 Good morning. Welcome to the Vermont House Human Services Committee. Today is Thursday, March 24th. And this morning we are going to start our, we're going to have an introduction to S74, which is miscellaneous amendments to patient choice at end of life. And as a way of beginning we're going to have a walkthrough so that we know what's in the bill. And then we're going to have former representative Sandy Haas talk about the history and talk about where we've begun and all of that because I thought it was important that we have a context. And this builds on on some builds on on some level, but we heard last week from the Vermont Ethics Network in terms of decision making at end of life and care and respecting people's wishes. Legislative Council. Legislative Council. Thank you. Good morning. Jennifer Harvey from the Office of Legislative Council. I'm not sure if I've testified in person in your committee yet. Oh my God. So I wondered, Madam Chair, if it would make sense, I wasn't able to stay for all of Cindy Brzezi's testimony last week, did she go over the law itself, the patient choice end of life. No, I think it may be helpful to do a bit on that to give context what the I think that that would be excellent. Okay, that would be helpful. Otherwise we don't know what we're amending. Exactly. And it sort of jumps in right in the middle of some of the provisions so it's difficult if you don't know what the framework looks like. Just to orient you in the statutes we are entitled 18 and we are in chapter 13 which is entitled patient choice at end of life. And it sets out there are a number of definitions and but the main part we're going to focus on is the process that out in section 5283. And so this is entitled requirements for prescription and documentation immunity. And so I think Cindy talked to you a little bit maybe about this the concept behind this law which is to allow a patient. To request medication to be self administered for the purposes of hastening their death, and the way the law looks at that whole process kind of through the prescribers lens the physicians lens. So, that's important context just to know when you're looking at it that section 5283 which is amended in the bill says a physician would not be subject to civil or criminal liability, or professional disciplinary action. If the physician prescribes to a patient with a terminal condition, medication to be self administered for the purpose of hastening the patient's death. And the physician affirms by documenting in the patient's medical record that all of the following occur and then it lays out the process but it's really looking at it from the physician affirming that all of these steps have. So first the patient made an oral request to the physician in the physicians physical presence. Look at that in the bill for medication to be self administered for the purpose of hastening the patient's death. So an oral request, and the second one is no fewer than 15 days after the first oral request, the patient made a second oral request to the physician in the physician's physical presence for medication to be self administered for the purpose of facing the patients. So one oral request, at least 15 days later, a second oral request. Number three is that at the time of the second oral request, the physician offered the patient an opportunity to rescind the request. Number four is that the patient made a written request for medication to be self administered for the purpose of hastening the patient's death and that was signed by the patient in the presence of two or more witnesses who were not interested persons and that's a defined term in the statutes, who were at least 18 years of age and who signed and affirmed that the patient appeared to understand the nature of the document and to be free from duress or undo influence at the time the request was signed. So at that point we have an oral request, at least 15 days later we have a second oral request. At that point the physician offered the patient an opportunity to rescind the request take the request back. And in this process as well the patient made a written request for the medication and that was signed in the presence of witnesses. Number five is the physician determined that the patient was suffering a terminal condition and terminal condition is defined as an incurable and irreversible disease, which would within reasonable medical judgment result in depth within six months. I know Cindy mentioned to you about the six months that's what the six months refers to. The physician determined that the patient was suffering from a terminal condition, based on the physician's physical examination of the patient and review of the patient's relevant medical records. The patient was capable was making an informed decision and made a voluntary request for medication to hasten their death and was a Vermont resident. Number six is that the physician must have informed the patient in person, both verbally and in writing of several things the patient's medical diagnosis, the patient's prognosis, including acknowledging that the physician's prediction about the patient's life expectancy was an estimate based on the physician's best medical judgment and is not a guarantee of the actual time remaining in the patient's life, and the patient could live longer than the time predicted. The range of treatment options appropriate for the patient and their diagnosis. If the patient was not enrolled in hospice care, then information about all feasible end of life services, including palliative care, comfort care, hospice care and pain control. The range of possible results, including potential risks associated with taking the medication to be prescribed, and the probable result of taking the medication to be prescribed. The decision requires that the physician have referred the patient to a second physician for medical confirmation of the diagnosis, prognosis and determination that the patient was capable was acting voluntarily and had made an informed decision. So the physician must have either verify that the patient did not have impaired judgment, or refer the patient for an evaluation by a psychiatrist psychologist or clinical social worker licensed to Vermont for confirmation that the patient was capable and did not have impaired judgment. Number