S.B. 31 Office of Professional Licensure Review Amendments: transcript

Thank you, Mr. Chair. Uh, this bill seems to always attract a lot of attention every year. Um, since we implemented scope with, uh, LER or Office of Professional Licensure, we, um, looked at a number of different professions. This bill has some moving parts to it, and there's a number of different professions we're looking at. Um, it's been a very thoughtful process started throughout the, it's been discussed throughout the, the interim throughout as we've discussed this in business and labor. Let me go through the bill and tell you, I, there is a substitute out there and it's substitute one, and that's what I'm going to address there. Also, um, there, there's a couple of minor, well, I wouldn't, I don't know if they're minor, hopefully they're minor, that we've, we've still gotta correct on some things and I'll talk to you about those as we go through. Uh, let me, in the spirit of time, let me just kind of dig right in. Okay. And talk about the specific, uh, professions that have, are addressed. First, as you, and this is kind of in order as you kind of go through the bill, uh, physical and occupational therapy, it would def uh, if you look at the summary that we've given you, and I really appreciate the staff putting this together. Tyler and Ronan have been amazing and doing this. And, um, the bill would, would expand the definition of dry needling is allowing under the scope of practice permit physical therapist to prescribe durable medical equipment and allow phy physical therapists to order medical imaging. Additionally, it would modify the scope of practice for physical therapy assistance and AIDS regarding joint mobilization techniques for occupational therapists. This bill would permit licensed therapists to prescribe DME and grant rulemaking authority to dopple to regulate supervision of occupational therapy assistance. You can kind of see that summary of the, with the check marks and the XS on, on what can happen there. Um, while, you know, if this physical therapist currently have statutory authority to order X-ray and imaging, it does encompass, uh, you know, the full breadth. So there's a little bit of change there. A physical therapist is still bound by statutory requirements to collaborate with a physician, including attaining an agreement from the physician to accept the imaging and requirements to refer a patient to a licensed physician for anything beyond the scope of practice. Moving to nursing, and this has probably had the, the most discussion about it, and there's, uh, it would limit, um, would grant limit limited peri-operative prescriptive authority to CRNAs. Uh, and so those, and re and so this didn't require A-A-P-R-N licensure applicants to, lemme, lemme stop. The CRNA portion would allow them to, uh, prescribe medications, you know, five days before or five days after a procedure. I will tell you that they're on, you know, this, the wording surrounding reference to scope of practice in line 1338. We're still having a little bit of discussion about that to make sure that's the correct reference. So it's tight enough, but not, uh, getting out outside the bounds of what it's supposed to be. So, but with that, that's, that's essentially what it's doing. It could be a, a limp, it could be a prescription, just a regular legend drug, or it could be a controlled substance two through five. Uh, this is the point where it's been probably the most discussion is about the a PR and licensure. So a nurse practitioner licensure. And, you know, the discussion has been, and how do we make sure that the, the student coming out of the school and, and moving forward for licensure, uh, has enough, uh, experiential rotation hours. And, and it's interesting enough as you know, you kind of got, I've given you this little dial here and we appreciate the American Medical Association for doing that. It's really, you can play with that a little bit and it's kind of fun. But let me kind of tell you where we started and where we, where we're at, and maybe how we got there. So as we started, you know, the, the reference recommended coming, uh, from LER originally was 6,000 hours. Um, the proposal and the bill is 2000, but that's also inclusive of the hours that are accumulated as a student goes through nursing school and nurse practitioner school. And, uh, you know, Senator McKay actually had some real thoughtful questions this afternoon that we were talking about this and how do we get there? Um, as, as a student in Utah goes through nursing school and then to nurse practitioner school, you typically get 1,250 hours as you kind of use this dial. And you scroll around and look at some of the professions, related professions and how many hours that, you know, each profession gets within their core coursework. You know, roughly is about 2000. You know, if you could average that out. So the proposal was to add that, that 750, how would that work for a student? So a student that goes to nursing school, uh, most of the students, uh, will work as a nurse for a period of time before they go to nurse practitioner school. Those students would always already have their 2000 hours. They're going to accumulating, even as a licensed nurse or in school as a nurse practitioner. If a student, uh, went straight from nursing school to nurse practitioner school, but worked as a nurse while they were going through the nurse practitioner school, they also very likely accumulate the 2000 hours. Um, they could accumulate them, like I say, either as a nurse or as a nurse practitioner. Uh, there's a small subset of students, and this was identified early on as ocular started to look at this, that there is a small set of subset of students probably somewhere between 10 and 15% of the applicants that would go directly from nursing school to direct then from nursing school to nurse practitioner school, and would only accumulate the 1,250 hours. Um, we would require that for those students, it would require that they get the additional 750 before licensure, which is roughly, if you're doing a 40 hour week, it's like four and a half months. But, uh, that, that's how we got there. Um, I will tell you this, that has been a very delicate and thoughtful deliberation and negotiation quite frankly because we, we have some factors that come into play here. You have the, obviously the local nurse practitioners, those representing that association, but you also have a national organization and they, uh, they direct, uh, what states qualify for full scope of practice in a state. Utah is one of 27, I believe, states that have that designation. And we certainly don't want to do anything to disrupt that. So as we were talking about the 6,000 hours and those thing when original that was, that was going to disrupt that designation as we started looking at it and focusing on what was best for the student coming out and the patients that they would be treating in looking at the 2000 hours, that does not disrupt that, uh, that designation. And we do have, uh, agreement from those organizations that they, they support, you know, this concept of the 2000 and how we're proposing to go about getting those hours, um, athletic training, um, it would expand the scope of, of athletic training trainer practice to explicitly permit them to work in occupational settings, create new restrictions on athletic trainers that require them to collaborate with a licensed physician for certain types of injuries and would provide an alternate cardiac care certification. Uh, respiratory care, I think you can read that. It says this bill would it basically just reinstates and modifies the respiratory care apprentice license, uh, physician assistant, um, here again, would looking at hours, uh, physician assistants, uh, my understanding go to one year less of school than a nurse practitioner. And they, the current requirement is 10,000 hours to, for a physician assistant to be able to practice independently. If you look on in the summary, there's some sig you can see that some states have different requirements. Utah has been higher than any of the other states, at least those listed. Uh, the proposal in this, this bill, uh, is to change that from 10,000 to 808,500. Um, there is one piece that I need to identify that I have not, we have not solved yet, but we need to, uh, we're, we just recently made aware that in the, with the cosmetology act that was passed back about 13 years ago, it was allowed the physician's assistants could do certain procedures with a dermatologist in an office. You know, for example, removing a mole or doing some suturing, those types of things. Um, there was a case that came forward and then it ended up in with, uh, in, in court and with, uh, doppel re recognizing the fact that the determination was that that really wasn't correct in code. So even though that practice has been in place and physicians have been using nurse PRA or uh, physician assistants for a long time to do that, it now currently based on that determination, is not, not appropriate in our code. So we need, that is something we need to correct and to basically just restore practices. It's been for the last 13 years that is not in there yet. That is something I still gotta solve and we're working on the language on that. I, it's, uh, we will have that soon and certainly we'll have before we go to the floor, if the bill moves outta committee acupuncture, there's, you know, some things with acupuncture. And also there was some, some, uh, thoughtful negotiation on that too, because there was looking at adding some, there was proposal to add some medications that we could use there, and we pulled that out and just, you know, decided to just leave that up to rule with dopel as and move forward if there's, if they feel like it's appropriate that way, all the, uh, all the stakeholders can have input on it and, and so we don't designate it in statute. Um, and like, like I said in the interest of time, Mr. Mr. Chairman, I think I'd, uh, that concludes my presentation and I'd be open for questions.

Yeah, I'd make that motion that way. Deleting title and body Senate bill 31 and replace it with first sub Senate bill 31.

Everything that I addressed you and the summary that you have before you is related to the sub.

Thank you. Chair. Did you say you were gonna add some cosmetology stuff in in this? Yeah,

Excited. I was worried that we weren't gonna do with cosmetology Act, physician's assistant's ability to do things related to the cosmetology act, but nothing

Here's, uh, okay, I'm trying, so I I the nursing, uh, question we talked about earlier. I'm just trying to figure out, you know, currently in the code, how many, how many minimal, minimal minimum hours of clinical nursing experience do they need? Uh, you know, before they become an A PRN?

Actually, currently there isn't any specified, so it'd just be assumption that the 1,250 that they accumulate in school would be it.

Yeah. So that's why I'm, I am, I struggle with these things where we, 'cause the phy, the physician's assistant actually highlights this problem actually better than the nursing problem in my opinion. But Wyoming zero, North Dakota, 4,000, South Dakota, 6,000, Montana, New Hampshire, are we just like, is our goal to be just slightly worse than everybody else, or slightly more than everybody else? I'm just trying to figure out the rational basis behind why we're drawing lines at entry to practice in a world where like, hands-on participation, you know, you've got AI and, and other, you know, folks talking about how the medical profession itself is going to be irrelevant in the next 10 years. You know, I'm just trying to figure out why we're gonna push people in their practice out longer before they can, you know, do their own thing or whatever while they wait for machines to take their place, I guess.

Yeah. Thank you. So just a clarifying question if I could Mr. Chair? Yeah, go ahead. When you're referring to that, are you talking about the PA hours or the nurse practitioner hours?

Both. Okay. 'cause the pa the PA we're looking at, you know, taking it from 10,000 8,500, which is lovely, but I'm looking at those other states and I'm thinking, well, why are we more than them?

