 I'm Dr. Louis Myers. Welcome to Health Care Today, where we're going to be talking with Ms. Jessa Barnard, who is the Executive Director of the Vermont Medical Society. Ms. Barnard graduated from Dartmouth as an undergraduate with a major in anthropology and a minor in neuroscience. She went on to graduate from law school at Stanford University. She worked over at the main medical society for some years and since 2017 has been the Executive Director of the Vermont Medical Society. She also has experience in working with legal aid and disability rights advocates. We're going to talk with her today about some of the really important issues that her organization has been lobbying for in Montpellier this year. Ms. Barnard, welcome. Thank you. Thanks for having me. So why don't we start by talking a little bit about the Vermont Medical Society. What is that? Who do you represent? Great. So pretty much every state in the country has a state medical society. We are the representatives of physicians and also physician assistants here in the state of Vermont. So we provide education to our members, a newsletter, educational resources, and then we spend a lot of our time advocating in Montpellier on bills that impact health care. Some maybe kind of the more traditional issues you think of physicians working on around licensure or reimbursement, but a lot of our issues are around public health, access to health care, improving public health for Vermonters. We're going to talk about some of these specific issues, but you have such a broad umbrella or number of physicians around the state, some of whom may have different kind of political views. How do you decide where you're going to stand on an issue, the organization? Yeah, that's a great question. So we have about, as you said, 2400 members that cross the spectrum from specialty care to primary care. They work in all different employment settings from independent practice to hospital employed to FQHC. So we do spend a lot of time trying to make sure that the positions we take represent kind of the majority view of our members. We have a resolution process. So if it's an issue we don't have a position on already. We set new positions based on resolutions that come from any member or group of members or committee. And then they go out for comment to our full membership with a member survey. And then our board, which represents kind of different geographic areas, different specialties, takes all of those comments and the input from the member who brought the resolution and sets a position for the organization. Well, it sounds like a very complex process until you get to the point where you do have it take a position. There were a number of really important bills before the legislature, some of which have been decided and voted on now, some of which I understand are still pending. Let's talk briefly about some of them. Shield laws. What tell us about the shield laws and where does that stand? So there are two bills that were taken up this session. One started in the House, one started in the Senate. They both have components to protect either providers of or patients who were seeking what might be more laws that have been or care that has been criminalized or stigmatized in other parts of the country. So reproductive health care services, abortion, contraceptive care, and also gender-affirming care for those who are transgender. And we know from just all reading the newspaper that some states have made these services really hard to get and in fact have put criminal penalties or even criminal sanctions like prison time on either those who provide it or seek that care. So these were two bills to try to protect those who are in Vermont seeking the care or Vermont health care providers who are providing the care to patients. Now, as we know, this is probably the most controversial, hottest topic in our country today across the country and within various states. Getting back to what we were talking about just a minute ago, how did you come forward with a policy and something this hot as it were? You know, we've taken a position on protecting evidence-based health care, including abortion or contraceptive care a couple of years ago. So when there were, when Vermont, the Vermont legislature was first considering whether to protections in Vermont's law or the Vermont Constitution for abortion care and other reproductive health care services. So we kind of went through the process of taking that position a couple of years ago. And since this law is really just protecting access to that care that we've already had a policy to support access to, we didn't necessarily take a new position, though actually we did about a year ago now. We did actually take a position to support shield laws, but the sort of underlying debate around access to these services was something that our members went through a couple of years ago. And also we had a policy that we had supported around access to transgender care. I mean, our view is really that any patient should have access to evidence-based health care. Both of these laws kind of mirror the evidence-based guidelines that national organizations like. What are the guidelines for transgender care now in this state? Obviously, I'm not a clinician, so in terms of the clinical care. No, not in terms of the legislation. So the legislation, we don't have any laws in Vermont that limit or prohibit any access to transgender care. It really defers to, it would be up to say the Board of Medical Practice or other regulatory entities to decide that somebody's not following the clinical guidelines, but really