evaluation service. Some limited exceptions. They've achieved a passing score on steps one and two of The US Medical Licensing Exam admission. And then they have, before they submit an application to the board, they have entered into an agreement for employment with a participating healthcare facility in the state who has an assessment and evaluation program, and can supervise and evaluate this individual's clinical and non clinical skills, and familiarity with standards appropriate for medical practice in Vermont, and they don't have any disqualifying grade surgeons. So the first step in the pathway is getting this provisional license issued by the Board of Medical Practice, which is good for two years, and then the provisionally licensed physician is eligible to apply for a limited license to practice. The second step, meaning to full licensure. The provisional license authorizes the individual to practice medicine only at that participating healthcare facility and only with supervision. There's some implementing provisions there. There's ineligibility to receive a provisional license if a person has had their license to practice medicine suspended, revoked, limited, conditioned, or otherwise restricted based on unprofessional conduct, or they've been convicted of a crime, or they have otherwise demonstrated a lack of confidence or moral character. And it talks about the criteria for a healthcare facility to be a participating healthcare facility that can provide the supervision and assessment.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: So I

[Jennifer (Jen) Garvey (Office of Legislative Counsel)]: won't take you through that so much right now, but there are certain provisions there, and then we get to this limited license to practice medicine. So within ninety days before the end of the two year period of provisional licensure, the individual can apply for a two year limited license to practice, can only be renewed once, and after that two year, after two years of practice under the limited license, the physician would be eligible to apply for a full unrestricted license to practice medicine and provide. And it allows the board to issue this limited license to practice medicine to an applicant who's on track to successfully complete their program with the participating healthcare facility. They have an offer of full time employment from a healthcare facility, either the one they've been working with or another one, which is located in Vermont and accepts patients covered by a Medicaid or Medicare or both. Now they have achieved a passing score of step three on The US medical licensing exam, they've had to pass levels one and two, or steps one and two, or the provisional license, and then this is looking to have kind of a seamless transition from the provisional license to the limited license, and then there is requirements if the board refuses to issue a provisional or limited license, provide specific reasons why, and that can be repealed. And then it directs the Board of Medical Practice to collect information as needed to evaluate the implementation and success of this pathway to licensure program, and a number of different pieces of information they would collect on that. Record that information annually to various committees. One Yes? I just wanted to

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: ask for a quick overview of section thirteen sixty seven, which is the appeals process in the chapter. So it's part of the appeals too. Does it go to the board itself? I'd have to to, I'd

[Jennifer (Jen) Garvey (Office of Legislative Counsel)]: to call that. Okay. I'm happy to review and Not on port right now. And back up. Do want me to finish going through the language or is it something we just went through?

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: I think it's what we just went Okay. Maybe I missed something, but is the limited license the same as a provisional license?

[Jennifer (Jen) Garvey (Office of Legislative Counsel)]: No, the provisional license is step one, and it's under supervision, yes, where they're getting kind of actively mentored and evaluated on their proficiency, and then, yes, and then if they successfully complete that, they can receive a limited license for two years where they're working at a particular facility. Yes, and then they can apply after that for Yep, a full

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: got it.

[Jennifer (Jen) Garvey (Office of Legislative Counsel)]: And so lots of data would come back about how many people have applied and been accepted and gone through, successfully completed the provisional license and the limited license and why have people been refused, and kind of how has this all worked? And then there's some rule making provisions directing the Board of Medical Practice to adopt rules including determining which country's licensure or other authorization of practice is acceptable for purposes of provisional and limited licensure and what criteria the participating healthcare facilities would use to assess and evaluate a physician's familiarity with Vermont Standards of Practice. This bill was introduced last year, so this would have it taking effect on July 1. If you proceed with the bill, you will probably need to move that date out,

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: and rulemaking should take effect on passage. So you can tell a lot of time for the rulemaking to occur before the process could be operational.

[Jennifer (Jen) Garvey (Office of Legislative Counsel)]: If you want, I could put up thirteen sixty seven, or we can come. No, I can go back to that.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Back to that. Yeah, you can. And then we're witnessing that every week. That's something the reportable do. I do have one more question if that happens. Thanks. Thank you, madam chair. The limited license should not be released more than once. So, they they don't want folks to have the limited license for more than four years. Right. Obviously the board is a big part of this, so I'll have to hear from them. Yeah. And so because I

[Jennifer (Jen) Garvey (Office of Legislative Counsel)]: did just look it up, the appeal is just an appeal to the Vermont Supreme Court on the basis of

[Jessa Barnard (Vermont Medical Society)]: the record.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Okay, so it goes directly from the board to the Supreme Court and it's on the record. Okay, thank you. All right, good. All right, so I'm gonna go to Diana Whaley. To Whaley? Okay. I should know that. And we're gonna Is someone here representing the hospitals? Yes. Josh Dufresne. And also

[Devin Green (Vermont Association of Hospitals and Health Systems)]: okay. Devin Green is on Zoom.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Devin Green as well. Oh, Devin is here as well. Okay. I understand is Mike Zimmer on?

