Vermont Legislature SmartTranscripts:

[Speaker 0]: Some of the things that have been presented to us and testimony to go. Point out what I've seen and can also point out what you have as well.

[Senator John Morley III]: This is as introduced, Jim. As introduced.

[Janet Harvey, Legislative Counsel]: We got Janet Harvey from the legislative council, six S 64, and I'm relating to amendments and scope of practice for optometrists. This bill would, section one, would amend definitions in the chapter on optometry to add in administering in addition to prescribing appropriate, say therapeutic pharmaceutical agents, gets defined in here. Under existing law, there's a list of things that optometrists can do in the area of, don't know, I can

[Speaker 0]: tell back all the way up.

[Senator John Morley III]: Certain

[Janet Harvey, Legislative Counsel]: practices, examining human eyes and visual system for diagnostic purposes, diagnosing and correcting anomalies, envision and, again, some of visual performance with a list of authorized activities. Then, this creates a new provision around an optometrist holding an advanced therapeutic procedure specialty and it creates that specialty. And there's a list of advanced therapeutic procedures that can be performed. So this is I think a lot of what you've gotten.

[Speaker 0]: And this is where all of the controversy begins. It's the expanded scope. Right. And what is non recurrent chalasia. It's not pronounced that way because it sounds like an M. It's sort of a chalasia. And just sitting by object not the current lesions. So the questions that have been raised, optometrists in the training section of this bill where they have had additional training suggests that they and state that they are capable of performing all IDs when they've had that training and the Office of Professional Regulations has validated that through the Sunrise report that we got. Ophthalmologists on the other hand believe a couple of things. One, that what some of the procedures here that include specific surgery, invasive surgery, it should not be included. I'm just trying to summarize what I've heard. No injections, no penetration of the eye or the external eye, no scalpel, no injections for that. And laser procedures appear. Yeah, and so, and then we'll go from there. So there's a difference of opinion around the procedures. That's a And huge we saw a video in here that came from the ophthalmologist, and we've heard from various folks from the optometry world as well.

[Janet Harvey, Legislative Counsel]: Go ahead. Okay, so that was in the definition, a whole new definition of practice of optometry, I'm talking about the scope, so it's appropriate, but I'm just reorienting this. There is a definition of adverse event, a definition of therapeutic pharmaceutical agent, and what that does is does not include. Section two relates to the renewal and some addition of an optometry license and some additional continuing, five hours of additional continuing education in advanced procedures for licensees holding an advanced therapeutic procedure specialty. Section three has some specific prohibited practices that optometrists could not do, except as very specifically set out in that definition under the practice of optometry, so not performing any ophthalmic surgeries with or without the use of lasers or injection procedures, except those that were affirmatively listed in the definition section. And then there's a whole list of procedures that an optometrist is prohibited from performing. I have

[Speaker 0]: a question about that. I was looking at it, is that in there? Why would you need

[Senator John Morley III]: to list prohibited procedures if you're identifying acceptable procedures?

[Janet Harvey, Legislative Counsel]: I think it's, I can't give you a specific can't give Great. Go ahead.

[Heather Schulick, Vermont Optometric Association]: Heather Schulick from the Vermont Optometric Association. That was put in there because, as many of you know, we've been working on this bill for five or six years, and we wanted it to be very clear to the ophthalmologists and Vermonters what we were and were not doing. That was actually a recommendation by OPR. OPR drafted this bill based on

[Speaker 0]: their report. Okay, that's all. So we'd have to ask OPR. Just offering clarity, this committee has to have in our own multiple five or six years.

[Janet Harvey, Legislative Counsel]: Okay, so that's the list. Lots of different surgeries and other activities. Also prohibits, affirmatively prohibits an optometrist from prescribing or administering a drug or other substance listed on Schedule I, nobody's allowed to prescribe those for the most part, or Schedule II controlled substance, a set forth in Subdivision II, and that allows an optometrist to prescribe or administer hydrocodone in combination with analgesics for not more than seventy two hours supply and no. All right, so then we have the sub chapter five, which creates the advanced therapeutic procedures specialty, authorizing a licensed optometrist to apply for an advanced therapeutic procedure specialty, authorizing them to perform advanced therapeutic procedures. They're on that approved list in the definition section. As far as who is qualified, an optometrist has to get the specialty in order to perform the advanced procedures, and the board of optometry can grant a specialty to an applicant who is licensed in Vermont as an optometrist, meets applicable requirements for education and demonstrated competency

[Jenny Horgan, Alzheimer’s Association]: that are

[Janet Harvey, Legislative Counsel]: in this section, and have completed the examination requirements in this section. Educational requirements, that if you may recall, there's sort of a split based on time of training. So, an optometrist who graduated from optometrist school or college prior to 2019 must do a post graduate course sponsored by a board approved organization with a minimum duration of thirty two hours and specific didactic classroom instruction. Need to surgically go through once you want to, and then an optometrist who graduated in 2019 or later does not have to do that, and I believe that testimony of you, Rick, is that that has been incorporated into the training in more recent years. Preceptorship requirements. Optometrist has to do a preceptorship, where they gain at least eight hours of clinical training supervised by a preceptor, and demonstrate clinical proficiency with hands on experience performing certain procedures on live human patients. There's at least two required of each of these, and the preceptor has to be either an optometrist with a substantially similar scope of practice who's been licensed to Vermont or another US jurisdiction to provide the advanced procedures for at least three years, or an ophthalmologist. There's direct and in person supervision of the optometrist by the preceptor, of taking place in a state where the preceptor is licensed and authorized to perform the advanced procedures, and the preceptor has to certify that the optometrist has competently completed the required procedures and provide a log

[Speaker 0]: to the

[Janet Harvey, Legislative Counsel]: board. There's an examination requirement, the applicant has to successfully pass written and clinical examinations administered by the National Board of Examiner of Psychometry, including ones on injection skills and laser and surgical procedures, and any other examination required by the board by the rule. Provisions allowing advanced therapeutic procedures, specialty by endorsement for someone who's already been licensed and doing this, and is in good standing in another state. If that state has this expanded scope of practice that's substantially similar to the one this bill, and has been in good standing, in this expanded scope of practice in the other jurisdiction for at least three years,

[Senator John Morley III]: and

[Janet Harvey, Legislative Counsel]: allowing an optometrist who received the specialty by endorsement to serve as a receptor. Reporting requirements, it would require an optometrist to report any adverse event, that's why there was the definition of adverse event, related to an advanced procedure within thirty days following the event.

