 Good morning and welcome to the Vermont House Human Services Committee. Today is Tuesday, March 22nd. And for a brief time this morning for about the next, we are lucky to, we're going to be focusing on H728 and act relating to opioid response services. And in particular, we're looking at pre authorization and as well as any other barriers to access to medication or opioid disorder. And we're very fortunate to have with us. Dr. Lachonis, Dr. Lachonis, please begin. Good morning. I'm Dr. Lachonis from Gifford health care. I'm an addiction medicine specialist and I understand that you've asked me to speak a little bit this morning about prior authorization requirements for buprenorphine containing products for the treatment of opioid use disorder. And I wanted to start out by noting that, you know, yes, indeed, we are in the midst of a opioid overdose overdose epidemic in Vermont and throughout the United States. The first contributor is synthetic opioids like fentanyl. And I think it's great that people are trying to think about new ways that we might be able to help our patients get access to safe treatment with FDA approved medications. I'm a little bit concerned about simply eliminating prior authorizations for some buprenorphine containing products. To step back, I think it's important that we remember that buprenorphine itself is an opioid, which can cause euphoria and can be habit forming leading to addiction. It's important that we make sure that supplies of buprenorphine most safely get into the hands of people who need treatment and not into the hands of people who may use it recreationally to develop to develop their own new problem. To step back, once again, I think we need to look at balancing harm reduction, such as decreasing opioid overdoses with public safety. One of the things that has been built into buprenorphine products is the addition of a medication called naloxone. It's a combination product, and that is meant to help decrease the risk of people injecting buprenorphine products. Should they inject a combination product, which can increase euphoria and the possibility of addiction, it can will cause withdrawal, because naloxone is something more commonly called Narpean. So I think one of the things we're looking for in eliminating the prior authorization is getting rid of or making accessible products that don't contain naloxone. I think that this is a safety mechanism that's built into the medication that should be left that way. That being said, there do seem to be a certain proportion of people who don't tolerate the naloxone that's in the combination product. They may absorb a small amount of their body and it may cause side effects. So I think we should have a mechanism within our prior authorizations to make it easier for providers who demonstrated that a patient is not tolerating a combination product to have them be eligible to receive the buprenorphine product. Before I go on, are there any questions on pharmacology that I'm just describing? I don't think so, but I'm wondering, sir, if you are you a, are you solely a a spoke provider, or do you also utilize, have patients who utilize private insurance? So I am a spoke provider, but I have a combination of private insurance, self pay and Medicaid. Okay, and all as it relates to opioid addiction. Or is the only patients are that you are seeing those through Medicaid. No, so I see patients who have private insurance on our self pay both for buprenorphine treatment and now tracks owner of the full treatment. Thank you, Dr. Luke bonus and just a couple of questions for you. One is, have you prescribed the mono buprenorphine product for your patients experiencing or needing medical assisted treatment. I have on occasion needed to use the mono product. And these are folks patients who reported in intolerance the combination product. Generally, I start with the film the combination of buprenorphine and naloxone. If that's not tolerated say, for instance, do the nausea and vomiting. For example, then I will switch to the combination tablet product because that also has less risk of misuse and diversion. If that's not tolerated then I would move on to the mono product. Wonderful. Thank you. And when prescribing the mono buprenorphine product do you see a difference in the process between those who are on Medicaid versus those who are on private insurance. Private insurance generally has more flexibility in what I prescribe as long as I don't exceed certain prescribing dosage limits like standard 16 milligrams. So in other words, the private insurance doesn't have a fire authorization in place for a mono buprenorphine product. It varies amongst prescribers but it's not as consistent as it is with Medicaid. Okay, thank you. Dr. Lacones thank you for being here this morning. I'm just curious as to what's been your experience with diversion with your patients and diversion. So I regularly talk with my patients about diversion you know what they have seen particularly when they're coming into treatment. It seems like the buprenorphine mono product is the preferred diverted medication. It's much more oftenly used intravenously, which can lead to a lot of bad medical outcomes beyond the risk of overdose, such as heart infections, bone infections. We have mechanisms in place where we try to detect diversion such as by looking at levels of buprenorphine and its main metabolite nor buprenorphine and people's urine samples. We do medication callbacks where we randomly call people to have them come in and count their medications. The nice thing about the suboxone films is they also have serial numbers on each package which are unique so that we can have a pharmacy photocopy those serial numbers, provide them for us and do a medication callback to make sure that a patient hasn't simply borrowed medication from someone else in order to make up a