Okay, thank you. Um, for the nurse practitioner, it, well, both of 'em, I, I think in the medical profession, especially people that are, are treating patients, uh, there has, it is, it is the norm that, and quite frankly, for good reason that students get good supervision as they go through experiential rotations before they are just turned loose. So for example, the, uh, a physician, you know, they're gonna go through medical school, they're going to, uh, do through an internship, then a residency, and they accumulate 12 to 1600 16,000 hours of supervised, you know, experiential rotation. Um, the value, it certainly determined that the value of that is that having that, that student, and I've been, that I've been that student in, in pharmacy, I, you know, I would really appreciate it when I had somebody look 'em over my shoulder when I was trying to learn some of these things. So the, the idea of for the hours simply is to make sure that that student is prepared once they, because once that student in nursing and once they reach the certain hours and a physician assistant, the, uh, and maybe clarifying physician assistant, the physician assistant that is not practicing on their own does not need 85, 8, 8, that 10,000 hours. It's only if they're practicing on their own. Right? Um, so nurse practitioner, if, uh, if they're, if they're going to be, once they receive licensure, then they can practice on their own, right? So that was the determination. There should be a little, uh, a certain amount of diff uh, change. But here, again, going back to that, uh, that student or that subset of students, you're, you're really only talking about a student that goes through nursing school then directly to nurse practitioner school, and then comes out the 1,250 hours that they typically get during school. Some of those are simulations, some of those are direct, you know, patient interaction. And so that's where the 750 comes from. And like I say, 8500, 80 5% of those students will already accumulate those errors for every ever graduate. Um, the pa um, uh, recommended was, you know, 10,000, um, or that's where it started at. We're recommending to decrease that. Um, I would, I, you know, just candidly, I would've preferred to a lower number, but those was some negotiation with stakeholders. That's where we're at on that.

Who wants these numbers higher? I mean, my understanding is this is, this is just me. LERs responsibility is how, how do we prevent the state from being a gatekeeper to entry to profession, right? How do we make sure it's competency-based? How do we make sure that it's evidence-based to reach these requirements? And my problem with the way LER has approached this is it sure feels like a dart board at the moment where they've got quote stakeholders, uh, that are trying to drive the numbers higher. And I get it. There's always the medical association who really, really, really wants to prevent encroachment in their practice area. The only one, you know, I mean, we could have got the estheticians in this bill too, that could have been more entertaining to Senator ER's point, but I'm, I'm just looking at, you know, even the wheel that that's on here, we're talking about 500 to 700 hours, right? Uh, on the nurse practitioner assignment. And I'm, I'm trying to figure out why we're at 2000 when the wheel here says five to 700.

Lemme clarify that. It's a decent wheel. If I could Mr. Chair. Yeah, Go ahead. This doesn't include the 500 they get from nursing. This is only while they're a nurse practitioner of the seven 50. So currently a student would have about 1,250.

So, but then even then, our 2000 is still exceeding this. It feels like, I, I'll say this, it feels like the nurses and the PAs are lesser constituents in this negotiation of stakeholders with ler. And I'll just tell you, it's very disappointing for me as a lawmaker looking over LERs shoulder. This isn't why they were created. They were created to streamline, to make things better, to make things evidence-based, and to focus on specific numbers that are competency and core based. That's a professional licensing program, right? This is my goodness. It just feels like we should have more hours for these people. And while I, I appreciate what LERs saying that isn't very persuasive. Like I, I'm just trying to find evidence. I, I see numbers that they're, that they're recommending, but that just feels like numbers. I, I don't feel like, so I don't know, feel like a, you know, if you're a long tail cat in a room full of rocking chairs, you're trying to negotiate your way, they put a blindfold on you and say good luck. And that's how it feels to me when I look at this, if I'm a nurse practitioner, or on the other hand, if I'm a pa I feel like at the end of the day, you're, you're sending me into negotiate over, you know, how badly I'm going to be hurt. I would feel badly. And I will just say this from my perspective, I just look at the, I can't get to a yes on this bill when it feels like, I mean, in so many other good parts of this bill are, are helpful. I just do not see, I've not seen any educated, you know, information. Is there a survey, like have they, uh, beyond a survey that they presented in interim, like the one in interim was, I don't know, felt like a opinion poll more than anything else. And there were a lot of MDs included in that opinion, which at the end of the day, you know, bless their hearts, they've got their own agenda to protect. So if I just then put all that aside and say, okay, what's, what's the right way to handle this? In my mind, I think we should take this back to wherever LER got it from on the additional hours and force them to come up with a number that is based on evidence that's going to show better care, that's gonna show better access to care. And that it also balances the cost. 'cause nurse practitioners bill and so do PAs bill at a lesser amount. And that in some ways feels like what the docs are trying to do. Bless their hearts. I'm using that a lot today. My grandma says it a lot about me. Um, but I'm, I just look at it and, and I'm, I'm trying to figure out, I appreciate that the doctors want them to have more. I just don't see any research to get it there, you know what I mean? And additional hours with no research means we're gatekeeping. Uh, do you disagree with that? Yeah,

Go ahead. Say I respond Mr. Chair. Yeah, that's the question. Thank you. Um, the, the practice and the assumption and the pro proof is in the fact that in medical fields, students need experiential rotation. Let me point out, physician assistant, how many hours do they, they acquire during their training, 2000 nurse anesthetist, 2,500 pharmacy, 17 60, 17 40, um, nurse practitioner, 750, we're actually giving the, the 500 plus the seven 50 bringing into 2000, which falls into the realm. That means that they're simply in their experiential work as they're in their core CU curriculum, are gonna get about the same number of hours If other professions have proven time and time over that, it's, it's best to have a student have that number of hours. And quite frankly, you can't, you can add, you can put a number on the hours, you can't put a number on the quality of the hours. I don't care if you're trying to become an attorney or anything else. It's those quality of hours. So it really is up to the preceptor and those people that are, they're working with. But that's, that's where, that's now I, I can't speak for ler, but that's where I came to the conclusion that that's what's best for the student and for the public. And by the way, I forgot to mention that that portion of it is, does have a delayed implementation date until 28, so that we can make sure we can work through it. So I don't know if that really answers your question. I can tell you, I just tell you how I got there. Mm-hmm. And why

Yeah. Um, so as I, as I look through the wheel, so let me just ask, the wheel comes from the American Medical Medical Association. Is that doctors? Is that, is that, who is that? I apologize.

I don't know. That would be doctors. Okay.

So doctors think it'd be a great idea to limit the practice of people who might competitive, be competitive with them. And this wheel is an interesting tool that I can see that they, they like. Um, but

Well, of course they do because it shows they're getting 12 to 16,000 hours on everything. Yeah.

And, and the debt they get to pay for, it's probably miserable. That just shows you how much society values lawyers. Literally, they haze us with an exam and then they say Good luck.

But it's just data. It is just, and I'm, I apologize material no's. I shouldn't be Interrupting. No, it's good. Yeah. It is just data. Right. Um, but, you know, and it might be based on averages. It's, you know, there's a lot of things that go into it, I'm sure. 'cause this is certainly, is certainly simplified. Yeah.

Okay. But I look at, I go back to the PAs, why, why can't we be 6,000 or, you know, like between Montana and, and I'm just looking right now, if I call a doctor, you know, my primary care physician, I'm at least 45 days out for an appointment. I've gotta schedule before I leave. And we're like hurting to get people into services in a lot of places. So I'm, so, I, I'm just trying to figure out the rationale of making it harder to do that, that that's, uh, legitimately I'm wrestling with. I know you're, you're picking your opinion. And, and, and that's fine. I'm just on the other side of it saying, why are we going to make healthcare less accessible, more expensive, and harder for people to get through to care for themselves? That's, that's my overarching question for you.

So overall, if as I look at this bill, there's lots and lots of what I would generally speak, look at as a conservative, your, I think, minimizing hurdles. So an even expanding practice. If, if you were just to simply say, out of all the different aspects, and there's a lot that you changed in this bill, is, is the item that was earlier that we were talking about in increasing those hours, is that the only, only section where you've, in essence, increased maybe the, uh, requirement or increased the hurdles with exception of, well, what is that? Is that the only spot you've ever increased?

Yeah. Everything else is, if I could Mr. Chair. Yeah, go ahead, Sarah. Yeah. Everything else is a, an expansion of practice to a certain extent. It's limited, but it is an expansion of practice. Yes.

That's, that's what way I looked at it as well. I, I do have some reservations along those lines as well, although this is somewhat overwhelming to me. Um, there was a lot of numbers you were throwing out there, and I'm still trying to wrap my head around them up here. But this, this is in my mind, a great bill short of one item. And I'm, and, and that item is the only part that I'm, uh, that I'm caught up on. Um, and I suppose, you know, your, your last bill, the one, was it one 50 on the technology? Yeah. Mm-hmm. Man, that was, that's just one of those things where I'm, I'm so excited for it because we can rely on kind of a process to establish scope of practice and everything. And, and, and we don't have that to rely on here. I suppose this still has to be someone in the field, you know, that knows this world. Um,

Yeah, I would say that, if I could Go ahead. Go ahead, Sarah. Yeah, I would say that the process has gone through by ler and I, and I can certainly let them come up and defend their, their actions, but it was done very much in the line of scope of how one 50 is set up, because they did involve a lot of, a lot of, uh, practitioners in the practice and others as they went through the, the research on it.

Thank you, Mr. Chair. You know, I come from a world of safety. Things are based, based on safety and safety protocol. And I think let's not ignore that. We've gotta have safety for the public. We've gotta have safety, that the training is adequate. And I think we need to be careful that we don't shortcut that. Thank you.

