Public Health, Welfare and Labor Committee- House

Amendment. Yes thank you Mister chair I just a minute just to correct something in the statute that we overlooked. You make a motion if I make a motion to pass on the amendment I have a motion to accept the amendment of any discussion all in favor signify by saying aye All opposed nay Motian carries your members passed thank you Mr chair all right so this bill the and brought the involved actually is the lead sponsor on this bill and I'm running for her as a co sponsor it's an act to prohibit the performance of a public health examination on an unconscious or anesthetized patient without prior consent of the patient so when the and first brought this to me I was kind of like what I can do that any House and her response was yes they can we have another member who had a constituent reach out to their Representative and also to Representative all at he went into the hospital for a normal procedure and was told after the fact that a public examination was done on her while she was unconscious for educational purposes and shall occur she's distraught over very upset time thought that should never have happened to her or did they give is ethical to start with so essentially all this does is say unless it's an emergency situation there has to be prior consent given for a pelvic examination so actually pretty simple and I will committee any questions. A committee and any questions. We miss single questions anyone in the audience to speak against the bill. And for the bill. Seeing none are you ready close I'm close Mister chair and I make a motion to pass as amended. I have a motion do pass as amended any discussion. Seeing none all in favor signify by saying aye. All opposed nay. Motion carries thank you miss you read later bills passed. From the school. You're you're recognized to present health Senate bill eighty eight right Senate bill eighty eight yeah. Thank you madam chair. A committee this is a clean up bill. from past code revisions this clarifies the number of board members on the Arkansas Board of hearing instrument dispensers. And it changes the number of members required to conduct business of the board it removes the requirement of a board member that is a position that is specialized in. Ontology hope I pronounce that correctly that position is currently vacant and has been vacant for two and a half years when it was not vacant only one of the appointed members in this position and representing this occupation ever came in the last nine years. There are few in this occupation Arkansas only about eighty people or in this occupation. even though this board only meets two to four times a year it's difficult for them to meet and meet the schedule and get the workload done. this changes it changes it to a member at large to represent consumers so that position would be a member at large. A physician could feel that at large position. Of. There was an amendment or a change to this is already engrossed to a man and the position that is specialized in otology in the advisory or non voting member role so there can be a member from that profession on the board in a non voting roll. So that's basically what the bill does And I'd be open any questions. Committee any questions from the committee. Saying nine are there any member speak for the bill against the bill. what's the you want to close for your bill I'm closed then I would make a motion to pass I have a motion to pass all in favor say aye. All opposed your bills passed thank you. Okay members moving on the on the agenda next bill is HB thirteen fifty one by represented wing. Represented when you're recognized thank you Mr chair of this house bill is a fairly simple all we're doing is limiting the harmful effects of perfluoroalkyl substances PFAS is what they're commonly called as well for our firefighters and for the environment so this all this is doing eliminating it for training purposes so that it protects the environment and also any exposure to those who would be using it so PFASs inserted into phones this is for class B. fires which is liquid fires were fuels us so you'll have you'll have things like this act of refineries at airports Little Rock Air Force base as well the DOD already has an implemented these procedures so kind of bringing that into code with what's going on with the department of defense already the concern about this type of foam is it would it would not it yet this this takes place of four where just of the just the training so for actual fires the firefighters can still use the PFAS foam but just for the training they would use phone that's not in fused with the PFAS have spoken with the Arkansas firefighters association's I spoke with the fire chiefs associations the the of agency that works with the chemical companies that make this they're all in favor of this as well as the department of defense as well as well so happy to to is fairly simple is no known opposition happy to take any questions. Represented pain you're recognized. Thank you Mr I'm just curious is whether the phone they're going used for training will be more expensive or less expensive. If if this if it's different well it it what's different is just if they've infused that phone with the PFA yes because with the PFAS does that surrounds the liquid fire the flammable it prevents the oxygen from getting to it and so they can use it for training purposes but they just won't have the PFAS ends inserted into it. So don't know if there's a fiscal impact them no. Thank you Mr. So is this in the these automatic don't systems phone systems you see around different manufacturing operations. Is it in that phone is for me talk about the phone I make don't systems it is far as I'm not sure if this this would be just what the firefighters would use when they show up on site and that this is This PFAS foams typically only used at places like refined where there's large scale liquid flammable things that could cause a fire so like I say at the airports and refineries and things like that you wouldn't find it in buildings like this. Right any other questions from committee. Seeing none anyone here to speak against the bill. For the bill. Seeing none ready close rebuild I'm close for the bill a motion to pass I have a motion do pass in discussion on the motion. Seeing none all in favor signify by saying aye All opposed nay moshing carries grads listen to bills passed thank you Committee. Okay we're gonna move on past the consent agenda here and and get into the school bills so the first bill we have is HB twelve fifteen represented Bentley. This amendment. You have an amendment for your bill. I do want to start with that amendment folks okay. You're recognized it's a very simple amendment I have a couple of pharmacists come to me and said I didn't think that we were going to turn midwives in the pharmacist which would we were not so on the amendment which marking out the ward dispensary so they're not gonna be pharmacist and we are adding the member to make sure they're not performing abortions that was also not the scope of this bill wanted to perform abortions so it's going to make sure that these folks are out here check your women infants and of a great need that we have across our state that's pretty much what the amendment does so. I'll let you get every chance to get the amendment for us for a vote on it. Bills passing the amount. There to get the amendment. Katie have a motion I'd like a motion to pass. Kayser any discussion there's a motion of do pass on the amendment any discussion on the amendment. You may need more time to read the amendment to the regime. Okay. Okay all right. Right any discussion on the motion to pass the amendment. Seeing none all in favor signify by saying aye aye those opposed nay. Motion carries amendment is passed you may proceed thank you I have with me Tucker Todd bashing here with us I thought I'd bring him up front so there's some questions to begin with he could answer some questions for you today so if you would introduce yourself and who you represent. my name is Todd basher government OBGYN with twenty plus years experience I've lived in Northwest Arkansas for four years in the role as a labor as and site director at women's creek willow creek women's hospital in fort and mercy Fort Smith I'm also a medical director of operations for a company called OB hospitalist group I've also worked at St Bernard's. I oversee approximately twenty three programs from el Paso to Milwaukee many of them are excuse me that have midwives either if the hospital or that we actively employee all right thank you Sir yes represented to you do you want to present your bill first or you want him to know I mean I'll present the bill let him that's fine that the bill all right okay thank you very much so colleagues today I'm really excited about bringing forth this bill to date of a billable work and recorded sometime of the group of ladies that are here with me and doctor branch of working on this bill today as many of you know some of our new members may not know Arkansas has the third highest infant mortality rate in the nation and growing we also have the third highest maternal mortality rate in the nation those are numbers that we are serving not proud of and things we want to fix today bringing for the bill that is not going to fix everything but I certainly think it's a good honest great step in the right direction a step the other tape states have taken twenty nine states across the nation have seen great improvements in women infant health in each state that has adopted full scope of practice for certified nurse midwives have seen improvement and not a decrease in health and increase affect the number one state in the nation for the best infant health rates and maternal health rates as Massachusetts and they have certified nurse midwives with the full scope we have full scope from Alaska to Massachusetts and all over the nation the places that don't have it have some of the worst numbers like Louisiana Mississippi and Arkansas we have restricted women to not be able to you certified nurse midwives I know that many of you have received emails from obstetricians in the state and many of them have been dealing with what we call lay midwives so let me discuss the difference between a license what we term lay midwife and a certified nurse midwife is a huge difference between those and right now in Arkansas we have practicing out delivering babies in homes is licensed lay midwives they've gone to high school they don't they're certified program and then the delivering grapes across the state that program is monitored by the Department of here in Arkansas and so that's. We have doing home personnel Arkansas's license lay midwives not certified nurse midwives Arkansas has the most restrictive draconian regulations in the nation that's what we have the least number of certified nurse midwives we require not only a collaborative practice agreement for them to work with the physician but also or intrapartum agreements in order even to get their license to be able to practice they have to get a physician signature so since somebody gas or not in the health care law we can relate to me with Bentley plastics so we have an Arkansas is it buys a Bentley plastics will deliver my cups to stores across the nation another manufacture popped up down the road that other manufacturers have to come to me in order to get my signature in order to open up their plan and it also have to give me money in order to distribute their cups to the stores across the nation what exit actually we have as we have just closed the gate to any competition and close the gate have more practitioners in the state and that's what our rest we can see with the numbers that was totally wiped out having certified nurse midwives in Arkansas to extent we have like less than ten and even less than that actually delivering babies in Arkansas. Being a certified nurse midwife is completely different than delivering like with the physician to physician the basin of thanks and and they're good about missile ones good ones bad incentive for different and women are different