[Speaker 0]: So the report goes to? To the board. That's the only route. Okay.

[Janet Harvey, Legislative Counsel]: Mean, it's my assumption that this is a report to your board, but it does not.

[Speaker 0]: It doesn't say that, which should say something about the subsection.

[Janet Harvey, Legislative Counsel]: Re designating just moving some sections around, and then could take effect on January

[Speaker 0]: And I guess it's a question for OPR and it's not sure we asked it.

[Janet Harvey, Legislative Counsel]: Oh, OPR, don't know that OPR wanted actually a year later. They wanna drop a year and have to stay on 07/01/2028, so I wrote in my

[Speaker 0]: Yeah, so that's a different date. So then the question, so the questions that, the things that came up while we heard testimony were the extent to which the procedures allow for expanded scope and we heard from ophthalmologists about the extent of that. There was a suggestion that I mentioned before on no injections and no scalpel. One in particular who I know, I keep teasing him about it, about how come, we need more eye care in Northeast Kingdom, so you can guess who that is. And then you look at the maps that the optometrists have provided us where there are aging ophthalmologists and then we have looked at the maps where there are zero optometrists or ophthalmologists in Essex County and in Grand Isle County. So there is that kind of that rural healthcare need that could be there. But it doesn't extend directly to all of these procedures. It's because when they asked for data on a number of these procedures in the state, we came up with 11 selective laser trabeculoplasty, I'm looking at Berlin, the data that we see we asked for, and 33 posterior gyne capsulotomies in the state. And I guess if you have, you know, who's doing them. If you one of the things we heard that was that reputa repetition is important for these. Putting out all the concerns that I've heard, and I know some of these are not concerns to some people, but those are the things that I heard. So I've heard geographic distribution and access to optometrists as well as aging ophthalmologists. I've heard disagreement about scope and how it might be limited, and then I heard about the number of these advanced procedures that a well trained optometrist might do and currently that ophthalmologists are doing. I don't know what else I heard. I've I've heard some pretty negative and uncomfortable and not nice, use other words, emails. I won't state who they were from, but I found it really inappropriate. This isn't a personal issue. This is a professional issue, We're trying to make a decision for professions here. If I had my way, based on some of the emails that I've seen, the bill would stay right there. I want people to know that and people who represent this bill. You need to know that. Don't ever do this again. Thank you. I've had my son. So, committee, let's move on to the bill, and we're here. We have the bill as it was introduced and the information. You guys, I guess, you've been privy to the information as much as I have. Heather, you wanted to

[Heather Schulick, Vermont Optometric Association]: say something. Yeah, thank you. Heather Schulick with Monarch Association. I just want to make sure that the record is clear. And as I said earlier, we've been working on this for six years. From the very beginning, ophthalmology has said no. And then the 2023 report that OPR was doing, once ophthalmology realized the report was coming out favorable, they walked away from the report. OPR called us and said, We're writing this report. We don't have anybody on the other side. And we said, Okay. They pushed themselves away from the table. That has happened every year since. And so for us, and Doctor. McNally testified, there is no negotiating. So we're not gonna negotiate with ourself when the education and training shows that they can do these procedures. Understood.

[Speaker 0]: It just doesn't I get it. We get it. So, there anyone who would like to speak from the other? It's not my funnest day. I think Venus and, what is it, Mars or. Okay. See what's in the notes. Hi. Committee, I've had my I've had I started the conversation. I wanna know what your thoughts are here on the bill, and does anyone wanna offer. Comment. I mean, we've got, there are a lot of areas here to consider. The one thing I did mention I should have brought up and that is we never have this conversation when we're doing this kind of work, malpractice insurance, professional coverage, and I don't know what this will do for optometrists if there's an expansion of scope to your insurance companies. So we haven't talked about liability insurance here recently about this.

[Dr. Dean Marshall, Vermont Optometric Association]: That's me too. Yeah. Dean Marshall, Vermont Optometric Association. So remember that 14 states already offer this and insurance companies that cover liability don't just cover one state. So it's a well established track to make sure that those changes aren't covered by liability insurance. And actually, most of our policies already cover it despite the fact that we can't do it. Okay.

[Speaker 0]: Can you give me a ballpark figure for what the what the liability because I know something about some liability insurance.

[Senator John Morley III]: Like, the

[Speaker 0]: cost of it? Yeah. Yeah. You know? It's a lot. I know it's a lot.

[Dr. Dean Marshall, Vermont Optometric Association]: I have other people who pay my bills.

[Senator John Morley III]: Oh, you see it.

[Speaker 0]: Sometimes I'll I'll find

[Senator John Morley III]: out about it. But, anyway

[Speaker 0]: okay. I

[Senator John Morley III]: just, same as you, I kinda tried getting everyone to work together, and it just didn't work.

[Speaker 0]: Not happening.

[Senator John Morley III]: Yeah. It didn't happen. And so I tried. Yeah. I've been fairly supportive of Bill and still has introduced and, either, you know, where I come from, the Northeast Kingdom don't have so we do have optometrists, and I've spoken to them. They reached out to me and stated they can applaud all these procedures. And if they don't believe they can do this, you can hope to do it, then they would, recognize them to go somewhere else. So that's all the guidance that I've been aware of.

[Speaker 0]: Is there any requirement that, temperatures carry?

[Janet Harvey, Legislative Counsel]: If that'll be our centers,

[Speaker 0]: any requirements, to carry insurance of malpractice? All

[Senator John Morley III]: of them. Yes. Okay.