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

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: So I understand that you have a a time limitation. He has to leave by 11:15. Yeah. Oh, yeah. Okay. So we may go to him. I'm looking at you for to direct me for the order. Testimony because this has been your work over several years. Would you like me to begin then? You. Okay, Scott. I'm happy to begin. Go ahead. I just brought copies of my testimony for you to take a look at. So, and what we usually do is we think about seven minutes for each person to testify, maybe a little bit longer.

[Diana Wahle (Windham County NAACP Health Justice Committee)]: I'm looking at this. The reason that this is longer, Senator Lyons, is because I am here representing the internationally trained physicians who are anonymously testifying. Understood. And they are in a position of wanting to testify in person, but not able to protect their safety. And I see that there's a lot there that we can read. You won't have to read all of their tests. Yes, I'll just give you a little profile of their the overview. That'd be great. Thank you for that. Thank you. So I write you in support of S142, and I advocate for qualified internationally trained physicians to use the supervisory model pathway to return to practice in Vermont hospitals and community health centers where they are most needed. I represent the Wyndham County NAACP Health Justice Committee, And these are our desired outcomes. Reduction of Vermont health care workforce shortages. Creation of clear pathways for internationally trained healthcare professionals to enter the Vermont healthcare workforce. Increased culturally sensitive medical practice through supporting more diversity in our healthcare workforce. So, and as Senator Harrison mentioned, we're using the term ITP. In the past, the term IMG has been very common. During 2025, we spread the word about the S-one 142 bill on social media to internationally trained physicians living in Vermont and nearby states. I just want to reference my dedicated colleague, Ruth Steinmetz of Winooski, who gave an enormous amount of creativity and time to this outreach for finding who would gain from this bill, who needs this bill. We received 23 responses. 16 of the 23 agreed to one hour interviews with me, which educated us about their hopes and challenges for relicensing. Those interviews came from Afghanistan, Democratic Republic Of The Congo, Republic Of The Congo, Egypt, Sri Lanka, Trinidad And Tobago, and Canada. 13 of the 16 interviewed live in Vermont and have been for a while. This is important. These are not people that are coming from their country. They are already here and living as Vermadters. The additional three who live in nearby states would move to Vermont if the bill is enacted. All were in full support of the bill. However, the bill's recency and length of practice requirements are significant challenges. Only four of the 16 that I interviewed meet the three out of the last five years stipulation. By the time they successfully pass their US MLDs one and twos, none of them will be eligible. The three out of the past five year prescription has become a significant barrier, limiting access to highly skilled ITPs who are ready Learning to from states in our region who have enacted similar bills with longer recency provisions leads us to propose changing the existing language to at least one year of practice within the past seven years. And I just want to make a comment here that in my communication with each of those I interviewed, they gave me this research about how they would not maybe be able to meet the stipulation that is in the bill, but they made it very clear that no matter what, they support the three out of the last five years, if that is what's required to pass the bill. So no ITP applicant can access this pathway without an offer of employment from a hospital or FQHC in Vermont. Recent interviews, and this is with Senator Harrison, Representative Bertacco, and myself, We interviewed six hospital CEOs that are in underserved areas. We focused on their serious concerns about the unnecessary barriers of the recency and length of practice requirements. They brought this up in our interviews with them. Strive to attract talent from across state lines. Each hospital's emphasis on patient safety ensures strong guardrails in the hiring process. They and their HR and CMO administrators are willing to testify to propose less restrictive guidelines to allow capable internationally trained physicians the opportunity to demonstrate their skills. I think I'll skip the next section, which is pretty obvious. There are three ITPs that did not have well, let me just say, I offered to everybody I interviewed the opportunity to create testimony for you anonymously. And so I'm going to jump to that and very briefly review. We also did a presentation, Ruth Steinmetz and I, called Bridging the Integrating ITPs into Vermont's Healthcare Workforce at UVM Health Equity Summit that was very successful. You have access to that through this letter. The first of the five who did complete one page testimonies, which are here attached, is from Afghanistan, age 29. His education was stellar from the finest private medical education, medical university. It's in Kabul, but covers the whole country. He worked in family owned clinic. And then after he was exiled from Afghanistan, he worked in after his evacuation in the one of the largest hospitals in Pakistan. So he's a general practitioner. He's young. He's vibrant. He is now studying for his US MLEs. And at Brattleboro Memorial Hospital, he began as a phlebotomist. All of these folks are very underemployed. But he just was raised to be an OR technician. So, you'll see here his aspirations and his dedication to being a long term Vermonter. Next is from Egypt, age 41, and