Thank you, Mr. Chair. Jeff Shumway, office of Professional Licensure Review. I appreciate the questions. Um, those of you who are on this committee know every year for the last three years now, we've come with a slate of recommendations that are 90% deregulatory each year. There's been one element where we were surprised that there was some unregulated harm, and we called that out. So we did that with cosmetology around requiring certain reps on the highest danger elements that they did with illicit massage businesses. We, we brought forward a recommendation to more tightly regulator illicit massage businesses. But then again, like nine out of 10 recommendations have been deregulatory. I think you all understand that. And that's based on the criteria we've been given by you all in statute to balance safety with, with access. In terms of the specific questions here, I was similarly surprised to find that, that there was essentially this loophole around nps we're supportive of full practice authority. We think it does wonderful things for the state. And I think Senator McKay's instinct there is correct. I do want to correct one thing that the sponsor said. The 6,000 hours recommendation that we made would've affected about 14% of licensees at 2000. It affects 1%. So about 75 of the total number of licensed NPS would've been affected by that. So it's very narrow, and it's targeted only to those essentially who would go straight from RN to NP to licensure, to then being able to open their own clinic. So the intent is simply to close that loophole and provide a speed bump for those very small number that might move straight through. One last thing to make sure everyone understands. Currently, the NP accreditation does not require you to have done live reps of any particular skill. So you'll be taught didactically, you'll do simulations, but you do not have to have any live reps on core skills, such as a pap smear, right. Things that are fairly core to being a family practitioner. And that's part of, of the concern here too. Thank you.

You said it's only gonna affect 1%, but all, uh, all uh, nurse practitioners have to comply with the, and all new entrants into the field have to comply, right? With The 2000 hours? With the 2000 hours? That's correct. So The one, so that number 1% sounds like 1% of current practicing, or 1% of, 'cause what I understand from Senator Vickers presentation is we got to 1,250 between the schooling that they had, you know, to get to that point. And then there was, we're requiring additional, what is that? Uh, seven 50. So we're adding another 750 hours. And our purpose for adding another seven 50 hours is for everyone. It is not just for those that are in that narrow channel, correct?

That is correct. Okay. Can I, can I explain the, the calculation?

Go, Go ahead. I'm just trying to figure out how you get to 1% when it affects a hundred percent. Yeah.

So the, when we did that survey, the survey was was of nps, and it asked them, how many clinical hours did you have upon licensure, so that we would know that as a basis to see if this was a big problem or not. The response that we got was, essentially, there was only 1% that would've been, that would've hit this screen of not having that additional 750 hours.

Okay. So it applies to all, we think only 1% would actually hit that wouldn't be able to hit that 2000 hours naturally. And how many did, was there a hundred percent participation or was this

Yeah, it was sent, it was sent to every single NP in the state. The response rate was quite robust. I want, I want to say, I wanna say 30%. Thank you, Jordan.

My name is Brad Powell. I'm on the board of Directors for American Physical Therapy Association. I'm a doctor of physical therapy and a private practice owner. And I want to draw your attention to the portion of the bill that talks about labs. I believe that LER has done a phenomenal job for our profession, identifying areas that are a significant barrier to us with DME and also with imaging. But, uh, part of it was removed with the labs. I believe labs should be included in that bill. Um, particularly because of the limitations of access to primary care physicians. OLER had us look at curriculum with the University of Utah. That was part of my role. I was interviewed in this, uh, investigation, and we looked at all of the curriculum at the University of Utah and Rocky Mountain, which were the two schools that, uh, allow that, uh, to have physical therapists in their, in their schools. And the curriculum is clear that we are, um, taught on all lab education. It is on our boards. Um, we are required to know all of those factors. And if someone does have limitations with, uh, balance disorders or fractures or electrolyte deficiencies, anything along those lines, it is, it allows us to order that imaging and to Senator McKay's point 45 days, it takes a while to get into primary care. So it allows us to identify that early. Thank

My name's Leslie Fabian. I am a practicing physician assistant of 19 years, and here representing UAPA as their current president. I wanna thank Senator Vickers for creating legislation to allow us to give our patients haircuts after we perform their annual exam. But in all seriousness, um, I do wanna thank Senator McKay for recognizing the legislation of our neighboring states in this country, uh, but also wanna state that UAPA is supportive of the change to decrease our supervised hours from 10,000 to 8,500 hours at this time. Thank you.

Go ahead. Hi, I'm Shelby Brook. I'm a current PA in Draper, Utah. I have practiced as a surgical PA for about six years now. I was recently sent a letter by Dopel saying I had to assesses a all ablative procedures, which included any vaporization, disintegration, or removal of live tissue. And after clarification, they said, this includes mole removals, skin tag removals, liposuction, scar revisions, which I have been doing under supervision for tens of thousands of hours. Um, and it's completely changed my practice. I've had to reschedule. My clinic is primarily in office procedures, which I've been, I've been trained directly by a plastic surgeon, and then four days outta the week I am in the, OR assisting him. Essentially, what this would do, he, they specified, even under direct supervision, I couldn't be delegated these ablative procedures, which means in the or, I would not be able to do my job, um, as many surgical PAs wouldn't be able to, which would make the profession obsolete in Utah. So, um, I think that's the additional language that we were gonna work with Senator Ipson of just clarifying, I do think patient safety has to be at the center of it, and there needs to be regulation, but not that vague. Thank you.

Hi, my name is Justin Keer. I am here representing, uh, I'm the chapter president of A PTA, Utah from Millcreek. I'll keep it brief. I just wanna thank LER for their thorough review, um, and work they did, which confirmed physical therapists are already educated for the responsibilities in this bill. SB 31 aligns with our legal scope within our doctor level training and exam diagnosis and triage without expansion. This improves patient access in Utah's primary care shortage by reducing handoffs, delays, extra appointments, and out-of-pocket costs. Uh, I think more, more particularly, more importantly, models like the military already trust PTs as neuromuscular skeletal providers within these boundaries. Um, SB 31 modernizes our practice act to match our education. Um, I also appreciate the words of Senator McKay and being mindful of maybe some other outside influences that may be trying to, um, change some of these things. But I appreciate your, uh, support and thought on this bill. Thank you.

Thank you. Next, My name's Julie Bock. I've been a proud nurse practitioner for 32 years. Um, I wanna thank the committee and Senator Vickers for their work on this bill. Um, there, it has been a long process, a lot, a lot of conversations, um, regarding this. So currently the nurse practitioner, so I represent Utah Nurse Practitioners. I'm their education chair. Um, the nurse practitioner portion of Senate Bill 31 is the result of a compromise between local and our national nurse practitioner organizations, as well as the Office of Professional Licensure Review. Although our organizations prefer not to have additional restrictions on our, um, entrance to practice, we do respect the legislative process, and we are comfortable with, um, the compromise.

My name is Wes Barton. I represent the Utah Association of Nurse Anesthetists. And, uh, we kind of want to say the same thing. We, we appreciate the work that LERs done and that Senator Victors has done to, to create this bill and to, and to provide parameters, uh, for us to, uh, prescribe medications, uh, in a safe, uh, situation. Uh, and we, we, we really, we, we feel like the, the, the work has been put into this bill to, to, to help us improve access to healthcare in, uh, especially in rural areas. Uh, one we do have one problem with, with a little bit of the wording, um, that, that does not allow us into dental practice or, uh, private physicians, uh, clinics. Um, but we're working with, with Senator Victors on that to, to clarify that. But we, we, we like the direction that we're going and we appreciate the work that's been done.

Thank you, Mr. Chair. Michelle McCumber with the Utah Medical Association, just to address a couple of, um, comments by Senator McKay. So, there are only six states that allow physician assistance to practice independently. We were the first, we, um, came to those hours after a, a, a lot of talk and, and consideration. Um, the, uh, our hours are collaboration. Some of the other states are supervision for those many hours, and it isn't just with a physician. The first 5,000 hours is with a physician, and the next 5,000 was with a pa. Um, there are 26 states that allow independent practice for, um, nps, but not all states. So we actually have quite, um, an extensive, uh, uh, workforce here in those areas. And, and we support, and we always have supported PAs in what they do and nurse practitioners and what they do. We do think it's important to keep in mind patient safety. The a MA wheel, by the way, was put together with the input by all of the groups in those specialties, um, on the hours, so it wasn't in a vacuum. So, um, we appreciate, uh, Senator Vickers work on this and, um, and LER and what they've done. We, uh, will continue to work, um, in the different areas like with, uh, fixing the pa, uh, piece that they've been able to do already. But, um, thank you so much.

Um, you mentioned patient safety several times, and I, again, I, I get some, what I'm gonna ask is coming from me and not knowing exactly all the details of this, but just doing quick research here, malpractice suits, it appears that physicians, uh, that clearly physicians are, are sued under malpractice more often than the mission. Uh, physician assistants, nurse or practitioners. I don't know what the, you can't quite access complaints, um, in, in Utah through Doppler. I'm sure there's another way I could access, but I couldn't get it. So can you just speak to that? Yeah, because we keep talking about patient safety, but it clear the data is not quite

Clear. That out. Well, I can, I can speak to that. Okay. You don't have nurse practitioners and PS that can do neurosurgery or cardiac surgery or other things like that. I mean, have much more acute

Much, much more acute care. And then you have, uh, different levels of care that are given in different areas.

Senator, uh, just a follow up, but isn't that, I suppose the, the point there would be the, it, by their nature, their practices would be less wide and less, um, put them in a circumstance where they need less training. And I suppose, um, I, I, I, I recognize there's a difference. That's, that's clear, but it's all about economies of scale, I suppose.

Right? Um, I don't disagree with you. I mean, but I don't think we're, you know, it's asking for the same amount of hours or the same amount of training.