[Speaker 0]: I'm there's been a couple news stories lately about people doing cosmetic surgery. They are doctors. Least they're supposed to be. And people dying, and no way for the next patient to find out that this doctor has had two people die under their care for something that's so I'm wondering, is there a reporting system before I go to my optometrist and letting laser my eye? Is there a way that can I look that up in professional regulation as to

[Janet Harvey, Legislative Counsel]: If there's been discipline There's been discipline? Yeah.

[Speaker 0]: How about compliance? That has to be demonstrated to be Okay. No. But I will

[Janet Harvey, Legislative Counsel]: also caution you that people can complain about all kinds of things.

[Speaker 0]: So I know. My eye just got done. I'm serious.

[Senator John Morley III]: That's I'll just say I thought you did an excellent job of summarizing everything that we've learned, And I apologize for anybody who sent you the type of email that you've got because that's getting close to you. Maybe

[Speaker 0]: we'll take it up tomorrow. Maybe we won't based on those

[Senator John Benson]: We will.

[Senator John Morley III]: You know, I I've listened to all all the testimony and there's obviously, two sides. I don't want to get together on this, but you know what I especially when you listen to the dean of the college shows that this is well within the realm of practice and the education that these individuals are receiving. And as I indicated, when we talked with the OPR, my own license and as John just said, if they aren't qualified to do the work and they're a professional, they will not do the procedure and will refer those individuals to somebody who is qualified to do it. So I don't have the issues with the bill.

[Speaker 0]: Well, my issue with the bill are the number of procedures that are here going whole hog when we don't have a lot of pathology out of state. It's a huge issue for me knowing that we're expanding it. I understood that people are well trained, but when you are well trained you also need to have repetitive exposure to the type of procedures that you're doing. So just opening these all up, guess, I do have concerns about that. I share that, I have shared that with others consistently. And thinking there may be a way to limit some of the surgeries that are here, the surgery overall, and include some of the things, expansions that would allow for some use of laser, but some of them seem, as we heard from Doctor. There are some procedures that are best done frequently and within access of hospital support services. That's actually another question I had, and maybe Dean can answer this, but once one of these procedures is performed, if there is a complication, how would an optometrist handle that complication? Is there 20 fourseven coverage? Will there be a relationship with a hospital or another practitioner for the patients so we're not sending the patient to the ED?

[Dr. Dean Marshall, Vermont Optometric Association]: Yeah, think the ED probably would be well equipped to handle. I mean, we deal with postsurgical complications already. That is within the scope right now. Most procedures, as you know, have some kind of global period. Right? So depending on the procedure that we're talking about in the bill, we're responsible for the the aftercare, if you will, for for the time frame. If you had one of the misadventures that's a big deal, I mean, you're really going to UVM or Gardner, and that's independent of whether you're an optometrist or just a private practice ophthalmologist. If you need hospital services, you're going to the specialist at the hospital. So,

[Speaker 0]: this is a good point. It came to me when I was looking through stuff last night. I know that in the past, when we've had the ophthalmologist coming in here looking to have their, the ophthalmologist in my district having their clinic approved and was all about the CON process and how they're gonna fit up and get ready to go, and then what kind of coverage will they have at the hospital. There was a big dialogue between the hospital and the practitioners. So my question's pretty basic. There has to be some relationship going on and I know it might be one surgical procedure in ten years is a problem, but having a relationship with a local hospital, with UVM, Dartmouth, could be Albany, depending on where the person is, should they have something stated about that?

[Dr. Dean Marshall, Vermont Optometric Association]: It's your pleasure,

[Senator John Morley III]: of

[Dr. Dean Marshall, Vermont Optometric Association]: I will point out that in this moment for this committee, it sure seems like optometry and ophthalmology don't get along. But I have a dozen personal cell phones of ophthalmologists in my phone and I call them and I say, hey, I need this or just this patient might be a little tricky or I'm worried about this. So, I mean, it's a small state and and we do have working relationships. You know, like, I'm the only eye doctor on staff at Gifford. So if the Gifford ER has a problem, they call me. You know, for a long time and and Escutney has added some providers. But for a long time, we took all of Escutney's ER stuff in White River too. So my residency was at the VA hospital. When I was there, there were no ophthalmologists there. Anything that walked into the VA hospital, and those are often very complicated patients, you know, that was optometry dealt with it. And if we couldn't, usually, we had to go to Boston unless it was truly emergent, and then you were sending them over to Dartmouth. But, I mean, the relationships there exist. I I wouldn't foresee that being a huge problem without writing in it if you wanted to make sure that there was some kind of working relationship. I would only ask that a working relationship other states that have instituted optometric scope expansion have found difficulty finding sign off when it is left to ophthalmology to sign off. Right? But it's another way of sort of holding

[Senator John Morley III]: things down.

[Speaker 0]: Okay. Well, it's just something to think about. We might wanna put something in there. Other questions or comments?

[Senator Martine Larocque Gulick (Vice Chair)]: I have my hand up, Senator.

[Speaker 0]: My boy is from the wilderness. Thank you for being here, Senator. Go right ahead, please.

[Senator Martine Larocque Gulick (Vice Chair)]: Oh, thank you so much. I just had a couple of thoughts as I'm listening in on you all. One is I'm thinking about what Doctor. Peter Provenos said on Monday, which is that a lot of times in these medical discussions, we end up in these two camps, you know, in our corners. And it seems like this is kind of an example of that and it's really unfortunate. And so I just wanna share that I'm really disappointed that that's the way that it's sort of come down. And his point was really stressing that we have to work together, right, for what's best for our state and for our constituents and for our citizens and Vermonters who need care. And then another thing that I keep thinking about is, do we trust OPR? Because at the very heart of this, this is an OPR report that they have put their name on, that they have worked diligently on, that they have backed. And if we trust our own operation of professional regulation, it seems as though we need to listen to what they're saying. And so I don't wanna dismiss their report and their work. And I am in favor of moving this bill forward. Thank you.