her medical specialty is obstetrics and gynecology. She is highly recognized with honors at Cairo University School of Medicine. She worked at the University Hospital for a number of years. She has become a researcher and even in Tokyo was placed as a researcher for three years. She now is at UDM Medical Center in the Department of Obstetrics and Gynecology and she's in a post doc associate position. She has published her research. She has delivered thousands of babies. She's published one research paper and is in the process of publishing about every procedure. The next is from Doctor. A. S. From the Democratic Republic Of Congo. Again, while he has specialized in neurosurgery, he sees himself in Vermont as focusing on general practice. He recognizes and is interested in the fact that Vermont's population is aging, and as a general practitioner, would want to focus on that age group. After twenty years of experience as a doctor, his background has equipped him. He feels very underemployed as a medical translator at present. But I just will read this last sentence here. Most of my translation work comes from hospital recruitment. He works with immigrants who have language challenges, where I can help clients understand medical terminology and communicate their needs. On the side, I often inform doctors about cultural backgrounds that might influence the patient's health. So this is a whole another aspect of these folks that I've interviewed is their skill in cultural sensitivity. Next, Democratic Republic Of Congo, age 41. Again, all of these would license as general practitioners. Extensive experience in internal medicine, maternity care. And what I wanted to highlight was the height of administrative responsibility that this testifier had. He was head of HIV and TB department, supervising 10 clinics, appointed clinical head for the COVID-nineteen management in the main hospitals where he were, and the senior medical officer assisting cancer patients. He now has, for a long time, did not have a work permit because he has more recently arrived in Vermont. But right after he achieved it, he's gotten hired to work in long term recovery in Richmond, Vermont for people seeking treatment for mental health and co occurring disorders. He's a certified medical teacher. All of these folks are studying their US MODs right now with CHOPERS. The final one, age 47, is Democratic Republic Of The Congo. Again, both in general practice and ophthalmology. And this is a group many of you might actually know because of the contribution to our community that he has made. He has, during COVID, he created a community radio show that provided public health education for immigrants. He now is producing a monthly television program for our immigrant population. He's been hired the part time at the City of Burlington as part of the Community Voices team. Finally, at Marner School of Medicine, he annually is part of working with three year medical speech on cultural competencies. I told what I have done with these people justice. I cannot tell you how it impacted my life to interview them and to get to know very personally what this bill is about. Thank you. Don't go away. This is amazing.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: They are amazing. Yeah, well, they are amazing, but the work that you've done to bring us this information is significant. That's the only word I can think of. Thank you. Thank you so much for having And as you've gotten to know these folks, it shows that you understand who they are and what they potentially bring to the medical community. Yes. Really appreciate what you've done. Along with Ruth Steinmetz in Munozky. Yes, she has been an amazing colleague and outreach assistant in all good work. Is there any other, any questions that folks have? I mean a lot of the, a number of the medical schools I'm looking at here are either have been established by or are currently English speaking or have been established by Western countries? Yes, there's a partnership and a recognition through the, I believe it's ACGME I, which includes International Review. It's an international organization that assesses and looks at the qualifications of the education of people that are hoping to license in The United States. And all of these universities where they have studied are listed in there. Thank you, Chair Lyons. Thank you very much for this. Some of these folks are my constituents, my friends and I was wondering Yes. Also, was going to say the same thing. I'm so sorry, too. That you brought us forward. I would say they some of the folks that you are mentioning here are they're they're not just great medical professionals but they're also really important members of our community and they give in so many ways and I really believe that any ecosystem that has a wealth of different perspectives and a wealth of diversity is stronger and so, I am really excited about this and I I really hope we can do something. So, thank you. Thank you so much for that awareness of how important this work is, and how much, whether it's in Wynnum County or Chittenden County, how we need a diversity of medical providers. Absolutely right. Thank you. Thank you. So, I saw Mike Zimmer shaking his head. I'm gonna ask you to testify next and then we'll move on. And I hope I have everyone on the list here, so I don't what's the name of the person? Guy I put all that. Oh, Joshua. Josh Ray. Oh, Yes. He's from North Star Health. Okay. North Star Health. So I'll put you next. That works? Alright.

[Jared Rhodes (Center for Modern Health)]: That works. Thank you.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: So what what Devin and I can put you after those? Okay. Perfect. Alright. Go ahead. Mister Zimmer. Is it mister Zimmer? Yeah. It looks like he's muted still. You're muted. You're muted. You're muted. My Jimmer is muted.

