 Good morning, everyone. This is the Senate Health and Welfare Committee meeting, and it is February 16th. And we're joined today in committee by Senator McCormick, who's going to give us his introduction to S74. So Senator, thank you for being here today and we appreciate that. We did have a run through of the bill. Just briefly last week, but we felt it really important that you as lead sponsor be here to give us the reasons for for the bill introduction so. Thank you, Madam President, I have submitted. I just got promoted, but I'll tell you. Madam Chair, I have submitted written testimony, but I'll, I think I'll speak more front spontaneously. First, it's good to be back in the committee I served on this committee for many years with Senator Cummings and with the chair. At that time, the chairmanship of Senator Claire air, who is successor from Madison County is now on the committee so there's certain continuity here. I have been out of the Senate for several years as a private citizen before coming back and serving on this committee. And during that time I also much of the work that did was as a private in the private sector as an organizer on the same issue of patient choice at the end of life. And I think the best work we did during my time on this committee was getting that bill, the patient choice bill passed. We, we modeled the bill, which is now the law on what was already an existing law in the state of Oregon. And the reason for that is that at the time that Vermont was considering this policy. It had already been the policy in Oregon for several years, and had worked well. So much of the opposition, some of the opposition was purely feel philosophical that the argument was that this is a choice for God, not for the patient and so on. And those kinds of philosophical decisions devolved to the question really, what is the proper role of the state we have never made a judgment on whether it is moral or proper or good in the eyes of God to hasten death but rather the matter for us was what is the proper role of government in the matter. And if there is a the will of God is a question well then it's up to the individual patient and his or her beliefs. Yeah, I voted against the bill and you are not characterizing my opposition correctly that was the total just to be clear there were other reasons to oppose the bill. Yeah, that was one of them but there were others. That's that's where I was going, actually. I said that the, the philosophical reasons. Ultimately, we had to the state made a choice, but the other widespread opposition, most of the opposition. This is not to accommodate my friend senator coming this is in fact where I was, what is in my written testimony as well. The, the opposition was conjectural because we were going into something new, and just as the benefits were somewhat unethical, so too were the, the opposition. What if, what if there are greedy grandchildren, hastening grandma's death so they can inherit. What if the patient is super annuated and not really totally in possession of his or her faculties. What if the prospect of imminent death is so depressing that the patient really isn't thinking clearly. What if the press patient is being pressured, and those what ifs were conjectural but perhaps worthy of being taken seriously. Similarly, any benefits were were conjectural, at least at the time that Oregon was considering their bill when they first passed it, because it was a. It was uncharted territory. And so they did not powerfully resist the what ifs, they responded to the what ifs with safeguards. And a major characteristic of the Oregon law was that it not only provided a dying patient with the option of hastening death under that that is her choice. They provided a body of safeguards various steps that had to be taken before that could happen. And those steps were all designed around the, the perceived problems. The same conjectures were raised in the Vermont debate. And the response of those was advancing the bill was to allude to those safeguards. And so several years down the road, and the, the law, both in Oregon, and in Vermont and now in several other states as well has been that the law has worked well, that the perceived problems have not presented themselves, and largely because of those safeguards, or at least the safeguards, as the term safeguard implies, guarantee that they that the feared problems not present themselves. What this bill does is it responds to the experience of the several years that this has been the law to identify some details of mechanizing the safeguards that do not have been shown to not be necessary, and in fact have been shown to make it more more difficult to for a patient to fully access the benefits offered by the law. Would you like me to go through the bill or I see that that Jen is here was drafted it. I suppose the other one. If you want to have, I will get I will get into the details if you if the chair prefers. I think, rather than get into the specific details. If you could give us kind of the thumbnail sketch of what the bill does I know there are about three very important changes made to the process. And so just, you know, just give a highlight of those and then when we go through the bill will identify them again with Jen. Section one removes the requirement their request for a prescription be made in person, allowing for requests to be made via telemedicine when appropriate. This requirement upon a telemedicine was not even on the table when we passed this. I guess it was talked about in theory but it was not in