nine is applicable the physician consulted with the patient's primary care physician with the patient's consent. The physician informed the patient that the patient may rescind the request at any time and in any manner, and offered the patient an opportunity to rescind after the patient's second oral request. The physician number 11 the physician ensured that all required steps were carried out in accordance with this section and confirmed immediately prior to writing the prescription for medication that the patient was making an informed decision. Number 12, the physician wrote the prescription, no fewer than 48 hours after the last to occur of the following events. The patient's request for medication, the patient's written request for medication, the patient's second oral request, or the physician offering the patient an opportunity to rescind the request. So again in the timeline we have first oral request, at least 15 days later second oral request with an opportunity at that point from the physician to rescind the request, a written request, and then the prescription written not less than 48 hours after the last of those to occur. Number 13, the physician either dispense the medication directly, as long as they were eligible under law so they were licensed to dispense medication in Vermont had a current DEA certificate and comply with applicable administrative rules. So if the patient's written consent contacted a pharmacist and informed the pharmacist the prescription and delivered the written prescription personally or by mail or fax to the pharmacist who dispense the medication to the patient, the physician or an expressly identified agent the patient. Number 13, the physician recorded and filed all of following in the patient's medical record, the date, time and wording of all oral requests to the patient for the medication to hasten their death, all written requests by the patient for medication to hasten their death. The physician's diagnosis prognosis and basis for the determination that the patient was capable was acting voluntarily and had made an informed decision. The physician's attestation that the patient was enrolled in hospice care at the time of the oral and written requests, or that the physician informed the patient of all feasible end of life services. The physician's verification that the patient either did not have impaired judgment, or that the physician referred the patient for an evaluation and the person conducting the evaluation said the patient did not have impaired judgment. Record of the outcome and determinations made during any evaluation the patient may have received a date, time and wording of the physicians offered the patient to rescind the request for medication at the time of the patient's second oral request. And a note by the physician indicating that all of the requirements for this section were satisfied and describing all of the steps taken to carry out the request, including a notation of the medication prescribed. Number 15 is that after writing the prescription the physician promptly filed a report with the health department documenting completion of all of the requirements under this section. So again the beginning of that section says physician is not subject to civil or criminal liability or professional disciplinary action, if they prescribe the medication to the patient and the physician affirms by documenting in the medical record that all of these things occurred. Subsection B says this section shall not be considered to limit civil or criminal liability for gross negligence, recklessness or intentional misconduct. There are also some other provisions in this chapter about there's no requirement that any health care provider participate in providing a lethal dose of medication to a patient. And they cannot be subject to discipline suspension loss of license loss privileges or other penalties for actions taken in good faith reliance on the chapter or refused us to act. There's also language. So that's the main one that we should look at. But and then there are others talking about health care facilities can prohibit physicians from writing patient a prescription if the medication is intended to be used on the facilities premises. Some other provisions, including a reporting requirement. So I wanted to give you that context before we jump into what changes this bill is proposing to make. And then there are questions about what the current law says. Okay, thank you for indulging me in reading that long list. We do have a question. So when once you have the medication and you've gone through this whole process. Is there any time limit on that. If you have to rescind it or it doesn't you can have it all and you can have it right so you get the patient gets that goes through the whole process and gets the are you talking about how soon they have to fill the prescription or how soon they have to take the medication. Yes, how soon they have to know there's actually no requirement that they ever take the medication. There are requirements that the health department adopt rules providing for the safe disposal of unused medications recognizing that these are intentionally lethal medications. Okay, okay. No, in fact, I think you'll see, I think the health department report which they put out every two years, because you required that says that there are some number of patients who have did not use the medication some of them died from their underlying conditions, or other other reasons. Carl. Thank you. Do we know how many people have made use of this mechanism. We do. Let me just call up that report. And as you pull it up, I, the health department has asked to testify and, you know, or has agreed to testify about their report, which has all of those details. I think we just send this current one to, I think it's on your website somewhere but I'm going to send it to Julie, she can post it if people are interested in looking at that today. But yes, what can I tell you. The most part I think these are. Oh no this is the full time so since there have since the beginning of this law since logic effect in 2013, there have been 116 events, which I believe is which people were prescribed the medication. And it talks about the different underlying diagnoses. So, of those 77% were due to cancer 11% were