as you all know limited for all different and someone would much rather prefer having certified nurse midwife and doing with the art of meter free versus doing with physician I've had both when I was I went to nursing school and I studied nurse mentor for that's really what I wanted to do. Somehow I got myself married and get working at children's hospital that went back to school but thankfully I don't waste my time because if I had wasted my time thank god back at my master's and my doctorate I wouldn't be able to practice here in Arkansas so it wouldn't be a waste of my time so thankfully I got side tracked we're the children's and thoroughly enjoyed it but when I was in nursing school in my heart I look to the difference between. Delivered with the physician versus a living with a certified nurse midwife and its really felt this throughout that I wanted to go so I was employed at children's ahead insurance but I wanted a certified nurse midwife and I looked and looked and finally found one operating thirty five years ago in Russellville and had my daughter at home with her and my son I chose to spend thousands and thousands of dollars even though I had insurance but I spend extra thousands of dollars to have the certified nurse midwife because I wanted that I want the attention it's a totally different thing with a certified nurse members one I want to develop a great relationship she's teaching you how to get ready to how to prepare how to give birth how to take care of your infant when it gets there nurse midwives have a much greater rate of breast feeding that physicians do much greater I'll concede that those numbers have increased in every state that is adopted for parks full scope of practice for nurse midwives has an increase in the breast feeding and remind you guys we have the tests may last year by airing bill Pilkington's breast milk bank bill. What president does for the health of women and infants is not just that one time as the cross our whole lifetime this great increase helps decrease high blood pressure the number thanks for women as they go on so that there's number of good benefits that come from certified nurse midwives that we don't get we do physicians and is against is a different thing someone want to go to the hospital that I want to feel a bit of pain they're all about get an epidural and getting Tosun and that's the route they want to go that's fine but right now we have blocked out the women that want to different option we had I have two is more tests on the computer based test money here what we got with different things we've got some folks here that I show that we have in Arkansas thirty seven of our counties do not have an OB we have actually desert's were women in our state have to travel our two and fifteen minutes just to get their prenatal visits and so as a result we have low birth weight we will not get into the appointments we have women that are waiting a year to get C. O. B. G. Y. and if they wanna get a pap smear or to get a fresh check all those things that are very important for the health of women if you have god forbid let me go through menopause you it takes forever to get a seat positioning for that because they're so booked would deliver babies they don't have a chance to do the dialogical Care so we have one wedding a year a year to get appointed to see in a gynecologist so we have a huge gap and here in Arkansas and consumer numbers that we need to make a difference and that's what this bill is about we can't keep doing the same thing And continue the status quo that would improve numbers here in Arkansas is is not going to happen we have to make a change and you guys have the opportunity here today to really make a difference to make a difference in Arkansas to prove women infants health and to lead Louisiana Mississippi in the dust I move Arkansas for this is really what I want to do so I'm gonna stop there because we have time to answer more questions adopted by bashing share a little bit and they will take a few questions before we get some testimony from the audits of that's okay term the best you're recognized thank you as with most physicians I had I did have initial reservations about working. With midwives however as a doctor I have examined some of the data in Europe for example eighty percent of babies are born to be a midwife With better morbidity and mortality in the United States Europe had eight to ten times midwives per ten thousand population. With the exact same number of OBGYN midwife practicing within their scope of medicine is a safe alternative. Since I've been in medical director of operations I've really focused a lot on patient safety and access to care as everyone knows and is represented Bentley spoke African American women in this country or forty six times more likely to die in labor than their white counterparts and that's corrected for education. economics and comorbidities. The Surgeon General wants the overall number of morbidity and mortality to decrease by four time. And. And this is actually going to take a systemic approach that's really going to take some bold government leadership one is. Internal level of care similar to what we have in Texas and then frankly just increased access of care for our most at risk members and Justin my tour this state and I've only been here for years and but I believe magnolia has one OBGYN Monticello has one pine bluff Jefferson memorial is always recruiting and is unable to keep good doctors in the community. I've Paragould is a very similar story Harris and and I. Central Arkansas also so I support H. B. I have twelve fifteen for the independent ability of midwives to practice if we open up midwifery as twenty eight of our sister states have Arkansas will be able to keep the certified nurse midwives that have trained. That are local to the state of Arkansas but have to leave because of the restrictions. The topic thank you thank you for your comments. A committee any questions from the committee. Represented more you're recognized. Yes Sir I just want to to kind of clarify so you there couple market corrections that I've heard talk about one you just mentioned a short would seem to imply shortage of obstetricians in the State of Arkansas but then also felt like I heard from Representative Bentley that there was not access to certified nurse midwives and I understand we could be correcting both but what seems to be the priority issue to you I mean because if we're just looking at the okay why ask just so you know one. This year the short is obstetricians is this really the best solution by allowing nurse midwives or should we do something else like increase residencies for obstetricians in the State of Arkansas and funded those differently or something just what inside do you have. I mean I I think you make a very valid point I think there is there is a shortage in the State of OBGYN However I do believe both. Forms will actually help the problem having midwives in these at risk areas gives access to care gives women a different choice of what to see and who to see but I. Again the most important thing to me is as long as the midwife is practicing within their scope of practice they're extremely safe and we do need the obstetricians to back them up on the more difficult cases so if if you have a severe preeclampsia with twenty four week at twenty four weeks. The midwife that's beyond her scope of care so I think you have to address both problems if I could follow up on that just before we go to the next question nothing is women desire certified nurse midwife that desire midwives and physicians do not offer what a midwife does so if you go into labor okay just give an example I was in your your contractions slowed down a physician has in a nursing there watching and say okay we'll think discover something Tosun's increases so we're going to we're going to fix the problem medically so we're gonna give protection which is gonna create more pain she's probably gonna want epidurals so that that's the track that that goes and there's a lot of women are state now that are leaving the state and having babies born with a midwife and birthing centers because they want the midwife is experience with a midwife to do instead of doing the toast and the such change positions let's do something different as a midwife is right there hands on she's done perineal massage there's things that a midwife does that obstetricians not trained to do it's not their scope is a whole different scopes are you missing out on the back this complete difference between having a baby with the mid one and having a baby with a position I've had both my first to where we're at home with a certified nurse midwives it was a great expansion establishment using things but with my third one Theresa moved back to California to to practice and so I didn't have a certified nurse midwife I'm not comfortable with the lay midwives so much which was to go to the hospital had My Baby with the physician so when I get to Baptist. I motions to the name and I want to get to the hospital. I was I was brought in there and shut the door and there I'm by myself nobody there with me nobody coaching me nobody giving me support nobody being my back up and that's what I'm nurse midwife offers the position this is not possible for that position and not trying to do that that's not there scope that's not the way they go nurse midwives in their us merry what can we do next we're going to do what she knows we already have built a great relationship and she's this is I can't tell the difference on their thrown in a room by myself I don't know do my husband is useless sometimes are good amendment did one do any coaching he just set the corner he wishes he didn't want to do so there I am by myself with no help with this is like I so court I know it's hard for guys to understand that I'm trying to get I'm being real personal doesn't want to understand so I'm I'm I came in they wanted to have an after birth like I do with my other two because the pain was so great I had no support I just threw my hands up for you just give me the stink interpreter all and so I had an epidural I did not want to butter but there was no there's no support or to try to get to the gross yes yes we need obese here when it all begins in the state we need to increase it we need both we are we have the third worst infant mortality rate in the nation the third worst maternal mortality rate in the nation we need both and I a hundred percent support you get more interns here in Arkansas I've been an advocate for rural health you know that I'm passion about the skin will be jeans when you've got a call to see what we need certified nurse midwives the women in Arkansas deserve a choice this woman across the nation watching women in Arkansas have that choice with getting it paid their insurance. That's the difference they want to be a birthing centers and hospitals women compared to this with the insurance right now we do not have that option we have shut the door to that and we've been complete monopoly two positions in the state. What I want to put at the bottom of the queue and get other people in the queue okay. And the in defense of your husband most men are useless in the situation I understand. That's why I wanted certified nurse midwives by itself represented pain you're recognized for a question. Thank you Mr chair so. I need money all to help me understand the. The boundaries of what we're laying out in this bill sure so they're already an AP are in advanced practice registered nurse and I will get these terms as used as fine Board on a there are already that so as an advanced practice registered nurse they do not have this prescriptive authority and and we're broadening that in the bill. And then they become if they become a midwife it says that we want to grant them full practice authority at the bottom of page two and it says that the full practice authority means evaluate patients diagnosed medical conditions order it and interpret diagnostic test an initiate and manage treatment and care plans I mean I don't see the boundaries that limited just to childbirth and right and natal care