it's about best clinical care. So we consider ourselves, our members, are lucky to live in a state where the laws and the medical board and nursing board and other professional boards follow, you know, really allow and support clinicians following evidence-based guidelines that are set by, say, national specialty societies or entities on comparing that to some other states that have actually said that, sort of said that providing certain kinds of care is against what they allow in their state, even if clinically, clinical guidelines say this is the care that should be provided. So this has passed and the governor signed it? Correct. These are both in statute now, H89 and S37, and they have protections for things like saying if you are disciplined in another state for providing care, but it is evidence-based and we in Vermont consider this evidence-based care, the Vermont Disciplinary Boards won't take automatic action based on action taken from another state, or if you are facing criminal sanctions in another state, we will only recognize those when we have to for constitutional reasons. So we're trying to protect providers who maybe face penalties from other states where care is criminalized from having that kind of follow them into Vermont. Okay. A second issue that came up is addressing violence against health care workers, and we may actually do a separate show on this in the near future, but why was this important now? Is there more violence occurring against health care workers? There seems to be, yes, whether it's partly related to the stress of the pandemic or the kind of decreased kind of social mores and feeling like we can take out our anger on other people. Health care workers are facing violence on a frequent basis, especially in emergency departments and settings like that where patients are under such, and it's not only from the patients, it may be from family members or others who have accompanied the patient to care feeling like if they're not getting what they ask for or not getting the care as quickly as they want, they may lash out, they may hit people, throw things. There was some very graphic testimony from some health care workers I know who have been injured. Yes. What does the new law say? The bill would or the law would permit arrest without a warrant for this threatening or violent behavior. The bill was narrowed throughout the process at this point to hospitals and EMS personnel. Originally it started as any health care worker kind of in any setting, and so basically it would allow police if the person's been stabilized and there was a lot of concern around well what if the person's still experiencing a medical emergency, so that is very clear in the law that you have to make sure that their sort of emergency health situation has been stabilized, then the police can remove them from the premises without a warrant. And arrest them. And arrest them and right remove them from that situation. I know it's been a frustrating, I know from my own experience working in the emergency departments, it's been a frustrating situation in the past because the police hands were often tied even when people have been injured or you know on the premises or hurt or being threatened, so yeah it does seem like this is a logical step forward. I know the airlines have also been experiencing something similar for flight attendants and whatnot. Suicide prevention, and I think this is one of the ones where we're still waiting, but tell us about the suicide prevention bill. Vermont unfortunately has a fairly high suicide rate and number of deaths by suicide and we know that one of the most fatal or successful means of suicide is with a firearm. Vermont also has a high rate of death by suicide using firearms. We've had, there was very eloquent testimony by one of our members who's a pediatric intensivist, so works with the sickest kids who are in the ICU, about how most people who attempt suicide but don't complete it don't go on to attempt suicide again. And so if you can catch somebody in that moment and intervene and get them support, most people go on to not want to end their life and to be grateful that they did not. If you use a firearm it is much more likely to be successful and to not have that opportunity to get the person help. And so this bill would require a 72-hour waiting period for the purchase of any firearm, which is really an important sort of cooling off period that you may have a really impulsive need or desire to get this firearm to try to end your life, but if you have that sort of enforced pause it is less likely that that will happen. We already have a red flag law as we know several years ago, Governor Scott took the stance that this was important and but this is an addition. Now this is this for anyone buying a firearm. Right. This is right. The red flag law is sort of after somebody already possesses the firearm but you have a concern you think they might use it to harm themselves or others that's a way to remove the weapon from them. This is to have a pause before they. So where's the opposition of this bill coming from? Well from the you know there honestly is a lot of discussion right now on what level of regulation of firearms is constitutional. The U.S. Supreme Court has put a lot of that into question with some recent decisions that any restriction on firearm possession has to be sort of rooted in history as opposed to you know and going back frankly centuries of so it's much it's a little more complicated to determine if something's going to hold up to constitutional scrutiny so that's been one critique and the other is from