[Michael Zimmer (World Education Services)]: Oh, there.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: There you go. You got it.

[Michael Zimmer (World Education Services)]: You guys were muting me. I didn't know I was muting myself. I apologize. And I also have to apologize for the shaking of the head. I'm sort of famous in the world for having the worst nonverbals, so I'll try to restrain myself. Chair Lyons, Vice Chair Gulick, members of the committee, my name is Michael Zimmer. I'm with World Education Services. I think I testified the last time this was up and also testified on Senator Gulick's own bill. So I love working in Vermont. WES is a nonprofit social enterprise dedicated to helping those with international credentials and training realize their potential through advocacy on state initiatives to break down barriers. As others will more artfully describe, The US and particularly Vermont are facing healthcare shortages. According to Vermont Public Health, there's a critical shortage of primary care providers already, 115 FTEs below national benchmarks, projected to rise to three seventy by 2030. As Senator Harrison indicated, this is a growing initiative throughout the country. Since 2021, a large number of states have begun exploring and or passing very similar ITP pathway legislation. It has been passed and implemented in Washington, Colorado, Illinois, Wisconsin, Iowa, Florida, Tennessee, Idaho, Indiana, Texas, Minnesota, Arkansas, and Oklahoma. States that vary significantly in their political makeup, geographic makeup, and demographic makeup. It has been enacted, but there's a process of being implemented in seven other states, including your neighbor in Massachusetts. And finally, joining Vermont, legislation is now pending in Arizona, Georgia, Guam, Kansas, Maine, Maryland, Michigan, Mississippi, Missouri, New Hampshire, Nebraska, New Jersey, New Mexico, New York, Pennsylvania, South Carolina, and West Virginia. And the list keeps growing. Wyoming dropped their bill two days ago, so it is now up to 20 pending pieces of legislation. The model created in Senate Bill 142 takes the best practices of some of those, of all of those, frankly, ITP pathways and uses them to create a Vermont specific two step model to address the shortage of licensed physicians in the state, physicians to actualize and realize their training and potential for the benefit of their workforce and allows for the increased cultural sensitive medical practice in Vermont. It contains important safeguards that were previously described to you that model again the patterns that have been developed in other states. Chair line and members of the committee. Thank you for affording me the opportunity to testify if you have specific questions on what's going on in some of those other states. I can certainly try and respond to them. There's a whole bunch of them right now, but I look forward to any questions you may have.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Well, it's just really fascinating that there's such competition for the immigrant medical population at an extremely confusing time. So kind of the paradox, isn't it? I

[Michael Zimmer (World Education Services)]: think there is a national disconnect between immigration policy and workforce policy. And I think states in particular are realizing the value immigrants and refugees bring to helping with their workforce shortages.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Yeah. Thank you for that comment. And it's not just in this particular area, professional area, but the other areas in the in the workforce world.

[Jared Rhodes (Center for Modern Health)]: Yeah.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Questions for mister Zimmer? No. Thank you. And thank you for being available.

[Michael Zimmer (World Education Services)]: And thank you for moving me up. My son is being sworn into the bar this morning, and for some reason, he wants me there.

[Jessa Barnard (Vermont Medical Society)]: I

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: would say congratulations. I was like Thank

[Michael Zimmer (World Education Services)]: you.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Election behind me. I know. That's cool. What is it?

[Jessa Barnard (Vermont Medical Society)]: The campaign buttons behind you are

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: very Campaign buttons. Are they campaign buttons? Wow.

[Michael Zimmer (World Education Services)]: Oh, I yeah. I have what my wife describes as an unhealthy obsession with political memorabilia. So

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: I'm one

[Michael Zimmer (World Education Services)]: of those people that when I do pass, and I I just hope my children keep them, but I know they'll just dump them.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: I'm not quite where you are, but I do have a bull moose.

[Jared Rhodes (Center for Modern Health)]: Oh, you do?

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Yes. Have a dupe button. That's about the extent of my campaign buttons.

[Michael Zimmer (World Education Services)]: I have a Herbert Hoover dice from the nineteen twenty eight convention. That's my favorite.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Wow. Wow. Nice. Well, thank you again.

[Jared Rhodes (Center for Modern Health)]: Thank you.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: We've been a move along, and we'll Lady Ashton right now. I can't see your name.

[Josh Dufresne (North Star Health, FQHC)]: Josh. Yeah. Josh.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: And because I don't have you on my list, Josh, but I've I've got you on your on the list now and if you would please introduce yourself and offer your testimony, that would be great.