free dental care and things like that it looks to me like. And your in one all the sudden become a nurse bill I that they could use it in our practice yes Is Your question or to pay to line three of that. On which page on the same page nine two. The school nurse mentor free includes. Care got article family planning services preconception care care during pregnancy childbirth and postpartum care care normal newborn during the first twenty days of that outline specifically what a certified nurse midwife and their scope of practice a lot of pain Page two line three three seven. So there's you know there's a nurse practice act which certified nurse midwives fall under suited for two years she can answer some questions on if he does have a service I'm a nurse midwife at I think we lose that in here that we think that nurse practitioners can operate in any scope they cannot they had their specific scope of practice we have some advice to the content can better answer that as well represent paid will bring them up in a minute but they have to operate under the certain areas okay lines two through seven on page two so no you can't be a primary care and whether it is operating in the area and that's why I took the we're dispense out of there so we can understand the not being pharmacist either but is a very specific area of care that their license I pray thank you take a test for study for and get their masters and certified nurse midwifery. So if I could follow up Yes go ahead so this section you're referring to is under The General Assembly finds that it's not necessarily. The action we're taking well that's their scope of practice John the scope of nursing right that's going to be able to the nurse practice at the nurse practice act for nurse Menifee includes that of course under undertaking here when this in labor you got to value at the patient diagnosed for treatments all the same all those are based on what they're nurse practice act is so under for certified nurse midwives they have specific things they can do one of the certified nurse. Midwife ACT so if you only as soon here to clarify that for you happen to get she's here order soon it'll become clearer as we go thank you Mr. Representan Allen you're recognized. Thank you Mr chairman. My question bills with the midwives have some type of liability insurance certainly cannot practice again I'll be a certified nurse midwife for that liability insurance okay so what happens in the situation when they're when they run into complications that that's about their the level of knowledge if so if I am with doctor Klein was living a baby in office and that that woman start having heart problems you're not gonna cardiologists if the certified nurse midwife is having issues not with some midwives who though answer this question for you part better than me for it because I'm not a nurse midwife but they're going to call a physician for consult just like we do across the board if a doctor classmates his his patient to get an epidural he's going to call and see all this and he's not going to themselves so their their work together collaborating with other members of the healthcare team like to do in every other state that they have full school practice for me to follow up with the terms for. Can you help me to understand that if it is my understanding that when I'm a midwife we'll see we actually deliver the the baby and in the person's home or. Majority of them are gonna be operating in the hospital and a birth we hope birthing centers and we help Arkansas about birthing centers for that some of them might but the vast majority right there in the hospital and that's the reason I want to pass this bill so that women right now don't have the option to have a a nurse midwives in a hospital is not available to them so we're trying to make that available to I just want one file sure so what what if a burdensome and hospitals not available and is there rule so Kim Hightower. What we what we have now is we have licensed midwives they have very no one near the scope and the practice of certified nurse midwife and I can't speak for this woman I don't know if they're going to deliver home of someone chose to use them at home like I did I can tell you that they're much more experience much more training they're gonna see a problem sooner they're gonna have a collaborative agreement working together with physicians and hospitals that work with as well so the transition will be much smoother than it is now with you know I will tell you that my daughter she was born at home and she wanted to have you know really want to use the birth center and office Arkansas but unfortunately closed down because of insurance issues so she had shows he's alive midwife at home and rented some very serious problems and and was rushed to the to the E. R. in full transition with a breech baby and that's not and that was with the you know license lay midwives so that's why I was read for the first time rules of trying to topple improved education and training what people that are more trained out there take care and I'm not gonna say about them others per there's people that have great experiences with with licensed midwives and this has really nothing to do with those people that choose to do that this is saying we need more for one we have to look at our numbers and say we can't keep doing the same thing and expect a different result that's not gonna happen we've got to make some changes in this allows more partition makes access to care and decreases the cost in other states that done we've seen a decrease since the Syrian sections would said decrease in a low birth weight babies who sent this the numbers improvement every state that has put this into practice has seen increasing better better health outcomes for women infants across the board no exceptions. All right representable you're recognized. Thank you Mr chair for a line of follow up here so back to what I originally asked asked about the market correction so the question I have that the follow up to that is what in the states that have authorized full scope authority for certified nurse midwives. Have there been any changes in the OBGYN per capita so his that the we seen a steady rate of OBGYN in those states of OBG winds increased in that state of they decreased so what has happened to the other care providers if if anything at all whatever insight you can give me thank you I've studied instead not seen any changes have you seen I've not seen anything that receives any changes. Represented Ferguson recognized. Yeah and I think represented family knew that was going to ask this map my biggest concern about the bill and maybe they got a call to send the nurse midwives can answer this is is he no not even a normal birth can turn bad I mean like Mary I have a terrible birth story I mean that I had a prolapsed cord completely normal pregnancy of unexpected things happen in delivery my concern with the bill is that there's not a transfer agreement with a hospital in and I'll be because he nodded at me my prod my whole problem with the lay midwife program all the time is that they pretty much if they run into a problem just dump them in the E. R. and there may not even be and I'll be there so I guess one of you explain to me how how is this transfer going to work if a paper birth goes bad. Go ahead to a charge and if it's okay I'm a grant for the midwives are here because they're being they answer their questions so I'll I'll answer the question with an example. I am working with a hospital in the Chicago area and there is there a person or is being opened. Down the road. The birth center has engaged with the hospital the exact agreement that you're talking about that if a patient risk out in approximately at this particular birth center forty percent of patients that show up there risk out and have to be transferred to the hospital for a variety of reasons so those agreements do you need to be in place to have a burst center to ensure that if a patient risk out because I think what all O. B. G. Y. ends are afraid of is that a patient is at a birth center. There's no agreement they don't know what to do there's a foot hanging out and you know it gets they get shown up in the ER and. All you know what happens. And that's it it's important that the birth center has that agreement with the hospital if the patient is risking out if we're having an emergency if we're having that situation we can transfer that patient to the hospital. And what you don't want to do is rely on in Colorado rules where you simply say I'm just going to take or to act hospital and they have to take care of her we want the so you do. A responsible birth center would have an agreement with a backup physician and the hospital. Have a good one midwives also compare when you would like to come up baby. Can we on everyone please introduce yourself my name is Phoebe systems so and I'm a certified nurse midwife may proceed. And good morning everyone I'm honored to be here today and I hope I can answer some of your questions well I'm I'm in Kansan I haven't been for all that long for about two and a half years I've lived in Rogers Arkansas I grew up overseas but my family is from pine bluff and I have lots of family throughout the state. as a nurse midwife and as a mother and is in our hands and I do care deeply about what happens to families in this state and that includes my own my daughter is with me today. I'm to tell you little bit about my nursing background I graduated from nursing school in nineteen ninety nine and became a labor and delivery nurse I've since worked in labor and delivery women's health and education for over ten years and actually many different locations but if you're in the United States and also abroad and I've worked in Los Angeles California Lawton Oklahoma in Seoul South Korea to name a few. I'm over the years I've seen first hand that what happens in childbirth really does profoundly affect women and their families and it doesn't matter where they're from before their background or ethnicity. And and because of my experiences as an RN this led me to advocate for a more woman centered holistic and empowering childbirth experience kind of what. Representative Bentley has been talking about for women and for their families so eventually I decided that the best way to do this would be to become a nurse midwife. So in two thousand nineteen I graduated from frontier nursing university of my master's degree in nurse midwifery and I took my national exam there is a national exam that we have to take. to be certified. however I was unable to find a job practicing full scope nurse midwifery in Arkansas or anywhere close to me and Northwest Arkansas full nurse midwifery as when you are also delivering babies and providing intrapartum care not just doing prenatal postpartum and well woman care. A four time I did provide educate have a job providing education and prenatal care but I could not get a collaborative practice agreement to provide that intrapartum care so eventually I took a job at a birth center and the Tulsa Oklahoma area. Where I have not worked for over a year. So I hold is the M. license in both of Arkansas and Oklahoma. But I can only practice in Oklahoma. So every week I leave my family and I drive two hours and stay for a few days in Tulsa Oklahoma providing prenatal postpartum well woman and newborn Kerr we do all of those. But best of all I also get to provide that intrapartum care and deliver those beautiful babies. I I actually do you frequently get calls from women in Arkansas who desire nurse midwifery care and cannot get it in our very small person or just in the last six months has delivered babies for three women from Arkansas. I'm even though the nurse midwives at Arbor center do not have to have a collaborative practice agreement in order to practice like they do here that does not mean that we're not well integrated into the surrounding medical community and I think hopefully that answers some of the questions we regularly refer patients to higher levels of care and consult with maternal fetal medicine obstetricians pediatricians on occasion also like