Thanks. Um, will you stay there for a second, Michelle? Oh, oh, sorry. Go. Yeah, I'm, I'm looking for, I'm looking for the science, right? Mm-hmm. I have doctors, you, everybody else yelling at me and telling me how important in 2020 through 2022, where is it to follow the science Uhhuh? Where's the science? I, I don't see the science. That's all I'm asking for. Prove to me how this improves care, how it makes medical care more expensive or less expensive. And prove to me that it makes it more accessible. That's all I'm asking. I know your negotiated point would probably have the hours closer to 20,000 for both, but let's just look on the other side. Okay. I want to hear the science. That's all I'm asking. Prove to us that the hours that we're asking for is worth it. Do you have science to support that these hours improve any of those things?

I I can get you information, um, that supports many much of this. Yes.

Much of this does not sound super encouraging. Well, but I'll wait for it. It sounds great. Okay. Bring it to me. That'd be great. Thanks.

Hello, my name is William Welch, and I'm representing myself today. I am a Utah native, but currently reside in Nashville, Tennessee, where I'm attending Vanderbilt University in a psychiatric nurse practitioner program. I would like to raise some current, some concerns regarding these specific hours that were required for nurse practitioners in the State of Utah. Students like myself began these programs before the bill was introduced under the existing statutory framework, which is not required. The 6,000 or now proposed 2000 hours without a grandfather clause. Individuals who complete accredited programs will then pass national board examinations and obtain national certification as nurse practitioners would nonetheless be unable to practice as nurse prac nurse practitioners in the state of Utah. This bill, as stated right now, would require those in my situation, who graduated as nurse practitioners, to then revert back to registered nurses, gather more additional hours, and then be able to then revert back to working as nurse practitioners, rather than continuing to working, gather experiences as a nurse practitioner. So I respectfully ask the committee to consider an amendment adding a grandfather clause that would allow those who are currently attending or who were enrolled in accredited nurse practitioner programs prior to the bill's effective date to be licensed under previous law.

Thank you. Chair. Could I ask him a question?

Yeah. If I could ask the witness, um, when do you graduate from nurse practitioner school?

I will graduate from nurse practitioner school this fall in August of this year.

Go ahead, sir. You would be Exempt from the bill. Yeah, you would be exempt. Okay. Is there, How many, let me ask a follow up question. How many hours have you accumulated through your schooling and outside work, either as a nurse or a nurse practitioner? Have you accumulated up to this point?

That's a great question. So my particular program in Nashville at Vanderbilt allows those who are not registered nurses to, uh, start this program and then eventually become nps. What they do value is other healthcare experiences, such as being a tech, being a scribe, being an EMT, but those are not RN specific hours. Okay. So once we graduate, we get our RN on our way to become a nurse practitioner. Uh, the schooling lasts about two years. I, I do not personally mark my hours down. I, I don't know what that would mean for the state of Utah, but, um, in terms of the specific RN hours, it is quite a, quite a barrier to those in this specific situation.

Okay. Thank You.

Yeah, because, because there is a delayed effective date. Right. Um, you in your particular case would be exempt.

Senator, am Am I live? Can you guys hear me? Yes, I can. You know the rules. Thank, thank you, Mr. Chair. I, I will, uh, echo what Senator Plumb said. It's intimidating to, to testify before you. I wanted to answer Senator McKay question. When we first ran the autonomous practice PA bill, the 10,000 hours was not just

Sorry.

Well, Mr. Chair, I am sitting right by the Jimmy Johns in Cedar City. Uh, okay. On my way to fly hot air balloons. My name is Kurt Bramble. I was the sponsor of Senate Bill 27, uh, 26 and 27 and 28, I guess it was, that established the autonomous practice. I, I, I'm currently affiliated with the Lockhart Group. Uh, the Lockhart group does represent the PA association.

So, so the 10,000 hours that originated, we looked at, at what physicians had to do in terms of residency and, and we modeled the autonomous practice section of this, uh, based on what was currently existing in the medical profession, recognizing that in subsequent sessions and subsequent years, oler would come forward and continue the march to redi resist, or, excuse me, reduce the barriers to entry in professions. I wanna compliment LER for doing that. What I would encourage the committee, don't let perfect be the enemy of good. This is a, this is a, a journey, not a destination incrementalism as we're, as a state we're working through, we're reducing these barriers. Um, this bill does that, and I'd encourage the committee to support it. This is entirely consistent with what the mission of ler, uh, was when it was first, uh, originated. And I speak from some knowledge on that since I was a sponsor of the bill that established LER and the, uh, independent practice of PAs. So, Mr. Chair, thank you. I realize the, uh, hour is late.

Alright. Thank you. Chair A, as we've heard, this is obviously a big bill and there's, there's a lot addressed in this bill. And so to former Senator Cullimore Bramble's point, you know, uh, maybe not gonna get it perfect on the first go. And, and it sounds like there's some stuff that could be addressed. And so, but I have every expectation that, uh, the good Senator Cullimore will, will continue to work with stakeholders and work on that. And so my recommendation or my motion is that we favorably recommend SB 31 for substitute.

I, I have my hand up before the motion, but I'm just wondering if the sponsor can clarify. Um, I'm not opposed inherently to increase barriers to entry or increased hours, but I am just curious after the public comment, what problems, what harms have we experienced in Utah that were trying to address with, with the increased hours?

Uh, yeah. As you know, Mr. Chair, um, everything within doppel licensure is, uh, complaint driven. And so the in information coming forward in these, in these particular areas, that drives the need to, drives the need in LERs mind to make recommend changes or specific complaints coming in within the profession. Um, uh, certainly not gonna go through each individual thing, but that just let you know that there were sufficient enough complaints in the area to drive the need for. Just felt like there was the need to make some changes.

Well, okay. Uh, well, yeah, I mean that, well, let me just ask this. Are, are people dying? I mean, I, I don't know. I, I think no matter what number of hours we require for any profession, there's gonna be some complaints. So I, um, with all, you know, with all respect to Senator Vickers, who I, uh, like and admire, I, I, that doesn't give me any, any, any helpful information. So,

I'll try. Um, I'm not aware of any deaths. I am aware of number of, of situations of, uh, malpractice or inappropriate therapy. And you can call back up the director of ler if you want to get, try to get more specific.

That's I, yeah. Thank you.

Thank you, Mr. Chair. Um, you know, I appreciate, you know, the, just the whole thoughtful deliberation that's gone on in this, this bill. And, and as you can see, and it was pointed out, there's numerous places in here in the bill that we're looking at, uh, expanding practice, expanding scope of practice, uh, has been thoughtful and deliberative. The, um, criteria that seems to be focusing around hours on, particularly in two particular professions, one we're reducing, one we're increasing slightly. Um, those have also been very thoughtful and negotiated and worked through with the, with the professions that we've been dealing with. And like I say, uh, I want to point back out that, and also one thing that was not touched on, but the, the, uh, person that the public comment from, from Tennessee, who is a Utah native, uh, talked about, we do have provisions in place for those students that are graduating in other states to still come into the state. No matter, you know, we have, uh, different, different practices already in place that can allow that. Um, but I do want do it, reiterate that, you know, it is on that particular piece, especially this, the nurse practitioners is a very, very small subset. And, and Mr. Shumway's, right? When we first looking at the 6,000 hours, it actually was about 14 or 15%. But when you ratchet down, there really is only about 1% of the applicants that would not already meet those qualifications. So, with that, I would, uh, appreciate your support on the bill.

I know you're tired. Um, I'm gonna vote yes, but I, I, I want to, I just wanna state, I have some reservations. I I think this may be the first time I voted for an increase or in a hurdle to a licenser to have been up here. Maybe not, but that's what it feels like. Um, and I have some reservations that I, I wish that I could have. We could have fettered out more of the complaints and the details of those complaints and the justification for under those claim complaints through Do o Doppler, the justification for the increased hours. 'cause it still seems, even though that's a negotiated number, and I recognize that I respect that, and that's why I'm voting, yes, it still feels arbitrary. It just does. And I, I don't know how, how to place a more accurate, uh, number than that, but it still feels arbitrary.

Yeah. I'm gonna vote no and, and specifically ask Mr. Sheway to come find me early next week. I'd like to just learn more about the need for the increased hours for nurse practitioners

Uh, thank you. I'm gonna, I am going to vote to yes. Uh, knowing that there's some, still some work to do on this, uh, having gone through this process before, um, I expect there to be a few changes along the way. I'm, I think there were some things that were said, um, that, uh, that can maybe help the bill. But, but I will say that the original 6,000 hours down to 2000 hours, uh, helped me.