legislation was not in law. The this requirement and this requirement has been burdensome to very sick people for whom it's difficult to go physically to a doctor's office by removing the requirement that the patient's oral requests be made are made, quote, in the physical presence quote of the doctor, the law would align with the practice allowing tell telemedicine when appropriate. Currently, Vermont is the only state in which physical visits are required for aid and dying. In all other areas of medical practice Vermont law allows the use of telemedicine based on Medicaid, based on medical judgment and standards of appropriate practice. The bill also removes the requirement that the prescribing doctor and herself do a physical exam when the doctor is able to make the necessary and required determinations through telemedicine and clinical review. Telemedicine was only a theory of I'm reading my prepared remarks I'd already written it. Section and also section two clarifies liability protections, but section one also makes a slight adjustment in the act 39 time timeline, the proposed amendment keeps the mandate of 15 day waiting period, but removes an unnecessary and burdensome 48 hour delay period after the second oral request. The last step in the process before prescription can be written. The additional period creates an added burden for those individuals who have already invested a significant amount of energy in the process. This is a very difficult time. The total of the 15 days and the 48 hours makes Vermont's aid act 39 timeline, one of the longest among the 10 jurisdictions that have made that have these laws, the amendment would delete the 48 hour delay. It clarifies that acting in accordance with the law would protect all parties involved in its use from claims of liability. Current law explicitly provides immunity only for doctors involved in the process. The Attorney General's office has to find that immunity for other providers involved in act 39 and specifically pharmacist is implied in the law. However, some pharmacists in Vermont are not satisfied with implicit immunity and have required doctors to sign onerous indemnification agreements prior to filling prescriptions for their patients. Other state laws immunity and have required doctors to sign onerous indemnification agreements prior to filling prescriptions for their patients. Other state laws. I'm sorry I'm getting lost in my text. Other state laws covering these laws provide immunity for all persons who comply in good faith with the with the law. This amendment makes what is implicit explicit. So that's, that's the middle. Just so what I'm hearing you say is that the provisions the proposed changes in the bill helped to bring Vermont law more in line with other what other states are currently doing. Would that be an appropriate characterization. In line with what other states are doing also somewhat updating telemedicine as I say was something talked about in the halls but it was not in law was not in legislation. We did that a lot of telemedicine just very recently and and to make to remove unnecessary impediments to the patients. Okay. Thank you. So questions for Senator McCormick. Senator Hooker. No, okay. I do. Yeah, I do. I'm trying to use my iPad for the first time. So this will be patient. Don't worry. Thank you. Thank you. So, Senator McCormick, when you talk about telemedicine, obviously you're talking about video. We're not talking audio. Audio only, which is another topic that we're covering. I don't know if the bill explicitly says about but that's certainly my understanding. Yeah, because I mean, if you're going to do an exam, you want to see something. But it's also, but it also can involve just looking at the medical record as well. I mean that's that's looking at at what what has already been researched what are test results. And I guess I'd be a little concerned if audio only were include looking at getting a sense of what Senator Cummings perhaps was opposed to in the initial bill, the types of things that could happen. So, and at some point I'd like to hear from Senator Cummings about what your concerns were when the bill was first brought up. I don't want us to be very cautionary about going back to the underlying bill. If the concerns relate to the current proposed changes then that's one thing, but I don't want to resurrect the concerns that were in place that for the for the underlying for the underlying bill right now. I think your issue around audio only versus audio visual is a very good issue for us to bring up as we look at the bill. I just want to caution us that this is not about, you know, removing the underlying. Yeah, so that that might be a good conversation offline with Senator Cummings but and I'm sorry to interrupt that thought but I do think we need to stay focused on what the bill 174 does and what it does not do so. Thank you. All right. Other questions for Senator McCormick. Senator Hardy. Thank you. Senator McCormick I'm just wondering if you have heard from people for whom these have been barriers, these various waiting periods or access issues, or you're just making the assumption that they are barriers. No, I, when we passed the patient choice law, the people the private citizens who had been organized in support of that policy formed an organization which is end of life choices, and in Vermont, and they monitor the conduct of the law and the experience of people using the law and they actually had had raised the issue with me. So I would expect that the committee would hear from them at some