due to ALS 5% to neurodegenerative neurodegenerative conditions and 7% to other events. Thank you. And there's some additional information. And they're about back into to you say 2013 2013. Yeah, it seems a shorter time. In that time, only 116 people. I believe that time reading this report there are 29 over the last two years. I do think that David Englander from the health department will be able to go into more detail. And no, no, no, this is important. I just wanted you to know that if there were things that legislative council didn't have a type of her. And then one of the people who I've already reached out to testify. Maybe can talk about what's happening nationally so that we know in context with that. Okay, so now we will turn it to the bill. S 74 is an act relating to modifications to patient for months patient choice at end of life laws. And the first thing it does is makes this add some new definitions and these definitions are added because they, these terms get used as we go into further into the bill so as a definition of health care services which is important because the next definition telemedicine it talks about health care services, health care services and this is our fairly standard definition means services for the diagnosis prevention treatment cure or relief of a health condition, illness, injury or disease. And telemedicine is the delivery of health care services such as diagnosis consultation or treatment through the use of live interactive audio and video over a secure connection that complies with the requirements of HIPAA the health information community and accountability act of 1996. So you I think you've heard some on the floor already this year and maybe talked in this community some about telemedicine and telehealth medicine is is one type of telehealth and it involves the that live audio video like zoom now we're all much more familiar with what live audio video communication looks like. But typically for telemedicine has to be through a HIPAA compliant connection. So to provide privacy. Section two makes changes to that long section we went through on the requirements for prescription and documentation. So this, and in the first instance. This would add to the requirements first and second for around the oral request for medication that the patient have made the oral request to the physician, either in the physicians physical presence and this would add or by telemedicine that live interactive audio video the physician determines the use of telemedicine to be clinically appropriate. So the first two provisions here are adding telemedicine as an as an alternative to request in the physicians physical presence. Further down in subdivision five, the physician determined that the patient and in subdivision a was suffering a terminal condition based on the physicians and this would take out the language requiring a physical examination of the patient. We'll be based on the physicians review of the patient's relevant medical records and a physicians physical examination of the patient. And then it keeps in was capable was making an informed decision subdivision D is just making a change for use non gendered language so it made a voluntary request for medications in case and that the patients own that and was a Vermont resident. In subdivision six. This is again adding a reference to telemedicine being to be an appropriate option here where the physician is informing the patient of certain information. This could be by telemedicine in addition to being in person. And 12 would eliminate the 48 hour waiting period after the last to occur of the specified events. The change in subdivision a is again to use non gendered language and the change at the end of subdivision be is changing an or to an and I see this as a non substantive technical fix it really doesn't make sense, or as much sense to say something after the last of the following events a B or C. It makes more sense to say last of the following events a B and C, but from a practical standpoint I don't think it has a change in meaning. In subdivision 13. We're again making a change to non gendered language, which is just something we're trying to do throughout the statutes when, when gendered language appears so this would say that the physician dispense the medication directly, provided at the time the physician dispense the medication that position was licensed, etc. Subdivision 14 is also a change to non gendered language. Subdivision 14 refer to the patient's own. Same in subdivision 14 be and he on page four. So the substantive changes then in this section would be to allow for the physician to work with the patient through telemedicine, rather than infert requiring everything to be done in person, and eliminating that 48 hour waiting period for the last to occur of those listed events. Section three would add a provision to the existing section on limitations on actions, where it says that nobody is under a duty to participate in providing a legal dose of medication and that a healthcare facility or provider shall not be a physician nurse pharmacist or other person to any penalty for actions taken in good faith reliance on the provisions of the chapter or it's usually to act. This would add a new subsection C saying that no physician nurse pharmacist or other person licensed certified or otherwise authorized by law to deliver healthcare services in this state shall be subject to civil or criminal liability or civil disciplinary action for acting in good faith compliance with the provisions of this chapter. There had been some concern as I understand it expressed particularly by pharmacists about their potential for liability. And this is taking a broader view the language in the current statute looks mostly at the liability of the physician so this is adding for other healthcare providers as well. And, and then it remembers the existing for reletters the existing subsection C to be subsection D, and finally section for effective date the act would take effect on passage. Thank you. In terms of the content. Right now do we have any questions for legislative council. Appreciate it. I just just trying to find what I absolutely and it was on page to the way down. Physicians based on the positions. And that's crossed out review with the patients for all the medical