difference in their count. Whereas with the mono product tablets there's no mechanism like that for trying to attract for diversion. Some make the argument that if patients want to divert, they're going to find a way to divert and I think that's true. If that is their intention, however, I think if you put some kind of mechanisms in place to help prevent that, you definitely do prevent the rate of diversion. I guess one of the things I'm trying to get at is I'm just wondering if you were to estimate what percentage of your patients you believe have diverted their medication. I'm trying to get a handle about how big of an issue it is. Well, it's hard for me to estimate but I'll tell you now that many patients or most new patients I have coming in are positive for buprenorphine and they haven't been prescribed it. So there's definitely a substantial supply on the street and I agree with harm reduction and it's wonderful for patients who have an opioid use disorder to be finding a safe way to manage their illness even if it is on their own without the best follow up. However, I do worry about sort of that being diverted into recreational avenues so that we're developing a new generation of people with opioid use disorders who have initiated with buprenorphine. Thank you. Representative Wood, you spurred a question for me which is thinking about knowing that there is a buprenorphine on the street and that you're experiencing folks who have gotten a supply from the street and are now connecting to health care. I'm sure there's some correlation between barriers to access in that. I'm wondering how often do we see looking at the crisis of opioid and overdose deaths in the state. How often do we see buprenorphine in people's systems when they are dying of overdose. Relatively and frequently. Okay. Yeah, thank you. Yeah, that's that's fairly, that's fairly uncommon. But that's not really the reason why I'm concerned about diversion, you know, I'm more, the risk of overdose from diversion is lower and it will likely be higher if we don't have combination products prescribed because of the increased risk of overdose but I'm more worried about simply putting lots of buprenorphine on the street because I think there's a misconception out there that it's not somehow not addictive and not harmful and we're going to be creating people with a new addiction and I have seen that more and more over the years that people come in where buprenorphine was the first opioid that they had used recreationally that led to a full grown opioid use disorder. Thank you and I want to echo the comments of the vice chair thank you for coming in. I am, I am curious you have expressed a support for the need for pre authorization and I want to say, you know, perhaps as it narrow it, I'm going to narrow it as it pertains to the mono. And the pre authorization for the most part is only for medic, for Medicaid, and you serve other patients who have for instance blue cross blue shield. Do not have the same pre authorization so I'm wondering how you balance that and what is the difference in terms of your concerns related to patients with met receiving their health care insurance through Medicaid, as opposed to, for instance blue cross blue shield. Well, I'm focusing on the patients who I most commonly see most of my patients are Medicaid patients, the blue cross blue shield are relatively in frequent. And I, I use my own parameters of starting out with the least attractive product for diversion which would be the suboxone films, even when I'm seeing somebody with blue cross blue shield insurance. So I use kind of the same protocol that Medicaid currently uses and in stratifying the manner in which it will approve reimbursement. So we have asked you lots of questions and I want to make sure that you have, if you have others. I think we've interrupted your presentation so I'd love to continue. Not at all I was just prattling on so. Yeah, I mean the other things that I want to bring up is that you know there's been some who might argue that in the age of fentanyl inductions might be easier with the mono product versus the combination product. And actually when we look at the data there is no data that supports that contention. We know that in the age of fentanyl induction with any buprenorphine product is quite difficult and we need to understand more about it. Even when you look at, you look back at the initial prescribing recommendations for suboxone back when it was manufactured by Wreckett Benkees or you know they made it very clear in terms of dosage limits that you know once you reach 16 milligrams for an individual patient with a combination product you should be very carefully about whether you need to go higher than that dosage. Because it may indicate that it's not an effective medication there may be a better treatment for the patient such as methadone treatment in a hub. And actually verbatim from the most recent suboxone package insert says dosage is higher than 24 milligrams daily have not been demonstrated to provide a clinical advantage. So I would think you know, at least you know any pursuit of elimination of a prior authorization for above 24 milligrams a day of combination products would probably not be a good clinical recommendation in my opinion. Thank you. Thank you very much. And thank you for excuse me taking the time out of your schedule to educate us and to share a different perspective than what we have heard. And I think that's helpful to us. Thank you for the opportunity. All right. Bye bye. Thanks bye bye. Dr. Lord. You are muted, sir. Thank you. Yes, good morning. Good morning and welcome to the Vermont House Human Services Committee. And thank you for being here to talk about whether it's you know pre authorization and you know removing barriers to access to medication assisted treatment. Thank you. I'm very pleased to be