hematology cardiology. And we have a transfer agreement with the physician group across the street. I'm they do not have to sign an agreement in order for us to practice but we have an agreement that they will take pay patients that we transfer to them. we also have a hospital directly across the street from member center and we enjoyed a wonderful working relationship with them we conduct their childbirth and classes in their breast feeding classes for them and they include us and some of their staff trainings just two weeks ago we did a newborn stabilisation class together. So together we work to provide safe care to the families in our community. From my experiences as a person nurse midwife I believe that certified nurse midwives are the answer to a lot of the maternal health problems that Arkansas faces today. Let me give you an example so maternal morbidity and mortality are really big issues here in Arkansas as we have already heard today. But please remember that this is not just an intrapartum. Problem at the moment of the delivery of the baby it is very very often also a postpartum problem. I'm a nurse midwives have definitely been trained to be part of that solution as well. At the birth center where I work we do not just to a six week follow up visit the nurse midwives to a home visit with each mother and baby at twenty four to forty eight hours post partum. And then we do visits at the birth center for both the mom and baby at one week two weeks four weeks and six weeks. As a direct result of this close follow up we have excellent breastfeeding success rates and very low post partum depression rates. And we are also able to identify issues in the newborn like jaundice poor feeding and problems in the mother like any media preeclampsia thyroid issues hypertension diabetes and we are then able to treat them or refer to others in the larger medical community as needed this kind of nurse midwifery care could greatly improve maternal and newborn health here in Arkansas just think what that could do. Therefore close I'd also like to advocate for the members of our armed forces and their families and this includes myself because I am an army spouse. My husband is an APR in as well he's a certified registered nurse anesthetist he was active duty military for many years and is now in the Army Reserve interest deployed to the Middle East two weeks ago. Ironically here in Arkansas he is also constrained to work under collaborative practice agreement but as soon as he enters active military service whether that is in a large Medical Center with the military or in austere conditions in a forward surgical team. He is free to practice independently and with full practice authority. Since the military believes strongly in evidence based care they use a lot of a PR ends in the Grantham full practice authority. Includes a ten review but the stay on this bill please okay it yep I'm coming back around to the. But this includes many many certified nurse midwives. Our military members are accustomed to nurse midwifery care and I have heard from many of them that they are very disappointed and very surprised that they cannot obtain that care here. You are all well acquainted with the discouraging statistics and systemic problems and maternal infant health care here in Arkansas and I really do think we can do better we can do better for the members of our armed forces we can do better for nurse midwives we can do better for families and for sisters and wives and daughters and babies. So please join me in advocating for certified nurse midwifery care here in Arkansas and I'll be happy to take any questions thank you for your comments a Representative McGee you did you still have a question. You're recognized thank Richard this is for represent Bentley and maybe for the doctor the to their. So. This this discussion to me has kind of gone from we talked about certified nurse midwives doing home deliveries at home. In Perry County or wherever you wherever you're at and then we sort of shifted over to talking about these birthing centers and the Barling centers have have these agreements where and even this witness testified they had agreements with a hospital across the street. My concern is it and I'm I don't have a problem with the with with the concept but as far as the birthing centers are concerned and certified nurse midwives do and doing those things my problem with this bill specifically is there's nothing in this bill that that. That certified nurse midwife has to do if she's delivered a baby in someone's home there's no transfer agreement where those. Where is that passion going to go I mean ninety percent of all we G. Y. and stuff is just pure boredom and happiness and great babies in ten percent sure terror and the time from decision to incision or a C. section is about fifteen minutes now if you're in a birthing center in your across the street from a major hospital and you have an agreement and they will be June people of the people that do C. sections are there that's great but if if someone's out in the country and they're thirty five minutes forty minutes and you don't have an agreement you don't have some kind of transfer agreement to a physician is going to be responsible there's nothing this bill says that that there's anything like that. Well I would like to answer from my experience working in small community hospitals direct I directed it to revert individually. We can answer and I and I and I appreciate that state I'll say this right now in Arkansas you have license lay midwives delivering all the time what happened to my daughter like to stretch about her okay I'm not going to speak for this one what they're gonna delivered home or not I don't know this is not require anybody to deliver at home what we want to increase right now we have the least number certified nurse midwives because we have such restrictive. What they have to go through for grants with the most restrictive in the nation so we have the lease number right now we have ten so I'm trying to tell you I don't know what they're going to live at home or not but I'm trying if they did used to their experience of those patients be a heck of a lot better off than they are right now the people have less experience less training and if the fees are already working physician she's going to have a good agreement with them anyway but this is not this is not promoting home health home delivery this is promoting certified nurse midwives to be able to operate in the State of Arkansas which they cannot now we have we don't shut the door that we have open we close the gate was that you're not welcome here. She graduation trying there's no question to operate and to work in Arkansas she she's striving to Tulsa Oklahoma to deliver Arkansas babies and Tulsa Oklahoma so we shut the door to them this bill is about opening the door to them I'm not sure where they're going to practice that's up to them but I'm telling you if they do choose to deliver home they're a lot much more experience I have been working with physicians but again I don't that's not the scope of this bill once every delivered home the scope of this bill is to say women in Arkansas deserve the right to have a certified nurse midwife deliver their baby if that's what they choose because we've given we don't give them the option would close the door to that option that's what this bill is about and the bills about to look at Arkansas mark archer numbers a horrible it's time to make a change we can't keep doing the same thing expect different results it's time for us to step up and say you know what we believe Mississippi and Louisiana and that does. Most of the women infants first and that's what the bill is about because we've seen the numbers improve and every other state that's open this up we've not seen the numbers go bad state which is in the numbers improved we sent inventory numbers go up I cannot tell you who's going to deliver a home but I'm telling you if they do choose to do that with their license but they're much better prepared the much better trained and also probably have working out agreement I'm not going to those words in their mouth in their spinners Act is is they have a transfer and have worked it out so we can bring soon again the reason or second thing that we need to do that's all right Phil can you get. Shepherd in here she's in the waiting room is amended to go over the certified nurse practice act because we don't allowance understand theories and that the guidelines that are given notice that when I signed on the license represented McGee was at your question or you have follow up another still though. There's nothing in here that says that someone choose delivered home that there's any sort of agreement that that certified nurse midwife has with someone down the road that to to take care of a situation that could be difficult I mean I'm not saying they don't do a great job and they can you know ninety percent of my home wi fi and but what about that ten percent that the I'm my concern is is there going to be out there practicing they're not going to have some kind of transfer agreement. In a birthing center they got that I mean that in that the medical legally they're going to have it liability wise are going to have it. I'm fine with that I mean if we want to go out bill birthing centers all of Arkansas input about all the hospitals in the state that's great but but I'm concerned that that there will be someone that will be out there and they won't have appropriate. Appropriate transfer agreement and when they get into problems that that person is going to end up in some emergency room somewhere that no one knew anything about. That shows up having difficulty you'll get transferred to Conway regional detected the call an ambulance and send you to the merger would come original and then whoever the undersigned obis on call take care of it but I just think there needs to be something. That that that the Titans that UPS I'm not against this whole concept I just think there needs to be something that tied up transferred patients. The in the appropriate manner. Represented me we need to move on other questions thank you thank you for. That's okay one quick response who wants to respond to that. Sure from my years of working in labor and delivery and small community hospitals typically in these more rural areas there it is not an obstetrician sitting right there they're either they're at least thirty minutes away zero you're dealing with the labor and delivery nurse and the patient so just to answer that and then to have a higher skilled person there certified nurse midwife that is definitely a step ahead for sure and there is no way to completely control things that happen in obstetrics sometimes are emergencies or people that deliver at home they're people deliver on the way to the hospital but ninety percent of nurse midwives actually work in the hospital and the rest of the mostly work and per centers so I think that there are we need to look at what we can do to improve where we're at and not we you can't close every loophole for whether or not an emergency is going to happen you would need to have the best kill people there at that moment that you can't and you like I said typically in labor and delivery and some of these more rural areas you already have quite a lag time there if you don't always have an obstetrician sitting there anyway. Let's move on represented cloud you're recognized. And they will not I want to answer the question about transfers to the nurse practice that assertive record answer that question so. If you can make a quick answer but we're we're. And we're having people presenting here we're in the question phase so. Please answer the question specifically if you can. So what is in the nurse practice act that that would would have someone that says certified nurse midwives out in the community delivering at home what what what's the obligation to them to have a transfer agreement or some type of agreement that that someone can can take care of the issues that come up there I mean I don't have too much of a problem within the birthing center the my