records and physicians. What I understand is the major change areas it's not prescribing position that is a testing to this person's issues, life threatening issues. Well, they are still a testing to the, that the person is based is suffering a terminal condition but it may be based on another position physical examination of the patient. They're their own physical examination the patient this would allow it to be another position. Ask a question about that. Yeah, go right ahead. I just want to hear testimony about it. Sorry. I'm sorry I just was thinking like, is that because we have some positions who do not wish to participate in this practice. Not the testimony that I heard in the Senate and, you know, you'll hear testimony as well it sounded it had more to do with the patient's ability to travel to where the position was, when the one the patient may be in an advanced state of disease. Thank you. Thank you. And committee this really is this is this is day one. This is a complicated and complex. Representative McFawn, do you have a question for legislative council. Yes, yes, Madam Speaker. Not now speaking not yet. Just promoted you. The, the, that that piece that number five, one page two. Does does does an individual always have to have a physician's physical examination. So the determination that the patient was suffering at terminal condition must be based on a physician's physical examination of the patient and not a fellow health. Sorry. And that, that examination can't be done over telehealth right. Right so the physical somebody must have some a physician must have performed a physical examination in order to determine that the patient is suffering a terminal, or to diagnose the terminal condition. The prescribing physician may have may base in part their determination that the patient is suffering a terminal condition on the other patients, other physicians physical examination that they must also have reviewed the patient's relevant medical records. Okay. Thank you. Former representative sandy house. How was your internet connection. So far so good. I can always call you all sales or go black. So I was asked to kind of put all of this in a historical context. So that's what I'm going to do. This legislature has worked for years to empower patients to get the care they choose. Long ago, Vermont clarified that patients have the right to refuse creating even when doctors don't agree with them. In the 1980s, legislation facilitated what were called living wills and durable powers of attorney for healthcare. As a practicing lawyer, I helped many clients who wanted to finalize their choice of refusing to be hooked up to machines, just to stay alive. Now, first year on this committee, we continued that work. Our advanced directive bill in 2005 became a model for the country. I believe you heard a lot about that last week from Cindy. That legislation makes it clear that medical providers must follow the wishes of a patient, or his or her designated agent. Later, Vermont implemented an online registry for advanced records, assuring that those documents could actually be located and used no matter where one ends up receiving treatment. Then this committee focused on palliative care. This was a field so new that many Vermont practitioners had not even studied it in medical school. In this work, we passed the first continuing medical education mandate in the state. It took us two terms to get that passed, because there was so much opposition from the medical community. Now doctors must spend one hour every two years hearing about palliative care and pain management. In 2013, we took up and passed patient choice in the blood, which is codified in Chapter 113 that Jen just talked to you about. That bill was intended to give patients one more tool to assure that they, not the medical establishment, can make decisions regarding their own treatment. Some will say that death is not treatment, but for a dying patient, the choice is not whether to die. The only questions are when and with how much suffering. Chapter 113 gives a last measure of control over the time and manner of that inevitable death. When we drafted the law in 2013, we chose to model it on a law that had been used in Oregon since the late 1990s, and in the state of Washington since 2009. Both followed a very careful procedure to provide that one final tool to a dying patient whose suffering feels too great to bear. In negotiations with the Senate, we found that not everyone supported that very careful procedure. As a result, we passed a compromise bill that forced us to reconsider that process at a later date. In 2015, we took up Chapter 113 again and voted to keep in that careful procedure, keep it in place. Technically that was accomplished by removing the sunset. Our 2015 amendments also required that the Department of Health review the physician reports filed under the law and report to the legislature regularly on the use of Chapter 113. So you've heard of you've heard about current law in detail from Jen, I will just go through it a little bit, a little bit more briefly. It continues the multi step process that was first adopted in Oregon in 1998. It permits a qualified patient to request a legal medication that has to be self administered. And that medication can be described only if the patient is a Vermont resident. The terminal diagnosis is given a six month or less prognosis that is six months expected life expectancy, and that that is confirmed by at least two doctors and to be a qualified patient, you have to be able to make a health care judge, health care decisions, not have impaired judgment, make an informed decision after being informed of the diagnosis, the prognosis, the range of treatment options, the range of comfort care options, the, the risks of the legal legal medication and the probable results. And as Jen laid out for you it has to be requested three times orally and both orally and in writing. And there's that 48 hour waiting period between the last request and the actual writing of the prescription. Participation participation under this law is voluntary. It's voluntary to patients, and it's voluntary to providers. It creates a very narrow path for a dying patient who seeks medication to hasten their death. If that narrow path is followed, both the doctor