here. And please go ahead. I don't know if you have prepared remarks that you want to start with. Sure. Well, thank you. I've been doing this for about 15 years now after my fellowship at the University of Florida and addiction medicine. And there are a couple of things, a number of things that I would like to talk about after reading the bill. Buprenorphine naloxone up to 24 milligrams is Dr. Lacanus just pointed out has not been demonstrated in the literature to have any positive clinical effect and in fact, early on in my experience people requiring more than that were in general diverting their medication, they didn't need it, and they were taking the extra medication and selling it. And that's just that was just a fact that I was able to demonstrate. And I have a number of patients on up to 24 and not a number but I have several patients up to 24 milligrams for reasons that I'm not sure but it's an individual thing. And I agree that, you know, prior authorization of Buprenorphine naloxone up to 24 milligrams for somebody who is treating someone with an opioid use disorder. That's an unnecessary barrier. Buprenorphine mono product on the other hand, I would support a relaxing of the of the prior authorization requirements, because there are a number of patients who have distressing side effects as a result of the combination of Buprenorphine mono product and currently, I have to practically get an act of Congress in order to get Buprenorphine mono product approved for these patients. They require, among other things, various means to treat the, and to mitigate the side effects. This is medically silly. We're not giving cancer chemotherapy here which you know that makes some sense to treat side effects. But if you have a drug that's producing side effects, and you can treat that with another drug that does the same thing that makes sense to me, that said, as Dr. Buprenorphine mono product is still the preferred formulation for diversion. It can still produce euphoria when injected. The street price of a Buprenorphine tablet on the illicit market, at least in this area is anywhere from 30 to $50 for an eight milligram tablet, as opposed to 10 to 15, maybe $20 for a Buprenorphine combination product. And there are also pharmacies that demand justification for Buprenorphine mono product to the point where I've had one pharmacy actually demand treatment notes, which fortunately the board of pharmacy stepped on as being completely inappropriate. I'm afraid that they need to do due diligence case the DEA comes nosing around and wonders why they are dispensing Buprenorphine mono product because the idea of diversion is quite, is quite on their mind. We support the relaxation of the prior authorization for Buprenorphine mono product up to 16 milligrams with the attestation of the prescriber that there are unacceptable side effects of the Buprenorphine combination product up to 16 milligrams. But again, we would worry about excess medication on the street and diversion, and I think a prior authorization about 16 milligrams is not inappropriate, as long as the barriers are not onerous. I would like to emphasize what Dr. LeConis talked about and the idea of precipitated withdrawal, particularly with any drugs, not just fentanyl. We've heard testimony that the Buprenorphine mono product of the Buprenorphine combination product is that the naloxone that causes the problem. It's not. It's the Buprenorphine that competes with the receptor pushes the fentanyl or the heroin or whatever off the receptor and causes the precipitated withdrawal the naloxone is scantily absorbed and has physiologically no effect whatsoever. So the notion that you can induce somebody on easier on Buprenorphine mono product than you can on the combination is simply a gross misunderstanding of the pharmacology of the drug. And that that comes directly from the eight hour certification course that SAMHSA puts on that I have taught in the past. However, fentanyl does cause problems with induction. And the reason is because the drug is very highly lipid soluble it sits in the fat stores and takes a long time to leach out. If we wanted to do something wonderful to help treat this requiring insurance companies to pay for a period of medically managed or medically monitored detoxification in a supervised setting like an inpatient setting would be wonderful. Because it is very difficult to induce somebody off of a full ag in this drug like fentanyl or heroin on an outpatient basis with Buprenorphine because of this competition and the precipitated withdrawal. A couple of other points I've had four cases of bone infection in a vertebral body in the back. As a result of infection of Buprenorphine mono product in the past 12 years. The med watch form that you've heard is such an onerous requirement. We haven't had to fill that out since October of 2020 so if someone's still filling it out I wonder why. And as far as waiting list is concerned I am unaware of waiting list to access medication assisted treatment in the state of Vermont with the exception of one program where they're having terrible staffing problems if you call my office this this morning to get an appointment for medication assisted treatment we will see you tomorrow. And that is also true in the opiate treatment program I'm the medical director of in West in West Lebanon. So, I'm unaware of barriers. More to the point barriers to treatment or things like transportation under or uninsured individuals, people with difficulty with childcare. That kind of thing, which are all things that we're working on to try to mitigate through grant programs and other things. Not to say that this is in a difficult problem but we have a lot of good people in Vermont that are working on this problem. And I think you should be aware of that. Thank you. Thank you, Dr. Lord. Before we take questions. I'm not