Now you've called the, the account. I, I just for the committee, I will do everything I can to get the information as requested, both from Senator McKay and Senator Weiler and have that available

Thank you, Mr. Vice Chair. Appreciate the opportunity to be before your committee again today. Um, The bill that we're for us today, and, uh, if it's with your permission, I've got some handouts for the committee, the staff prepared. Uh, please do. Thank you. Yeah, if you can give that to their staff so they can hand those out. I really appreciate our, our legislative staff and putting together some of these really good summaries. And I think this is a bill that deserves a good summary so that you can look at it. Um, it's a, a product for a lot of work. Uh, this is the, the bigger LER bill that we do every year starts, you know, in the summer we start looking at things and even a right after the session, really, and looking at different profe professions and then making recommendations going forward. So it, it has a number of moving pieces in it. So, let me go over. It touches physical therapy and occupational therapy. It touches nursing touches, athletic training, respiratory care, physician assistants, PAs, and acupuncture. So, lemme kind of outline some of the proposed changes in the bill dealing with physical therapy and occupational therapy. It's going to permit therapists to prescribe durable medical equipment. Uh, it's going to grant physical therapists the ability to order medical imaging, and it addresses scope of practice for physical therapy assistance and aids. Those are, I think, pretty straightforward. Not a lot of, um, you know, detail on that in the nursing section. It's, first, it's going to deal with CRNAs or nurse anesthetists. It does under a, some narrow guidelines, allow them to have pre prescriptive authority. The bill would permit A-C-R-N-A to prescribe medication, including controlled substances to a patient in a period not to exceed five days before or after a procedure. The ability to prescribe substance would be restricted to procedure performed in a healthcare facility, a private physician's office, or a dentist office with the participation of the CRNA that has been, has an established patient record with the patient and the prescription must be related to the procedure. This is really the CO as we looked into this, that was really more driven from maybe a rural perspective when this might play. To be honest with you, I don't know how much of this is really going to happen, but it does allow for, in certain circumstances to allow that patient to receive medications when they need it. Uh, a next piece that with dealing with nurses would be the nurse practitioners. And this has been one of, have a lot of discussion when we put change the Nurse Practice Act, nurse Practitioners Practice Act to allow for nurse practitioners to go on their own, be have their own office. Uh, we did not put any requirement in for any experiential hours. Uh, the proposal in the bill is that we would change that to 2000 hours. Now, a nurse practitioner will go to school, they'll go through nursing school, and then they'll go to nurse practitioner school. Typically through, between those two components, just in school, they'll pick up about 1,250 hours and they would, and if they're working along the way in any way, shape or form, if they're working during nursing school, most, most of them take a break between nursing school and nurse practitioner school. They would pick up, they would be working there under their nursing license, or if they're working under their nursing license during nurse practitioner school, they would have that. In fact, if you look at it, it really comes down to about one or 2% of the students that would not have those hours when they finished. Um, so that this is a, a small increment forward, looking at what we can do to make sure to ensure that the practitioners, they go out on their own. They have, you know, good experiential rotations and good experiential, uh, opportunities to go forward. Um, I'll talk about, there is another piece with nurse prac nurse practitioners that I'll talk in conjunction with physician's assistants that we came across on athletic training. Uh, the bill would expand the scope of athletic training practice to explicitly permit them to work in an occupational settings, create new restrictions on athletic trainers that require them to collaborate with a licensed physician for certain types of injuries and mandate cardiac care certification, uh, respiratory care. The bill would reinstate and modify the respiratory care apprentice license, which allows an individual to perform limited respiratory care services under supervision during the final year of, of education leading towards, you know, their, their respiratory care practitioner license physician's assistants. Uh, here again, we, when we changed the Physician Assistance Practice Act, we required them to have 10,000 hours beyond e their, uh, beyond their license, their graduation license, to get to the point that they could go out on their own. So a nurse practitioner would come outta school, they, you know, with our Nurse Prac Practice Act, they could go into their own own clinic or their own office, have their own office. Physician assistants would have to have 10,000 hours under supervision before they could do that. Uh, they also have a little difference on their schooling too. So that's probably the differential between the two. The proposal and the bill would be cut that to 8,500 hours. Uh, acupuncture. The bill would grant dopple additional rulemaking authority, uh, around injection therapy for acupuncturists, allowing the division to define the minimum coursework and experience to perform proje injection therapy and add new items to the list of approved sterile substances. Additionally, the bill would allow acupuncturists to delegate supporting services to be carried out by an unlicensed aid. Under supervision, there is an amendment, you'll see, um, amendment number, Senate amendment number two. When we put the bill together, there was a change in the acupuncturist board, and we had the, you know, it'd be two licensed acupuncturists for some. We, we took out that component thinking that, uh, DOPA would just handle that, but it, quite frankly, it, the optics of it caused some concern in the profession. So the amendment just puts that, that nomenclature back in saying that those two individuals should be licensed. And so when, when it's appropriate, I request to, you know, to move that amendment. Now, let me explain the last component of the bill that really came to us late in the process. And this just a couple of weeks ago, there was a, a Supreme Court case in the state of Utah that indicated that, uh, there was a challenge against a nurse practitioner that were performing a certain minor surgical procedure. And the ch the court, the, the court ruling changed the dynamics of what our code has been allowing going back about 13 years ago. We, we, uh, passed the Cosmetic Act and it allowed for, you know, these practitioners to go forward doing minor surgical procedures, think of things in a DER dermatology setting, you know, removing a mole and doing suturing, those types of things, the court case. And then we, and along the way, what we also changed our practice act for both physician assistants and nurse practitioners, uh, the court case changed that and said, our current, uh, code of our current way of allowing that to happen was now long, no longer valid. So we sat down quickly with a group of people and tried to figure out, okay, is there a permanent solution that we could propose at this time? And we determined it's a lot more complicated than we thought. So in the bill, there is basically a, you can call the bandaid, you can call whatever you want, but it, we put some fairly, uh, generic language in to allow nurse practitioners and, and PAs to continue doing what they've been doing and allow for these minor surgical procedures. And there's also a two year repeal on it. And the reason for that is that we've got to solve this on a permanent basis. And so that repeal is the onus to get us, you know, to come back. You know, the plan is to have it done by next session, but it is going to take some work during the offs. During the interim, we're going to have to put together a task force of people and excluding legislators and some on this committee. Hopefully we'll be on that and we can move forward in looking at that and addressing it. There has been some suggestions for d different language changes and every, and quite frankly, those, those suggestions are potentially good. But it's one of those things, I think they're more for the discussion of the, the permanent solution than right now, the temporary solution. Uh, we are looking at just trying to keep the status quo. We're trying to continue to allow those practitioners to do what they've been doing, at least for a period of time, talking to Doppel, they're comfortable with where we're at on that. They've, you know, based on, you know, the complaints and other things I we're fine with. They, they feel they're comfortable that they'll be able to, to manage that going forward over the next period of time as we, you know, find that permanent solution. And like I say, that one came to us that did not come to us during the interim. We weren't able to have to have those kind of discussions. It literally has just been back last couple or three weeks. So, with that, Mr. Chair, I'm open for any questions. Thank you. Appreciate it.

Thank you, Mr. Vice Chair. And thank you senator for presentation and all the work over interim on this bill. This is a significant, a significant bill as an understatement. I'm just confirming, are you speaking to the third substitute? No, we're actually on the fourth substitute. On the four substitute. Thank you. Yeah, Currently we, we had, we did make a four substitute before we sent it to the house. So the amendment would go to the four substitute. Thank you. Could you speak just a little bit more to the Accu Actu, I can't speak right now, acupuncturist piece of it as I've got some questions over the last couple of days about some concerns in that area. The questions that, the biggest question that I saw was about the board, you know, in the bill, you know, if, I think it's 1711, if you look at line 1711, um, Wish I could scroll faster. Um, okay. Um, on that, on that line, it says, this is calling the create created the MA board of massage therapy and acupuncture consisting of, you go down to slide 1711, it says, two licensed acupuncturists is defined in section 58 72, 1 0 2. And we've stricken that out and just put acupuncturists, that was where the question was kind of why did we strike that? Actually, in talking to the drafting attorney, we, we felt comfortable that we refer to it in another section and that DOPP would take care of it. But the optics here, again, the optics, uh, don't look good. You know, and I can, I can understand why the acupuncturists would be concerned with that. And so the amendment would simply just put that language back in.

Chair. Senator, thanks for your hard work on this. I have a question on athletic training. It looks like we're adding flexibility on who can authorize or direct a trainer to work on people. Am I, is that correct? Am I mis Say that again. Okay. It currently says on line 1411 that an athletic trainer identified by a directing physician. Now it's saying athletic training, a physician, uh, licensed nurse practitioner, a pa, or a pt. Mm-hmm. So they can now direct athletic trainer. Yes. But just expanding that to different practitioners. Yes. Alright. So currently as I read it, a licensed physician has to say, you can benefit from an ATS work. Now we're allowing others to say that. Is that right? Yes. We're allowing the supervision to expand to different, yeah, different, uh, practice practices. H then how does the collaboration come in online? 1431. What can you tell me when that's needed? Collaboration between means consultation direction, blah, blah, blah. But it still requires collaboration with a physician. I'm just trying to figure out how it works when now we've expanding the number of professionals it appears that can authorize somebody to, for athletic training services, but this collaboration still only with the physician.

Yeah. You know, if your permission, Mr. Vice chair, I, if I could ask, uh, Jeff Shumway from the Office of Professional Licensure Review come up and that would be great. Talk about that one.

Jeff Shumway, director of the Office of Professional Licensure Review. I was really hoping to make it it through this bill without coming up here. Thank you all very much. Um, You knew that wasn't gonna happen. No. The, the, the quick answer to this, and my analyst had to remind me of this, is there's two different settings for an athletic trainer. One is in a medical setting where they are under the direction of a provider, and that allows 'em to have a much fuller scope of practice. The second setting is when they're operating independently as an athletic trainer under their own license. And that's the instance where collaboration comes into play. Once they bump up against a certain boundary, they have to go collaborate with a provider.

Okay. Thank you. So I see the list of all the things they can do under collaboration, but it's not that same list when they're under the direction of others. Okay. Thank you.

Seconds is fine. Scott Isaacson concerned citizen, I think it's already been addressed. The licensing requirements for the acupuncture board. It was going to remove licensed acupuncture, but now that's going to be replaced. So I'm very supportive of that. I would just add two more comments. One is that in the future, I would hope that Utah could lead the nation by retaining a high standard of training and certification requirements for acupuncturists and not diminish that in any way. Right now, the board is going to be retained with high qualifications, which is good. And I would hope that in the future, that we could have a board that's unique to acupuncture that would have qualified licensed acupuncturists on that board, specifically looking at, at acupuncture and not combining with massage or something like that. Uh, carpenters poke things with nails, but wouldn't combine combine carpentry with acupuncture just 'cause they poke things. So I would hope that an acupuncture board could be unique to acupuncture. Thank you.