problem is out in the homes. The other store see patients having problems show up in an emergency room like they do now. Having difficulties when no one knew anything about. I understand represent negate your your concerns about it there's nothing specific in the nurse practice act this is there has to be a transfer agreement a common practice is the all A. P. R. ends no what to do when something falls out of their scope and it is to transfer patient to another qualified providers. But there's no specific words that say that okay thank you. Thank you. A represented client you're recognized. Thank you Mr chairman of for the nurse midwife if my question again kind of piggy backs off the transfer agreement were you practice right now use you said you have a transfer agreement but there's nothing in writing or anything of be interested to know does that facility have a labor ist for if there's no a. Written agreement but how what is the agreement and how was it made after bashing one answer that I want to do now because he's practices a lot with our state once and they had a better answer. Simply put right now it's one of the hospitals I work at we've reached out to a group of lay midwives that are practicing and saying just very simply. If a patient of yours risk out you have they have a home here call us early and we will take care of the patients. And it's but we are the of where I am it's a labor as we're on twenty four seven on the unit and so we do have that agreement where they call us give us an S. bar. check out send the patient over and we accept them and I train all of our physicians to follow impala which is we asked two questions number one can we take care of this patient and number two do we have a that if the answer to both questions is yes. Bringer and. Does that answer the question yes you can follow. Thank you Sir for that enter of appreciate that but in Arkansas under so many places that do not have a labor wrist and so again my concern is kind of what Representative McGee has voiced is. We've got laboring patients out there with no formal. Motive coverage other than what's required by federal law not state totally understand that and to my knowledge that's that's never come into effect in Arkansas no one's ever been referred at refuse care for it for any reason as far as that goes but it's for somebody that has has a plan labor pattern and and they've got a train professional that's watching over them that can take care of that up until the point of an obstetrical emergency I think it would be awesome in Arkansas just to have some sort of transfer agreement I do believe in I'm gonna let the midwives answer that better than I can that in their training they understand what they're scope of carrots and as an example when I met my hospital and I get a baby that's beyond of mom beyond my ability to take care of her I get on the phone to angels at UAMS and say look I have a woman whose blah blah blah. And they accept her and we transfer the patient I don't have a formal transfer agreement with UAMS. But I do have I know what my scope of care is. And I know when I'm quote over my head and I know when I need help and I believe midwives certified nurse midwives have that exact training to know what that line is for them. Committee we need to move on and keep your question specific and try not to answer ask questions that have already been discussed represented Alan you're recognized. Mike. Mr chairman I'd like to make a motion that we the limit the discussion to two minutes per person. Well we're we're still in the question phase from the committee so I don't think I can take that motion right now. We have to wait till we get to the presenters but Committee we've got a number of people that want to present they may answer your questions you hate you can discuss it later on if we have a motion so let's try to keep on track and shorten our questions and short or answers if we could as well. So when I move on to representing gray you're recognized. The represented Boyd you're recognized. Hi questions for Mr when she just comes back to me. I just ask my question I'm not one of the issue one of the things in here's primary care I just want to clarify that because when I think midwives I think of someone providing. Natal care so does this open the door for someone to truly practice corrected primary care and three blood pressure any time or you know atrial fibrillation or whatever might be considered a primary care doctor that I know the instruments to answer. No it does not allow open them to tell the total primary care every APR in regardless of which type of a pure and then have to practice within the scope of practice and start a nurse midwife is only primary care related to women's health issues that doesn't include all the other primary care issue so it's totally related to the women's health. Gynecological issues. Represent Payton you're recognized. Thank you alarme need mustard for back because when I was talking about this earlier represented Bentley I think mention her name. I'm still looking for the guardrails of read through this several times. The first part is all about Legislative findings. And then on page two line twenty eight. It says it is the intent of the General Assembly to grant certified nurse midwives full practice authority. So all the findings before that. Is is the reasons why but then we get down here and that's what we're doing with the law and you just stated that it doesn't cover anything other than women and there's a line in here that talked about their partner their male partners but anyway. That's a sideline it goes on versus on the line thirty. To define full practice authority. It doesn't say anything about their scope of training or whatever to talk about full practice authority evaluate patients diagnosed medical conditions order an interpreter gnostic test I understand it's the intent here to be midwifery. But if I start on page two line twenty eight and read the action we're taking with this bill. We're changing the Arkansas. To give them full practice authority. There were not setting much Garber many guardrails in place there to keep them within the scope of midwifery so help me with that I think you are maybe your understanding of full practice authority is different than a regulatory point of view full practice authority with any APRN and with the nurse midwives their education is this they have to practice within the scope of what they were educated for they can't go outside of their scope just like any other appearing cannot go out of their scope if I why wouldn't we say that in the definition because full practice authority from a regulatory standpoint when you talk to other regulatory agencies to us it means getting rid of the collaborative practice agreement only that is all I see this bill doing still waiting collaborative practice agreement the leading enter part of the agreement nothing else will change with what is in the midwife is allowed to do or not do because their education their certification and their practices defined in this law is set in it is not changed. Thank you thank you Mr. All right thank you for your comments representan Allen you're recognized for motion. Thank you Mr chairman a motion to limit this question to three minutes. So it's three minutes per person. Three minutes per person the. Representantes Jim Cummins. Can I just chairman folks that travel here to amendments and sent us you're recognized thank you Mr do you have of. A break down our list of how many people we have signed up to speak for against this just to give us an idea. We have five people signed up I think one is already spoke so it's for people and once Dr Todd here as well so just for people. Not force all I have on the list. If we limit debate. That would be twelve minutes total until the end of this bill or. I hope so okay. Thank you. All right. So. Represent Wardlow for what reason substitute motion. You're recognized substitute motion two minutes per Speaker per side did not hear that from Representative Love Me now Allen but percent per side per Speaker two minutes it would be my such to motion. That includes everything from that Speaker and questions and questions. Alright motion is two minutes per person per side discussion on the motion or no there will be. so is there any discussion on the motion. I just wanna briefly say and I appreciate your time there was given sometimes I have people that have been waiting for two weeks to in order to testify so and I traveled for hours on them to be here two and three hours to be here LCB spoke just two or three so I'm final two minutes but I would like this bill gracious this people that drove all this way to share their hearts with the so I would except for three minutes is often three minutes could pretty much cover everybody so it's almost substance within three minutes instead of two. So is it a substitute motion yes please. Okay I want clarification here on that's three minutes per person per side. So clarification that's not three minutes for each side that's three minutes for either personal or okay per Speaker that okay. What does that include the questions. I guess that's what everybody wants service rented out here will say it's all right committee The the motion is three minutes per person per side including the questions answered. Any discussion. Seeing none all in favor signify by saying aye All opposed nay. Is haven't motion carries. First person that we have on the list. Thank you read this. Stephen rester that unit not to mention did you have additional comments you only have three minutes okay. kill C. guilty that okay please come forward. Please include yourself in the represent hi my name is Kelsey Gillingham Is certified nurse midwife and a resident of Rogers Arkansas. good morning Mr chairman honorable members of the committee thank you for dedications our great state and your consideration for a bill today I come to you today as a dedicated and concerned or Kansan I was born in Fort Smith graduated from Rogers high school received a bachelor's degree from UCLA it was during my senior year of undergrad while working as a CNA and I first heard my the term midwife the idea midwifery intrigue me and ended up writing my honors college thesis on the subject growing up I never aspired to become a nurse practitioner I was perfectly content delivered delivery nursing care for women and children that manner however my rate research led me to a new path a path forged out of a new found passion rooted in the says city and need I saw first hand how the majority of us in the state were conducted I saw the high rates of caesarean section vaginal tears inductions and about girls conversely what I found in my research is that many states in our union and almost every other industrialized nation in the world this is those statistics were not the same I discovered alternatives exist there evidence based cost saving alternatives that also bring higher rates of patient satisfaction these benefits are not only in relation to pregnancy and birth but also for the postpartum and newborn stages becoming a CNM was not my original plan but I knew I needed to become a part of the solution to bring these alternatives to the women in families in my state after gaining years of hands on experiences labor delivery nurse I went on to get my master's degree from university of Cincinnati I knew being a midwife in Arkansas would be difficult but I greatly underestimated how difficult after nine months of cold calling and meetings with would you mind groups to explain the value of ending with two free practice to the group I was hired at the freestanding birth centers Northwest Arkansas. Really over a year later the center had to close due to poor insurance reimbursement for services rendered I was fortunate that time to have a large patient base that needed a place to deliver and was there for absorbed by nearby physician group and give a hospital privileges unfortunately in may of twenty twenty myself in fourteen other nurse practitioners were laid off by the hospital system due to financial woes they were under in the wake of the code nineteen