House & Senate Health Services Subcommittees of Public Health Committee

Yeah. Okay members will call the a a meeting to order Uh whole body objects but we're going to go just a little bit out order Senator hammer has a. Herbal five verifiable issue that he's got to deal with so I will let him go first. Senator hammer. I just leaning. I have probably from the down front at the table would be best. And while he's going down there we're going to representing Ferguson she reminded me that were supposed to adopt the minutes. A motion and a second any discussion on. All in favor say aye. Any oppose okay those minutes will carry. Senate committee have. Three so which one are you doing first. Thank you Mr chair members of the committee of I'll Tate G. first if that's right Mr okay members of a bill to G. fanning Percy when you're ready to ready Senator thank you Mr chair this is a I. S. P. to study removal of the collaborative practice agreement requirement for Vance practice registered nurses granny advanced practice registered nurse full practice forty including full practice authority and Mr chair the. Points that I would like to make are on page two line twenty four through twenty seven. That says whereas twenty two states authorize advanced practice registered nurses will soldier intelligence by reading this in its full entirety but we are not the only state that would be doing this we're not pioneering at but also we choose not to be the last to do it and so I'd just like to point out the twenty two other states to that and then on the top page three study since nineteen sixties have showed no difference since health care outcomes including patient health status numbers prescription written and return business requested or referral to other providers and payers between health delivered by advanced practice nurses and health care delivered by physicians and then down at the bottom page three of the collaborative practice this is line twenty eight collaborative practice agreement positions not on site even with the close the sanity of advanced practice registered nurses so as it is right now you can have a collaborative agreement and the physician does any have to be in close proximity so what this would do is it's an entrance thirty to bring to the legislative branch of for consideration during the full session a manner in which we can remove that with safeguards in place so as to make sure that the safety of the public is protected but also that we're expanding the ability for residents of Arkansas to get full access to care and with that Mister chairman of the lead answering questions okay culture Ferguson I believe she has a question or comment. I guess I just have a request you know I mean you and I have talked at ma'am my main concern is about the background in education and practice requirement that sort of resembles a family practice residency and I know there's no national IP are you in guidelines for that every state does something a little bit differently the I I guess if you could sort of not just say twenty two states but so the defined. The parameters of ram what kind of educational background those states require if they do it yes ma'am I'll be glad honor that request fact as I noticed this morning over the weekend on the agenda did have a chance to talk the Representative Johnson but we kinda have bills that are shadowing each other I think there is a spirit of cooperation among legislative branch work together to make sure that you know what we do is in the best interest of our Kansans and I'll be glad to look at that number the notes so as not to forget it. Thank you. Representative Payton. Are you pushed or you up Sir I'm here thank you thank you Mr chair of Senator hammer I know we've had several bills like this in past sessions can you just real quickly drill down on the difference between this and the one that we consider the last session is not reflected in this but in the conversations with those who I'm running the bill on behalf of one of the things that we're gonna be looking at specifically or the number of hours that would be required to do this so as to make sure there's another layer of Security another layer of confidence on the part of the those who choose to support this so that it's not just opening up the door so to say but that there would be some some. More accountability put into what we're asking that's not necessarily reflected in the eyes P. but in the language that will be coming forth it would have that in there not think that's gonna be one the distinguishing differences from before. Thank you I'm concerned with the upcoming session the you know time is going to be limited and we're gonna have a a tight schedule and I just hate to rehash the same ground we've covered before is that basically the only difference I think that'll be the primary difference is that it's going to it's just going to bring some greater safeguards to you know to make people feel easier about accepted because unlike previous where was we weren't having the requirements of all there will be some some requirements in there that I think addressed the issues from the previous conversation that's what's gonna make a difference thank you thank you Mr chair and I'll write a note for that center by Representative Payton. Okay. I don't see more questions I know that we've said this in previous meetings of course especially with the covert session we have coming up the more this that we can get worked out behind the scenes the better so again we always knows this one is controversial so we have asked the groups to work together and if somebody's not working with somebody of. If those would get with the chair so that we can try to help that along also so Senator hammer you'll go to the next one yes Sir which which one is it in. Which one the N. as in Nancy. Members he's doing in. Centering start whenever you're ready thank you this bill is pretty simple and cut forward it's clear itself thirty three thirty four activities read law enforcement military and rescue services the athletic trainers are requesting that they can have these three areas available to where they can it's not it's not up. Mandating it there there were some that mentioned that perhaps this would force municipalities or other entities as listed here to have to hire athletic trainers but this is permissive it's just opening up the door for them to be able to do what they're currently doing in several areas and add to the list law enforcement military and rest in and rescue services and specifically a I don't have copies for what it but I do have a copy of my desk from general pain over at the military base stating that he is in favor this because they would like to have athletic trainers that could work with them because actually law enforcement military and rescue services those individuals are athletes in order for their jobs and they would like to have them work with them in order to make sure that they get the proper training that they can head off issues before they occur and just like a strengthening coach to a football team that's what the Affleck trainers would be to these areas and their intent and it's been documented and shown that actually can reduce off the job time for recovery because of injuries and also can help with regards to prevention workmen comp claim six cetera if they can have access these individuals to be made available to work with their law enforcement military and rescue services. Cochair Ferguson. Again that you know this will be a I think a controversial issue with physical therapy have you talked to physical therapy about expanding the scope to include law enforcement and military. I mean I would hope that like like a like a chair say it might be something to do you should get together before you run the bill to make sure that everybody's okay and this athletic trainer. Issue is being a real source of scope problems in the past it yes ma'am I understand like so many other ones are all hot topics but as far as being approached by the PT's in opposition in this I have not been but at the same time of not entered into dialogue with them they are aware of this bill I will say that and and actually the athletic trainers on like the previous bill they are not looking to get into the PT's business in this area because this is more pro active they're wanting to have them in place so as to prevent injuries and what this language would do is allow them to be available in these three settings which they're not allowed to be and so this is this is intended to be proactive before PT would even be involved in the picture in helping to prevent injuries by having them present to work with these three identified sources. So they're only preventive they're not going to do treatment if there's an issue with law enforcement I'd want to reserve of I'd want to have a conversation make sure that that that is a hundred percent accurate but as presented that was that was the intent yeah I I mean I would encourage you to get with physical therapy they killed if you're not bills in the past and manager the last year to the chair and to the members absent on public health my entire legislative career this is not session to have a blood bath during it I'd rather have it before someone walk in there it's a lease all worked out everybody knows for sure what points of contention or that I'm just sharing that with use of Phil legislative that's fine ten. We do appreciate that now hope all stakeholders understand that because if we get into session is we're not saying that we will have it worked out. There has not been any attempt it is not going to go it's moved for the for the presenting party so we do appreciate you Senator hammer for that you will go to the next yes Sir may make up man make a comment to what you just said Sir that's one reason I really wish that and and I am going to pick it up and continue pushing that we could hire consulting group to come in and look at all the scope of practice issue so we could have won blood letting instead of letting us along the way so I just encourage members to if you would please be open minded to that is I'll come forty percent that the near future thank you Sir thank you. A P. isn't Paul. Members is going to pay. Yes Sir peers in Paul. You can start when you're ready. Okay this this bill. Actually mirrors some of what is already allowed by nurse practitioners but the the P. A.'s are one eighteen two she Mr government. In future short of the P. H. or OR one thirteen to have this language to find As far as what they would be allowed to do. And I actually. Sorenstam wing Mr hi one second if you would please. This one allows for a if you look at page to the bottom on page page two line thirty four through thirty six a the establishment. In the event that a vacancy exists in the position of a licensed physician sister pointed in subsection affected Russian actually session position shall be appointed by the governor this actually helps establish A a board if you look at lines twenty six through twenty nine should qualify license practice physician assistant point by the governor it actually allows them to have a seat at the table and it's it goes to the title is to amend the membership of the Arkansas state medical board to allow supervision and in a P. forty of the physician assistant that is part of what the bills intend to use to give them a seat the table for for those discussions If you go over page five. Lunch twenty nine. Physician assistant may provide health care services position PA assistance license otherwise authorized form under the agreement with the supervising physician this language is actually modeled after what's allowed for a nurse practitioners now the P. A.'s wanted to to bring themselves in line with that and I'll be glad to answering questions Mr. one other thing a page six you may not know it but a PA cannot pronounce a death the hospice nurse can a physician can but a lot of times PA's are in a position involving the death and they are not licensed to pronounce this would also in page six line twenty eight through thirty allow them to have that same practices will. Thanks hammer anybody have any questions on this. The center I don't see any was that your last one that's it okay members of force all we're doing is just hearing these as are being presented so there's no action to be