[Speaker 0]: Thank you, Senator. And as I said before, my concerns rest with the extent to which we're expanding scope. And I'm not sure that we all understand what it means to require surgery of the retina, excisional surgery of extraocular muscles. Cosmetic surgery for the eyelids, but that you were bringing up. There are others there. There's also surgery of the eyelid when it's impedes with eye eyesight. Removal of lesions along the eyelid margin. And then the one that we don't do very well. Somebody can help me with this.

[Senator John Morley III]: It is where is it?

[Speaker 0]: You get to a c.

[Senator John Morley III]: What kind of begins to say?

[Dr. Dean Marshall, Vermont Optometric Association]: I

[Speaker 0]: want everyone here.

[Dr. Dean Marshall, Vermont Optometric Association]: I think one or two of those to read might be from the prohibition list, not from the allowed list. Oh, is from the prohibition list. Just, yeah. We're not doing any eye muscle surgery. We're not doing any retinal surgery. We're not, like

[Speaker 0]: It's from the prohibition. Thank you. Right. That's why I couldn't find the one I wanted. That

[Dr. Dean Marshall, Vermont Optometric Association]: language was added as part of early discussions to make sure that methodologies didn't feel like we weren't Good fences mean good neighbors.

[Speaker 0]: Go ahead. I've gone both ways in this. And I think at the end, I I share your concern about the lack of patients. You don't want the doctor that does one knee surgery or one kidney transplant a year doing your knee surgery because they're learning. But I added that to the presentation on education, And if we had two people from the optometrist, and a, I never saw any presentation of anybody working on an actual patient. It was models. And b, they just didn't have the gravitas that I would I got from the medical profession. It did not inspire confidence in me that this was a serious procedure that was trained for, you know, under strict supervision with an ophthalmologist present on a live patient because there's a difference between a model, models don't bleed, and human being. And it's I'm not comfortable at this point with I'd be much more comfortable with a stepped procedure where we did two of these, probably the least invasive, taking things off your eyelid maybe, and then move forward. But the transcigens and maybe that's recent, but I'm just I'm not there yet. I'm I'm in a place where you are, and that is there's just too much here. It's just like it should be all of us. So good. Thank you for sharing where you are with this right now. This is really important. We got it. And thank you all for being in the room with us while we're doing this. Over. What I'm gonna say right now is we've got two other bills that we can look at, maybe three, maybe four. Still working. So we're gonna set this one aside, we're gonna come back to it tomorrow. But honestly, if there's a way, I think there might be a little more willingness to move forward on the bill with a couple things. One is that having the link with the hospital or 20 fourseven care, you know, and needs. And then also how do we limit the procedures that are here? Some of are pretty striking that we saw as Senator Cummings' comment can't be.

[Senator John Morley III]: You know what she would say next. Yeah.

[Speaker 0]: Yeah. Can

[Heather Schulick, Vermont Optometric Association]: I just say one last thing? Not right now.

[Speaker 0]: What was it? I can't resist.

[Heather Schulick, Vermont Optometric Association]: No. Go ahead. In other states, legislation is Go ahead. Often drafted as as taught, and we could have done as taught, and that would have given you way many more questions. So we tried to be super transparent and so I did

[Speaker 0]: that. Thank you. And I know that the that OPR did work very hard. We, yes. We know. Okay, so thank you all. We're gonna move along to a new draft. Before we move to the new draft of 01/1989, Jan has for us, we are going to go to very briefly to 01/1954. Just quick testimony on that. And then 01/2189 to add your very briefly. I mean, so brief. I'll let them know. Thank you,

[Dr. Dean Marshall, Vermont Optometric Association]: Adi. Thank

[Senator John Morley III]: you, everybody.

[Dr. Dean Marshall, Vermont Optometric Association]: I am completely sorry about the.

[Speaker 0]: I'm It's not

[Senator John Benson]: Well, I'm just scared.

[Speaker 0]: I'm okay. I'm trying

[Janet Harvey, Legislative Counsel]: to escape.

[Speaker 0]: I'm trying to. Then it's,

[Janet Harvey, Legislative Counsel]: you know, difficult. And guess what? I'm ready

[Speaker 0]: to stick it up there and leave it alone. You know, I've I've I'm not a happy person right now. Mars is in my brain. I'm sorry. I

[Senator John Morley III]: get a couple of other bills. I've been playing up with a. Understand.

[Speaker 0]: I told one group once that I was a sponsor of a bill. That if they didn't back off, I was going to put pictures of it. Okay, so thank you for being here. For the record, your name is?

[Senator John Benson]: My name is John Benson.

[Speaker 0]: Good to see you again.

[Senator John Benson]: I live in Hartford. Yeah, thank you so much. I know you guys are extremely busy. I really appreciate you. Right, so if you could

[Speaker 0]: just sort of summarize, we'd love it, and we'll put it up on our webpage.

[Senator John Benson]: Perfect. So what I really wanna do is I wanna talk a little bit about my experience. So my wife, Jimmy Simon Bob, was a really active, engaged in the community person, loved colors, loved people, was really a really wonderful person.

[Speaker 0]: She was wonderful and she was in this room.

[Senator John Benson]: She was. She might have been wearing And hair. Yeah, right, exactly. And, but her life ended two and a half years ago from dementia, probably Alzheimer's. She got a diagnosis about early in the year 2020. And it was, you know, so she lost her ability to cook, quilt, you know, all the things that she loved to do. The back in 2020, if you were diagnosed with Alzheimer's, you were pretty much given given some support but get your life in order, you know? Yes. You don't know how it's gonna progress. You don't know how fast it's gonna happen but you know, this is nothing that you stop. We can't even slow it down. So there's some support that you can get from aging resource centers or that sort of thing. There's some training that you can take to learn how to become a caregiver and I did all that. But she, her life ended, sort of a mixed message, ended rather suddenly, so she didn't reach the point where she'd know anybody. She actually got home, was brushing her teeth one morning, and she had a seizure, fell backwards, and banged herself on her vertebrae, and it was a 72 year old woman, used to operate and repairing vertebrae when somebody has dementia. So it was kind