[Josh Dufresne (North Star Health, FQHC)]: Certainly. Thank you, Senator Chair Lyons and the Senate Health Committee and Welfare members. Really appreciate being here. It's an honor and privilege. I won't be redundant of a lot of things that have already been spoken to you. A little bit about me and who I'm representing today is the area of Southeastern Vermont for North Star Health. We're a federally qualified health center or FQHC. We have 10 sites and we see approximately 100,000 visits per year and about 24,000 patients annually. One of the most things I'm most excited about S142 is the opportunity to expand recruiting and retention capabilities for us and our patients. I can tell you I've been involved with healthcare in Southeastern Vermont for the last twenty years. One of the most difficult things that faces and challenges us is recruiting physicians and qualified practitioners to our area. Some of the pieces that we've taken part in over the years, I have worked with American trained physicians or United States trained physicians who have changed different specialties. So moving from say emergency medicine to family medicine and there's been a re emerging practice if you will that's gone through the Board of Medicine and that's been successful for us. In addition, we've worked with foreign trained but American residency physicians as well that have come from China, they've come from India, Pakistan, have in Canada and they've been integrated into our healthcare model and without any concerns or issues. It's been fantastic. This is the next logical step. I really appreciate the mentorship and evaluation process of this. Being able to expand for our sites will allow us to provide better access to our patients And our last community health needs assessment for 2025, one of the top answers, sixty seven percent of residents cited primary care as the most urgent need in our area, which is heartbreaking for me because we do offer that and it's hard to get people in. We have a lot of people relying on our walk in and acute care because it's hard to find somebody to expand a panel for primary care. And I also want to share a brief story. I just hired a certified medical assistant last week, went through orientation. He's originally from Venezuela. He's a trained orthopedic surgeon. He had a practice in Peru, and he's joined us, and he's been established as a certified medical assistant at my local health center. It'd be nothing greater than to be able to offer him a pathway to be able to practice in The United States and provide care to the folks that desperately need it. So I would say supporting a pathway to licensure aligns directly with the purpose of community health centers and the needs of Vermont's increasingly diverse population. S142 is a practical thoughtful response to Vermont's healthcare workforce crisis and stands to expand access to care and strengthens the primary care system. On behalf of North Star Health, I urge favorable passage of S142 in support of community health centers, the patients we serve, and the caregivers committed to Vermont's future. Happy to answer any questions that anyone may have.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Thank you. I do have a question you can answer and that is will you be able to please send your I have it, I have your testimony. Excellent! I just refreshed because I got it.

[Jared Rhodes (Center for Modern Health)]: Excellent! All

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: right, good. Thank you and where exactly is North Star located?

[Josh Dufresne (North Star Health, FQHC)]: Our head office if you will is in Springfield, Vermont.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Okay, so you're in Springfield. Is that affiliated with the hospital in Springfield or is it separate?

[Josh Dufresne (North Star Health, FQHC)]: We're separate.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Okay.

[Josh Dufresne (North Star Health, FQHC)]: Yep, we work very collaboratively with a lot of hospitals, but we're separate.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Okay, thank you.

[Josh Dufresne (North Star Health, FQHC)]: My pleasure, thank you.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: We're good, I think we're good. All right, so Devin Green of the hospitals, welcome.

[Devin Green (Vermont Association of Hospitals and Health Systems)]: Good morning, thank you for allowing, Devin Green, Vermont Association of Hospitals and Health Systems, thanks for allowing me to testify remotely. I'm trying to kick the cold, finally. And I also want to thank. Diana wall- for all the work that she's done on this bill and her interviews with- folks who would qualify and also. Our CEOs and partnership on this issue. We really appreciate all the groundwork she's done on this. Vas supports this bill heartily. As you all know, we have a workforce shortage. And one thing I want to bring to your attention today is we've heard a lot about the primary care physician shortage. But when I have met recently with my chief medical officers, I heard from them concerns around shortage of specialists as well. And not just because there are fewer bodies available, but also because the specialty world is further specializing, and that doesn't necessarily work in a rural community. So previously, a rural hospital would have an oncologist, and now a lot of physicians being trained come out specializing, in certain cancers as opposed to being a general oncologist. And so, a lot of hospitals are left with the prospect of if they lose one individual, they could be losing a whole service line for that community. And so we are really interested in all efforts to expand our workforce. And we think this is a good option to bring in not only more people, but folks who may have practiced in rural areas and understand the dynamic a bit more and the needs of those types of communities. We also feel that with the bill having this supervisory infrastructure and mentorship, that it'll support both the physician and ensure quality care for the patient. And so to that end, we are very supportive of this.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Thank you. Thanks for that testimony. As you were talking, was thinking that we probably have some of the highest qualified phlebotomists in the country. Questions for Devon? Okay, I think we should say take care of yourself, seems like. Yeah. Right, Jessup Barnard is here.