sure everyone around the table, or for that matter people who are listening on YouTube. I want to know your background and know where in fact you are a doctor and whether or not you're participating in the as a spoke. And so if you could talk a little bit about that. Certainly. I, my, my specialty is addiction medicine. I'm certified by the American Board of Preventive Medicine in addiction medicine and also the American Board of Addiction Medicine. My work was at the University of Florida in in Gainesville under Dr. Mark Golden, Dr. Ken Thompson. I've been practicing in Windsor for approximately the last 15 years I'm currently the medical director and chief executive officer of Connecticut Valley addiction recovery, which is a addiction practice in Windsor, Vermont. I primarily provide medication assisted treatment to almost 300 patients for opiate use disorder, as well as alcohol use disorder, and other substance use disorders. I'm the medical director at the comprehensive treatment program. I'm currently at Habadocco in West Lebanon, which is an opioid treatment program providing methadone and a hub program for the Department of Health access with buprenorphine, which I have been for approximately the last five years before that I was at the American Clinic in Southern New Hampshire. I'm currently an assistant professor of psychiatry and addiction at the Geisel School of Medicine. And we treat, we teach PA patients at Franklin Pierce University and the addiction psych fellows from Dartmouth. And I'm the president elect of the Northern New England Society of Addiction Medicine. Thank you. Thank you. That's very, very helpful. Dr. Lord, we have a question. Yes, go ahead. Thank you. Thank you, Dr. Lord. Just wanted to make sure I understood that you would say that preferred or sort of preferred but there was really nothing wrong with the combination medicine versus the unit, nor being I thought I was hearing that that was the non preferred product was the combination of those two together sounded to me like you said that you would think that it's as good as not better at the buprenorphine but maybe I misunderstood that. The buprenorphine combination product is the preferred way is the preferred drug that we use to start because of its low, its low abuse potential. And I think that it is been extensively studied. It works just fine for most people. There are some people who have unacceptable side effects for a variety of reasons either the naloxone causes unacceptable side effects. I that is present in in some of the combination products causes problems the filler products, the film themselves I've had people with develop ulcerations under the tongue and in the oral mucosa because of because of the films. And that reason the having the buprenorphine monoproduct as an alternative is certainly a reasonable, a reasonable thing and I think that makes significant barriers to its use are not helpful. I've said the buprenorphine monoproduct again is the preferred formulation for people who choose to abuse the drug because the reason the naloxone is in the combination product is to cause problems if somebody tries to inject it. It is not absorbed well under the tongue or orally but it is quite well absorbed if you inject it and it will cause problems it will cause people to have some degree of withdrawal that doesn't stop people from doing it, but they would rather inject the monoproduct because the naloxone is not there, because the naloxone is not there. And that's why I tend to be extremely careful with with who I prescribe monoproduct for because I, you know, as I said, I've had people run into problems and develop significant complications from doing anything. And I, you know, so I want to avoid that, if at all possible. Thank you, madam chair and thank you Dr Lord for being here today and offering your perspective. So it sounds to me like you are very. There's no discretion about any time that you do prescribe a mono product. And yet you say that right now the current prior authorization process for that is described as an act of Congress to get this through. Could you describe a little bit more about why you described it that way and what does that what kind of impact is that amount of work have for a patient's treatment path. And if somebody, if I think somebody needs mono product and they don't actually have a flat out allergy in other words a rash difficulty breathing swollen face the whole works, then they, it requires that we document what the what the side effects are and then we have to document what we've done to treat the side effect. So if someone has significant nausea, what did we do to treat the nausea. If they have a headache what did we do to treat the headache. If they do have other side effects what did we do to treat the side effects. And, you know, a lot of times the treatment of those side effects is really not all that effective. And I've had people want to abandon treatment if they can't have the mono product if they can't. You know if they can't take a medication without getting horrible side effects they don't want to take it and that of course makes sense. It's very difficult for us to, you know, to get prior authorization for the mono product under any circumstances. Now that said, I don't believe that we should completely abandon prior authorization or some breaks on on the prescription of mono product for the reasons that I have stated. However, I have to say that of all of the insurance companies that we have to deal with and the prior authorization Vermont Medicaid is been the most cooperative and has done the most to streamline the prior authorization process for almost everything else. Of everything I mean I have very few problems with Vermont Medicaid and if you'd like to hear from my nurse. Dr. Shaffner who does all of my prior authorizations for me. I checked with her yesterday