taken. We thank you thank you Mr chair and to the members of the I don't like cut in line from anybody but I'm going to conduct a funeral for constituent forty five year old nurse to died of a brain tumor and so I really appreciate the letter to the chair additional one general thank come cut in line without any good reason yes Sir and prayers prayers for that family and all involved. Okay members we do appreciate you allowing the sender hammer to go do that next up is going to be duty represented board were you going to present that for Representative Bentley. Again maybe members were doing the. Can you start whenever you're ready represent board. Thank you Mr chair and and I just want to start with I think there's a little confusion about whether I espys have to pre be presented here or if they just have to be adopted by the main committee and that the with the house rules so that was kind of the the concern so when I talked represented Bentley this morning she just wanted me to present it just in case sure so basically there's she has a concern or there is a concern of lack of access to Healthcare for pregnant patients and and people and being able to deliver babies this is looking at nurse midwives and whether or not there are some opportunities to expand scope and provide opportunities for more care so that role our Kansans have access to the appropriate prenatal and postnatal care. Ten if you have any questions I'll be happy to try to answer. Okay on your initial question. Would you like staff to try to explain that yes if if you don't mind. The. Now it it is are always with the sponsors option to present a subcommittee for discussion and hopefully let other members know that this issue is coming forward in a in a piece of legislation and. Hearing getting a up convo preview on the pluses and minuses of it those people or those groups that may be for it or against it or hell however the sponsor would like to tweak it. To the to be successful come session catches so the so just to clarify so it has it. Really it just has to be adopted by like we do at one o'clock today when we hear these for adoption that's that's what we anticipate that rule means okay thank you for the clarity so that set any questions on this I'm happy to try to answer them okay members again of represented board he presented exhibit day is there any questions on that. Representative Payton. Your button pushed it is all right you should be a thank you Mr chair yes Sir. Well I'm not sure if you're the best answer this represented Bentley but. Ever maybe even staff but I mean basically there's no. Legislative proposal here is this a shell bill is gonna be a vehicle. To become a shell bill later What we have here. I mean basically it's just the the way I interpreted represented Payton is she's just laid out some some challenges and one of the things that she wants to look at is where is the increase health care provider choices and access to maternity prenatal postnatal reproductive health care services for the citizens of the state this General Assembly should consider methods to properly utilize certified nurse midwives it does not specifically lay out. A a specific way it's more of an open ended we should study look at so that she could come back or someone could come back under this ISP in and follow scope something that could be argued as a scope bill regarding nurse midwives so this is a blanket ISP that would cover several ideas that could come up later. I'm not Representative Bentley I hesitate to speak for but as a sitting legislator that is my interpretation okay thank you thank you Mr chair. Anyone else. Thank you thank you Sir. The next one is easy Representative love for you here to present. Europe Sir. Again members raised Mr represent blows about two ET and you can start whenever you're ready. Thank you Mr chair thank you committee This is a this is a bill that was born out of a A. H. of the task force then I was participating in for the Arkansas department of health basically what this bill is to authorize pharmacists to dispense age of the what they call pet which is post exposure prophylaxis. It is it is known or the scene that if someone is exposed to HIV if you print if you provide them with a house with help then the the ability for the body not to take hold of the of the virus is greatly increased and so therefore by given in this medication and expose and provide them the medications early what you can do is kill the virus in the body and therefore it they may not they may not have HIV. Now of course this is the time the timing is why it is important that we allow pharmacists to dispense this drug time is of the essence If you if you are able to provide someone that has a possible exposure within seventy two hours the ability for the the anti virus to kill the virus increases and so the time is of the essence and so this bill lays out a number protocols that will allow the pharmacists to going in to dispense the drugs and the and referred in the refer them well refer them to their primary key or out for physician and so that's basically what this ISP does will be looking at it and the Senate this is borne out of the age of the task force that I participate in from the Arkansas department of health and I take any questions. Members are there any questions on this. I don't see any questions but of assume this one might possibly be controversy also just the same as within sit within Senator hammer we would just to. Hope that we can get all the all the parties together prior to to to see what the issues were all have before it's brought up in the session okay Representative Boyd. Thank you Mr chair I apologize I just allows the I was a little concerned by the use of the word shall and here as opposed to to may under a statewide protocol pharmacist shall and so I just wanna make sure that. I would have a concern moving for it under state wide protocol the pharmacist shall the spent at least a thirty day supply and up to a sixty day supply of HIV for exposure Prosto prophylaxis if I just wanna make sure we're not forcing people to do something that they might not be comfortable doing so I just wanna raise that concern. Representative Johnson. Thank you all right I guess my only question would be about the counseling involved in the in the administration of medication it looks like there's a standardized factsheet it's going to get provided to the patient. to make sure they understand the indications contradict cations side effects that kind of thing not the you know when I've had these conversations with patients of the years you know something we see frequently in the in the emergency department will see people that Neil stakes will talk to the process of of HIV prophylaxis in your there is some. The it's not a there are some things that have to the to be discussed you know in a I just wanna make sure I don't of an issue I don't think on the surface with this being provided to the pharmacy I just wanna make sure that the patients getting the right information and in a way this not just in their machine necessarily but I'm also sort of discussion so that they understand you know what the pros and cons are what the risks benefits are because that is a conversation I think that probably needs more than just a your here's the sheep created because there are some things you can be misunderstood that be the only request I okay. Representative gray. Thank you Mr chair and. My things I'm not opposed to protocols in general as long as those protocols don't require any kind of diagnosis on the pharmacist behalf Senate looking at page three where the patient has to present a negative HIV test result where can they obtain that test result for that where they get tested they have to go to a clinic to get tested any now thank you go to a clinic how many I'm I'm assuming that the pharmacist could also give them an HIV test. I think that's where my issue would lie is in at that point the pharmacist becomes diagnostic and they would then have to diagnose a patient in order to give the medication because if there have to go to an HIV clinic or they're having go to PCP any hell to get tested than that provider could prescribe already some just on that out there that's my as my hesitation is the whole diagnosing peace okay well but a she knows you know what we're trying to it. What we're trying to do is make sure that I mean even if somebody is has a potential that they've been exposed then they can go ahead and get the that the drug dispensed to them and then go to see the primary care. Income from A care physician instead of having to wait and so what I I do understand exactly which is the and so we'll look into that as well yeah let's talk about it thank you. Are you done represent correct all right thank you ma'am absent person. A thank you Mr chair at one thing you might consider because you know moving you saw with contraceptives moving drugs to pharmacy dispense can be pretty controversial from the scope aspect they're they're quite a few platforms out there now to do telemedicine or tell health delivery of for at just like for there are for **** and FOR birth control so I mean personally I think maybe a telemedicine platform might be a better choice for a person getting prepped and. The pharmacy but the you might just look into that. Representative rare you in twenty six. Europe Sir insurance thank you so much Mr chairman just have a question Representative for it and maybe some of the pharmacist here can answer for Senate office with this of the training for a. The physician and the Pharmacist does I have the same training. Of four. Testing for HIV images of pharmacists know as much about this is say a physician's order yes I would I would assume the pharmacist will know exactly about help because I mean this this is not this is not like a new drone this is something that's already been administered the thing about it is that this allows it to be administered in a more rapid response because the time is of the essence and so this is this is not like a new drug on a novel drug or anything it's just a different way of just getting it distributed and gin and distributed more quickly. Yes for fleas yes Representative for years of is it like a twenty seventy two are winners or that is correct okay thank thank you Mr chairman yes Sir. Representative Ladyman. Thank you Mr chair Representative love up representing gray in person actually touched on my question but like to add one thing are there other advantages to this bill or this SP other than the timing I mean is that the only. Reason we would do this is for the timing are there any other advantages local really the timing is is really the biggest advantage because by by administered it within the seventy two hour window the possibility of somebody contract and H. I. V.. Goes down domestic drastically so I would say that that's the really the biggest thing is is that the time is of the essence if you go with that will outside this any two hour window then there for the person will probably. In the Dixon possible exposure and they will probably develop aids versus coming HIV aids instead of not. Develop an HIV aids so that's the that's the biggest thing is that the time is of the essence. Well I would just add that you know with telemedicine and merge the clinics quick clinics those kind of things are are available so you know and then some of the concerns about training and reactions in that you know we we really need to look closely at this whether the advantage outweighs the negatives. Suggestion thank you Mr yes Sir Senator Irvin. You should be on now thank you so much apologize for coming in late so you may have already answered these questions but did you work with anyone on this yes I'll serve on a task force and age of the task force from the Arkansas department of health this is one of the recommendations that they hand in regards to to dispensing payout okay and then what about the pharmacy association I have I have not worked at the pharmacy association on this okay are you aware of just the federal laws as it regards to Pharmaceutical companies and doctors and what's the federal laws are and in regards to the sunshine laws that are in place. No okay so the sunshine laws at the federal level are in place because in the past you had physicians to Pharmaceutical companies were wining and