those who you know don't think there should be restrictions on anyone possessing a firearm. We and we don't know as you mentioned this is one that we're waiting on the governor has five days after a bill lands on his desk to either sign it or let it go into law without his signature or veto it. So today is the fifth day the day that we are recording this by the time people will be listening to it we'll know whether he has allowed it to go into law or if Vermont's law and if he signs it could we end up in the Supreme Court or has it already been? It is possible it could be challenged yes I believe that we have indicated you know that if it's passed and goes into law the Attorney General would then defend it as one of Vermont's laws but that it could be challenged in court. Well that we will know hopefully later today. Correct. And the Vermont Medical Society is in support of this. We are in support of it going yes being enacted. For other reasons you talked about saving lives. Correct. Let's talk about another life-saving intervention which is access to opioid treatment. As we know this is just a horrible problem ongoing get seems to if anything be getting worse after we had made some progress leading up to the COVID pandemic. So there's a bills about expanding access to opiate treatment and harm reduction. Yes and actually we the governor just signed this bill a couple days ago with a very supportive statement this is S-222 and one of the big pieces of this bill is allocating the funds that have cut him into our state with a huge multi-state settlement with the some of the opioid manufacturers. So Vermont will be getting several million dollars a year for the next at least 10 years I believe to help address opiate addiction and there was a committee set up the legislature last year set up kind of a process for prioritizing how those funds will be used. So there was a committee that the Department of Health brought together over the past six months or so to come up with kind of a list of priorities for how to use that funding and then this is the bill that actually allocates it. So there will be more funding going to things like more hub locations around the state to make sure it's more equitably distributed. They are this bill actually authorizes drug testing at some of the harm reduction sites. So if somebody you know one of the real reasons we're seeing so many more fatalities is some of the really high potency synthetic opiates that people don't even know they're getting mixed into their drugs and so this would actually allow somebody to bring their drugs for testing before they decide to use it or not. It would distribute more Narcan, more Naloxone overdose reversal medication and a number of other sort of components to increase access to care. Narcan is or will soon be over the counter. Correct. One issue has been its cost so this might help defray that cost. Now when you talk about testing the drugs legally being able to bring someone bring their drugs into test that is leads me to my next question and I did talk with Dr. Levine in our first show in this series about harm reduction centers where people could actually use the drugs they brought in under some supervised setting and that's really controversial but does the Vermont Medical Society at this point have any? We did we actually took a we took a position a couple of months ago on that issue knowing that the issue would be coming up in the legislature and then there have been bills on this in the past years. Our board did adopt the statement in support of harm reduction center though recognizing that resources are limited and that this may have limited geographic impact that we prioritize other harm reduction strategies before we put a lot of resources into a harm reduction site you know I think they will be difficult the logistics are the difficult part you know make keeping it staffed make how do you how do people from around the state access it also some political consequences many people might not want it in their neighborhood and where would it be site yes exactly there I think there will be hurdles there would be hurdles to overcome if one was to to move forward but we we would support that as a component of options available let's move on to cannabis which is you know it has been a process in the last several years as Vermont has moved step by step first to decriminalizing cannabis then legalizing it and now trying to set up commercial markets I know that there's also been some movement toward loosening the regulations even further in Vermont Medical Society has taken a very strong position on this tell us about that I think you summarized it well there obviously retail sales are here but our position is has always been and continues to be that public health also needs to be protected and so the two issues we that have been sort of highest on our priority list right now are around advertising and potency so when the regulations first passed and when the retail sales started there is there has been a potency cap on both solid concentrates higher concentrate products and cannabis flower and then there's also been a fairly significant advertising restrictions and there has been pushed back on both of those components to loosen those and we don't feel like now is the time I mean sales are certainly on target they're meeting all the expectations from kind of a commercial standpoint of what the state would be bringing in for tax revenue and we know especially high potency products have do have health impacts I think there's in Vermont in particular kind of a low perception of harm from cannabis