Uh, Utah site of anesthesiology. First I wanted to thank Dr. Or Senator Vickers and the committee. We've worked a lot with the UMA and with Senator Vickers to try to get the, uh, nurse anesthetist part of this bill. And, uh, we're really happy with all the progress we've made. We've added in pearls, we've separated out the licensing for those who have the skills to get that prescribing right. And those that don't. Um, recently in the fourth edition, we did notice that, um, there was the addition of a private physician office line 3 13 66 or dental offices. We continue to be concerned, uh, in the prescribing for, um, non-surgical related reasons. Um, and then also as this committee is well aware, last year you guys passed R 1 56 37, this did allow e-prescribing for all prescribe prescriptions throughout the state of Utah. So in, uh, green with DR. Or Senator Vickers that this may not be necessary, this prescribing, right. We encourage all committee members to think about any surgeries, uh, that you or family members have had, and ask yourself if you ever received a prescription five days before, five days after from your anesthesia provider. If the answer's no, I'd recommend you, uh, vote against this. If it's yes, then give this prescribing right to someone new.

Hello, Mr. Chair. And, uh, Margaret Willy Busse, executive Director of the Department of Commerce. So great to see everyone here. And first, just wanna thank Senator Vickers for his, uh, Herculean task in taking on this really big bill. Um, that, uh, upon recommendations from our Office of Professional Licensure Review, there's so many different changes, as you know, that we're making, but just as you know, you guys have kind of been, many of you, um, have been on this journey with LER for a long time and have seen how really what we're trying to do, um, and what was put in statute and the creation of LER was to, to try to reduce unnecessary barriers to licensing. And so this bill just goes so far in doing that with multi a multitude of different professions. And we just appreciate your support. I know many individual members here have been up here, have been helping with this, um, in addition to Senator Vickers and our floor sponsor, Representative Kyle. So thank you so much and, uh, really appreciate the, the efforts of, of all of you, uh, of all of the many different organizations that you and our Office of Professional Licensure Review has worked with, and we very much support this bill. Thank you.

Thank you. Sharon Lockhart, licensed acupuncturist in Layton. I've been licensed and business owner in Layton since 2005. Um, the 20 years that I've been here, we've always required to be, to be licensed. Um, the licensed acupuncturist here in this state have between three and eight hours of graduate degree education before we sit for the National board to then become licensed here. So I ask that again at seven line 17, 11 of SB 31, please add back in licensed acupuncturists because we would be the experts to keep the public safe. If there's any kind of, um, action that's brought up or someone's investigating a licensed acupuncturist, we would be the experts to say this was safe or this was not safe to touch on. The acupuncture technician, uh, requirements that are in there, I'm not a fan of the acupuncture assistant. Um, if I put in 10 needles into someone, it's my responsibility to make sure that there were 10 needles taken out. That's the safest for the public. Um, I think that there's a push for receptionist to be able to take out acupuncture, but I think it's a, it's an underhanded language to cheapen the profession. If we wanna start a school here in the future, that's fine, but it needs to be national certified, not a cheapened water down education. So again, I'm not a fan of the acupuncture assistant. I'm responsible for the safety of patient in my clinic and myself alone. Thank you.

Yeah. So I would like to move that we adopt Senate Amendment number two, I believe is the correct number. Okay. Would you like to speak to that? Uh, I would, I mean, for all of our acupuncturist friends here, I mean, this, this really was just a typo and oversight, no offense was intended, or no policy was intended to be changes. It was just an oversight. And so this amendment does correct that, and hopefully that makes, um, everybody feel a little bit better that we weren't trying to do something sneaky. It just was an oversight.

No, I appreciate it. We've discussed that well and we just, it's an amendment we need to make. Yeah. Okay.

And then back to the maker of the motion. I will waive. Okay.

Move that we adopt House Amendment number one in my name. Would

I would. So, uh, colleagues, so what this does, we, well, Let me, sorry. Uh, three, number three. Three. I'm sorry. I got the wrong number. Uh, so here's the issue with the nurse practitioners. There is a problem with the schools, and we worked over the interim to try to figure it out we're, we have a solution that's kind of agreed on. I look at that. I don't really actually think it solves the underlying problem. And if we pass this and everyone say, well, we come to an agreement, it was a compromise. Nobody really loves it, but it's the compromise. It's the deal. We're gonna have a real hard time coming back again next year and solving the real underlying problem. So I would rather that we just take out that marker and go back to where we are, work on it over the interim, and then come back next year with a real solution to really what is the problem. And the real problem is kind of complicated. The problem is actually with the schools, not with the nurse practitioners. The, the problem is that it used to be fairly well understood that you got your RN degree, you go get some experience, you come back, you get your np, you're good, everybody's fine, it's all good. But there are some schools, especially some of the online schools that are accepting students right out of rn, they get their bachelor's degree, their rn, they go right into the program. And it's just, it just breaks the system when that happens. And so that's the problem I think, is really on the school side more than on the nurse practitioner side or the licensing side. This kind of creates a false promise that this will actually do something. Um, and then there are other people who just feel like, well, that number's way too low, it's ridiculously too low, and we have these big fights about the number. So I think the better solution is to let's pull it back out, work on o the improvement, and then come back with a real solution to the underlying problem. And that's what the, that's what Amendment three does.

Yeah, thank you. Comment on the amendment. You know, I appreciate that. And, you know, and, and a good representative of the sponsor of the amendment, uh, indicated, you know, there's a lot of negotiation that went into it. Yeah, you're right. Um, I, I agree with you that there needs to be some additional work done in this area. I would prefer to leave it where it is. And let me explain why. There's a couple of things. One is I think that puts us in a little stronger position to look at going forward, but it also puts us in a position, at least for the next year, as we're looking at some additional work that we have, we, we are requiring some additional hours, even though it's maybe, I know a lot of people think it should be more, but the same token. And, and so I, so I don't disagree with you. There needs to be more work. I just feel, I feel like we'd be in a better position if we left it the 2000 hours and then did some additional work on over the summer. We're gonna put a task force together on a couple of things dealing with this practice act. And so that would, we could be done at that time. So, like I say, I, I'll leave it up certainly up to the will of the, the committee and, uh, you, you can decide it would just, I, in my opinion, having worked on it for a lot of months, uh, it would, I think we would be in a better position, a stronger position if we kept it at 2000. But I'll leave it up to the, the will of your committee.

Thank you, Mr. Chair. Um, for me, it's funny, as I look at it, I'm thinking whether it goes back to the 1250 hours, which is basically graduating from school or 2000 hours, which is only three months later. I, I can't believe that was the negotiation portion because in comparing, I, I, who has, who's independent, who can prescribe, who has a broad scope, that includes nurse practitioners, who under this bill would only have three months, uh, before being after school, before being able to practice a PA who also has a master's, just like a nurse practitioner, they have to have 10,000 hours. They used to have to have 11,000, 600 hours. And you're telling me that 2000 is equivalent to what a PA does for 10,000 hours after, after school. That, to me, that's crazy. So whether we go back to the baseline, which is basically 1200 hours or to the, the substitute, which already has 2000 hours in it, to me three months is all that, that the negotiation brought. And this is not anything, um, uh, to the sponsor, the bill, because I just finished my own work of licensure bills. And it is a ton of work. I'm going to the, to the nurse practitioners as a whole. That to me, to push back for, for only a three month experience, work experience before being able to be fully independent, fully prescribe, and have a broad scope. To me, that's crazy. So I am fully supportive of continuing to address this in the interim and studying it. And, um, you know, if PAs need 10,000 hours, nurse practitioners should at least be six or eight to have those same kind of re um, prescribing and broad scope, um, authority. So I, I, I totally agree that this needs to be discussed further.

Thank you, Mr. Chair. I, I do have a question for the sponsor of the legislation, um, if that's appropriate. Um, Senator, so in, in your conversations and collaborations as you came to this 2000 hours, did you make any sort of, um, uh, deals or, or, um, statements that, that this would solve the problem? That we wouldn't be working on it or continue to work on this hours in the future?

No, we were trying to get to a point to where we could felt comfortable, at least going forward. We have some additional hours required. And I apologize for making a phone call. I was, I just had to verify that we weren't, that the amendment wasn't going to pull out the minor surgical procedure portion. 'cause that would've been a disaster if it did. But, but no, we did not indicate that. We did indicate there would probably be some additional looking at it, but we, we do feel comfortable, at least at this point in time going forward, requiring some additional hours, you know, to have experiential, uh, rotations and experiential hours going into their practice because you realize they would be, they potentially would be going right into their own office. Not, not everybody does that when they first come out of nurse practitioner school, but that is the potential. Yeah. And, and so I think it'd be clear to say that they expect that we'll continue to have discussions on this, that this is not going to solve the problem. As far as the nurse practi Practitioners, I think there's, it's clear that there, there would be additional discussion on it because there's been a lot of discussion amongst legislators here. Uh, some feel like there should be a lot more hours, uh, you know, some even on my side thought there should be less. So.

Okay. Uh, Mr. Chair, I, I, uh, I agree with, with the good representative from, from Bountiful that two, 2000 hours seems absurdly low for the amount of work that they can do, but I do think this is better than the status quo. So I don't know why we wouldn't take the incremental change and at least have that in place for the next nine months or, or year until we can get other legislation and more work done that pushes us to where that, that, uh, appropriate number of hours is at. So, I'll, I'll be voting against the amendment.