dining and taking them on trips and all kinds of things and so the federal government passed sunshine laws to prevent that type of thing from happening so physicians now can't really even get a pen that has the name of a pharmaceutical company on it in the past they could and they could do various things and actually knows somebody closely he with a whistle blower on a federal case because a physician was. And basically using two companies against each other and demanding that they pay him money under the table to use this product verses that product and says somebody I know very closely with the whistle blower on a federal Medicare fraud case because of that the reason I say that is because no I'm concerned about when you have pharmacists and notice regard to any of my pharmacists are friends that are my pharmacist like a Representative Boyd here but I've seen it you know in in the world of medicine is if you're the one this that's diagnosed scene and dispensing of the medication. My concern is is that the decision making process then becomes could lend itself to making the decision on what's not not what's best for the patient but where my best margins are. On the medication so I make better margins and I make more profit on this medication than I do on this medication so I'm going to give you this medication and stat and so you know there's a there's a reason why you have as a difference there's a reason why you have doctors that diagnose any of pharmacists that dispensed the medications there's a reason for that and there's a reason for the sunshine laws that are put in place so that we can prevent somebody from being in an and ethical you know dilemma and making a decision based on you know the money I'm gonna make verses what's actually best for the patient and in the case that happened with the physician you know obviously the decision making process about which product to use in that surgery with that patient was not what was based on the quality of the product wasn't based on you know I have a better result for this diet this device verses that device it was it was he's going to take me to the US open and who's going to pay me twenty thousand dollars in cash under the table. And so it's a product becomes a problem and so I you know I just I invoice that and say that because not a lot of people are aware of that and what has happened in the past on the certain situations but we have to be really careful I think as we proceed when we start to cross those lines so that we don't create policy that puts people in that type of a situation where they could be making a decision based more on the profit margin persons on what's better for the patient so these these bills bother me because of that and it's not just this one at some of the others but I I I tend to really really be concerned about the policy decisions were making and then how that is affecting patients out there because because of what I know has happened in the past in the in the Madison area so I I just say that because I I want you to be aware of the sunshine laws that are in place at the federal level for those reasons and and we're concerns might be. Outside of the issue that you're bringing forward with HIV and aids. Thank you. Thank you senator Irvin. There any other questions on this. I have one question sent to me do you know if other states are doing this Representative of do you know of other states. Are doing it this particular law in our X. yes I've known knowing that there's several states that are are dispense intent through through the pharmacists okay again that was just sent to me so anyone else. Okay Representative we appreciate you presenting thank you Sir thank you committee. Okay with that. We're on the air Senator Irvin. Do you mind presenting from the table. sorry that is a couple other members to do that. Senator Irvin you're ready whenever you want to start. Thank you thank you Mr chair members of the committee what you have before you as an interim study proposal that came to me four with the folks that a deal with prosthetics and says senator Malick and I actually work together on this and so all will be carrying this as you know senator Malick has a prosthetic due to his injury and so what this does is it allows for those at that have at that are have graduated from a graduate level OR thought it Chris that it could educational program approved by the National Commission on or thought it and prosthetic education to be able to work with these patients and at it was it was something that was in the law that they needed to be able to utilize so that they have so that these graduate level and folks could work with us patience and that's really all that it does. Thank members you've heard you heard senator Irvin anyone have any questions. Centerton I don't see any okay thank you ma'am thank you I don't think there's anybody at that's supposed to this. Thank you okay. Okay members center hammer's already done G. he's already presented G.. We'll go to H.. Representative Gonzalez or. Look. Okay we'll go to a. Represent board I'm sorry you snuck in only Representative. Okay members will go back to eight Representative Gonzalez. And you're set to go whenever you want alright thank you Mr this is one that I had filed for Representative Charlene Fite as I think everybody ought to have have the opportunity to run legislation that they want to run she approached me with this I agree to follow us before so she'd have opportunity to On her bill. Okay so this is ACT to amend the signature authority of the advanced practice registered nurses. Jerry okay members is there any questions representing Ferguson. I know this isn't your bill but I would have a real problem with reducing the aged at the ready and the reason we've always had it to be seven is because the most important part of these well baby and young child checks is when they come in to get their vaccinations and if you're missing saying those children in their heist area of growth then you're really not starving you know it's not in the service of the best treatment for children so I mean I would be very opposed to moving the vexing stand at the rate just. You can share that with okay. He's of. Yet that's that's okay that. That's my comment on. Right of that okay Representative Ferguson was on that that was probably my mistake because I had went went to that next agenda item but we back back up to each so members we our own age. Center and you have a comment on age. Okay Representative Ladyman on H.. Yes thank you Mr yes Sir just comment I not really a question but Representative I talked to me about this and and I personally have had this experience so understand what she's going with this sometimes it's very difficult to run down position to get a signed document for for people not only children but adults to be able to participate special epics and many times it's it's a minor thing in the position is very cooperative if you can get a hold up on so I think it's really needed hi I know we need some safeguards in there but I think it's a good I SP to look at that and see if there are any negatives that need to be added to it hi so my only comment. Thank you Representative Ladyman okay members I say no one else on this. Any other questions comments. Absent Gonzalez thank you for presenting. A do you have another one yes I have a couple more let's go ahead and close to those will. Just tell me which ones they are okay J. as another one again that's that's one that a problem myself members were doing J.. I think everybody has it. This will we. You can you can control open questions is. Okay what's the title on this bill this is the back to ensure the. Healthcare professionals with prescriptive authority may dispense will prescriptions. Members any questions only at. I don't see any questions will be a solution Irvin. Again Ron Jake. Total centerman I'm trying to we're trying to get you. You should be on. So if you don't mind just explaining the difference between perhaps yours and senator hammer's or what year is is there a difference or are you trying to do the same things or is there. a. But in here I was here one Senator hammer presented his honest I haven't looked at it um this is just to allow anyone with prescriptive authority to dispense from their clinic certain medications. It's far as antibiotics and things like that on the other states do it and and it's convenient for patients and a lot of times there's. Considerable savings and allow them to do that so just thought of something we'd have a discussion on. Okay. Thank you senator Irvin Representative Payton I think you're a. Thank you Mr chair so. We have different schedules of different classes of drugs this basically does away with that and just no no it does not do away with that at all it does limited the it eliminates a schedule two drugs there. Hydrocodone oxycodone those type drugs limited to will be like. Some diabetes medications and high blood pressure medications antibiotics things like that but no it doesn't affect the the schedule at all that's well when I say that I'm I mean somebody will prescriptive authority. I don't know how many different levels of prescriptive authority we may have but the schedules are what control what they prescribe aren't they. Yeah the the schedules are set federally we don't set those in the states we can affect but this basically says that the we won't have any difference in people were prescriptive authority they'll all have the same level of a of prescriptive authority that correct. No they still won't be able to dispense anything that they that they can't otherwise dispense so it doesn't change that. Okay one perplexed thank you Mr chair. Yes Sir. Represented board your question. I do yes Sir Europe thank you so just out of curiosity would like say nurse practitioners have to have the exact same you know rules in place that a pharmacy does on labeling and counseling and. Storage who would come in and inspect those places to make sure that things are being stored appropriately I just have a lot of practical implication questions because it's really easy to think a system some a mock Cicilline that's not dangerous who cares we can just put that in a little bag and tell the patients take it the next thing you know you know what about making sure that the bottles or child proof from me who who is going to have oversight or we also going to remove all about those requirements for pharmacists as well. Yes I don't for C. removing any of those requirements and But I guess that's that's up to the health department for those inspections and and I would. Applied to this as well so the health department would come in and check you know oversee physicians dispensing all right the board of pharmacy does that in pharmacy but wait we would delegate that to the department of health and send that would have inspectors that would come in and give people a great. Amend the something we can discuss some legislation one okay get to that point I guess well I'm I mean I'm just open the open whatever suggestions you have on that on this for so how that needs to be handled. Okay I just that's that's the question is because again we could have an unlevel playing field where this it's easier to it's less expensive for this group to do it in this group because there's a whole practice act over here that require certain things that the don't so I mean me of course I have concerns you know as you can imagine you know they're been it is senator Irvin pointed out their checks and balances that we had in our system in this state for a long time this completely does it but the big thing is it's like. Right now we have if a prescriptions build in another state and then mailed in yeah they're not necessarily playing by the same rules that pharmacists are in the state of Arkansas and that that bothers me to so it's not just if if another profession started dispensing prescriptions of what that would that would mean but I do want to have a serious conversation with you you know at some point time about that aspect because there might be more to it than than what makes the eyes one. Open the. Thank you Representative board represent a great question. Yes thank you Michelle yes thank you and I think just to kind of clear up for Representative Payton I think all this bill does and then I'll ask my question but what this bill