[Senator John Morley III]: of a downward spiral another two and a

[Senator John Benson]: half months after that before she basically died. The reason this is really so important, that that is, things have changed so much in the last three years, just want you to know that. In 'twenty three and 'twenty four, the FDA approved two drugs that will effectively slow down the decline due to the health of virus. That's really significant. I've met some people that have been perfectly competent, been on tables, excuse me, on, they've spoken in front of tables and committees that have described their experiences and they're doing great. Less than a year ago, the FDA approved a blood test that detects Alzheimer's. Well, it's not a direct thing, it's a balance between two different proteins, but it does exist and at this point in time, Alzheimer's can be predicted pretty early. They haven't gone through the process yet to see whether they can predict it before even symptoms begin to show, but we're sort of hopeful that they will. So given these two pieces, if that had been available when Judy was beginning to get concerned about how she was able to think and reason, and knowing that her father had died with dementia of some sort, we certainly would have gone in the direction of trying to get a biomarker testing to see whether something was developing. And if they had been early enough, it would have been early, and these other treatments would have been available. So tremendously improved her life, would have definitely elongated her life a lot, and the other point I would make is that the biomarkers of testing is relatively inexpensive. I mean, can't tell you what the cost is now. But compared with getting PET scans, brain scans, and having those analyzed, it's less and probably has to do it more better. So that's why I think that health insurance should be covering biomarkers. I appreciate your time. Thank you very much. I hope you've moved this forward.

[Speaker 0]: Thank you. Well, I think what we'll do, we'll try to get it down to finance where they can deal with some of the financial money issues because we're not a bottomless pit when it comes to funding here, but at least we can get something started and the chair will do what she does. We need to eat it, Paul. That sounds good. You know? Yeah. Keep it in my ass. It's just Thank you, John.

[Senator John Benson]: Oh, I am I I get that. You get that. I just let you sleep breakfast for Monday. Was very clear.

[Speaker 0]: It's very challenging here. Yes, sir. Thank you. Thank you very much.

[Senator John Benson]: I appreciate it.

[Speaker 0]: Appreciate it. No. We appreciate your time and being here and being patient with our schedule today. It's been interesting. So, wow, as soon as Jen comes back in, we'll go right to one hundred eighty nine. She has a new do you have a poster of the new draft? Okay. Why don't we post that up? Oh.

[Senator John Morley III]: While you're waiting for

[Speaker 0]: Drew Wait. I'll be very

[Jenny Horgan, Alzheimer’s Association]: brief. Okay. So, Jenny Horgan with

[Speaker 0]: the Alzheimer's Association, and thank

[Jenny Horgan, Alzheimer’s Association]: you so much for the opportunity to address you all again. I know I spoke to you all a couple weeks ago, so not to overcute myself too much, but we certainly think that biomarker testing for increasing access not only benefits families, it benefits people living with the disease, but also has significant financial benefit to the state, that $63,000 in some of the cost savings that we see for individuals living with this disease. So $13,000 in personal savings, 20,000 in Medicaid savings, from $30,000 in Medicare savings. Also, just to really focus in on the

[Speaker 0]: cost of the disease, which

[Jenny Horgan, Alzheimer’s Association]: is incredibly expensive. It's 158,000,000 estimated Medicaid cost of the state pays alone caring for people with Alzheimer's.

[Speaker 0]: Now, John spoke so eloquently to,

[Jenny Horgan, Alzheimer’s Association]: you know, when we get people access to a test earlier and a diagnosis earlier, that can lead to the opportunity for them to access FDA approved treatments, delay their possibility of them entering long term care, and also just very briefly, the science is moving so incredibly quickly. Unfortunately, insurance is just not keeping up with that. So we want to make sure that everyone in state of Vermont has equitable access to these resources to not only benefit them and their ability to figure out how they want to move forward in their life after getting a horrible diagnosis of this disease and dealing with

[Speaker 0]: all that, but also to ensure that they can maximize the best treatments that not only help them but also will benefit the state as a whole.

[Jenny Horgan, Alzheimer’s Association]: Very, very quick and certainly always happy to answer

[Speaker 0]: that. No, this is good. I think your testimony will probably be most effective. Of course. We

[Jenny Horgan, Alzheimer’s Association]: will afford to it hopefully, but it doesn't happen

[Speaker 0]: with you. Yeah, it depends on our time. We've lost two thousand people off of the just because of the cost this year. And if we add anything that isn't on the federal list, state has to put that entire. Sure. That will that will be the hard one. I think it's good.

[Senator John Morley III]: I've I'll wait

[Senator John Benson]: for it.

[Speaker 0]: In an adult day. Yeah. And the only way to truly know who knew who was Alzheimer's was autopsy on the Yeah. Yeah. And A living person. You had to go in, see if there were all the Right. Calcifications. We had one lady that was diagnosed with Alzheimer's, and after she got out and got active and Yeah. She was just depressed and lonely. Yeah. So Well, we're gonna we're gonna go with the ability to diagnose. Especially if there's stuff that you can do.

[Jenny Horgan, Alzheimer’s Association]: Treatments and health. Yes. Absolutely. And again, just want to be right, the science is moving incredibly quickly. We're so excited to

[Speaker 0]: see that. That is good.

[Jenny Horgan, Alzheimer’s Association]: And we want to make sure Vermonters have access to that.

[Speaker 0]: So we're going to end here, but I will say this, I just will say one thing. When you have a test that becomes predictive of Alzheimer's and it's validated that the test links with the post mortem evaluation of the brain, then you know it works. So that's what we're talking about here. We're not talking about we're not talking about the woman who went to No. But if you had able to do a simple test Yeah. You would know what we were dealing with what should. So, we're gonna move on to one piece of time. Seen it again, Harvey. You will help us understand. Thank you. Thank you, Johnson. I

[Senator John Morley III]: think that's all for. I don't know.

[Speaker 0]: A a present for for senator Gulick on her desk. She gets all the papers. Good. I rounded out my cow collection. Oh, okay. Oh, your cow collection. My cow collections are old.

[Janet Harvey, Legislative Counsel]: Alright. Hello again. I'm Harvey, that's that council. This is good. I got a little extra charge on my battery, so it stopped being low battery. Wait, do you need a plug? No, I'm I think I'm we're only here for a little bit.