and family members are protected from criminal liability, what we call in the law as safe haven safe harbor excuse me. In advances in pain and symptom management. We heard that there are always a few patients whose end of life suffering cannot be relieved. Chapter 13 will pass to assist those patients. And I think what you've heard about as 74 is that it proposes a few modest changes to that very careful procedure. And you will hear from other witnesses how that how that would play out now, but we've had in place this this multi step process for many years now. And, and people who have worked with it have proposed those changes and having read the bill I support those changes. Thank you. I'm going to move on to former representative house. And former representative house was. I think that committee member who for each of these sequential steps from position, continuing ads to advance directives. reporting the first initially on the House floor and then the amendment. So she really knows it this way. And I thought it was important that we hear the history going back to what she talked about, which was a long time ago in terms of thinking about palliative care and end of life and how we can enable Vermonters to approach end of life in a way that works for them. Questions or comments or discussion? Yeah, I just, it's so, hi, Sandy. I just find it so interesting what you said about palliative care and how the physicians were so against it from the Vermont. I just, and now it's the thing to do and people really are physicians encourage the consideration of palliative care. So very, very interesting history. Well, it was a little pet peeve of mine that radiologists said, well, I don't need to know about this. And my feeling was, you know, if I'm behind you in the groceries floor line and I say, Dr. Jones, you're a doctor. Have you heard of palliative care? I didn't want the answer to be no, even though the radiologist was unlikely to ever use it in any way. I thought at least they ought to know what the word means. And I think I'll stop there, but I could go on about what I consider the arrogance of doctors. What, the arrogance? The arrogance of doctors. Who we all love and adore. I think somebody said that all surgeons are really psychopaths. Sandy, during the testimony that was given when this law was first enacted, I know there was a lot of pushback by the disability community as it relates to maybe, I guess what I would call a substituted decision making. And so how, and maybe this is a question for much counsel. So if a person has been determined incompetent by the court to make decisions on their own behalf related to healthcare and they have a guardian, whether it be a public guardian or a private guardian, this seems to speak to the individual. And I just want to confirm for my own mind, because this happened before my time, that that means the individual, not the person acting on that person's behalf if there is a guardian. That is correct. This law does not allow substituted judgment. Thank you. Carl. Justin, maybe you can answer this, Sandy for what I've counseled, but again, going back to paragraph five on page two, this change about the positions can be another position, not the prescribing position. How does that marry up with the fact that there have to be two independent diagnoses by two different positions? Does that mean there'd be two positions that were not the prescribing position or not? I understand somewhere in it says there have to be two diagnoses independently. As I read that language, and I will defer to others on the intention there, I believe that at least one position has to do a physical exam, but there would still be a requirement that another position look at that at all of the records. Look at the results, not necessarily performed. My name is Anne. Okay. Now perform a physical exam in person. Thank you. So legislative counsel, maybe another way to ask that question, how many different physicians does a person who is considering this need to connect with? At minimum two. Okay. So at least two, there could be three or more. There could be one physician who would perform the physical examination, a second who is the subscriber, and a third who is doing the medical confirmation, or it could be within those two providers, but never less than two. Okay. Tapper. Thanks Madam Chair. On page three, we've taken out Sandy at the 48 hours. Madam Chair, are we going to get, is there a reason why the 48 hours was taken out? I will, if she wants, I will let Representative, former President Cross respond. We will be taking lots of testimony. We will be taking testimony from the supporters of the bill in terms of why and what was needed. What is the problem that this removal is trying to address? And we will be hearing from individuals who did not support the law in the beginning and who do not continue to support the law. And so we will be doing, so I don't know, I guess I'm saying I don't know if Representative Haas can answer that, or if legislative counsel, if that's a fair question for legislative counsel, or we should wait. So I will just jump in and say that you will be hearing my understanding from following this in the Senate is that this is exactly one of the areas where the, what is it now, nine-year experience in working with this law as written, you will hear from people who have used it who will say that they are suggesting this change and why. So I'm going to defer to the people who have been working with the law. That's what I use to do and what you do now is we take laws and we see how they're working and we make adjustments to make them work better. So we'll hear from somebody then, right Madam Chair? Yes, and that's everyone, you know, I think this is an introduction. How's that? And I think, you know, my understanding broadly is that this was to remove unnecessary barriers for those individuals who wanted and continued to want to exercise their options under this law. And we will hear, we will hear from those and we will hear. We have an email out to Mary Honsburg Beardsworth as to when she is available or whether someone else in her stead, as she has reached out and we have reached out to her and she is someone who represents a constituency that has many concerns about this, about the existing law and the