does best I can tell is it just allows providers to be able to dispense from their clinic setting instead of having to go to a pharmacy it doesn't change the collaborative practice for prescriptive authority at all just allows dispensing and that's I think I just want to reiterate would represent a Boyd is saying T. on if pharmacies have to be inspected I think the same thing should apply to an outpatient clinic it's going to be doing this sort of thing just like if we do a diagnostic tests in a pharmacy they should have to have a clear certificate the same you see what I'm saying so I guess that really ought to just reiterating what and what he said that if this is the direction we go you need to make sure that they follow the same rules that are already in place for pharmacists thank you. Represent Johnson. Yeah I was just gonna say the same thing shall said in the end I do have one question so it in a I think I understand what this is to the first part of the funds healthcare professional services healthcare professional dispensing and into the rest of legislation in section to the talks specifically about a physician. I'm in the right does your daughter now like I don't know if you want to clarify that the if we're going to have one definition place when the other probably I should seem to be the time. Yes I agree and the my thought on that is that there are nurse practitioners have to follow the medical practice act is forced prescribing now anyway so they would fall under that anyway there may just be a good time to clean up that language yes so that it matches to. Senator Irvin. Thank you just clarification I apologized and the As a so in on page three what you're saying is you want to be able to dispense and I I mean I think we have to have this conversation because I think and then you know exhibit I it talks about. Pharmacists prescribing administering delivering and distributing and dispensing so I think I see what you're trying to do here my clarification is on an. Page three. And I would agree with the comments by Representative gray I think it's I think I mean if we're gonna blur lines and we're going to allow one group to do it not the other I think you do have to have a level and fair playing field so I I I do appreciate I think what you're doing here but I think it needs to be clear and of those funds need to be made clear but what I think you are talking about on this that this chapter and I'm not sure if you need to add anything to this or not but on compounding or dispensing I'm not sure if others that are listed would be does that compounded and dispenser own prescriptions but. You might look into that one. Where it says apply to a physician dentist or veterinarians compounding or dispensing his or her own prescriptions. So. Make a back to the healthcare professional and then perhaps. Singling that one out. Okay. It may not be a problem it may just be that we're looking at these different sections kind of without the context of the whole statute that may not be a problem but just something to check with from pure BLR. Thank you. Thank you senator Irvin Representative Ladyman. Your bill yes thank you Mr A just a suggestion you know we you've heard people talk about the time limit that we're gonna have during the session and we can limited debate. Six a few things now so we will be debating that in committee as much and I people have touched on this but I'm just speaking as a non medical professional on a late Lehman. It would be better if you clarified the limits and like talking on page three there where there's been a lot of discussion. If you really clarify the limits of what drugs or that that are covered under this to make it clearer and more defined which would probably cut down on the debate during committees so just a suggestion if you could tweak that may make it more definitive okay. Yet again I'm open to to discuss on this all the group before we get into the and a committee meeting and. Have a bill filed. For others. Okay members I don't see any more is good discussion in the great comments that it for a appreciate a little help the help during the session if we've already addressed a lot of those. Representatives also I don't have anything else did you have another one I didn't see another one Was gonna do one for McCollum not sure with the is that K. E.. There's one here and ACT to allow pharmacists to prescribe Mr deliver distribute dispense vaccines yes the person's three years of age. Yes okay there were I will go back to sign a minute with Justin to a skews me to represent the board so I don't know if those are about the same or not but if you wanna go into okay that'll be fine. Okay again this is one that McCollum had that he asked me to do because he wasn't on public health and was too late to get it following the other way so. I will do my best to answer any questions for for him so he can run his legislation again again members were okay. Senator Irvin as yours your question okay yes okay Europe ma'am. On section two it talks about minor as and now I'm just can I'm confused because it seems like now pharmacists are gonna try to be are are being doctors that the way I'm reading this correctly because minor non chronic health condition means a short term condition is generally manage with minimal treatment or self care including without limitation influence of streptococcus lice skin conditions such as ringworm athlete's foot and minor uncomplicated infections. So are we. Are we creating doctors offices within pharmacies now and pharmacists are going to be doctors. Is that what I mean. And are we get a bill out for those services. Yes I have some concerns about some of these myself as well on on all of us please but I guess my position on the reason for me doing this is I think that were were all you know equal representatives and should should have the opportunity to file legislation That the we want to run the the we see see fit so I just agreed to do this for him for okay he would have the opportunity to to discuss that in committee or or have a have the opportunity to file this bill okay thank you. Thank you senator Representative Johnson. Yeah I guess most of my questions would be for represented McCollum so I'll give you pass on and we can discuss it later thank you thank you Sir. Representative rye. Yes Sir thank you thank you Mr chairman a Representative Gonzalez at the present time you know look at Walgreens or any of the other drug stores of. They're a. You know I ministering close shots and things like that now is this just an extension of that or can you explain that may be a little bit better to those yeah that's that's one way to look at it um in all the these things just extend the scope of practice and your we have rules in place on scope that these things have to be filed in a nice B. before you can run legislation. So that's what thank you Mr chairman thank you Representative Gonzalez thank you Sir represented Ferguson. Yes I want you all to understand this is not like giving flu shots this bill goes way beyond the S. this is the Walmart billed to do strip strip and the virus testing in their pharmacies and that is a very dangerous thing because there's no history and physical required you can't just get a strep test in charge Ford if you haven't done history and physical exam on the patient check the temperature check the lymph nodes I mean I've I was aware that this bill was coming of from Michael latency and this is a bad bill I'm telling you it is bad medicine. Any other questions comments. Representatives house we appreciate you a presenting all those thank you thank you Sir. Representative board. Are you you're going to rise that correct. Okay will nine members. Should you give me the letter to the jump around a little so well he was sitting there Hey I'm I'm here for the duration Hey I appreciate it thank you Mr chair so let me start with some background and I'm just being honest the federal government had authority to expand scope of practice in a way that I wasn't aware and so because of rulemaking by the federal government right now today in the state of Arkansas pharmacists may. Prescribed it minister immunizations between three and eighteen for childhood immunizations and FOR three and up for code immunizations which we obviously don't have a covered vaccine today but they're in place so that when the rollout begins pharmacist can do that so. Those supersede in some way that I'm not an attorney and can explain to you Arkansas state law but what I've heard from house members is if it's good enough for you know the emergency why can't it be good enough all the time so that's one thing the other thing is is it creates confusion because right now state law does not allow that but somehow regardless of what state law is. When push comes to shove every time I've talked to the board of pharmacy and any other health care attorney or authority that I can it's it's pharmacist may do this today and so the history is is you know early on in March when you know we started closing down health care because we were you know flattening the curve then we got backed up on childhood immunizations. And so there was a decision somewhere in the federal government as I understand as pharmacies might be part of the solution and and catching up now full disclosure I hi don't do any childhood immunizations I'm not give I say that I've given a couple tetanus shots to people who needed to play catch up usually well over the age seven but there are places there are pharmacies in the state of Arkansas as I understand it who are who have been consulted in Aston there is a need in their community so they've done some immunizations downed age three since this federal law went into the affect our federal rule went into effect so what this does is it looks to change the pharmacist go practice to help alleviate the confusion that exists right now and it would allow pharmacists to prescribe Mr deliver distribute or dispense anti allergy medications we're talking about vaccines were not talking about a diagnosis were top of talking about our criteria met to meet the needs for that that. vaccine so right now. What happens say it again it's not that I'm just talking about my pharmacy but if I can explain it from the perspective of my pharmacy it's easier to explain. So I have a protocol with a physician and Fort Smith and you know so I can. You know. First percent to that protocol I can decide if somebody needs a certain vaccine I can bill that vaccine I can administer that vaccine the other thing that creates confusion I'm I'm taking a step back here is with the federal rule. It allows since the pharmacist can actually be the prescriber of record it allows the pharmacist then to delegate to the pharmacy technician if that technician has been trained according to the rule to be able to physically administer the vaccine so right now if if I use the physician's name that my stores protocols under then I can't delegate that to the technician to administer so it creates a practical thing so we're gonna have a situation where technicians are administering you know vaccines today but when the rule is taken away when if either one emergencies over or twenty twenty four then all of a sudden technicians were able to do something that they're not going to be able to so. In essence for an in my view pharmacists already today are prescribing vaccines the difference is is is being billed under a physician's name rather than a pharmacist name so you know. That said I'll be quiet try to answer any questions. Thank you Representative board. Members any questions. Senator Irvin. You should be on I read that you're also adding anti allergy medications so you if you're if you're added administer a vaccine. One in a million times there's an anaphylactic reaction and you have to be prepared so you have CPR training you have to you know you're prepared to call nine one one but you also have to be able to you know administer Benadryl and if necessary epinephrine. So that's that's where the anti allergy comes in that's. M. my my intent well I know but I I mean I I A so your intent is just anti allergy medications as it relates to vaccines are immunization that was what my intent was absent and maybe I wasn't very clear in the way it was written but that's what because again any time you're doing in vaccine you have to be