before I made this statement and she agreed that Vermont Medicaid is the easiest for the most part to get prior authorization from it's the buprenorphine mono product that we have the most issue with Dr. Lord we have another question from actually represent women asked my question so okay representative McFawn. Thank you, Madam Chair. Dr. I want to switch a little bit. You mentioned that there were no waiting periods that you were really aware of, but also you mentioned that if somebody comes in today, looking for help. You tell them, come on back tomorrow. We can see him within the 24 hours. Can you just talk about a little we hear a lot about you need to strike when the I am hot. When somebody's looking for help. Well, I mean there. Help me understand what you mean. Well, you know there are practical considerations if somebody calls it four o'clock on a Monday afternoon. You know, I don't know a doctor's office in the world for anything even for cancer that you're going to get an appointment the same day unless you're, you know, unless it's a medical emergency. We do our level best to get people into the hot, you know, in here just as rapidly as we possibly can, because we understand you're absolutely right you strike when the iron is hot when the patients ready the patients ready and we need to get them in. Absolutely. There are, there are, there's a program I mean I noticed in the end of this bill that you talked about the emergency response to, to opioid emergency response support I think it's section 11. There's another program that DB, the diva has has sponsored it's called the rapid access to medication treatment program. Under this program somebody can, who is ready for treatment and it was, you know, wants to get in right away can present to the emergency, for instance, in this area, a patient can present to the emergency room either at spring field or in the hospital, be evaluated if appropriate given given their first dose of buprenorphine that at that time, and then people call me the ER calls my office and we will see the patient tomorrow. If they call early enough in the day and there's time we'll see them this afternoon. I mean we do have, you know, compared to a waiting list of you know three or four weeks or a month which was true several years ago. We've come an awfully long way in making sure that people get into treatment just as fast as possible. And I have to tell you something else too. There are a lot of people, they're particularly at the methadone clinic. We get people who call in extremists, and we say fine come in the next day and they don't show up. And I tell you the number of times I have come in, expecting a full load of patients that day and wind up sitting around reading the newspaper or doing paperwork, because people don't come. So, you know, this there's there's a balancing act here, but patients, you know, if patients want to get in we get them in just as fast as we possibly can we and we don't sit around letting flowers grow under our feet. Representative seriously we do our level best to get people in just as fast as we can, as practically possible. Um, Dr Lord thank you so much for being here today I kind of wish that we had heard from you first off you have some great suggestions and thoughts and clearly amazing background I am. I'm wondering about what you you talked about a little bit which was the other barriers to this care things like child care issues and transportation issues and you you brought up a grant program and I'm someone in this committee who works a lot on child care and I'm kind of curious. Was that around child care or how how are you, how are you trying to help your patients with those things we do have something around transfer a little bit of transportation I think with a van in our bill but I'm curious. Well, I'm not sure about that van. It's an interesting concept. The problem with the van is that I wonder how we're going to, you know, how we're going to make the counseling component work or, you know, we're going to have, you know, mobile counseling sessions. I mean, you know, medication alone is not going to treat this disease. It doesn't treat this disorder you have to have a combination of that plus psychosocial interventions. So, I'm not sure about the van as far as transportation is concerned I think that that is the number one barrier to the patients, both in my, both in my OTP opioid treatment program method on clinic up in West Lebanon, and here. Now, there is a program that we had a program called ride to recovery that was supported by a grant through the Springfield turning point, which worked great until it ran out of money. There's another grant program and I'm sorry that the name of it escapes me but there is another program that is ramping up. I think going through volunteers in action. And, you know, I can certainly learn more about that we heard about that in our Windsor County substance use disorder collaborative last week, where transportation is going to be addressed we have a number of people in our practice who have volunteered for various things and some people would like to help with transportation we're going to refer them on to them because this program is going to do background checks and vehicle checks and, you know, the kinds of things that, you know, safety would require. Yes, transportation is a huge issue and Medicaid transportation is not always terribly reliable it's better in Vermont than it is in New Hampshire but it's still not always reliable I mean I have had patients left stranded because the Medicaid ride didn't show up show back up to home. So that is an issue childcare can be an issue. You know, we, we wind up having kids in our in our waiting room that's not terribly appropriate because it's hard to do therapy hard to do counseling when you get, you know, you worried about your kid running