point. Okay, thank you. Yeah. Yeah, thank you. Yeah. Exactly that this is the beginning of our testimony but we will have those folks in and others who have an interest in the bill itself. Any other questions for Senator McCormick? Wow. Before I leave. See you did a great job, Senator. Thank you. Thank you. As a point of personal privilege, since I'm here before I leave, I would like to say I am well now one hour into the effort to get my COVID vaccine appointment and health and welfare committee might want to lean on the health department a little bit to get a more workable system. Well, you'll have a chance tomorrow to ask that question of the commissioner. I'm not sure that we can dive into all the software issues that exist out there if we did we'd be here all day but your point is very well taken there are a lot of people who've had difficulty. Senator Taranzini. Thanks, Senator Lines I was just going to mention since you mentioned it Senator McCormick. Senator Brock in our Republican caucus this morning was very frustrated as well he had been almost an hour trying to get through as well so it's certainly felt in all areas of the state it seems so. Thank you for that. I don't feel so bad. No, don't. That actually, when you think about it, it could be the good news with the bad news the good news being that people are so interested in making appointments that there's a backlog so but we don't want to go there yet we want to make sure that the system is totally functional. In defense I set up my thing yesterday and I got right in today. But I had trouble getting Regis registered in in and he called. And they had him booked in five minutes. Tell us how good. I called and they told me to go to the to the website. They did the first time he called they were not taking calls because they were inundated. I think it's variable today is the first day it's been open for 70 plus and so the first day is always hard. And, you know, Senator Taranzini mentioned Senator Brock he said in our committee and finance that when he went to get a shot. Everything was really smooth. It went really great so it's obviously a mixed situation right now some people it's smooth and some people are having a harder time. Regis is just getting his first shot as we speak. Well, so he was further booked out because he was later getting in. I have one for next Tuesday. All right. Madam chair, I apologize for getting this started. No, I'm trying to get Regis registered it. And even me, it would not take a password that met all their qualifications. It took me a while to find a password. Put a lot of symbols in it swear. That was the only way I got through one symbol did not do it, along with one number. All right, well. Thank you, Madam chair thank you committee. Thank you. Okay, take care. So, Jen, I think, Jen Carby, are you there. There you are. So I think we have been through as 74 but what would be helpful I think just for a few minutes. And then come as then we want to move on to the flexibility bill to identify for us in the sections of the bill where the proposed changes are and remind us of exactly what they do so we could pull that bill up together and and look at the end of the I think the outstanding question is on telemedicine is it audio only is audio only allowed or not so that's an important question. Sure. Jennifer Carby legislative council so do you want me to put the bill up on the screen. Yeah, I think that's helpful. Okay. Great. All right, so you should be able to see it now. We'll go to the very beginning so this is as 74. And we'll go past the statement of purpose for now because we're really looking at the language. As Senator McCormick had said this gets rid of the requirements that these oral requests to the physician be made in the physicians physical presence so it does not speak to what alternative modalities may be used if physical presence is not required it doesn't speak to either telemedicine or audio only telephone or something else. It does have to be oral so it would have to be something that the physician could hear but it doesn't specify. And just one small clarification. There was actually the first telemedicine legislation had been enacted the year before this legislation was enacted although this legislation that the patient choice to end of life. The legislation had been discussed in a number of previous bienniums, but actually in that when it ultimately passed it was the year following the first year of the telemedicine legislation being enacted so they did coexist but I don't think it was nearly telemedicine was not nearly as prevalent as it has been and certainly since the pandemic. So if you are interested in, in looking at removing the physical presence requirement you may want to think about whether there are certain parameters that you would want to allow, like audio and video together, or if you want to, if you want to be less involved in that I mean again, look thinking about the audio only language there's a lot of emphasis on what's clinically appropriate so it would have to be clinically appropriate to be doing this part of the process by audio only telephone if that was the choice that the provider had made. So that may weigh into your calculations as well. So that's the first piece is taking out the physical presence requirement for the oral requests for medication. And then, going along with that, the physician's determination that the patient was suffering a terminal condition, taking out the requirement that that be based on the physician's physical examination of the patient