prepared for that one in a million casts a Mayweather's the doctor's office or the pharmacy or the health department you just have to be prepared and you it doesn't do any good to have the authority to administer the vaccine but not have the authority to be ready for that unfortunate consequence right okay so I I I I hear you and I see that I just there's a different because if you have broad language then that can get into it you know I want I mean and just been seen or whatever and anti allergy medications for all children and then you become a pediatrician you know I'm just I just think you need to be clear and the language if that's your intent so so let me just offer to you that if I want up writing a bill to do this I'm very happy to work with you on the language I was not there was another ISP that basically would like it did the same thing I did this on short notice because it is really creating confusion in the industry if you will and I fell and we were running out of time for scope thing so I decided to file this because there's that much confusion you know in on the situation of that's why I normally I stay out of pharmacists cope things but this was important enough to me because of the fact that the really is confusion and we need to clear that up hi so it might not be that I follow bill it could be that there's one related to the one on on the columns for something but if I were I'm I will work with you on that language in making sure we get it the right way okay thank you thank you. Representantes in there you're not no my question was answered thank okay Representative rye. Yes thank you Mr chairman of Representative board. This at the present time it's seven years is that right Sir yes that is current state law but right now federal law preempts that in the case of childhood immunizations in covert faxing okay so it can be at three years and up right now today in the state of Arkansas because of something the federal government has done that again I'm not an attorney I'm not going to. But every time I call the board of pharmacy they have there's attorney is look at this and clarify that it supersedes Arkansas state law okay question represented board rushes save that the the covert shot is right before us here in the next months maybe too much however maybe quicker I mean I don't know but room issue this of Representative. If by chance this is okay do you know we get the the shot down immunization true you know the federal government to we need something in place. To make sure that all the folks that are needing. shashin will be able to to get that without any problem order we need some kind of legislation. In Arkansas and make sure that we have all different angles covered. Right so so Representative rye today there's an emergency other act there's a rule in place and it defines at the federal public reading as an emergency preparedness act also known as the prep act as long as that's in place were covered the risk is if that goes away then there could be but you know that doesn't mean there aren't other avenues for hello. Immunization delivery it just. They would be different than what it is right now follow publisher. Yes Sir will represent board do but do we need something in place to make jail with federal is one dollars that that's my point is right now there's a federal law that supersedes state scope of practice laws that says pharmacists and pharmacy technicians may do these things so. This would. Help to align state laws with that federal role. Thank you Mr chairman thank you Mr. Yes Sir. The represented first. Okay just so I'm clear the federal rule is an emergency rule is that right. It's call the federal public reading as an emergency preparedness act and it is a rule that either ends when the emergency ends or ends in twenty twenty four is my understanding. Right because my my initial instinct was let's not worry about this but the the challenges is it you know because I'm like well we've got until twenty twenty two right but that might not be the case because the emergency could end and then were again we have people who were doing things one day then all of a sudden. In essence a I mean what I how would I mean I'm just being honest what I tell not. Patients walked into one of the service a bill I will the state ended that you know can't do that anymore because the state failed to that you know the federal government had confidence but the state didn't. Well I mean it is a federal emergency order as well and that you may not you know how I feel that I think it's inappropriate for pharmacists to give vaccines to kids under seven for this reason I said but the broader issue I don't want all of us to fall in this trap of thinking that we ought to extend everything that's been done under these emergency orders that's a very dangerous concept we see it already and and doctors offices dental offices people who have delayed care. And have on really serious problems because of that delay in care and these emergency orders are meant for just that to to to serve people under difficult circumstances they're not a deal it is not ideal medicine of it and some of it's been good I mean I think a lot of the technology diffusion we say with telemedicine a lot of those things have been great but they're also a lot of things that are compromised tales that do not need to continue. Thank you for your comments Representative Ferguson. Okay I see no other questions on that thank you represented board I thank you. Okay represent Johnson I see you have. Three on here are you going to all three Inc yes Sir. Members will be starting with a bill. Representative Johnson you're set to go whenever you're ready. Thank you Mr chairman percent also held is a bill that the athletic trainers came approached me about I know this is consider scope issue I know that we've looked at athletic training issues in the past and you as with so many things when you start looking at a statute you end up having more question sometimes than the initial question you look that so the initial approach was. I was told that athletic trainers could not practice under the supervision of a physician I've been the supervising physician for athletic trainers grew at high school for about eight years so in my practice I felt like that was wrong it turns out that that athletic trainers can practice under a physician the the definition in statute your trust to parse out the difference between eight clinical setting in A nonclinical setting and if so what you're the way the way the current statute reads to me is confusing it says that I can supervise it says under direct supervision the only physical set of only physical therapist can see rice but then it goes on to say. The. The of athletic trainer to practice under the direction of a physician but only the nonclinical setting and it does really going to define nonclinical setting so you're the the question is your Amazon in a clinical setting when I'm on an athletic field and someone is injured how do you define clinical setting minimum mind if I'm treating someone or someone is treating someone this injured. That's arguably clinical setting I wanna make sure that what I'm doing first of all is allowed by law and then the second thing would be the question would be. You can't a physical therapist under the current statute supervisor athletic trainer in A nonclinical setting because as it currently reads it parses out those two differences rot so it says that a physician can proc can supervising this nonclinical setting that goes on to say that the athletic trainer or to be surprised by physical therapist in a in a clinical setting so to me as I looked into this I became more confused by the current language and want to make sure that the current language in the statute syncs up with how we're actually practicing in Arkansas also believe personally that if I can supervise an athletic trainer in A nonclinical setting how we choose to define that that a physician ought to also be able to supervise and athletic trainer in a clinical setting either I'm able to supervise an athletic trainer or I'm not that I don't be placed in this position of trying to decide in my doing this in a clinical setting A nonclinical setting I realize this raises some issues the athletic trainers have been talking with the physical therapist about this trying to come to some compromise my understanding is this conversation have gone. Well I have not heard from the physical therapist but ET either enter into dialogue I just think as we look at this it the current way it's written to me is is unclear and needs to be clarified in some fashion. Thank you Representative any questions. Representative Payton. Thank you Mr chair I guess I'd rather ask it in here than in the bigger meeting this afternoon but. House I'm are we creating another collaborative agreement situation here so I don't I mean I don't it's a good question right I mean you you can the statues in front of you as it currently reads I mean it doesn't say anything about collaborative but it does it defines direct supervision by saying direct revisions to reserve athletic trainer In the wake currently reach in a clinical setting in which the supervising physical therapist. it must be readily available so current language. I'd would you call that a cloud agreement well I guess is there piston that athletic trainer I know that in practice I have to sign a form for my athletic trainers saying that I agree to supervise them well that's what I'm getting down to I mean direct supervision I think is the key and how we define that but if it's just going to be in a doctor sign off on it that you know and and not really direct supervision then that's kinda like the collaborative agreement and so I don't necessarily disagree I think that's why bears some discussion I mean currently in practice I signed a form at the beginning of each year saying that I will supervise. Mon athletic trainers is that a collaborative agreement I don't I don't know I signed it because I will do that they will help my school and help the athletic trainers I am readily available they call me we talk weekly anytime they have an injury I'm available for phone call to talk to them to go up and see that the athlete this the physical therapist sound the same kind of agreement with the school athletic trainers I don't know but as I currently read the statute if they are in their pricing and nonclinical setting. Is that allowed by this current law I don't I don't know I think it's confusing at the needs to be clarified. Thank you thank you Mr chair yes Sir Representative gray. Thank you Mr chair I think like one of the points of contention this is tricky bill trying to read through this even though there's not much changed. He is on page one line twenty eight were direct supervision first of all which I understand it's already in statute but they don't have to be on the present the premises that be in direct supervision but I understand it's already that's not something you're changing it's already there. But I think what happens here is if you allow a position to supervise the athletic trainer you're essentially. Then what's the need for a physical therapist lobby there's there's a lot of things a physical therapist can do that the athletic trainer cannot do you and this does nothing to expand the scope of practice of what an athletic trainer can do athletic trainer can only treat athletes doesn't change into the statute the kinds of treatments they can do it doesn't change that under the statute always changing all all the statues really looking at is do you take a position is qualified to supervise athletic trainer if they are why does it have to be non political versus clinical what's the what's the parsing out point this says a physician's qualified to supervise athletic trainer this nonclinical setting which is ill defined but can't supervise one in a clinical setting it doesn't. I think it's including yeah I don't think a I agree with what you're saying and I again I get where you're going nothing just I think the contention will be it almost pushes physical therapists out I think that'll be the way it seen a little bit is your question that physical therapist out of the clinic setting some you will need them as much I would argue that it potentially does the opposite because as it currently stands I think