that it's safe it's natural but some of these products are not at all like what the type of cannabis people were using 10 20 30 years ago it's extremely high potency and those are the products where people can end up in the emergency room end up even with we do know there are real mental health impacts of using these those specific types of products we've certainly seen it in in our hospital and other places one of the issues of course is that with cannabis there is a large and established black market and that if the state is going to tax legal cannabis in order to try not to encourage massive use of the drug and also to bring in revenues that they will take the price of that legal cannabis will so be so much higher in the black market that people will just stay with the black market that's happened in New York City and other places how do how do we deal with that honestly I don't know that we're going to be able to solve that problem California for example still as you mentioned it still has a lot of black market sales you know Vermont especially because we allowed grow your own cannabis several years ago probably will there will always be cannabis available and products available on the black market I think it's the reality of the market I but I don't think that's a reason or a valid argument in our view to say well those products that we are selling in the regulated market should be a free-for-all we should allow anything of any potency or any type of product because otherwise they'll get it on the black market to us it's you know once the state has kind of put their seal of approval on something and they're saying this is regulated we have said this is meeting our requirements that that means it should be at least as minimally harmful as possible now your lobbying working hard and to maintain these what seem to be healthy limits in terms of the cannabis lobby itself big money I am assuming it is getting to the point of big money yes I mean and and interestingly you know on some of these issues we also don't see eye-to-eye with the cannabis control board so that's the that's the regulatory body charged with setting up our market in Vermont they have been fairly supportive of the advertising restrictions but they have actually been one of the strongest voices for eliminating the caps on THC potency so it's some of it is from the you know retail market and where there is you know there is more more money over time to lobby on issues but it's also from the regulators themselves well we're gonna probably do a separate show on that as well let me ask you about the I think it's called right to die yes which is Vermont was one of the if not the first state in the country to allow people to choose the time that they wish to die and and and to allow physicians to assist in that now Vermont recently also passed a bill which will allow people from outside the state to come to Vermont there's some concern that there could be a tourist if you will tourist dying industry what are your thoughts on that what is the medical society's thoughts on that because I know physicians have very mixed feelings about this they they do and our members have had mixed feelings on this for issue for years we have a fairly neutral policy that we adopted in got my year right I think it was 2017 on aid in dying as a as a topic and so we as an organization were neutral on the bill that passed this session it was fairly modest changes to the law so some other you know for one of in one instance allowing some consults by telehealth and then as you mentioned the other pieces allowing non residents to be able to access the law I was actually just on a educational webinar about it and I think the given the number of other hurdles that need to be met to before you can qualify and the fact that they are giving very strong advice that the patient be located in Vermont for all aspects of taking advantage of the law because other states that don't have similar legislation may not you know it may be considered a suicide or other you know sort of non endorsed action that could lead to consequences for the patient or their family I don't foresee at this point a huge influx from out of state of those who are even able to take advantage of the law the console by health is a little concerning to me I mean we we remember senator Frisk who was a cardiothoracic surgeon many years ago got some trouble because he sort of diagnosed from afar a young woman who was on in a terminal condition following a long-term coma so I do have some concern about people making these some of these decisions or consultations like truly life and death decisions by telehealth but maybe we'll have a separate show on that as well it is a whole yes I'm sure you could have a certainly feel a half an hour on it I believe I could be wrong on this that it's only one of the two you know you have to consult two different physicians and I believe it's only one of them that can be by telehealth but I would have to confirm that finally a couple more issues in the time we have remaining let's talk about gambling many states around the country have have perhaps rushed to legalize state gambling you know eager to get some of the revenues involved I think Vermont has not yet or I know there was a bill under discussion this session around sports betting and I actually that is a good question I don't know the outcome of that it is actually not a bill we took a position on though certainly like any other addictive action it's it is I think it's the same it's a very similar question around cannabis do you prohibit something or do you legalize it and