shut downs to this day I still have not been able to find physician group willing to add a midwifery practice and hire me my patients were immediately left with the decision to deliver with my collaborative physician choose a home birth with a license lay midwife or travel out of county or state find another scene and delivered with code nineteen magnify the existing issues with currently is a regulations regarding the practice of nurse midwives an attorney care crisis in our state women need and want safe evidence based maternal care this is not solely given by physicians but due to the current regulations I cannot start a hospital based practice or freestanding birth center I am completely at the mercy of a physician willing to collaborate with me under their license for both intrapartum care and prescriptive authority two seconds if you are close to the center respective I can't even start my own lives health practice performing annual exams cancer screenings or even treating you TI's because it without physician willing to collaborate with me a competitor I cannot prescribe essential medications like birth control antibiotics. As I mentioned for never Sparta counters practitioner but I did it for the women of the state my neighbors my friends my family members I don't want to move out of this state I believe in Arkansas and I believe in those women I want to be here and I need y'all help for that. Thank you thank you for your comments. Of. I think it's a miss sister go did you already speak yes okay thank you. Jonah Varnell Gianna Marnell. They get that right. Jody Joni answer. Please introduce yourself and who you represent Joni Yarnell the nurse midwife. And I had three pages think I'm just going to wing it to do that would you pull at my closer to you please can you hear me. I have three pages points that I felt were very important to make a but I'm going to just try to focus on some issues that have come up with a start out by saying that I've been in practice since nineteen eighty two comment or Kansan and been here a prior to see it all the time initially as an OB genders practitioner for ten years and that is a certified nurse midwife at one point I did have to travel to Oklahoma to work in the community to a very rural hospital Indian owned and just about fifty miles from being and did that for eleven years until another job opening came up here in Arkansas. I need some water but excuse me. The issues that I'd like to focus on address the safety and the checks and balances that I've been hearing questions about and with regard to the intrapartum agreement the collaborative practice agreement these checks and balances I think thank you so much. I hope will help you see that we still have a guard rail so I think with the team term used in place. It. So in order to be certified and maintain our certification we made standards of practice of that include having written practice guidelines and that's regardless of whether we have full practice authority or limited practice authority in all the settings are fortune we've always had those and those written practice guidelines clarify what the midwife is going to manage independently with the midwife is going to refer to the physician for or what the physician the point is going to call the physician about which would be called consultation those guidelines are all written out and depending on the setting thank you very so when I worked practice in Oklahoma we are in a very remote rural area. And we had didn't have the ability to take care of certain higher risk patients so our hospital for example always transferred patients were labor that were less than thirty four weeks yes thirty seconds if you calls when I needed a teaching hospital we have physicians on hand all the time those guidelines were very different for how we practiced and those guidelines will remain in place even with the passage of this this bill. Right you get a few more seconds of yet one more comment okay the other point is hospital privileges at the last date I saw ninety five percent of that nurse midwives are in hospitals and we have to be credentialed approved investigated and our privileges are approved or denied just like that would be for a physician. Thank you for your comments. Okay next is Aaron got guide McGill Miller. Sorry about mispronouncing the names. The senators yourself and who you represent. Hi my name is guilty I'm with the March of dimes. And I just wanted to kind of address some of the things here access to quality maternity care is a critical component of maternal health and positive birth outcomes especially in light of high rates of maternal death and severe maternal illness or chronic it issues and the U. S. in recent years so the March of dimes report found that more than two point two million women across the country of child bearing age live in maternity care desert's maternity care desert is an area where there are no be providers there are no hospitals or birth centers birth centers offering OB care and there's a proportion of women eighteen to sixty four without health insurance so thirty seven of Arkansas seventy five counties are considered maternity care desert's that's a hundred and five thousand women ages fifteen to forty four years old live in those particular counties so that can be an issue so I just wanted to say one more statement says moreover even as a nation struggles to address one of the most severe pandemics in U. S. history Arkansas's requirement for sign collaborative practice agreements restricts the in Ms from exercising their full scope of practice or from receiving hospital credentials clinical privileges or third party reimbursement for services that fall within the scope of their training and licensure barriers that restrict the supply and bitwise and can prevent women from accessing midwifery care. So the evidence and research on midwives tells us that nurse midwives are an essential part of high value high quality women's health care the safety and quality of care by a certified nurse midwives is indisputable C. N. M. as in the US exceed all international standards for men with free competencies and standards of practice midwifery care is been shown to decrease the rates of cesarean birth. Preterm birth stillbirth severe perineal trauma which is birth trauma severe blood loss newborns with low birth weight and newborn admissions to the neonatal intensive care unit which is the neck you so women and states with independent nurse midwifery practice have lower odds of sustained delivery preterm birth and low birth weight and thirty seconds okay and one thing I did want to address here is that Arkansas does have thirty nine birthing hospitals that are within what used to be called perinatal regionalization in this state so that means that there are guidelines that hospitals have to follow in their levels of care that are provided so Arkansas hospitals are levels one two three eight three B. and level four which is Arkansas children's hospital so all of those issues that were addressed today actually dressed in those particular guidelines. I thank you for your comments. So that is all the people that we have signed up is there anyone here who wants to speak against the bill. Anyone else who will speak for the bill. Seeing none represented mentally are you ready to close for your bill. Yes I'm asking colleagues in the hallway on the way down. I'll close slowly I'm a bill. I appreciate your patience everybody being here today and listening but this is a big issue hi I'm I'm wary weary of Arkansas being forty eight we deserve better than that we deserve so much better the woman an infant in this state deserves so much better than what they're getting right now does this bill fix everything by no means is this bill fix everything but is a huge step in the right direction it's not going to solve the issues that C. McGee had was gonna make it better and we're gonna work on this more we can sit here and do the exact same thing and we'll get the exact same results or today you guys have the opportunity to make the first step to make a difference in our state and do better for women and men across Arkansas. I hope that you'll join me in saying enough is enough let's start making some changes here the status quo is not good enough for Kansans and with that. I make a motion for do pass on house bill twelve fifteen. Is amended. All right committee The motion is do pass as amended during discussion. Representing the reference. I don't. I'm applaud you for bringing this forth and and and and I think it's a good bill overall but I go back to this problem about transfer and and that's a real issue that's a real issue even the American college of upstate the option to traditions and gynecologist stated in their they they they came out in favor of the US but they state that needs to be appropriate our I'll read what they said. The availability of timely transfer and an existing arrangement with the hospital for such transfers are prerequisites for considering a home birth I'm not talking about the birthing centers they were there they're going to be covered. But there's nothing in this it says that they have to have any kind of transfer agreement and and and have someone that's ultimately responsible of the thank you. Ninety nine percent of the people are going to go in there and they're going to do the right thing they're going to follow the rules they're gonna have transfer agreements they're going to they're going to do all that but there's one or two percent that may not and I'm worried about that one mother this got someone that's out there on the edge of treatment that that does not have that transfer agreement that's why I think that needs to be part of this that's the only reason that I against thank thank you Mister. Represent Arkansas K.. I was gonna say that and I appreciate that stable right now we have that problem with licensed midwives out there doing the same thing this this bill gets more trying people out there. Again we can't fix everything this is a huge step in the right direction so to say I'm not fixing a hundred percent the problem no I'm not fix a hundred on the probable fiction a huge portion so to say we can't go all the way the Amerisur were not going to this is a good step in the right direction and a lot of women want to deliver the certified nurse midwife in the hospital and we close the door that will close the door to percentage because of what we've got here I want to open the door wide is it gonna fix every I can't fix every problem unfortunate can't fix our accent I can't I can't stop actions on the highway from stop I can't fix everything in the world I wish I could but this is a huge step in the right direction we're saying if we say no to this bill we're saying we're sorry we're good with the status quo I'm not good with the status quo Arkansas I want to move things forward we need more obese here and are Arkansas I'm glad we got our nurse are schools in Jonesborough Fort Smith what else is certified nurse midwives to come alongside them to increase access to care to decrease cost this is a great bill and step in the right direction and I appreciate a good vote. Represent Boyd. Get a. Represented gray. Thank you Mr chair. So I told you going into this that have an open mind is I'll tell you kind of where I'm falling is I want to vote for this a day my concern because I told you my concern was rural Arkansas and people being so far away from a hospital my concern is the same as as Dr McGee's is that is that transfer agreement I guess what I'm asking you is would you be willing to talk with us and just talk about and what we're talking about the transfer agreement is it's it's very simple actually she's making sure that that midwife has. Credentials has a path to the hospital just to make its for our comfort level to make sure that that there is a path to the hospital for them when they're out in the field in rural Arkansas and so I guess I want to vote for it that's that is my biggest concern and that's the concern that I've also heard from the positions in my district about I approved I would love to work with you on that