[Jessa Barnard (Vermont Medical Society)]: Wow, everybody's moving so fast. I was like, I'm thinking we're

[Jennifer (Jen) Garvey (Office of Legislative Counsel)]: running into lunch here. Thank

[Jessa Barnard (Vermont Medical Society)]: you so much, Jessa Barnard with the Vermont Medical Society. Thank you for taking the bill up. I will echo the thanks to all the groundwork from Senator Harrison and Diana to really bring together whole group looking at this issue over the summer and fall. Those conversations have been really helpful, I think, in educating everyone around the need for the bill and also the approaches taken in the bill. We also share the goals of S-one 140 '2 and expanding the workforce of Vermont. I won't repeat sort of what you've heard about that, but we agree that we can be doing a better job to create pathways into the medical field for folks with more different backgrounds than training. I think I'll skip, I gave a little background about the difference between existing pathways when you've trained outside of The United States versus this bill, but I think you've already heard some of that and I'm sure you will be hearing from the Board

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: of Medical Practice who will They asked them to come in today, but they said they were unavailable. Right, yeah.

[Jessa Barnard (Vermont Medical Society)]: So I'll sort of skip that. I'll go into just a couple of points, a little more specific on the bill. We do support, and I appreciate that getting to follow Devon, the bill allows pathways for both primary care and specialty care. Some states have not taken that approach and have only limited it to primary care. Not only do we think that Vermont has needs in not just primary care, but specialty care, but we also think it should match the background training of the individual. We shouldn't be funneling everybody to primary care if they trained as you just heard orthopedic surgery or whatever it may be, that's not where their training is and it wouldn't really be the right fit. And also, will just say candidly, we heard from our primary care clinicians about that approach, that in their view that leaves the impression that perhaps primary care is less specialized or needs less skill, and that is certainly something they take issue with and feel like in fact in primary care you're treating a whole range of ages. Anything to walk in your door, you have to be highly skilled. So if it's good enough for primary care, it should be good enough for everyone. We should be building a safe pathway for any of the clinicians who

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: are saying qualify for this approach.

[Jessa Barnard (Vermont Medical Society)]: We do support actually maintaining the section of the bill that says that the individual shall have performed the duties of a physician for three out of the last five years. Our members do believe in general that a recent practice experience is important to demonstrate that you have sort of fresh, you've maintained your clinical skills. That is parallel, and the board may say more about this, but that is parallel to the requirement for all other physician applicants to be licensed in Vermont. You have to be engaged in active practice within three years prior to the application. So we support that consistency. We also support giving a fair amount of, I would say, rulemaking authority to the board to implement the bill. It's fairly, I I don't wanna say brief, but it sort of, it lays out the good framework, but there are certainly areas we think it makes sense to defer to the board to develop more details, such as the acceptable countries of licensure or the standards for employers to use in evaluating positions. We think that rulemaking authority is important. One thing that's not addressed in the board, and I actually, I haven't even really talked to the board about this, but in our opinion, it would make sense, if not be necessary, to give resources to the board to establish and run this licensure pathway. There's nothing in the bill that addresses, for example, licensure fees. All other applicants or reapplicants have an every two year licensing fee, and the bill, at least to us, appears to put a substantial burden on the board for evaluating licensees and employers, rulemaking, actually quite a bit of reporting on outcomes. And without such support, first of not sure about the person power to implement it, but also the fiscal cost would fall on existing licensees. So we do think it would make sense to look at something like whether it's a fee by the applicant or the employer to establish a grant. Well, it could

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: be for the applicant, but an employer might say what.

[Jessa Barnard (Vermont Medical Society)]: However, we understand some of the applicants themselves may have limited resources, so we necessarily want to propose that, but whoever may be able to support, again, the cost of grant program. So, yes, so thank you, that's all I have for this morning. I appreciate you taking up

[Jennifer (Jen) Garvey (Office of Legislative Counsel)]: the bill, I'm hearing from tonight, so

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: I'm hearing you say three things, you support the three out of the last five years and the suggestion that was made about seven years not. And then the rule making and maybe putting in more criteria evaluation

[Jessa Barnard (Vermont Medical Society)]: No, standards or sorry, we support what the bill already says though. We're keeping that as of yes, we appreciate that that is in the bill.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: But then the fees, obviously. The fees, it's

[Jessa Barnard (Vermont Medical Society)]: silent on that, which I would say would be no fee. Mean, not to speak for the board, I

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: don't know exactly what they would say they would need to implement it, but if they need resources to implement it, support some way of funding that. Yeah, so I know that we've added some licensure requirements for telehealth and other things, or temporary licenses are out of state, and the board has come in and made suggestions. Maybe they'll do that for us. Anything else? Okay, this is terrific, thank you. Thank you. So, I'm looking around the room and I don't know who you are, are you here?