you can make an argument that a physical therapist cannot supervise. Of an athletic training in A nonclinical setting so this is an opportunity clarify that language so that we can clearly say there's a role for physical therapist to do what I'm doing right now agreement ofschool okay thank you. Absentee board. Thank you Mr chair this so when when Representative grace as amended just may make the quicker I think you answered and so you said physician and I guess my immediate thought was will is it a physiatrist is it an emergency department physician is the family medicine physician are we talking about an OBGYN are we talking about a dermatologist I I mean so how would we have who would make that determination about any physician or that's a good point I think under current statute is just defined simply as a physician licensed by by the state in the state of Arkansas is with the current state you read so I mean your point you're correct you could have an ophthalmologist supervise athletic trainers that better then at a physical therapist at there's opportunity in reading the statute to clarify several things that I think could be clarified in again you know I I'm new at this but it seems like this happens regularly someone brings you an issue and it seems like the simple straightforward issue right I want to get the the athletic trainers to be able to be surprised by a physician and then you start reading it in you read what's currently in statute you just thank man this is muddy and here's a chance to clarify a lot of different issues are I think your points greater mean you can go in here and defined that further if you wanted to to to list a set of physicians who were practicing fill in the blank emergency medicine orthopedics family practice pediatrics have you wanted to define that to to exclude the loop call of you know a physician of any variety supervising athletic trainer I think there's opportunity to improve that when you look at it. Representative Ladyman. Thank you Mr chair up we may be over thinking this amendment there's a lot of discussion here about good points that are not in your bill so I think we ought to stick to the bill and it seems to me that all you're doing is clarifying that a physician can supervise and eighty without. Where they do it and that's simply what your bill is doing that the truth this for a bill but I'm my intentions for being home study proposal so as an incentive because I'd like to be able to look at the variety of things that are of concern to me as I read to the current statutes so hopefully with interim study propose we have the latitude to come in and to amend the bill and create something that maybe does something even better than what you initially attendance is certainly the intent of this bill is very clearly to just extend physicians the ability to supervise and athletic trainer in both the clinical and nonclinical setting which to me doesn't make any sense why would have the bill just supervise in one area of not the other either I'm qualified or not but in looking at this I think there is opportunity why were opening the book so to speak to go in here and clarify several things that occurred to me as I read it. Well that's great if you can add to it and and and make it a better bill but you know don't throughout the good for the perfect thank you Mr thank you. Okay members. We run a hell any other questions o'neill. Carol C. any other so. You agree on sure that I was easy one. So we'll look at em um so. I mean this is an issue we are familiar with this is the issue of of how to create a pathway for autonomy for nurse practitioners in the state of Arkansas to create freedom from the collaborative practice agreement which they currently have in you can phrase that many different ways one of one of the ways is phrase calmly as full independent practice authority so the the goal of the bill of this nature whether someone you have before you whether it's center hammer's bill that was heard earlier committee I mean the goal is the same the goal is to try to recognize in Arkansas that there's a subset of nurse practitioners who met the ability to practice free from collaboration with the position in personally I believe that I believe that to be the case I believe that there is a subset of of nurse practitioners practicing primary care in Arkansas under cloudy practice agreement you have both the experience the education to practice free from that clarity agreement now not all my colleagues would agree with me I and I am somewhat in minority times in this particular stance but I do think that is happening currently in Arkansas I think the club the practice agreement is confused often with supervision to to represent a paid this point collaboration is not supervision these are different things so what I'd like to do the my tent with this bill is to create a better product than what we have now so you know the the bill as I understand Senator hammer is gonna be happy worker Senator hammer and and I want to work with all parties involved in this issue I think this is Tom to resolve this issue in Arkansas it's time for us to get past this is been a scope issue that comes up every session and I'm eager to work with the any the represented in the senator's any the parties involved the one stick point for me which I try to dress with this bill is at some point if we're going to create a pathway for autonomy for a nurse practitioner with a practicing primary care in the same fashion that your average family practice doctors practicing primary care in Arkansas then there has to be some accountability back up to the. Medical board in my opinion because at that point the practice of medicine me for all intents and purposes they're doing the same medicine as a primary care provider. Did any other position Arkansas's doing that's that's the go so that's going to happen for me it's important that there is some accountability to what they're doing beyond just the nursing board now by Ken ability what I mean well what this bill attempts to do is to create a sub board of physicians and nurse practitioners who with first of all look at the qualifications of the nurse practitioners and try to decide who in this subset that wants to practice on promptly by the way there many nurse practitioners in Arkansas they don't seeking freedom from the collaboration there many nurse practitioners are perfectly content to practice side by side with physicians continue to site collaboration agreements in different specialties this is a small subset of nurse practitioner ginger seeking this the idea would be to create the suborder positions in our practitioners the could feel these applications for autonomy. Invent them for qualifications this bill outlines ten thousand hours is something similar it's been proposed for of of practice this is a negotiating point right this is one of the points that we argue back and forth over how much experience is is enough to qualify for autonomy freedom from clarity practice in this bill the proposal be ten thousand hours as a gate keeping mechanism and then you would apply to this sub ward three members appointed by the nurse practitioner board three members I'm not nurse by the nursing board three members appointed by the medical board one member from the pharmacy board to create a total seven in the sub ward the surfboard would look at the applications bet them for credibility and then decide whether or not to grant freedom from Claverack for clarity practice for practice authority. Once that was granted you within you have in Arkansas nurse practitioners that we're continuing to practice under the collaborative practice agreement in this subset they were practicing with full independence toward. In this scenario as these full independent practice nurse practitioners are practicing in Arkansas. Senior in their clinic tree for high blood pressure tree for diabetes doing disease prevention acute disease management all the things that we do in a in a in a clinic with when we practice medicine if there were problems or issues that came up with that provider. Those would be addressed by the same sub ward so this sub board would serve as a filter between the nursing board in the medical board. They would look at these compliance with these issues and concerns and decide is this a nursing issue or is this a medical issue one of the things that was brought in last session when when a proposal like this was discussed was so the nurse practitioners and Hey we're not practicing medicine we're still practicing nursing in that may be there will be the case there's definitely a difference between nursing and and medicine. This would create a board the could look at these concerns issues as they arose and parse them out as to is this medical if so let's referred the set to the medical board for consideration is this a nursing issue of so let's refer it to the nursing board for consideration. Each independent boards and then recommend back to the sub or any kind of action they want to recommend so if it's a critical issue let's say there was an issue with how they were prescribing antibiotics for certain condition and this was a complaint that came up to the board the medical board might recommend back to the sub or did this autonomous nurse practitioner attend some sort of continuing education course on it about a prescription if it were an issue with they were starting out these in their clinic in their mission lots about bees the nursing board might say Hey this is a nursing issue refers to the nursing board the nursing board comes back and says Hey you need to do some skills sessions on starting up these The action. Would be up to the sub board each the medical board in the nursing board to make recommendations the sub board has the ultimate authority over what actions recommended the most punitive action that could happen. Would be removal of the full full practice the authority so the cell board would have the authority to say to the nurse practitioner Hey we've got multiple issues with how you're caring for patients in Arkansas. They don't have any licensure authority that still lies with the nursing board their full authority would be you have to go back and find a collaborative as is that's that's the most punitive paying the sub or to do. So it would still place licensure. For nurse practitioners under the nursing board the only action this board to take other than recommending you know remediation of some sort would be to remove the collaborative a good movie remove the full if it practices story and and require them to go back and find a Class ready. That's a lot of information I'm sorry at the one a lot at yes but it's a concept that I want to try to get across in this feels like the best format to start that conversation if there's questions I'd be happy to try to answer them and maybe that's the right time to pause and answer some questions. Representative Ladyman do you have. Question. Yes thank you Mr chair a represented Johnson this to me seems like a novel idea that I haven't heard before do you know the subcommittee idea. Do you know if that's been use in other states we talked about there's a number of states that are doing something so Senate not to my knowledge would be the first state to be it creating this kind of sub board but I think it's important again just because we're the first to do something doesn't mean it's not the right thing I think the important thing to recognize is that we're creating a system for accountability for how people practicing care for our Kansans if you're practicing medicine in the state of Arkansas you need some accountability track back to the medical board the main criticism of her of this over time has been you know we don't want our licensure under the medical board I don't either that's not what this is advocating for this is advocate for some path of accountability at the most if if we were to just say okay we're to remove the collaborative practice agreement and there's no path of accountability back to the medical board that as nursing as as nurse practitioners have to place just like positions to I mean we get complaints all the time to the medical board it would just go to the nursing board and currently nursing board consists mostly of and I don't know the exact numbers but it's mostly our ends I don't I don't know