around. So we've, we've tried to, you know, we've tried to address that somewhat. We do participate in the hub spoke program we are a single specialty addiction program here at at CVR and we have a spoke nurse. Ms. Jones is a certified case manager and she works very hard to help address the transportation childcare economic services issues, insurance and that kind of thing that that that people run into. We also as a nonprofit entity we also have a small fund to cover shortfalls in insurance such as copays and and deductibles for people who just aren't able to afford those sorts of things that we do have a small fund that helps cover that and we have a sliding scale for people who have no insurance. So that, you know, nobody is denied payment is denied treatment because of because of an inability to pay. We wrote off $53,000 with the free care last year. Thank you so much for all that you're doing out there. Thank you. Dr. Lord I'm looking around the table and on the screen to see if there are any further questions. Although I think I speak for many of us we could sit here and pepper you with questions for the next three hours. I'm free till I'm free till 10 o'clock so have you have you shared your thoughts with or is there anyone to share your thoughts with around the mono product to see if you can be a voice for helping to change that. I guess I'm wondering if you or your nurse have have commented or shared the feedback that you shared with us to the folks at Medicaid about having to move mountains for that. Yes, we have and as a matter of fact I had a very long connection with Mr. fallen. I don't know if you guys know Tony fallen he's with with a DAP. He's also the state opioid treatment authority for Vermont. And, you know, and I've also spoken, you know, Dr. Luconus and I, we all talk Dr. Luconus Dr cluster who I think you're going to hear from tomorrow. Dr. Rappaport and Barry Dr Brooklyn and Burlington. We all talk. We, in fact, we meet every Friday I don't go to those all the time because I have other commitments but we meet frequently and talk about this. And I think we are all of a mind that you know it would be nice if the if the if the prior authorization requirements were somewhat more relaxed. But I think we all agree that buprenorphine mono product is a is it can be a double edged sword and we all still believe that we should be careful with it. It should not be. It shouldn't be treated lightly. For the reason that I've said. Thank you. Thank you, Dr. Lord. Since this is out of my wheelhouse the concept of what you one has to go through for pre authorization. When you say relaxed. What does that mean. What it means is if I if I was to say if I was to call Vermont Medicaid or if I was to call whoever and say this patient we have trialed or has trialed buprenorphine mono product that they have the following symptoms. In my professional opinion, the patient should have Vermont should have buprenorphine mono product as a reasonable thing up to 16 milligrams. They should say okay. Okay. And instead what happens instead I have to I have to as I as I've said I have to I have to demonstrate that you know I have tried to treat the nausea and the headaches and put the patient through, you know a difficult time dealing with side effects that are oftentimes treated. And, as I said, you know back when in the recent past I was a, you know I practiced orthopedic oncology way way back. And we prescribed Adrian my son and methotrexate and all kinds of other terrible poisonous drugs. In those circumstances, it is entirely appropriate to treat side effects because the drug was necessary and there's no getting around it. In this circumstance, it's silly. And there's no other drug that I think that that has been that you do that with I mean, if you take a cholesterol drug and produces side effects do they give you medication to treat the side effects no they put you on another drug. Right. So, you know, you know, again, cholesterol drugs don't get abused all that much so so it's a little bit different, but still the concept is the same. You know, if I think that somebody should get monoproduct because they have unacceptable side effects. I think my word ought to be good enough. Okay. Thank you. Thank you very much. This has been really very helpful. And as others have stated thank you for what you are doing in Vermont and in New Hampshire, but we're more focused on Vermont. Well, so you know I can throw a rock from my office and hit the Connecticut River so it kind of hard to avoid New Hampshire, you know. So thank you very much for helping us as we figure out what our next steps are or what we might ask the Department of Health access to explore right or something like that. Well, Madam Chair, it is my great pleasure to be here I appreciate the opportunity to talk with you this morning. And I mean this sincerely if there is anything else that our practice can do to help or information that we can give or, you know, anything, please call on us Julie knows how to get a hold of me. And, you know, I answer my phone. So, thank you. Thank you, Dr. Not only will we take you up on it but as this bill proceeds through the process and goes to the Senate. We will highly recommend that the Senate Health and Welfare Committee connects with you as well. I believe Miss Clarkson is on that committee is she not or Miss Nica wanted to. She's not on health and welfare she's on government operations and economic development. I can figure out a way how those committees could hear from you. Maybe I will. Okay. All right, thank you very much. My pleasure. Have a good day everybody. Thank you. Thank you. Bye. And this ends our morning session. And if there is time based on what is floor action 15 minutes when the floor is over we will come up and have a further discuss committee discussion before taking up more testimony tomorrow morning.