so it's still based on some sort of examination of the patient and a review of the patient's relevant medical records, but it doesn't have to be a personal physical examination. Well, but it does imply some kind of visual. I don't know how you have a, have an examination we'll have to hear from the, from folks about this. Right, I think it would be important to hear from the medical community, what they would determine to be the appropriate standard of care for an examination of the patient, if it is not a physical examination. And then we have the, that waiting period that Senator McCormick spoke about this is that provision saying that the physician has to wait at least 48 hours after the last to occur of several events. That includes the 15 day waiting period between the two requests but taking out that 48 hour requirement after the last of those to occur before the physician writes the prescription. And then lastly we have the section to more general immunity, not specific to physicians as is what's specific explicit in the bill. He was talking about making the implicit explicit this is that language saying that no one would be subject to civil or criminal liability, or professional disciplinary action for acting in good faith compliance with the provisions of the chapter. I have a question here. Is this, is this something that the judiciary committee in any way should look at as as we're going through the bill. I think they had looked when when the original law had passed I think they had looked a fair amount at the immunity language so it might be right now I will leave that up to you either officially or unofficially to consult with the chair there and find out if that's something you would want to look at. We'll do that. Madam chair. Yes ma'am. May I ask a question of Jen. Oh no go ahead. So you mentioned the provision that's actually in our audio only bill and I don't want to conflate the two too much but it's kind of relevant to both about the the clinically appropriate. And I think that makes a lot of sense to have here as well my own personal opinion but I'm wondering in both instances, is it the physician who determines what's clinically appropriate how who who get who makes that call. Yeah I think it's a good question I think in the, in the immediate timing it would be up to the physician to you know in that in the moment to make the determination about what's clinically appropriate but I think that can play out in in further role of ways if there was a malpractice claim brought there probably be looking at whether it was clinically appropriate and what the you know what the appropriate standard of care is within the medical community for whether it was appropriate to deliver care in that way, and then also for insurance or Medicaid reimbursement. They could, they could potentially decline to pay for something if they did not deem it to be clinically appropriate and that's why there's in the audio only language some requirements for documenting the physician to their provider to document the reason that they thought it was clinically, that they determined it was clinically appropriate to deliver the services using audio only telephone so that there would be that information immediately available if there was an audit or, or other exchange with the payers. And speaking of payers are the services provided under Act 39 these end of life services are those covered by insurance or, or not believe they are specifically required to be. I don't think there was a I'm just skimming through here. I don't think there is a requirement for them to be covered so it may. It may depend. And it may be that some of this conversation happens as part of it or these various conversations happen as part of medical appointment that would be covered. The processes may be sort of inherently covered in that sense, but I don't know for example if the prescription medication that would be provided to hasten death is on a form, you know on the insurers prescription drug formulary such that the regular cost sharing would apply or not that would be something you might want to hear from providers about or from pay the payers about. What they are specific rules regarding hospice care within Medicare that are different. This is not hospice. No, but if if the individual were in hospice that would be different so anyway, or if they were in a I'm thinking of a nursing home or other location. Okay, go ahead Jen. I don't have anything else. That's it. We've got it all. Okay, so we do have, we do have some questions I will I'll circle back with Senate judiciary about the liability language to so that they can review that on our behalf. And we'll want to hear from end of life choices and others about the specific requests that are in the bill specific changes that are in the bill. And we'll get that on the agenda sometime fairly soon. Any questions other questions committee members. All right. I guess I need a clarification as to what's clinically appropriate. You know, how is that defined and is I'd like to have some discussion about that perhaps with some of the providers or whatever. We can we can try to do that you know this is the clinically appropriate definition is one that gets it becomes somewhat controversial. So we'll, we'll try to at least address it a little bit but I don't know that we're going to resolve that one in our committee we can try and certainly understand the differences of opinion around it. So we can consider it, but good point, Senator. All right. Any other questions. I've written that one down. Thank you.