Thank you, Mr. Vice Chair. What the amendment before is, is something that I've been personally wrestling with. We need to ensure that our nurse practitioners are trained and experienced to be able to practice so every one can be safe. And as visiting with over this topic over the interim, really appreciate the research, the work that has been done by the Department of Commerce and LER and their analysis and recommendations as we really debate it and work through this, through the, um, through the interim process. My wrestle is that this is addressing a element of the problem, but not the underlying core issue. The underlying core issues, it relates to the national accreditation and it relates to the academic programs in the universities and how they're working academically to teach and train and prepare nurse practitioners for practice. The underlying issue is that national accreditation and universities are, some are becoming online diploma mills of cranking that out. So rather than looking at specifically what that hour rate should be right now, I would propose that we look at the underlying foundational problem of academic issues with programs and also the national accreditation. As we've heard here in the discussion, there are some that are saying those hour should be significantly higher, and there's others saying they should be very much more minimal. So looking at the hours is one element of it. I would prefer looking at and solving the underlying problem permanently, which is why I'm supportive of the amendment right now to focus on this and to let the nurse practitioners and the academic programs and the national accreditation be aware that this needs to be worked on and will be solved over the interim.

Thank you, Mr. Chair. So, I agree with Representative Whyte. I think the underlying school issue needs to be looked at. However, I would prefer that we leave the 2000 hours in because we can implement that right away, and that will at least be a higher bar than where we are right now. If we take that out, we're not, the schools are not gonna be fixed, and we're gonna have lower hours this way. At least we have the higher hours until we can solve a broader underlying problem. So I prefer to leave the bill the way it is. Thank you.

Yeah. Thank you. Uh, like I said, I, you know, I certainly live up the will of the committee. That's the legislative process and the beauty of the legislative process, quite frankly, getting a lot of different eyes looking at things. Uh, but it, in, through my experience with the bill and the negotiations with this, I think we'd be in a better position if we left the 2000 hours in the bill. Uh, and, uh, Representative Whyte alluded to the fact that there's a national organization that determines whether we have full scope of practice for our nurse practitioners in the state. And, you know, that was part of the negotiation process that we got through to the 2000 hours, is making sure that we, that our nurse practitioners do have full scope of practice. So thank you.

Thank you, Mr. Chair. To me, this is doing something for the sake of doing something, not for the sake of solving a problem. Everybody who looks at that 2000 hour says this really literally does nothing. We already heard comments about that earlier. Um, it's, it's about three months beyond what they're getting in school. There's no restrictions on what quality they get. They could literally just take an internship over their summer, just changing bed pants at the hospital as a, as a volunteer. And so it does nothing. So having that in the bill makes some people feel like, oh, we solved the problem, we solved the problem. Or as I heard, maybe at least it's better than nothing. The extra answer is, it's not better than nothing. It's the same as nothing. It's exactly no different than what we're doing today. It's just exactly just put in there. And I think that, I actually think it makes it harder to come back next year and negotiate on hours because they can say, wait a minute, we were just here last year and we had a deal. We negotiated 2000 hours and now you're coming back for, for before the same committee and asking us to negotiate to a higher number. That's not fair. And we hear that all the time, right? We hear all the time people like, Hey, we were just here last year, we now we're back again, nego. And you now you want more. I think it puts us in a worse negotiating position to, to have a number that is in the bill that doesn't do anything. It doesn't help anybody. And then people can point to that and say, we were just here last year and that was the negotiated deal. So I think taking it out sends a strong signal to everybody that we are not pretending then to solve the problem. It's not gonna be, uh, a redo next year. We're gonna have to come back with a full solution that involves the schools, the accrediting bodies, and everybody else. So I, I, I think that that's, that's my concern is, is that if we leave it in there, there's some sense in which that's the deal and we're gonna have a hard time negotiating against the deal. But, so I would prefer that we take it out and people know we don't have a deal, and that we'll be back next year with some other solution. I hesitate, even hesitate to say that the solution is ours. I actually don't think the solution is ours. I think the solution is probably more fundamental than that. But we don't know what it is. And so we're gonna have to dig deep and figure that out before we come back next year. Okay. Thank, thank you.

Thank you Mr. Vice Chair. I'd like to make a motion that we pass with a favorable recommendation, Senate Bill 31 fourth substitute as amended Office of Professional Licensure Review amendments. Clar Clarification. Oh, nevermind. I apologize. I, we did the First amendment, so I wanted to make sure we got That in. Yeah, we, we got both of 'em in there. All right. Uh, so the motion is that we, we, we, uh, pass out favorably, uh, SB 31 for substitute as amended, uh, with a favorable recommendation.

We'll go to the sponsor. No, thanks for your time today. It's always entertaining. The legislative process is great and, and it's good. So, you know, I appreciate your work you've done and, and appreciate hope you appreciate the work we've done as well leading up to this point. So thanks.

Thank you. Uh, I'd like to just say I really appreciate all the work that's gone into this bill. It's been a monumental, uh, exercise. Uh, the, uh, department of Opular and the Department of Commerce and the Senator and co-sponsor, and everybody's been involved and the negotiations that have taken place as well. We are grateful for that. I think it is very, very clear that, uh, we love our nurse practitioners and, uh, um, but we need, we do need to work through some of these issues, and I think we're going in, in a, in the right direction. So support the bill and thank you all for participating.

Thank you Mr. President Proto. So this is the, um, I guess you can call it the annual LER license review bill, that we look at all, all interim and then it seems like it is, uh, it continues to go on throughout the session, and that's kind of what's happened here. We're looking at a number of different pieces in healthcare this year. There's a few things, let me explain to you. It covers, uh, physical therapy and occupational therapy. So it permits therapist to prescribe durable medical equipment and grants. Physician therapist, physical therapist, the ability to order medical imaging addresses scope of practice for physical therapy assistance and AIDS in nursing. Um, it grants limited perioperative prescriptive authority for CRNAs. And so it just allows them to write, uh, prescription medications that pertain to that particular procedure five days before, up to five days before and five days after. So it's very limited. It, uh, Extends the time and, uh, a nursing student may serve as an apprentice. The one key change with nurse or nurse practitioners is that right now, uh, there is not a, a number of additional hours needed for licensure that we're proposing that the, the, that they're required to have 2000 hours, but this is an assumption that they're going to get 1,250 between nursing school and nurse practitioner school. Literally 98 to 99% of the applicants will already have 2000 hours before they go through, before they're ready for licensure. If they are in, if they're working as a nurse in any of those, those settings, either during nursing school, in between nursing school and nurse practitioner school or during nurse practitioner practitioner school, they'll have more than 2000 hours for those. That's very, very small subset, that one to 2% that actually only go to nursing school and then directly to nurse practitioner school, there would be a requirement for additional 750 hours. They could do that. They could, they could work as a nurse to get those. But like I say, it's a very small subset. Uh, with athletic training. It clarifies the scope of practice regarding occupational injuries. And when a trainer's required to collaborate with a licensed physician, uh, creates a respiratory care apprentice license, uh, with phys physician assistants. As we start looking at these hours, actually we're reducing the number of hours that are required for physician assistant from 10,000 8,500. Let me clarify too, both a nurse practitioner and, and physician assistant. So the physician assistant, the 8,500 is for an individual for a physician assistant that is going to work individually. Uh, nurse practitioners when they come outta school by the practice, they can work as individuals acupuncture. So that grants rulemaking authority to authorize substan substances for injection therapy and allows ac acupuncturists to delegate supportive tasks and unlicensed acupuncture aid. One other thing that came up late is there was a, a back about 13 years ago, the Cosmetic Act, um, was after we deter passed that we determined, and then when we changed the nurse p the Physician Assistant Act, in between, it was determined that we would allow physician assistants to perform minor, minor surgeries like ablated surgeries after a dermatology visit or something along those lines. Um, there was a court case that challenged that and the ruling that came down negated that opportunity for those. And so in this bill, we, as we did the research, trying trying hard to find a permanent solution at this point, realized that it was complicated. And so therefore, in the bill there is a, uh, a bandaid, if you might say, we are for two years. We're going to allow physician assistants to continue to do those, basically practice as currently allowed. Uh, there's a re repeater on that for two years to give with the idea that we're gonna have to fix this. And so the the idea is to fix it next year, but to of course, to, in order to give it a good window, we gave it a two year window. So that is, you know, we've been working with their organizations and others to make sure that we can get this right. And so, but it just became a little bit more comp. The complicated factor is that the, the Cosmetic Act was 13 years ago and then we've changed the practice act in between and so we've gotta go back and try to figure that out. So with that, I'm open for any questions.

Thank you. Will the sponsor yield? Will You yield Senator Vickers?

I will. Okay. Proceed.

Yeah. Thank you Mr. Uh, president pro tem. I think that on line 1455, we need to make a verbal amendment to change the and to an or so with the sponsor's, um, blessing.

I I I'll make that amendment. Which line? 1455.

Just to make sure you're looking at the third sub. I believe so, yeah. Yes I am. Okay,

Hold on. Okay. Does the circle have that at? Yeah. What third We're changing the N to or, Um, Mr. President Prote, why don't we just circle, lemme get with, uh, Senator Weiler and we, we can work on that.

Thank you. So colleagues, I don't usually find myself on the side of expanding tort recoveries.

Yeah, it was, it simply does change, uh, on line 1471 change as an or to an and. Okay. And that was agreed upon language is actually was in the second sub that we didn't use and when we transferred it over, it got switched. So

Thank you Mr. President. I, I'm not gonna rehash the presentation other than to point out that there was one piece with the 2000 hours with nurse practitioner licensure. As I mentioned, it's a very small subset, but I did wanna mention that that is a consensus number. I can reconfirm that today with both the local and the national organizations. And with that, I'm open for any questions.