change. Thank you, Madam Chair. Sandy, it was nice seeing you. Wonderful presentation. I have to leave. I'm sorry. Please take care of yourself, Topper. Other questions right now for Legislative Council in terms of the content or Sandy in terms of the experience and history and what were some of the, or other things as relates to how we got to where we are today. So folks, this is, so let me lay out some ideas that I had in terms of who we hear from. I think it's, and look, before I do that, who do people want to hear from? I mean, whether it's individuals or whether it is a constituency. Well, I think we probably should hear from the Medical Society and maybe some physicians who have actually participated. Right, actual doctors, yeah. I'm sorry, I can't hear. I was agreeing with your actual physicians who have actually participated. And people. And people, family members who have been impacted. Yeah, okay. The leader of the nomination of the church, I don't know what one of would be, just to hear with a perspective from the religious community. Maybe more than one. Okay. We'll figure out how to do that. And we have the health department. I just want to circle back to Carl in terms of figuring out which are the, the religious community is very wide. And I want to say probably the religious community being very wide has very different perspectives on this. And I might suggest to each and every one of you who has a connection and for whom their religious community is part and parcel and important to them that they check with them. And we will, I believe that Mary Han Spirgworth represents a non, non, she's not necessarily connected to a particular denomination, but I think she represents and her views are, are rooted in a religious context. I'll change it. I'd like to hear from her. Oh, absolutely. Absolutely. And so we've got family members, some sort of connection to the religious community, the health department. What? Drinking. That's challenging. It is. It's very challenging where, you know, whether it's, you know, from the state, probably just going over legalities. Okay. Which I don't question. Okay. So since we're being in this way, I don't know where we have ledge counseling, but on every other bill that has legal questions, we've had people from, you know, the Donovan's officer or whatever. Journey general. Okay. You know, so I mean, it's not a question of that. It's just, that's what we do. Okay. Yeah. We don't get to pick and choose when we're going to do it. Okay. I am, and now I'm turning. Yes, Carl. Could we hear from some family members that may have had people. Good idea. Yes. And I know there are, I know that there are several who have experienced this recently who would like to testify or who were, were offering if this is not too hard for them to testify. I also have been thinking about there is a, there's an organization in Vermont for people that they have questions. And as there is a national organization. So to have representatives from both of those groups. And do you want us to hear from the disability community again around this? Let me check in. Okay. Folks. I know that the primary and big issue was around substituted decision-making. And emotional pressure. Yeah. Or family members or other people who are guardians of an individual with a disability making the decision for them that it's time, you know, for, for their life to be over. And I think that that was, that was a quite a large concern back in 2013. It hasn't proven to be the case. And by not enabling substituted decision-making, even if you are a guardian, I think that elate a lot of people's concerns. So I will check in Madam Chair. Okay. I do want to put our witness on the spot. Sandy has, if you remember what, if you can, what some of the issues, if there were additional issues or concerns. Well, there was, and how, and how, let me say, and then how we, how we tried to, how the law tried to address them. I think the, there were, there were concerns about family pressure. And, and that was one of the reasons that we were so careful to follow the, it must be the individual deciding, it must be the individual self-administering the drug. We, there, you know, the, the witnesses have to be people who are, who are not interested in the estate of the, of the, of the ill person. One of the reasons that we followed Oregon so closely was that Oregon had a track record that, that revealed that many of those fears had not been realized in all of that time. All of the, all of the concerns that we heard in 2013 had been raised in the 1990s in Oregon and, and they had been reporting right along and had found no evidence that any of those things happened. And I was just, I had, it's, I'm glad that you found the 2022 report from the health department because they don't have it on their website. And I was intrigued to see that of the 29 people who, who, who quote, used the law clause quotes in two years, only 17 of them actually used the prescription. So, so I think, I think on one level the numbers by themselves reassure us that, that this is not being used. Thank you. I hate to be so ignorant on this, but I don't recall in the initial bill what the situation was with life insurance. In other words, if somebody chooses to take their own life and they would not be eligible or their estate would not be eligible to receive the benefits. Is that true or not true? I don't know the law. Yeah, what's in the law? Yes. So in the law in ATVSA 58287 it specifies that a person and their beneficiaries shall not be denied benefits under a life insurance policy or actions taken in before this is checked. So I'm surprised that life insurance industry didn't protest more when it's low. Anyway, just following up on that. It's a good question. Yeah, that's a good question. I think we need to hear from the insurance industry if these changes, I don't know, reading it, I don't know what these changes would do to make it, let's say easier to or affect the possibility of insurance or not, but it might be useful to hear from the insurance representative. Okay, life insurance. Just a thought. We're asking for a suggestion. No, I appreciate that and we can figure out, I mean, what the response is and yeah. Yeah, thank you, Madam Chair. I think a question that came to my mind and hearing that not all individuals