then at least in theory put some of the funding into prevention guard rails for example in some states the big gambling companies are now advertising directly to college students right who are tend to be more vulnerable in terms of developing gambling and and whatnot so we'll we'll see how that develops in Vermont funny the last issue I want to talk to you about is is scope of practice pharmacists I understand have been lobbying to prescribe certain medications psychologists have long been lobbying to prescribe certain psychotropic medications and I think those are on hold or under study and at least until next session you do represent not only physicians as you mentioned but physician assistants and I wonder if you could talk about the physician assistants what their training is and how they slot into our continuum of care here in Vermont the other they're generally described as mid-level practitioners but the other mid-levels are the nurse practitioners here in Vermont and I know that there have been situations where nurse practitioners have been able to apply for jobs where physician assistants have been completely ruled out in terms of even being allowed to apply so what what is what is the Vermont Medical Society stand on this so a few years ago we worked with there's a and there there's also I should say an association for PA is separately so the physician assistant association of Vermont PA AV and we worked closely with them a few years ago to modernize statutes around physician assistant regulation because that was a concern that we had heard that because in in Vermont at least after an initial two-year collaborative practice requirement nurse practitioners advanced practice nurse practitioners practice independently they don't need a relationship with a physician PA's at the time needed a supervising physician at least one and that was seen as a barrier challenge sometimes to finding employment and so Vermont did go through a process with statute change the Board of Medical Practice rules changed so physician assistants now need a collaborative relationship with a physician but it's a little different than what the old supervisory model was we supported that change working with that we had a group of our members who worked with the PA is to sort of say you know what the way we approach any change in scope of practice from any practitioner is we consult with our members and we get their feedback on do they believe that they have the education and training to provide this care safely and there are instances where we've worked really collaboratively with other professions the with the PA's is one example with the pharmacists pharmacists actually now have limiting limited kind of prescribing authority in Vermont for things like emergency contraception or it's short-term extensions of prescription so our members gave us feedback on that and we thought those were sort of reasonable changes to to certain professional scope if there's an issue where we think something would not be safe for the best outcome for patients then we will try to you know work with that profession or the legislature to to not have that change I guess and you don't represent the nurses of course but now the nurse organizations oversee the nurse practitioners so they're not overseen by the Board of Medical that's right in Vermont there's sort of two pathways for health professionals to be licensed MDs and PA's and a couple other professionals are under the Board of Medical practice which is through the Department of Health then the Office of Professional Regulation which is in the Secretary of State's office licenses most other health professionals nurses pharmacists well I'm gonna put you on the spot here if the nurse nursing industry here educational industry here in Vermont is overseeing nurse practitioners do they have the same guardrails if you will in terms of looking at the scope of practice that for example the physicians and the Board of and your organization has in overseeing the physician assistants it's a fairly similar structure so even though they're under different sort of oversight located in different agencies they both have boards of a mix of professionals and public actually who hear cases cases of administrative complaints so any patient or any individual anywhere in the state can file a complaint with any health provider under their correct board and they have to investigate that complaint hear it you know I don't think I can speak to an individual cases with those two boards come out the same but the the structure is very is very similar and we've had a really actually quite good collaborative relationship with the Office of Professional Regulation they now passed a statute a few years ago that any change of scope of practice needs to go through what they call a sunrise review which is actually a fairly thorough process of studying what is a professional's training and background and oversight do they think they have the education or training to provide services and that the goal of that process is to avoid making these disagreements so political and decided in the legislative arena where often legislators don't have the level of background in what the differences are between different professionals so this that process is actually I think been a big improvement for having these conversations well we'll look at and again another issue we'll look at more depth but I appreciate your input on all of these issues you have a full full slate of things that you have to be busy so get back to it and thank you again for being with us thank you and we'll see you next time