[Speaker 0]: That's what's

[Janet Harvey, Legislative Counsel]: I mean, if it if it works. Well, it might not work. I'm not thinking.

[Speaker 0]: Works on mine if I go, it looks right. My new iPad

[Janet Harvey, Legislative Counsel]: specialized iPad. You got. Yes. And it does say slow chargers. Speed up charging.

[Speaker 0]: Use a 100 watt charger. Yeah. I plugged my phone in, and my phone got hot. I had to unplug it.

[Janet Harvey, Legislative Counsel]: Alright. So I'm back with a new draft of s one eighty nine. I just incorporates all of the previous changes, and so it's 3.1. Gulick has it posted.

[Senator John Morley III]: I wonder if you don't think just keeping.

[Janet Harvey, Legislative Counsel]: Oh, should I forget to take the highlighting out? Well

[Senator John Morley III]: Certainly.

[Janet Harvey, Legislative Counsel]: Yes. That oh, this is not the right thing. Either I didn't send her the right thing or is this posted? So ignore that one. Okay. And I will put up the version that is on my

[Speaker 0]: screen. So

[Senator John Morley III]: that's gonna be 4.1?

[Janet Harvey, Legislative Counsel]: No. It should oh, a 3.2.

[Dr. Dean Marshall, Vermont Optometric Association]: That was yeah.

[Janet Harvey, Legislative Counsel]: 3.1 is what we looked at this morning. Right.

[Senator John Morley III]: Alright. So

[Janet Harvey, Legislative Counsel]: I'm not sure

[Speaker 0]: if it's on good or not.

[Senator John Morley III]: It's alright. You're gonna put

[Speaker 0]: it on.

[Janet Harvey, Legislative Counsel]: Alright. Then I'm put it on. It's the changes are minimal. It's just we talked about.

[Speaker 0]: Four. Technological issues.

[Janet Harvey, Legislative Counsel]: 3.2. So, they incorporated intentionally. Whatever else I can put here. So, the change that I made was here, and I didn't try to show straight up whatever, just flagging it for a year. So, board may adjust on the school's budget as necessary to reflect the elimination or reduction, may include directing savings, a return to to address affordability concerns or to payers to be reflected in health insurance premiums or are reinvested in primary care prevention and other community services. So, flute, payers, and Vermonters, we kept the affordability concerns specifically around Vermonters. The payer was also kind of in that area, we said more specifically reflected in premiums. And that's it. That's the only change.

[Speaker 0]: I'm not seeing the I don't think Oh,

[Senator John Morley III]: you don't have it at the

[Janet Harvey, Legislative Counsel]: Oh, I know. I'm not

[Speaker 0]: sure if it's posted. Oh, I think Yeah. I can't post it. So she's back. Didn't.

[Janet Harvey, Legislative Counsel]: I think I did send it to you. So where did she go for me? Maybe because she wants to make copies of something for me. But

[Senator John Morley III]: I don't know. I Can we grab a piece

[Speaker 0]: of paper? Here. Who's the clerk in here? Here's

[Senator John Morley III]: the clerk.

[Speaker 0]: Oh, it's yay.

[Senator John Morley III]: Oh, here she is. Here she comes.

[Speaker 0]: No. We need a we need a thing for that. I'm gonna ask for the motion on S one eighty nine, graph 3.1 as presented.

[Senator John Morley III]: 3.2.

[Speaker 0]: Oh, 3.2. 3.2.

[Janet Harvey, Legislative Counsel]: That's why

[Senator John Morley III]: I couldn't I think it was not on there. Yeah. Okay. Yeah. What's the it'll be today's date, Jen?

[Janet Harvey, Legislative Counsel]: Today's date. Yep.

[Senator John Morley III]: On the

[Janet Harvey, Legislative Counsel]: overdraft? Yeah. Here, I'll I need to go back up on this. 190. This is 189. 89. Yes. And there should be 32. I should keep trying to email instead of sharing my screen. Go for it. Oh, and Senator Gulick has her hand up.

[Speaker 0]: Okay, Senator Gulick what? Senator Gulick has her hand up, go ahead.

[Senator Martine Larocque Gulick (Vice Chair)]: I'm sorry, I think my brain cells are not firing quite as quickly as they normally would, but is there any way someone can summarize in a few words the changes that we made from the original bill?

[Janet Harvey, Legislative Counsel]: From the original S-one 189? And Yes. That you're talking about, sure, I can do that. So the original S-one 89 was a review and approval process. So it would have prohibited a hospital from reducing or eliminating any service without approval from the agency of human services, and so it still had the public engagement process that's in the bill, but then it would direct the agency or give the agency authority to approve the proposal, or to disapprove a proposal. And this instead has, and then still have the Green Mountain Tribor to look at the budgetary impact if it goes forward. This instead has the public notice and engagement process, but has the agency of human services review and provide a non binding recommendation instead of having a strict approval or disapproval process. And then when the plan is in place, it will go to AHS to continue to do this? Yes, it is now plan agnostic as far as when the plan starts, but it does have them reviewed for consistency with the plan once the plan is established. Right.

[Speaker 0]: Vote. Senator Gulick, does that answer your question?

[Senator Martine Larocque Gulick (Vice Chair)]: Yes, thank you, I appreciate that.

[Speaker 0]: Okay, and remember what we heard from AHS was they aren't regulators in this arena, and so they felt that we're also in a stage of development around the statewide plan, so we tried to put in the transitional process for this.

[Senator Martine Larocque Gulick (Vice Chair)]: Yeah, and that's great. I just wonder where does the buck stop actually?

[Speaker 0]: It's a good question. And it's probably something we're gonna have to deal with once that plan is in place. You muted yourself. I don't know if you're still talking.

[Senator Martine Larocque Gulick (Vice Chair)]: I know, I'm trying to, I guess I'm a little disappointed that we don't have a clear, final arbiter in what happens, you know, that's just, that's a bummer.