Senator Vickers Baldy Lewin Bremmer Bus Colmore Escamilla Fillmore Grover Harper Kins Aye. Ipson Aye. Johnson Juab McKay, Sir. Mikel Milner Mussman Owens pitcher Plum Rebi Sandal Stevenson Stratton Bickers Aye. Weiler? No. On to Wilson. Aye. Winterton President Adams Aye. Third substitute Senate bill 31. Having received 25 yay votes one nay vote three Being absent. Shall read a third time?

Needs a break? Yes. Be happy to. A Motion to saunter.

Thank you. This is the, the licensing bill that we discussed, uh, this week. Uh, the change in the force of, it's actually just corrected some things with the nurse practitioners. There's, if you remember the dialogue I had that, that we'd run into a situation where a court case, a Utah Supreme Court case had put in a put the ability of physician's assistants and nurse practitioners in jeopardy of being able to continue to perform minor sur minor surgical procedures. And the this force substitute puts puts a correction in that to make sure that we can move forward, uh, some of the key points. It deals with a lot of pieces. There was a question on the floor when we were originally debating that Senator Weiler had about athletic training portion that is an and which was the, the requested change in that. And, uh, it does keep the requirement that a nurse practitioner wouldn't require to have 2000 hours of experiential, uh, work that could be accumulated during nursing school or, uh, also nurse practitioner school, which is usually typically is about 1,250 hours. So there'd be another 750 most, in fact 98% 98, maybe 99% of the, the students will will have that by the time they graduate 'cause they'll be working as a nurse. But, uh, with that I would be open for any further questions.

I wait further the submission move the fourth substitute Senate bill 31 pass.

I don't have any, I don't have any news. I wanted to run a bill. Oh, That's the news. That is news. I haven't been here to run one all session.

What's that? I Think it's on the second reading calendar.

Yes. This is the, uh, OPULAR licensing bill. Uh, the provision, one of the provisions it was, uh, heavily negotiated it was the adding additional hours, 2000 hours to a nurse practitioner, uh, requirement. Uh, the house decided, the house committee decided that we, we'd like to pull that out and work on that as some do some additional work on that. So that provision was pulled out. And then another question was we were expanding slightly the ability of a, a nurse anesthetist to prescribe and it was, there was some concerns about ketamine so we specifically said that they would not be able to prescribe ketamine.

Okay, roll call vote. Senator Vickers Baldry. Aye. Lewin Brammer Bus Comore Escamia. Aye. Fillmore Grover Harper Aye. Kinins Aye. Ipson Aye. Johnson Juab McKay. Aye. Mikel Milner Aye. Musman Owens pitcher Plum Rebe Sandal Stevenson Stratton Vickers Aye. Weiler Wilson Wilson Winterton President Adams

Thank you Mr. President Pro tem. Motion to not concur.

Four substitutes, Senate Bill 31 Office of Professional Licensure Review amendments by Senator Vickers. This bill was heard in business and Labor with a vote of 15 0 1. The house sponsors Representative Kyle.

Thank you Mr. Speaker. I, I move that the house, uh, adopt house amendment four in my name. That's, uh, four substitute four, correct or no, amendment four. Sorry. Please Amendment. You're

Yes. Uh, this is a licensure bill and, um, we're in the bill. The, the underlying bill expands the, the use of, um, or the ability of CRNAs to prescribe medications. And this is just saying that they cannot use, uh, prescribed medi, uh, ketamine.

Representative Ward. No.

Nope, sorry.

Thank you, Mr. Speaker. This, this bill's been a, uh, a lot of work. A lot of people have, have put time into it. LER did a, a study and they, they looked into, um, a lot of pr well this into licensing for, uh, different types of healthcare clinicians. And, uh, I'll, I'll, I'll go through it now. I I only have five minutes, but it, it's quite extensive. Uh, so, uh, one, one thing, first thing that it does is that it makes it so that nurse practitioners, uh, can, uh, do, uh, minor surgical procedures. There was a recent healthcare, uh, there was a recent Supreme Court case where the, our Supreme Court ruled that our current law does not allow them to. Uh, this does have, um, some, a Marie Peeler language in 2028, so that we can dig into it more, uh, over the next, next year, um, that this was added late. And we, we just wanted to make sure that our, our, uh, nurse practitioners and, uh, physician assistants are able to do these, these, uh, minor surgical procedures. Um, there, there's also, and, and the, the repe is there just to make sure that we revisit this quickly because it, it, it needs, it needs, uh, more study, um, in nursing. This also it, uh, for CRNAs, it, um, it adds a, um, it adds a, a limited five day supply of prescription drugs or grants. Limited prescriptive authority for that, uh, extends the time a registered nurse may work as an apprentice. Uh, instead of just doing it as the, in their final semester, they, they can do it for the final two semesters. Now, Uh, it requires, uh, applicants, uh, or an advanced practice registered nursing license to, uh, or you, it, the original bill required them to have 2000 hours. We took that out because we decided that that needs a little bit more work as well. But, so you might have gotten some emails about that. But every instates the respiratory care practitioner apprentice license that was, um, is issued during the COVID-19 pandemic. It also reduces the amount of time a, a physician assistant must work under a collaborative agreement. It reduces that from 10th an hour, 10,000 hours to 8,500 hours. Um, it allows doppel to approve accrediting bodies, uh, besides the ones listed in statute for A-C-R-N-A-C-N-M and PA programs. Uh, for phys physical therapy, it, it expands PTs imaging ordering privileges according to their training expertise. It allows, uh, uh, PTAs to perform, uh, non-trust joint mobilization. It updates the definition of dry needling. And then for, it allows occupational therapist to prescribe, uh, durable medical equipment. Uh, it allows them to, uh, to, uh, allows super, um, OTAs to supervision provisions from, uh, statute to rule where OLER recommends increasing the supervision ratio for, for OTAs from two to four, uh, for athletic trainers. It, it changes the, the directing physician in collaboration. And it clarifies that a athletic trainer can, uh, must collaborate with a physician only when rehabilitating an injury, uh, that is not responding or it's, uh, beyond the athletic trainer's scope. It allows, uh, and it explicitly allows athletic trainers to, uh, to treat workplace injuries. Um, for, uh, acupuncturists, um, it, uh, we, we did put an amendment in there. We had a, a, a drafting, we can call it an error or something that the, the profession didn't like. We, we fixed that. If you've got any emails about that. Um, it allows, uh, uh, the licensed acupuncturist to delegate low risk tasks to do to unlicensed aids. Um, it allows the injection therapy to be practiced on tendons and joints and give, uh, gives dopp dopple the board, uh, the board, the authority to set formalized training requirements and define allowable injectables in, in rule. So, uh, if you guys haven't had the opportunity to run a licensing or bill, if you really want to meet some passionate people, I suggest you do that. Uh, so, uh, but it, this has been a, a very well negotiated, uh, uh, bill. It's, uh, it's to a point where mostly everybody, uh, is good with it. This will require more work, especially in the, over the next year. Uh, we, we plan to do more work under the, in the area of nurse practitioners. Uh, but I think this is a good place and it'll help our, our, uh, our clinicians, uh, be better. It'll allow for them, uh, us to meet our workforce needs. And, uh, it'll help, uh, Utah Utahns get the care that they need. Thank you, Mr. Speaker.

Thank you, Mr. Speaker. Um, I'll be, I'll be brief on this. I know we're running short on time, but I just wanna, I rise in support of this bill with just a little caveat. I know they've worked a lot of hours trying to come up with some compromises, and as the, the good bill sponsor mentioned, um, there was 6,000 hours in there for nurse practitioners, and that was whittled down to 2000 and then taken out entirely. And, um, I think it's very important because we, a few years ago gave full practice capability to nurse practitioners, which I think is great. I actually voted for that. Um, but it's also when I thought that they were getting that experience between nursing school and nurse practitioner school. And we are finding a lot of programs right now have zero experience between nursing school and nurse practitioner school. And so I'm, I'm grateful that they've just taken that out because it needs to be looked at and it will be looked at with a microscope over the, over the interim where we can look at what, where can we get this experience for these nurse practitioners who have all the same capability as a, um, family practice physician and a and a pa. Um, it needs to come through education, years of experience and hours. And anyway, I just needed to stand up and say that, but I do support this bill and I appreciate all the good work.

Thank you, Mr. Speaker. Uh, this is a really good bill. A lot of work has been put into it. Appreciate the, uh, floor sponsor here and also the sponsor over in the Senate as well as our departments, dopel and LER and the Department of Commerce, all those who have really participated in this. Great bill. Thank you.

Thank you, Mr. Speaker. Will the sponsor yield to question Representative? Kyle, will you yield? Yes. Thank you. I just wanted to just double check what you mentioned about a Sunset date and the reason why we needed to do the Sunset date.

Yes. So, uh, for the ability of this, uh, um, physician assistants and the nurse practitioners, there was a recent court case that went up to our Supreme Court that took away their ability to perform, uh, to perform biopsies and, uh, like skin tag removals and, and very minor surgical, uh, procedures. And so we put the sun site date in there because it requires more study. And, uh, so we want to get it right. We put in some vague language right now that allows them to, to continue doing what we they need to do, but we just want to, to revisit, make sure it's there to make sure that we get it right. Nobody wants to them to not be able to do this, but we want to get the language right and, and, and that's going to take a lot more work. Thank you, Mr. Speaker.

Uh, thank you. I appreciate the comments and questions and, and support. Uh, a lot of work has gone into this, uh, um, and it's, it's to a good place and it, it, it'll serve our state. Thank you.