island passes out here today move this forward to work with you on I promise you that I work with Susan is to be a nurse practice everything is as what we do with the guidelines I can't you know I think we've got today we're going to move this forward I promise to work with you on that business to be in rules I would say was suing is gonna be something would have to put in there to work on but I I we need to move this for things a great bill moving things the right direction I'd be happy to work with you on that to make them feel more comfortable at it but we don't pass that we're still gonna have the same situation we have right now this gets more people out there better training better care and increasing women's health and infant health in Arkansas so I will work with you and I promise you that over that before we get together in thank you that's Mr chair if you'd told me that I think that's my concern and that that changes my vote so I think if you're willing to talk about adding that language either in this bill or through the regulatory process and put in the nurse practice act right then I vote yes okay it gets a five oh yes it gets to the other end and nothing happens. Obviously then there's nothing I can do with that I will be very upset and feel like I was misled us I guess I want to tell you that makes a difference in my book today Sir will work on it okay. Represented first you're recognized. Yes I'm very much like of rips gray and you know I mean we've both been in these national meetings hi I certainly think anything we can do to improve the care in home births I'm not for home buyers I mean I think infants are seven times more likely to that a home birth and in a hospital birth. But there a lot of crazy people out there thinking that they want to do it natural and and it's a it's it's just not safe and it's certainly not safe. The way it is now if we can improve home buyers by having actually certified nurse midwives doing it instead of like people then I think that is an improvement in that direction. At a I guess a I'm a little concerned that this will actually. Improved access if the northwest hospital went out of business because of the reimbursement. Hanam Adam November conflicted about it but I I would like to see a transfer agreement for the home births hated it at least would see we can do on that okay all up missed was the one that. Well I have to come in I I like this bill I think some of the concerns that have been mentioned here there there are great concerns but I think some of that's going on right now. And I agree with you Representative Bentley that you know we don't want to continue to be forty eight. And we have got to make progress and I I believe this is progress. you know. There's a book and I won't mention it but it has a verse Senate that says if you wait on the perfect you do nothing. We don't want to wait on the perfect we need to get out of this forty a slot I truly believe this is a step in the right direction there are problems I agree but I think it's a step in the right direction any other comments represented Dotson euro you're recognized. Thank you Mr chair that I I appreciate your your commitment to represent of gray to work on that because as we discussed this was that was my primary concern. And so I appreciate that and and sue working with that whether that's regulatory or on the other end trying to get something done that that has solidified my vote for this thank you. Any other comments. Seeing none. Most on floors do pass as amended yes Sir all in favor signify by saying aye aye All opposed nay. Motion carries congratulations represent your bill has passed thank you it's a huge a huge went on my part thank you so much thank you for all the Midwest over here on the women's health the women Arkansas are are are excited and tell you so thank you all so much. You were going to move on to is represented Johnson here yes represented Johnson it you're recognized to present HB eleven seventy seven. Thank you Mr chair committee. Procedure patients today House Bill Levin seventy seven is a bill that was brought to my attention by the national organization for rare disorders there's over six hundred rare disorders in the United States many of these require very specialized medicines for care and treatment that are readily available on every ambulance many require specialized physicians to treat that are readily available at every facility in the state this bill would empower paramedics to administer a patient's own medication that's been prescribe to that particular patient only under the scope in which they can practice so in other words if the if they're not trying to give a medicine I'll be they can't give that IP it but it but it would allow them to have access to the patient's own particular medicine give that in a setting where it might be a life saving the best example I can give you is there are certain bleeding disorders that are that are rare in which patients have factor that they carry with them to help caught their blood but they don't have the ability to give that back to themselves and so we can create what's a minor injury Intel after anyone because the bleeding that's there this would empower the permittee's to give that patient there medicine as prescribed by the physician it also allows the able to services it is possible to transfer to a patient to the patients requested facility even if it's not the closest one now the point things This Is permissive language it doesn't require an ambulance to transport that allows a patient to request it so a good example of this would be if a patient was picked up north of Conway and they had some sort of rare disorder that was being treated at children's hospital or you a mess because that's where the positions were I didn't know how to treat this rare disorder they can request that to be transported directly to that facility in bypass local facilities if they're specialized care was was at that facility again it's important now that doesn't require that it be Mrs the other thing it provides for is a pathway for coordinated care the way over to finding that is. it requires the emergency the the the emergency medical Advisory Council to to put forth some standards for local services to coordinate care with these patients with their primary care physician it doesn't require that coordination but it requires the council to come up with some ideas of how that might work so that's important for if you're patient living in say Sebastian County and and you know you have this rare disorder where some condition might come up or you had an emergency it would allow for a pathway for the local ambulance service say Sebastian County amass to work with that person's position and and they're in can help coordinate their care so that if there was a nine one one emergency the local paramedics would be educated on this person's particular rare disorder again it doesn't require that a local in the services but it does required some standards to be developed so that the English service could potentially participate in this coordinated care in this fashion this is a bill that I've worked on with DMS section of the department felt in the endless Association they've had a chance to review this bill and make some suggestions members which we did before we drafted before we filed it so it's a good bill that doesn't get things here in the state I think it's gonna be important for the people have these rare disorders to have this opportunity to have these meds administered then I'd be happy to answer any questions about the bill if anybody has any. Representing Gonzalez you're recognized thank Mr a look at the bill at like I think it's great bill agree with everything but the one thing I did notice about the transportation is there a way that the spaniel services are going to get reimbursed if they don't go to the nearest hospital because a lot of times of payers require that I go to the nearest right yes so it's going to be the bill would fall back to the patient in that happens now you know if if if if if a if a insurance carrier that I understand reimbursement aimless is if an insurance carrier will pay because you transferred a patient requesting decking you can request that now right you could pick me up it didn't occur at north Crawford County it's a I don't want to get a quote for memorial I want to go to. Back to sportsmaster and you're gonna have to be real do the patient they would be responsible for the reimbursement of the difference in mileage is the way I understand how that reimbursement will work so the of the billing is a separate issue but it at least that provides a pathway for them to ask for that and I think it's something that's worth looking into in the future store you know how to maybe require providers in the settings to pay for that kind of reimbursement. A committee any other questions. Seeing none anyone in the audience to speak against the bill. Bore the Bill. Seeing ninety ready close I'm close from a bill Mr chairman most of. Motion to pass I have a motion do pass by represented Pilkington any discussion on the motion. Seeing none all in favor signify by saying aye. All opposed nay. Motion carries congratulations sales past thank you Committee. Represented Johnson you're recognized to present HB twelve fifty nine. The so on the surface that this bill would to see more contentious than the last bill I know there's minute historic conflict between at times between eighties in Petoskey MI committee if you all that'll be on your computer science communication so we can hear I'm sorry I do have an amendment to this before we get started after I forgot to have the amendment yeah motion yes wait wait to get the amendment thank you sorry about that. Go ahead and present your amendments search to this just amendment adding representing mackenzie as a cosponsor sheet SPS co sponsored. I have a motion do pass on the amendment by Representative Johnson. Any discussion. Seeing none all in favor signify by saying aye All opposed nay. Motion carries. Your amendments minute doctored with when they. Thank you you're recognized to present your bill is amended per se that Mister chair committee I'm sorry forget about them then that CS so um this is a bill that's been worked on it's pretty diligently for a couple of months so as with scope issues you know knowing the challenges that we have with those I tried to do my best to do our due diligence before we came to the session before we can before you here today committee with the I had multiple meetings with the eighties in the PTC discuss first of all what their goal was the eighties came to me with this bill and then what did you teach needed to get comfortable with the bill so to understand what we're trying to do this but I think it's important gender case understand current statute so currently in the state of Arkansas and athletic trainer may practice under the supervision of a physician but not in a clinical setting so it the the way the statue reads as they could practice under me as a physician but only a non clinical setting and they can practitioner PTC in a clinical setting being a hospital or outpatient clinic but but they can't practice center physician in service of the eighties can we with the request that we we want to be able to practice under a physician in a clinical setting just like just like PT's to me that's a reasonable request as a physician I currently supervise athletic trainers and have for many years in a non clinical setting at the school the fifteenth to say that I'm not qualified to then you know supervise a athletic trainer in a clinical setting to me does it doesn't really make any sense if I'm qualified to supervise you at a school I should be qualified to supervise you in a hospital in a clinic adds on the surface this seems like a relatively straightforward issue that really has more to do with physicians scope of practice that athletic trainer scope of practice this is more about am I allowed to a supervisor athletic trainer in a clinical setting the challenges with that is is you know their concerns on the PT's part that that might create a pathway. For