[Speaker 0]: Well, and the debate will go on between the board and AHS, I think we've gotten to a place that's doable and in the future it might it might be be more, adjusted more toward budgetary decisions, but right now it's more toward planning decisions. So we're all in the same place of limbo.

[Senator Martine Larocque Gulick (Vice Chair)]: Okay, thank you.

[Speaker 0]: Yeah, thank you. How did you do that? You were muted. She talked and she was muted.

[Senator Martine Larocque Gulick (Vice Chair)]: I can unmute myself.

[Speaker 0]: I know, but when you said that before, it was red. That's curious. I don't know. Right. Alright. Go ahead. Move. Yes. Three

[Senator John Morley III]: times a joke.

[Speaker 0]: That we approved s one eighty nine version 3.2, and I don't have, is it, it's still, it would be threetwelvetwenty six?

[Senator John Morley III]: Yep, yep.

[Speaker 0]: And I don't have time.

[Janet Harvey, Legislative Counsel]: Time is 11:01.

[Speaker 0]: And 11:01. To the full Senate as amended. Yes. Are we good with that? All right, discussion on 189, any further questions? Senator Gulick, you raised a good question. Good discussion.

[Janet Harvey, Legislative Counsel]: Is there anything further? I'm looking to you first.

[Speaker 0]: I can't see her anymore.

[Senator Martine Larocque Gulick (Vice Chair)]: No, I guess I would like to hear from my colleagues in the room how they're feeling about it.

[Speaker 0]: Okay, we'll do that right now. So any discussion?

[Senator John Morley III]: I mean, to me, the most important part was the public process and that this bill gets us that

[Speaker 0]: And that was something that was put into the bill. It wasn't in the underlying bill. We added that public process.

[Senator John Morley III]: I would, John, on that. Heard that public process was important. I did. Go back.

[Speaker 0]: Yeah. I all of this is is a real balancing act. We were asking the hospitals to do a lot, at the same time we're asking them to cut their costs, at the same time, majority of them are in danger of going under financially, and so if we tell them to cut their costs and then tell them they can't cut anything, unless the public entirely approves, we'll put yeah. We're we're asking to do the impossible. And it's it's gonna have to be compromised or the whole system will Well, I think there's another issue in this, and I think it's the one that Senator Gulick has really identified and that is the responsibility for decision making between the board and the agency human services. And that's gonna be an ongoing debate and we are gonna have to face that in here and make absolutely go through who's doing what, when and how. Right now there's a lot going on out in the real world with hospitals and community services which is another whole thing, but we're going to have to face that. I think Senator Gulick, you did raise that question and it's really on target, so thank you for doing that.

[Senator Martine Larocque Gulick (Vice Chair)]: Thank you, Lyons. Can I ask a quick question? Because Senator Cummings keeps aptly mentioning that some of our hospitals are on the brink of going under. Can someone expound on that a little bit?

[Speaker 0]: Well, don't, going under, I think is they're in the red. So a hospital like Springfield, and then last year Gifford was at the same place,

[Janet Harvey, Legislative Counsel]: they're all in the

[Jenny Horgan, Alzheimer’s Association]: think you've got a lot

[Janet Harvey, Legislative Counsel]: of testimony from the roster and the board earlier this year showing a They've gutting just a whole

[Speaker 0]: bunch. Country Yeah, in the they were all in the and they're all, that's why they're all working really hard right now on transformation so they can pull themselves out of the red and into a block. We have it charged. It came from the Green Man Care Board when Owen Foster testified, and I I have it I have it actually right here with me. I'm trying to pull it up and

[Janet Harvey, Legislative Counsel]: see if I can find the I have one right here.

[Speaker 0]: And even if he BMC just made it over into it's the number of Builders. Testosterone. And Yeah. They were at the lowest level of where

[Senator John Morley III]: because it was

[Speaker 0]: So I could tell you Central Vermont, Copley, Gifford, Grace Cottage, these are all 23, 24, the final, most recent data. North Country, Northwestern, Southwestern, East Springfield are all.

[Janet Harvey, Legislative Counsel]: Here's some testimony from Owen Foster from the beginning of this session. Is the FY26 budget, you can see the days, cash on hand, operating income, operating margin.

[Senator John Morley III]: Right.

[Speaker 0]: So, there's a bunch. Yeah. Yeah. Okay. Any other discussions? Questions? I'm good with moving ahead with the bill for all the stuff that we've done, and we also have concerns. I get that.

[Senator John Morley III]: We got you. Well, always gonna have a chance. Mean, just ready. Ready? Yeah. Senator Benson? Yes. Senator Gulick? Yes. Senator Morley? Yes. Senator Lyons? Yes.

[Dr. Dean Marshall, Vermont Optometric Association]: Five zero zero.

[Speaker 0]: Good. Good discussion. Thank you for that.

[Senator John Morley III]: I'm not gonna put the time on.

[Speaker 0]: So now we're gonna figure out who's gonna report this little darling, and I'm going to do it if nobody else wants to do it? No. I'm Oh.

[Senator John Morley III]: You're happy with it.

[Janet Harvey, Legislative Counsel]: I'm anticipating having a doctor. I know you will.

[Speaker 0]: I may not get them out, but if I do, I will have Yes. I'm looking at two more drills that I definitely wanna do, and I know others are gonna wanna do some of

[Senator John Morley III]: these things.

[Speaker 0]: I'm happy to do it. You see it as lesser of several evils. This one should be mesicaine. I think it's Yes. So we have S142, and what I'm gonna suggest is that we give ourselves ten minutes for the day, unless one hundred forty two is the International Medical Graduate School. Yeah, and I've had a conversation with Department of Health. They desperately want to figure something out and reach out and look at other states and figure out what they can do. So they would like to have the bill be put out further. So I'm

[Senator John Benson]: trying to

[Speaker 0]: think if you will allow for some dialogue with Jen. I was thinking about having the Department of Health do that, reach out, and bring back suggestions that would improve the processes in the bill by a date certain so that there is a deadline, and if the deadline, if they don't come back and we don't, they don't fix something in there, we don't, it into effect, and that's a hard stop. But on the other hand, goes to the house. So I'm trying to figure out what we can do in the minimal time that we have and anyone who has a better suggestion, I am open to that. And so we'll get a suggestion from the Board of Medical Practice, Department of Health, and they will help us with this, and then we'll look at it tomorrow. The best we can do with that. Yeah, I think it's worth moving forward totally standing that it will get by to me.