how many APR enter on the medical board I don't know how many LPNs there's no physicians practicing medicine and so yes this would be Knobel the just because it's novel doesn't necessarily mean it's it's a bad idea giving us a to briefly as there is in there is a sub board pathway already established under the medical board FOR PA's so the difference would be is that the medical board has licensure over PA's they do not and would not under this bill have licensure authority over nurse practitioners. Well as you said earlier this is come up recession since I've been here and probably before that so there definitely needs to be some kind of a compromise and and I think this is one good option to at least look at and discuss so I think it's a good scent it's a good idea to discuss thank you. Centerville. Thank you just and calm and response represent of Ladyman some states have done different variations of types of things in order to address these issues I mean I think his is a new one but it's if there are other states that kind of two different types of approaches on these types of things so much may not be exactly like this but I know other states that have taken different types of approach because of these issues that come up across the I like the idea of this because. Because you really do have such a mixed bag with when it comes to education training experience the different levels you you may have there there is the ability to get an a degree online and so you know there's a lot of discussion about whether an online degree equals you know and in person nursing program at you I am mass I would argue they're probably very different from one another and so you know that that's the type of thing that something like this could really evaluate evaluate the circumstances and decide if it's going to be you know and and to look at all the circumstances and where they're located in you know the need of the community all those kinds of things could be you know does deciphered I would think perhaps in this committee and then like you said if it's a nursing issue at the licensure issue then easily trance you have koncept over but there has to be some sort of accountability as you said back to the medical board and people that are practicing medicine and as we continue to blur these lines you know the bottom line for me it comes down to is patient care and making sure that patients have good solid healthcare and they're not getting you know so the bill good right I mean and that and that we're real clear about that because we want to make sure that you know that's our job as policy makers to ensure that that happens to because of the the people in the state of Arkansas on the citizens were responsible for making sure there's clarity there so. I appreciate what you're trying to do and I think there's just there's such a mixed bag when it comes to education and experience and and you're exactly right there are a lot of collaborating partnerships that exist that will continue to exist just because of the set up in the arrangement and what they're comfortable with and what they're not comfortable with that I appreciate you bringing it for. Thank you senator. Representative Payton. Thank you Mr chair. Representative Johnson I certainly wish you well in putting this issue to bed and I think we've had a lot of discussions as I tried to understand more about your profession in the last couple of the sessions but when you say that the medical board in the nursing board will appoint members of this board. Will I be appointed from within their own board or what could they just be appoint and other people yeah my intent would be they can point to the people it would have to come directly from the board I'm not sure there's enough nurse practitioners on the nursing board to fill I don't I don't have the mind to would be that it would be upon is a large not necessarily from the board from your licensed to practice medicine license for nursing it I do think it's important that the appointees from the nursing board be you know practicing advanced practice nurses nurses and not just our answer opinions I think they ought to be. Nurse practitioner okay well under clear clear that up I have say a probably agree with you there. There's gonna be some hesitation I mean I have visitation when it comes to create new boards or commissions or something like that. Is there any Willingness by the nurse practitioners to if they changed their scope of practice the equal of position would they be willing to just going to the medical border we hit a brick wall there and again I can't speak for every nurse partition the state I have not spoken with any nurse practitioners who would support the idea of just flowing into the medical board I have spoken with with their spectators to like this idea understand what I'm trying to do and appreciate it would does every nurse practitioner agree with this idea now does every position absolutely not and so you know this is this is to me this is the middle ground that I'm seeking to try to find as with any compromise they're gonna be people this point in either side that that I don't know that I. I don't know that I've talked any nurse practitioner to be willing just to flow straight into. Well thank you for that and I'm openly advocating that we reduce the number of ISPs so that we have more time in this session to do take up issues and learn and doing right but I believe out of all the ones I've seen so far I want to make sure this one makes it across the line thank you thank you Sir appreciate it. Okay members. We for any other questions on this one. Representative Ferguson culture partition. What about staff privileges if there allowed independent practice or that they're they allowed stepper just hospitals have will it affect that practice that'll be up to you to the hospital every hospital said some bylaws you know there are restrictions on positions currently and hospitals are there many hospitals are required full completion of residency in board eligibility before they can get staff privileges so for instance in my hospital you have to be board eligible in your specialty if you haven't taken the boards or are eligible suffer the board you can't get privileges so that'll be at each facility in and to decide how they want to find their Sir you know there's a hospital in Chicago that pretty much fired all their doctors a tired A. P. orients it's a fair concerning any time we're talking about scope issues you know there's always this concern that there's gonna be bleeding into territory your medicines vaulting how we practice medicines involving that's I think that you all the scope issues are symptoms of that and you know it. It's it's it doesn't change the fact when you try to dress in some way and what about liability of the nurses in collaborative practice now create same liabilities family practice so it it again as I understand it nurses nurse practitioners carry their own liability insurance at the collaborating physician also ET nurse practitioner collaborate with the have some culpability in liability for that it is the collaborating physician not directly supervising a fallen doing is collaborating and they've a plaque or pricing independently their their liability generally stops and starts with them as I understand it again I'm getting out into territory that I don't necessarily feel confident speaking on with with a lot of authority but my they would they would stay with they are still I think required to Kerry liability insurance we continue to I get I mean I don't even know if they have the same level liability but maybe that should be part of the bill that they're required to carry the same level of love at least in my friend I those are good questions for me to look into an asked have to do that okay thank you. Okay members we're finished bill with the that particular one. Represent Johnson when members we got about five more for everybody's here we're gonna go to is that correct yes thank you Sir percent Mr I think the representatives also approach on this bill as a big thick bill that was brought to me by The. As a psychologist here in state of Arkansas who works there are some psychology association is the compact licensure bill these have been looked at in the past in Arkansas sometimes they've been approved and there's a nurse I think there's a nursing compact licensure bill that was approved Uh this one specifically looks a psychologist and tries to facilitate licensure across multiple states because is a compact licensure bill is until by bill are there's a there's since there's some language in here this fairly standard the one question that has come up is is assuring that this doesn't preempt any Arkansas state laws and I'm looking at that what they are so medical society right now and also looking that would be a large I don't have a lot of information on this bill this was one again I think the German the brought this to me is approach several representatives and and senators in the house in Senate I was the one that picked up the ball and headed to be allowed to rot and so on the one standing here with the ISP of this far as having great amount of information on the details of this I've I really don't I just it in and I'm not entirely sure the scope issue but in in I've been told by bill arts not there's some question might be so I wanted to and followed as an I SP to meet the deadline. Members any comment on this one. Questions. Representative Ferguson. At a talk to a. To represent Johnson about this so he he knows my concerns I also talked to the psychologist that one it brought my concern with these interstate compacts the way I read it and I know you all are still working day the legal issues is that this particular bill preempt state law when it comes telemedicine. And I think that's getting into a dangerous territory see it all the time with state law for insurance where the a recess in the big selfinsured don't have to abide by state insurance law and there's no recourse for people have issues so if it turns out that it does preempt state law with the compact that's a concern the contacts like the nursing home packed as I understand all the state laws still apply in the disciplinary control allows with the state but the way I read this bill is that it does preempt state law for telemedicine so every that would that would be a concern for me and then I appreciate you bringing this to me those thoughts and I don't disagree with you guys certainly not my intent with this bill to preempt any state law and hopefully dealers working on an amendment that would that would clarify that issue force and still satisfy what the psychologist or want to do. Thank you I would have no other questions. Thank you Representative Mr. Okay members of that was I believe Senator hammer is already done E.. Q.. I don't. I think Senator Flippo was. Planning on I've got a text your from another stakeholder this is that uh there will be a request to the cheers to allow him to percent. This afternoon so that that'll be coming you may want to look into that Mr somebody here that wants to present this. Okay. Or. Representative Penzo were you going to present this Europe Sir. What if you get to the table you can start to. Thank you Mr chair. This is an ACT to create the Arkansas natural path that position licensure act I'm not sure if anybody in here even knows what a natural paddock position is probably call. Familiar with the medical doctors DO who's one of my favorite a knee surgeons of northwest Arkansas is actually DO a natural path the positions I'm familiar with the. A measure pathetic position here a that used to practice in northwest Arkansas that's a lot of you all familiar with my food allergy issues I went to three different medical doctors nobody could really figure out what my problem was and I had a friend that went to a medical school in Arizona to natural Patrick school down there and she pretty much diagnosed it over the phone said clinch got food allergies come in we'll do some testing on you. we did some allergy testing pretty much every issue I had was resolved just by changing my diet ahead joint issues skin issues laundry list of health issues my cholesterol improved blood pressure everything seemed to get better just by removing certain foods are not that that is allergic to. So in this case