[Jared Rhodes (Center for Modern Health)]: I would love to if I can, yeah. My name's Jared Rhodes.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: And you represent?

[Jared Rhodes (Center for Modern Health)]: I'm with the Center for Large Health, so a public policy big thing.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Would you like to come up and speak? I'll be sure, yeah. Right, and do you have anything in writing that you I

[Jared Rhodes (Center for Modern Health)]: did, I sent it up

[Unidentified Committee Member (Senate Health and Welfare)]: I for

[Jennifer (Jen) Garvey (Office of Legislative Counsel)]: know why I don't have your name

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: on the ASSN public health. So I'm just gonna look now.

[Jared Rhodes (Center for Modern Health)]: Yeah, do.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: So, by the we have time this morning, so welcome.

[Jared Rhodes (Center for Modern Health)]: Okay, well thank you. As I said, I sent in like two and a half pages, but I'll chop that down on the fly.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: So, it's Jared Rhodes?

[Unidentified Committee Member (Senate Health and Welfare)]: Correct,

[Jared Rhodes (Center for Modern Health)]: yeah, Rhodes, R H O H Okay. E All right, well good morning, and thank you for this meeting. My name is Jared Rhodes, I'm the executive director for the Center for Modern Health. It's a health policy that works on federal and issues across many states. I also teach health policy at government, but I'm not here under that affiliation at all. Mentioned that just over the border in New Hampshire. I see the proposed change in s one '42 as a as a great opportunity. I think like everywhere will benefit when they have greater to physicians' shorter wait times, better choice among providers. We've heard about the cultural public and see, which I think is great, and certainly more doctors willing to practice in smaller and more rural communities. Is a, sticking around here, it is a known thing in the literature that doctors of this type who come in through this pathway are more likely to practice in rural communities. I can find numbers on that. Didn't include them in my testimony here, but I can provide the meeting with information on that, peer review kind of stuff.

[Jennifer (Jen) Garvey (Office of Legislative Counsel)]: That would be helpful.

[Jared Rhodes (Center for Modern Health)]: Yeah, yeah. Skipping through, we think of this as, as this bill is providing something that's something that's oral and practical solution. It's always nice when those things align. First, we kind of look at this as a health, economics, and the homeschool case as well. On the health argument, we see this as, look, more physicians are going to need greater access to care, shorter lead times, like I said, better health outcomes, particularly in the primary care rural communities. So, you know, this really does address a really growing need. On the economic argument, you know, occupation licensing exists, in theory, to protect the public from unqualified practitioners, in theory. Redundant training requirements, though, are kind of a waste. There are there are waste of resources, waste of human resources every year that that a qualified doctor spends redoing training is a year that he or she can't be practicing otherwise, and seeing patients and not contributing to the local economy. You want to sell this on the basis of creating and generating tax revenue, you could also think of it that way. So I I would say reforming the reforming this part of the state's medical licensing rules allows human capital to flow to its highest value use. Lastly, on the moral, I I just think that this is a something that these these individuals have who have demonstrated their qualifications to serve the freedom to practice in a different profession. And I think for monitors to look at the consumer side of this, monitors to serve the freedom to choose which doctors from a wider pool of qualified providers they would like to see. One last thing that I'll just touch on that has come up today about the, for instance, the receipt requirements and the limited licensing provision. I wonder whether, we've heard about three three of the last five years being what's in the bill right now. We've heard, you know, one out of the last seven maybe a change to that. Maybe what we go for is a three out of the last seven. That would be a nice compromise here. Was pronouncing that. Three out of the last five is what I see when I look at other bills of this type from others, other states. So maybe that's the most standard, but there's no reason that we just have to take take a stand in there. It would be nice to be a little bit more relaxed on that. There are, of course, other things that come into play, and I mean, that's not the only, you know, that's not the only gatekeeper. That's, you know, not the only quality control. There are, you know, there are other organizations that have to input their judgment, right? There are checks and balances in the system already, and so we can take a look at that, that recency requirement. And then just as a final nugget of thought piece here, so in this bill right now, you have the provisional part for two years, and then you also have the limited part, right, and that can be your new ones. There are places, Tennessee, for instance, that after that provisional part or their their equivalent of it, it it goes to a it gets automatically converted, and you don't have to do the limited thing for for an additional two years. That might be something that that this this entity might wanna take a look at. Tennessee, they put their bill into law only a few years ago, and so we haven't been through a full cycle of a lot of data on that, but I have yet to hear any sort of horror story after that, and I think it's worth going to write all around them. With that, I'll just close there and say thank you.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Thank you. I'm glad you're here. Where is the Center for Modern Health located? Hanover, New Hampshire.