who are prescribed these medications ultimately take them is maybe hearing from a pharmacist or somebody like that. But my question is sort of what is the follow up in these cases of like proper disposal or retrieval of those medications after they're prescribed if somebody's not going to use them. Also if we could hear from one of those people who decided not to take the medicine, they might be interested. Well, they still died. They still died. Yeah, they still died. I mean, they're they either died. Oh, I think that's the main reason they didn't take it. They chose to die naturally instead of. They chose to die naturally rather than take it or maybe something happened before they took it. Of course, we also know even if somebody has been diagnosed with a terminal illness, it doesn't always mean it is terminal. But usually, as I agree. Committee, my sort of thought about this is that this is still, I mean, well, this is Thursday, but we're not going to take any more testimony this week on it. Julie, how are we working on next week? All of the witnesses for next Thursday. Okay, so their witnesses for next Thursday and they have been confirmed. And whether or not we have another day or a short thing is up in the air. And then we will direct more, more concentrated time on it the week after. So that's that's why I want to know what people's opinions and thoughts were. So I think I think that gives us I hope this gives us all a good beginning and to begin to think about this and who we want to hear from and know that it is one of the Senate bills that we have. We have two Senate bills right now and we'll be getting a few more. And my plan committee is to have to have a walkthrough of what those Senate bills are. So then we can figure out what we do next. So with that, Representative Haas, thank you very much for joining us today and for helping set the stage. Good day. Bye. Committee, it is earlier than I wasn't sure I wanted to leave sufficient time for this because it's it this can be a hard discussion or a hard issue. But now that we have some time, rather than coming up after the whatever we're doing judicial retention, how I believe that Representative Whitman has shared an amendment with you on on our bill. And so if you could present that first straw poll. Yeah, so I'm sure. Yeah, I forgot my straw. We'll find one. Okay. Thank you. So yeah, glad to hear back from quite a few of you that you had the chance to look at this last night, sent an email after a lot of close collaboration with the Department of Vermont Health Access and going back and forth and checking with a lot of interested people based on this floor amendment, which is essentially to offer alternative policy moves around prior authorization. I won't completely rehash it. I think a lot of people here know that we gave an initial proposal. The potential costs associated with that were higher than we had anticipated. And but in the efforts to continue on a path forward to address barriers to treatment for people seeking medication assisted treatment. There were a lot of proposals put forth to the committee and a lot of considerations about what potential opportunities for changes there could be to prior authorization that would potentially make it easier for providers and patients to get the treatment that they needed. So basically the path that we're taking within this floor amendment is to task the department with sort of a deep research of all of the available in the feasibility, the logistics, the potential costs of all of these potential changes to prior authorization. And then for them to propose these to the relevant boards that are currently tasked with reviewing decisions related to prior authorization, that's the drug utilization review board and the clinical utilization review board. And then they will provide recommendations after considering those that research, which will then be presented to us. So I'll kind of walk through the amendment right now. This is good practice for me this afternoon spent a lot of time writing this and now a walk through but so let's see I'm looking at the calendar but it would be page one of the amendments that I emailed everybody yesterday. The new section three of the bill essentially codifies the existing practice which does exempt one medication within the classes of methadone, buprenorphine, and naltrexone from prior authorization. But it's just specifying that it goes through the drug utilization review board. So essentially this was current practice but it was not in statute so we're codifying this current practice. That's yeah so this would be like a it's read a section three because it's within the bill as a whole. Section four is the report which states that on or before December 1st of this year, DEVA will research the following and we included specifying and consultation with individuals representing diverse professional perspectives. One of the reasons that we're here is that we heard diverse professional perspectives on whether prior authorization is good the way it is or it needs to be changed in order to delete barriers to treatment. And we'll submit its findings to the DURB and the CURB for their review consideration and recommendations. And what we've ended up including for their research and following recommendations is quantity limits and preferred medications for buprenorphine, the feasibility and cost of adding monogrupernorphine products as preferred medications as well as the current process for verifying adverse effects to monogrupernorphine. Three is how other states Medicaid programs address prior authorization for MAT including the 60-day deferral period that we've seen in Oregon. The appropriateness and feasibility of removing annual renewal of prior authorization as well as the appropriateness of creating parity between hub and spoke providers with regard to MAT quantity limits. This says quality limits. So that's a Scribner's error, I guess. The person who wrote your report needs to. Then creating the consideration of creating an automatic emergency 72-hour pharmacy override by default. So basically what this following section says is that the DURB and the CURB will include this review as an agenda item at their meetings related to prior authorization. Basically so that this is giving notice for public