me as a position to set up clinics with eighty somewhere with athletic trainers where I wasn't present and the athletic trainers within practicing without my. Guidance and so in order to try to rectify that part of the compromise was we're requiring physicians to be on the premises to supervise athletic trainers and it in fairness if I'm going to be S. as a physician to be on the premises to supervise an athletic trainer it's only fair to ask the same thing the physical therapist what we're trying to do is level the playing field here between the positions in the physical therapist and what what what we do this this bill. Adds a physician as being available to them to supervise an athletic trainer in a clinical setting it requires them to be on the premises it also now makes that a requirement of the PT and that it defines the clinical sect setting and the direction language you know as with any negotiate a compromise I'm sure there are PT's in eighties in the state that don't necessarily agree with every aspect of this bill but the leadership of those organizations are here with me today and they both worked very hard with me I commend both of them for that process they've done a lot to come to the table with what I think is a great compromise bill that supported by the leadership of both organizations so you may have received some emails or text I've received phone calls from eighties empty teas that the majority of the athletic trainers entities in their leadership are supported by this bill in this change and again they're here with me today and would be happy to answer any questions. All right committees any questions. Representing gray you're recognized thank you Mr chair yes my question being as I've been here I have every terms we've been here I am is in the past the physical therapists in the association have been against changes such as these can you tell me or could we call them up to the table and let them tell me. What changed in this bill and why they are known as an association are now comfortable with it sure I and I have folks here with me for about the situation so if if if the P. T. folks would like to come to the table okay not split so the. Since we had a question the people that are here to speak we have one two three four five people who speak for the bill no one to speak against the bill so I'm gonna just go down the list and if the people in the audience want to come up and speak or if they want to pass over let me know but will go down the list and that way you'll you'll hear from all the people that want to talk. That so we'll start out with court where. In the past. Terry. Terry. Benham Benham it could read the writing. All right thank you Mr man. Gosh I can't read this one Jonathan. John. All three come up. Senator self I can't read the last name sorry hello it'll run. This is the button right. My name is Jonathan all right I'm the president for the Arkansas athletic trainers association I'm also practicing athletic trainer and of I just wanted to share that this has been a lot of compromise I really appreciate each of you for hearing This Is I appreciate our sponsors for working with this I appreciate the PT leadership for coming to the table and as represented Johnson alluded to there are some athletic trainers are crazy about the bill but as an association as the leaders of that association we do feel like this bill helps athletic traders that helps move us forward toward physician direction and as an association we do support house bill twelve fifty nine. Thank you for your comments. Seth Colter. I am a says colder the president of the physical therapy association Arkansas and I'm with you but in the battle with these for several sessions the difference here is that the supervision is on site and not off site as it has been in the past this addresses a very specific problem of a physician wanted to hold a after competition injury clinic with the athletic trainers that have actually been participating with the student athletes and not have prep prior to this I had to have a physical therapist in the clinic in order to comply with the state eighty practice acts and this allows that physician the ability to supervise on site the athletic trainer as they're working with student athletes. All right thanks for your comments. Read the Phillips. A pass okay all right that's a reminder that we had listed to speak for the bill is there anyone here speak against the bill. Seeing none me ready close. I'm sorry was our question. Represent Wardlaw you're recognized. Motion to pass. I have a motion do pass as amended any discussion on the motion. Seeing none all in favor signify by saying aye. All opposed nay Motian carries graduation your bills back thank you Mr chair committee appreciate it. All right committee will move on to the last bill on the agenda H. B. twelve fifty four represented Wardlaw you're recognized present your bill. Thank you Mister I think the good news about all these bills today is we're not to see any of these bills on the floor to mark because they all have an amendment include monster so with that I'll give the staff a second to pass out the amendment. Let me correct that we we do have an item on the consent agenda if we have time we'll do that one but. Mr if you wanna go ahead and start because the amendment deletes a couple paragraphs and I'm go ahead and how like those for go ahead and present your men submitted your following me to page two of the bill you look at line thirteen will be deleting line thirteen and it's certain to our nurse instead of nurses and then on line seventeen of the same thing and then on the lines eighteen through twenty one to be a total deletion of that paragraph of those paragraphs. So with that I'd moved for adoption of the amendment. Okay is anyone the more time to look at the amendment. If not we have a motion to pass the do pass a discussion. Seeing none all in favor signify by saying aye. All opposed nay moshing carries graduation amendments passed you're recognized to present your bill thank you Mr chair so basically the The nuts and bolts of this bill is it deletes the fact that a nurse practitioner would have to have a referral to see a Medicaid patient so right now if you're Medicaid patient and you walk into an urgent care care are you walk into a clinic that's only a nurse practitioner present your PC's P. your doctor would have to send a referral for that nurse practitioner to get paid for that visit. This delete stop one thing we're trying to do a Medicaid and you're going to see with the the new Medicaid expansion ideas that come out as we're trying to cut costs and costs being to the E. ours and different places where those costs are a lot higher and this is one of those barriers that are out there that drives people to an ER and we resolve these patients seen at the most efficient cost effective method and by deleting this it allows patients to be seen when they need to be seen without having to wait on a referral. So with that I'd be happy to take any questions. Any questions from committee. Represented Ferguson you're recognized I guess I'm trying to understand how this will work with the patient center medical home in the all of those. If if they're getting rid of the referral and. One thing my understanding is is it should actually help with face and medical home because those patients are going to the ER that cost is going negatively against those homes today are does not say homes but those units so they should all. Not really sure what we have going on in here. But this should help bring that cost down even inside the pace in America home because you won't have many people going to the E. R. and and that's kind of the objective of I plan on having a second bill that comes behind this had been in conversation with Medicaid working on it I don't want to talk about it too much but there there is a number of visits that are limited right now and that also needs worked on as well because when those visits are hit you have to go into an extension of benefits which means that office staff has to put time in it and you're doing all that for basically a thirty four dollar visit and that's a problem in itself to being you look at the cost of the R. which is extremely higher than that and these people are conscious I'm a business they have and where they're at and that and they will go to the ER and we need to keep him out of the R. fall possible the ours for heart attacks in real emergencies not not. Common cold and flu. Yes for a and I'm certainly for extending the days it summing it is a process to get the extension benefit but will this count as one of their twelve visits it will at the moment yes. Representantes and you're recognized thank you Mr chair represent Wardlaw looking through this I just wanna be clear in my mind this. The the reimbursement rate for the nurse practitioner basis stays the same day's saying and although the only thing lines fourteen due on the second page which I know that's confusing language there just make sure that while that patients being seen by a nurse practitioner those labs are reimbursed at the same rate they would have been reimbursed at any other office so that's why it says one hundred percent there's just for the laughs of the physician reimbursement rate might might be higher than a nurse practitioner rate but the rich the nurse practitioner is only going to be reimbursed at their rate for the visit and then the lab the lab and things like that will be reimbursed at the same level okay thank you yes Sir. Good question thank you for the the other questions. Seeing none. To anyone in the audience who wants to speak against the bill. For the bill. Seeing ninety red clothes and I would make a motion to pass and create a good vote. As amended I have a motion of do pass as amended any discussion on the motion. Seeing none all in favor signify by saying aye. All opposed nay. Motion carries congratulations your bill is passed thank you Mr chairman and committee represented Boyd are you prepared to run H. C. R. Tennell to. while he's coming out there represented Davis represented cloud to represent Penzo after the meeting I'm I'm I feel that come up on the top you just a minute okay after the meeting. Represent Boyd you're recognized. Thank you Mr chair for the opportunity quickly present this up Amendment OB so basically there's an amendment in the whereas section and honestly I forgot you have a copy of. Thank you Mr sorry for obliging thank you for a bludgeon me on that so on line thirty two the first page there's an additional whereas that wasn't there when we approve this before it just reads individuals with disabilities that are substantially more likely to suffer from substance to substance abuse disorders at two to four times the rate of the general population and are also less likely to receive treatment for their substance abuse. That was an amendment adopted in the Senate by Senator Gilmore at al so that this would like your authorization approval. All right of any questions. Anyone speak against the bill against the resolution for the resolution. Seeing none. You may close yes I'm I'm closed and I'd like to make a motion to pass for the amendment to the resolution. Okay the motion is to do pass for the amendment. Of any discussion seeing none all in favor signify by saying aye aye All opposed nay moshing carries congratulations your resolutions passed okay members tomorrow when major attention on this tomorrow at four PM in this room we will have a special meeting. To consider one amendment from the Senate on a bill that we have already passed. With the current amount twelve twelve it's a concurrent amendment on H. B. twelve twelve the reason for this is this bill this is the unemployment bill if you all remember to forgive the unemployment for the small businesses in Arkansas this has to be signed by Friday by the governor so in order to do that we have to have the special meeting so at four o'clock on Wednesday appreciate child to come in and and listen to that amendment. Okay of. Again I want to talk with represented Davis represent cloud resident Penzo. And Committee appreciate your