some. Not necessarily down on the doctors they were just were trained on. Food they're trained on drugs you know and none of them sent me to a. A dietician which could have been an option but I just think that. The the way that was set up couldn't bill insurance couldn't the she couldn't even draw blood in the clinic had to send me to a separate facility to have my blood drawn and to take my kit with me million myself get the results back then she could reserve review the results with me there several states that allow Natural Pratt the physicians to practice we just don't have a license in Arkansas judge would create a license I don't know that it'll be a controversial does point I don't think it will be because were place in under the medical board so I don't really FOR see there being too much of an issue senator Ballenger actually those interested Mrs will there actually his wife has cancer they're actually going to Arizona for treatment because the healthcare team in Arizona at the cancer treatment place they're going to actually has a natural Patrick physician that works with the oncologist and the Indy actually focuses on diet and. More of a holistic approach not just the whatever chemo treatments or whatever she may be been administered to the oncologist so five any questions I'd be happy to answer any to the. Okay members you heard the presentation representing Ferguson. Yes this is very controversial and we have had it come up before you were elected okay of I mean it you know there are I just want to assure that I'm not sure for the bill at all but certainly I want to is qualified that they are in dis and not just any natural path over here is understand that there's people that run around at their and call themselves in these it took a two week course right now you can call yourself an Indies you then you can't massage therapist so it's it's one of those deals were like I said I'm not Knockin Indies at all because I mean like I I've got a background as a PTA and I'm a big fan of my chiropractor and that's you know there's time for physical therapist there's a time for a chiropractor in my opinion I think they could in these could be a great asset to our Kansans in their choice for you know what they're looking for for treatments yeah I mean it's there's actually language that prevents people from calling himself natural Patrick positions and like I said this I don't want this to be a controversial apparently it has been in the past but date the need medical training from an accredited college it's comparable you know it's different than in these indios but they have to go to medical school and if that's not the intent the somebody sees in the bill we can work on language and yeah and I had read the bill but I just wanna make sure in the bill that it's that qualifies they have to graduated from a four year in the school that certified and you know that you know like you said there's a lot of people out there Collins so we have to pay at the doctors that or not yes the do you think that we do we do need in Arkansas. Representative rye your question Sir yes I do Sir thank you Mr chairman of Representative Penzo on page two. One two it mentions the. Department of Veterans Affairs. Of. More than thirty two hundred farms just for credited. And number four and and number five it also mentions the department of Veterans Affairs. And in six in line thirteen in. M. mentions the up the United States Indian health service which I'm is that the American Indian. That was making about here thank you probably on the room. Notion Ron pieces. I think it's just not Q. this is our or on shorter I'm sorry Sir no problem I got it was sales no problem thank you mistranslated is a. Thank you senator Irvin. Thank you are you saying the N. D. R. M. E. N. D. natural path okay okay okay because. Well it yes the language just because your were saying it's and on page three it says an individual shall not use or same the title on natural path that physician so I didn't know if we'll worry use any words letters abbreviations or insignia indicating or implying that the individual holds a so. Physician Dr I I'm I mean that's just a little technical thing but is it may I mused my golden natural Pat the doctor's this language was copied from Arizona number I referred to as natural paddock positions right but I think common is the term for and in the okay I didn't know that they're not familiar with that but you might you know you may want to just clarify that in the language that incentive in in P. or in it you know what I'm saying the war in the year whatever yet that might elaborate on that yeah and then did they have prescriptive authority or that. Because I didn't read that in here I'm I'm not sure if they have prescriptive authority in and there's owner or not Dinners they have a hole there entire separate board and I didn't even want to try to approach that when I knew that would be controversial perfectly fine with being on the medical board I don't. I don't know okay perfected the owners own I don't I would be okay with a member's screwed with forty I don't know if that would be a conflict amend the owes an M. dis do I would have to look at how other training if it goes around that usually usually they're more geared towards natural herbal Things of that nature so I don't even know if they would try to some states allow to do minor surgical procedures you know I'd I'd be open to leaving that up to. Discussion in. You know see with the board felt about that I'm sure we're gonna have some discussions we I mean at this because I don't I'm not familiar with this education I don't know what this education looks like either so that's why I'm asking the question I don't see that it's in here you know that they're it and I probably would prefer it not to be in here or if they didn't take you know a good pharmacology course load or curriculum and then they don't need to be prescribing writing so. I'm a surgical skills I mean they're not they haven't taken gross anatomy there you know I have issues with people for for means surgeries to. Didn't take a gross anatomy you know course served or trained under a surgeon's so but I but I just ask the question because that wasn't in here and this is a new licensure so I'm just trying to understand once we you know we create and the licensure then what's the next. Thing and not I just don't know what that looks like because I'm unfamiliar with that that. As I know we have lots of people tested for food allergies you know under the current. Mainly children three children's hospital has a very good allergy but you're an adult so that probably would not apply to you but I just wanted to ask the questions thank you thank you. Thank you senator of five Representative Ferguson and then we'll go to represent Laderman. A I might say this just to as the help of. One of the reasons that other states have given them licensure because without licensure and parameters it is kind of the wall west out there I mean anybody can call themselves a natural path and do you know whatever they want to see to like so we need to find natural path in set rules and you have licensure it does provide some protections because I do think there are some baggy to homeopathic treatments but I mean that that is one of the arguments for providing licensure is that it it defined stature path with certain training so anyone working outside of that can be of chart you know charged with a crime this. VX seven there's there's a lot of people that refer to themselves as natural path that doctors like I said it took a certification course in the you should be able colors of a doctor that particular certification course of full totally agree with you. Representative I'd. Thank you Mr chair Representative Penzo you may have answered this I'm not sure but I know you look at Arizona's bill this is kind of based on what they're doing how many states do you know how many states have this licensure program right I don't off the top of my head there are more than one level I would assume so yeah okay I thank it's just there's on was a state I was familiar with because it's were a mod by indie restrained was in Arizona and Roche's dresses several sessions ago but she's actually no longer working in Arkansas because it was too difficult to Michael Levin with all the restrictions honor. Okay if they know of no further questions on that thank you Sir thank you. Okay members we are going to AS. Representative gray. You're set to go whenever you get there. Thank you Mr chair yes ma'am all right so I actually is filed this late to a last week I believe as a response to rule forty six that came before us in a L. C. I just a month or two ago I dealt with a static saying cosmetic procedures. I didn't whereas language because it got to be honest I'm not entirely sure what the problem is I've worked through and work through and had meetings and meetings I know we probably need to do something in the find it a little bit better defined the scopes a little bit better but I don't entirely know what that is yet so I just broadly did somewhere as language in hopes that that would satisfy the chairs to move forward with this I would say that with this I would like. The state medical board the nursing board and also those practitioners to are doing these procedures both physicians and nurse practitioners to all be in agreement I don't want to run something that's going to have somebody mad or upset I just to have nothing. because honestly I'm not entirely sure what the problem is right now and so anyway she's running this preemptively in hopes that if we can come to some sort of an agreement that will run it through as a scope of a bill this next session that's kind of what we deem the language that they brought to was a rule forty six is that it was in my opinion it was some scope changes so I'd be happy to take any questions. Representative Johnson you have a question just a comment if I can yes Sir Senate just appreciate the thought I think it's the right thing to do that I hope that the committee would consider this and give some leeway to this option because I do think it's something that there may be some up to better define anti to clarify and and provide you know better care across the state in this round and so I appreciate the effort and hopefully we can get to it like you say if there needs to be action this opens the door for that thank you. Sender one. Echo those comments just because. I think my big concern you know I don't want an LPN they they there's got to be some real Claire language here and and I think eighty are and send physicians physician assistants perhaps to my need to be looked at I don't know if that's the case or not I don't know if that came up in our discussion or not that it might be something that we need to look at but I do think there has to be a kind of a level there and I'm I guess you know I think maintaining the current. Love who can and who can't but then figuring what's actually going on out there and bringing for the solution is needed but I have no idea what that looks like. Thank you are they be there if I tried to write this I couldn't figure out what exactly I need to do just yet though I mean I you know I do want to say that on rule forty six I do I do want to thank the the medical board got beat up pretty badly and and I you know and they they tried really hard to work with the nursing board and and everybody and so I just I do appreciate what they did and the nursing board to I mean I do appreciate the two of those people those groups coming together and trying to figure this out so I'd you know I hope that we can kind of men's a little bit of that because I think they were just trying to come I think they're coming from a good place but got messed up in the cross hairs thank you I I agree. Happy to help you with that thank you know what I agreed to it was actually it was great to watch both boards work so well together add to try and come up with something addition I feel like we we didn't quite get there but I think we can get there during the session. Thank you senator Irvin represent gray I don't see any further questions so thank you appreciate your presentation thank you okay members there's nothing else on the agenda are there any other comments questions before we adjourn. Okay seeing none will will consider it adjourned.