[Senator John Morley III]: Totally. I agree that the issue was who has capability to rid infections. Yeah. It wasn't on the Central Association. They were looking at contracting health.

[Janet Harvey, Legislative Counsel]: Was They suggested that as something they might explore.

[Speaker 0]: Right. All of which means money.

[Senator John Morley III]: There you go. We

[Speaker 0]: don't. That's said Well, it it just would be great. Be fine. So, madam

[Janet Harvey, Legislative Counsel]: chair, can you clarify? Are we so we're not doing any kind of, we don't need anything new from me on this for tomorrow, you're looking for something from the board on this, or are you looking for me to? I'm looking for language that will

[Speaker 0]: come from the board, and maybe you and I can have a conversation, and then we can bring something, a suggestion, onto the table. I don't wanna be writing it outside of committee, but I think at this point,

[Janet Harvey, Legislative Counsel]: we'll see. I mean, you want me to sort of have a general concept of or go look at ways to do this and come back and report it as January. I can do something like that. That would be helpful. Do you know what date, certainly you would like further date out you would like for the effective date of the I'm looking

[Speaker 0]: right now, what has been the effective date in the absence?

[Janet Harvey, Legislative Counsel]: I think it was, well it was introduced last year, so

[Speaker 0]: it needs a new effective date anyway.

[Janet Harvey, Legislative Counsel]: It was gonna be a year out, that was July 1. So if we did nothing else, I would be updating it to 07/01/2027.

[Speaker 0]: We could make it January 28, or

[Janet Harvey, Legislative Counsel]: we could leave it twenty seventh. I mean, right now it's '26, so it has to get amended anyway. Yep. But that was because it was introduced last year.

[Speaker 0]: So if they come back with recommendations, we'd have to have time to change it, right?

[Janet Harvey, Legislative Counsel]: Yes. Yes, and part of the reason for pushing it out was to give them time to do rule making. So you do need to factor rule making and Yeah. So if they come back in January was something, I think January 2028 would be the earliest you could have that video, and that may not be enough to So if they

[Speaker 0]: bring it back in '27, then this would, would have time to work on it. You would, but if you changed what you

[Janet Harvey, Legislative Counsel]: were telling them to do, they might not have time to do rulemaking by January 28. Understood. Got it. So maybe you wanna make it July?

[Speaker 0]: Right. Oh, you're talking just about Section eight. Section Oh, oh, just to those sections. Yeah, got it, yeah.

[Janet Harvey, Legislative Counsel]: Right, the go forth and look at things would be effective on Right, Okay,

[Speaker 0]: and then the rule making and other stuff. Yes, so we'll do July 1. We're not voting anything else right now. We've got two minutes. So Senator Gulick, are you listening? We've got meetings. I am, yep. Okay, so are we okay with trying to do something like this so we can get this bill moving?

[Senator Martine Larocque Gulick (Vice Chair)]: Yes, yep, as long as we can vote on it tomorrow, that's great, thank you.

[Speaker 0]: All right, good, and then the other one we wanna vote on tomorrow, and I know it'll be a heavy lift, but I might talk with Jen about the cost of the biomarkers. I don't know we can cover everything, but to the extent practicable or that would allow for I cost don't know how we say it. Yeah, I mean, don't think you can

[Janet Harvey, Legislative Counsel]: If you put in a coverage requirement, the state will have to pick up whatever the, defray whatever the increased I premium for the qualified health plans don't have any sense for what that will ditto be.

[Speaker 0]: To cover costs for initial and untested year. I have no idea for the sake of that.

[Janet Harvey, Legislative Counsel]: Yeah, either. I it seems like maybe you want the information about what the premium would be, increased premium would be before you decide what you can fund.

[Speaker 0]: We'll have the finance committee do it. I just got, I just ran over a wall,

[Senator John Benson]: so

[Speaker 0]: I think it goes to the finance committee.

[Janet Harvey, Legislative Counsel]: Right, so I mean, right, you could vote it out of here as it is and then print it down to them.

[Senator John Morley III]: I like, like, like it.

[Janet Harvey, Legislative Counsel]: But the cost aspect of it, like the land, the cost aspect is gonna land in appropriations, not finance. It would be in finance for the insurance aspect. Right. You might have to ask for a pre referred, which is I don't think it, it may not be crossover. Wait. Well, it wouldn't go to finance by operation of rule 30 because it doesn't affect the revenue of the state, it affects the appropriations.

[Speaker 0]: But it came from finance.

[Janet Harvey, Legislative Counsel]: It came from finance because it went into finance because finance has jurisdiction over insurance. Right. Didn't go to finance because it affects the revenues. Understood. So it still has insurance in it.

[Speaker 0]: Maybe I should talk to I would talk

[Janet Harvey, Legislative Counsel]: to Bloomberg as well.

[Senator John Morley III]: Vote on this tomorrow. Okay, because the way I understood it, it's it's gonna be passed out of the committee of jurisdiction.

[Janet Harvey, Legislative Counsel]: It has to be passed out of generally out of policy committees, and the money committees get an extra week because of the money aspect. Absolutely.

[Senator John Morley III]: Not because Right. Finance.

[Janet Harvey, Legislative Counsel]: Insurance reps, but not because it goes to finance on an insurance issue. It's because So that's what I want to clarify. Yeah.

[Speaker 0]: I mean, the other thing we could do is lift it and send it, be relieved of it in this committee and send it to you. Yes,

[Janet Harvey, Legislative Counsel]: think you'll just need to get some clarity from Secretary Muehl get clarity. Whether tomorrow's deadline applies Understood. Finance this consideration.

[Heather Schulick, Vermont Optometric Association]: All

[Speaker 0]: right, we're good. So, that's a wrap.