comment, essentially what this section says. And then honor before January 15th, the department shall submit a written report that basically contains that initial research that they gave to the DURB and CURB as well as the DURB and CURB's recommendations. So that'll be coming to us for consideration of potential further action. Seven is the reports. Again, these are the reports that were with sunset. Now we're looking to renew them and we've also bolstered them. What was being sunset? I'm sorry. So remember when I would kind of read from that table that says like there have been 3,000 prior authorizations and 95% have been approved. So those reports started in 2019 and they basically timed out after three years. So we're renewing those reports as well as asking for additional data just so that it leads less up to interpretation. Maybe a lot of the questions that we were asking the department could potentially be answered ahead of time through this report. And so what the report will include is which medications required prior authorization, the reason for initiating prior authorization that would be a new point. Like why was this medication? Why did we have prior authorization now and not for the other 10,000 times this prescription was prescribed? And then how many prior authorization requests the department received and of these how many were approved and denied? That was already included but we also want to include the reason for approval or denial as an additional data point. The average and longest length of time the department took to process a prior authorization that was already there and how many prior authorization appeals the department received and of these how many were approved and denied and the reason for approval or denial? This is a new piece within the statute. Our understanding is that the department already was presenting this data. So and that's that. So yes I just wanted to mention to folks that I know we had talked about the corrections thing yesterday and I did reach out meaning folks who transition from correctional on MAT and then move to the community and have to sort of immediately switch over if they're able to get immediate access as it is. And so the chair of the joint so I sent a note to the chair of the Joint Justice Committee to see if she would take that up during the off session and she responded that we will take that up during the off session. So we'll take additional testimony on that issue and you know potentially bring back some recommendations for consideration next year. And the Joint Justice Committee. I told her I'd wait for her thing to print out but it wasn't didn't print and it wasn't in the queue whatever she was looking for. Oh okay. Just for folks the Justice Oversight is one of the summer or interim joint committees and it has members the the chair or designee from institutions from human services from judiciary and I don't know that's it and in both the senate and the house and I'm the rep for human services in the house. So before we thank you for that update before we vote on your amendment Topper had and he's he had he had to go away but his his request and he has he he has sort of emailed that he's okay was that we needed to know the amendment what our amendment was before we voted on for we took a straw poll on accepting the Appropriations Committee amendment which is what started this whole thing because they they they they struck everything about pre-authorization. So let's first do a straw poll on the Appropriations Committee amendment to our bill all those who are in favor of the Appropriations Committee amendment please raise your hand. Okay so if it's something wants to zero sorry oh sorry those opposed. Just wanted to vote so I know she had to run but okay so it is a straw poll it is a straw poll so you can um I could text her she's yeah okay you can you can text her to tell her to come back I don't know where she went but she was talking about it on top of top of this too and so I so what we will Topper gave his approval in in an email that the amendment was okay with him but when he gets back I will which amendment one the appropriations no he gave his approval of of the second amendment not the first um he did not give his approval but we didn't ask that specific question of him so I will um when he gets back we will circle back to him. As of now I have eight one two two absences right now you have eight one two and it may that may change and it being a straw poll sometimes a straw vote sometimes by the end of the session these straw votes happen on the floor of the house with someone going from either the committee they huddle in the corner in the corner on that kind of thing so we're not really diverting too much from process and so now I enter a straw poll on accepting the amendment as proposed by Representative Whitman and all those opposed so that is um nine zero two until we hear from other people so thank you very much I don't think we'll have a reason to come back we'll we'll have the opportunity to um come back today I think we have a day on the floor I'm going to text you I mean we do have a bill on the floor so sometimes there may be an amendment or something so think about potentially being here at nine o'clock tomorrow morning if not on Friday 15 minutes after we get off the floor and I will I will confirm that text and email to everyone about Friday okay as far as committee right as far as whether whether well committee right well given where we are and everything I think we will need to check in at least for you know 45 minutes and whether that is first thing in the morning in case there's an amendment to the bill or something like that or whether it is when we get off the floor and when I look at when I look at the calendar the only what we have for first reading on Friday is the capital bill and um then everything else looks like it will be third reading so um if we do if we so I meant so if we don't come first thing in the morning we'll do a quick at the end you know because I don't we won't be we won't be till four o'clock on the floor on Friday so we can point out we don't have any witnesses tomorrow and we don't we don't have any this is just to um to check in um and uh that so um with that uh we have a few minutes before we are going on the floor so this ends our