[Jared Rhodes (Center for Modern Health)]: Where? Hanover, New Hampshire.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Hanover, New Hampshire. Did you drive up here today? Sure did. We're glad you did.

[Jared Rhodes (Center for Modern Health)]: 59 miles or so.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Well, that was a beautiful day for the ride. Yes. That was good. Thank you, and thanks for being available. And send us that information.

[Jared Rhodes (Center for Modern Health)]: I will.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: That would be really helpful.

[Jared Rhodes (Center for Modern Health)]: Yeah. Good stuff. Yeah. Again.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Serenity. Great. Okay. Any questions?

[Jared Rhodes (Center for Modern Health)]: Sorry, sorry.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: No, I'm just saying. Good. So we get conversations. So, did you wanna say anything at all?

[Jessa Barnard (Vermont Medical Society)]: Mary Kate moment for the record by State Primary Care Association. No, I don't need to add anything. I have written testimony that's been submitted. We're generally supportive of the bill and I think Josh DeBrin from North Star said it best.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Thank you. That's really helpful and I'm going to go back to Diana and the exceptional amount of work that you've done on this bill. Since the last time we've looked at it, I know you worked hard on it initially and now this is a new bill that I think has captured a lot of the concerns that were there last time. We've learned tremendously from, as Senator Harris had mentioned, that we have what I call a coalition of supporters. Each of them brings their own perspective, whether it's the Office of Racial Equity, whether it's by state, that has been tremendously helpful. And then, of course, each of the interviews. But it's I certainly have been on a learning curve with making sure this bill fits and serves in the best way. Yes. So I understand that the Board of Medical Practice may have a different perspective what we've been hearing and we've asked them to come in and we'll have them come in and talk about what their thoughts are and we'll do that ASAP. Unless I hear differently from members of the committee or we get a deluge of pushback on the bill, I think this is one that we want to move forward before crossover. I mean, solves a lot of problems, health, economic, moral. Yeah. There certainly are other CEOs that are offering to testify as well as Vermont professionals of color. I don't know if the committee needs extra time and extra testimony, but they are available. Thank you for that. And we do have list that you sent us in. We may add one or two as we look at the bill again. Okay. Well, the committee, is it do you want to go look at the bill anymore this morning with Jen? Is there any other questions you have? One point of contention seems to be some three out of five. Yeah. Which going forward, I think is probably reasonable, but I'm thinking of the phlebotomist who's definitely overqualified. Because this path wasn't available, maybe we need to set up an alternative path for people who are here, maybe, another thing of supervision or something, but it's still no fault of their own that they been able So that's a good thought and then I mean as you look at the people who Diana and Ruth have interviewed, think about who they are and what they've been doing, and maybe we can convince the board of medical practice to help us with a more positive pathway. On that line, it's not

[Unidentified Committee Member (Senate Health and Welfare)]: a job. I'm thinking the same thing as maybe the three to five is the standard, but they have an opportunity to present their credentials to the board and to get a waiver or something from that requirement based upon their actual credentials and experience.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Good, I mean this is a really good conversation and it's one that we will have to have after the board comes in while we're here. I know some of you folks are in the room or on Zoom with us. Don't expect you all have to drive 100 miles to be here, but it would be really helpful as we look at the bill again to have you available and talk with us because we do that. We get into a conversation about what fits. And I feel like we're there. We just need to hear from board members. Just one other comment, if

[Unidentified Committee Member (Senate Health and Welfare)]: I could. Chair is we heard that one thing that's missing from the bill is the licensure and the fees. And if we could get some language on that before we actually look at the bill the next time

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Okay. So things up. That we might be a little premature on that because we need to hear from the board of medical practice. There's the ones who will be implementing this, and I'd like to have their testimony. And then we'll ask them for that. You can be the one to ask them for that.

[Unidentified Committee Member (Senate Health and Welfare)]: I won't jump ahead.

[Sen. Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: We're all ahead. We're all getting there. Good. Okay. So next week we have other bills that we're looking at. We're gonna try and get this one on the agenda at some point during the week. We have a full week of the bills that we have been engaged with, and there's also a vote on what day, oh, Thursday morning, we're interrupted with the Adjugen Inspector General and Vermont State College's Board of Trustees, so we missed one there. So we'll put 142 up with the Board of Medical Trackers ASAP. Thank you. And we're gonna call it a wrap. And, your