fIf

CHAIRMEN: Senator Gerratana

Representative Johnson

MEMBERS PRESENT:

SENATORS: Holder-Winfield, Kane,

Musto, Slossberg, Welch

REPRESENTATIVES: Arconti, Betts, Cook, Conroy, Davis, Demicco, Hovey, Klarides, Maroney, P. Miller, Perillo, Riley, Ryan, Sayers, Scribner,

Srinivasan, Tercyak,

Widlitz, Zoni, Ziobron

SENATOR GERRATANA: (Inaudible) for the Public Health Committee here on Friday, the 14th, and we will start with James McGaughey from the Office of Protection and Advocacy. When you do come up, please identify who you are, put the little button on there, as Mr. McGaughey did, and you'll see that the microphone turns red, which means it's live. And state your name, and you can proceed from there. Welcome, sir.

JAMES MCGAUGHEY: Yes. Good morning, Senator Gerratana, Representative Johnson, Members of the Committee. My name is Jim McGaughey. I am director of the Office of Protection and Advocacy for persons with disabilities. And I'm here to speak about one of the bills on your agenda this morning, Raised Bill Number 413, AN ACT CONCERNING THE DEPARTMENT OF PUBLIC HEALTH'S RECOMMENDATION REGARDING MEDICAL ORDERS FOR LIFE SUSTAINING TREATMENT.

Basically, this bill would authorize DPH to establish two pilot programs in different regions of the state where medical orders for life sustaining treatment could be used to document decisions about treatment options that have been made by people who are approaching the ends of their lives after discussions with their physicians and other healthcare providers. Our office is support for this. I have submitted written testimony, so I'm just going to summarize if that's all right.

SENATOR GERRATANA: Certainly.

JAMES MCGAUGHEY: Basically, I became aware of this proposal and of the need for it through experience we gained conducting fatality reviews for people with disabilities. We -- we run a -- we operate a -- the state's Fatality Review Board for individuals with disabilities. And in the process of that, we review the deaths of all people who are clients of the Department of Developmental Services and many other folks with developmental or intellectual disability.

And we come across situations where there are individuals who were quite capable of making decisions about what they wanted in terms of end-of-life care and who had communicated those decisions and who, in fact, in some cases had even executed advance directives. But their -- their wishes were not honored, because -- not because of their disability but rather because they had been transferred from one facility to another or because somebody couldn't find the paperwork or something like that happened. And it was -- it -- it sort of troubled us that this was occurring.

Now you may recall that last year there was a proposal similar to this. It was not exactly the same. And that proposal had come forward based on language that was suggested by a national paradigm for what they call POLST, Physician Order for Life Sustaining Treatment. And in Connecticut, we decided to use the term medical order, because it's not just physicians who can sign these orders. It's -- it's also advanced practice registered nurses and physician assistants. So we're calling it Medical Orders for Life Sustaining Treatment.

But the proposal last year raised concerns in the disability community, and, in fact, there were disability advocates who testified against it. Our office raised -- raised concerns. And those concerns had to do with the way that similar programs had rolled out in other states. And there was a good deal of research that was done by an organization, Second Thoughts Connecticut, and -- and Stephen Mendelsohn found a lot of this information. He's going to be testifying later in support of this -- of -- in support of this bill as well.

But there were situations where people -- physicians rewrote MOLST orders or POLST orders without consulting with the individual. There were situations where long-term care facilities insisted that every single person who was admitted execute a -- a MOLST order or -- or have a MOLST order in place, all of which are against sort of what the fundamental idea and principle that the -- the national paradigm was working towards, but nonetheless there was this potential for -- for these -- the -- these orders to become just another routine piece of paper that is filed like a checklist and does not really occasion a -- a thoughtful conversation with the patient to determine what their wishes really are.

Department of Public Health pulled us all together over the summer, and we have worked together in a working group to come up with language that we think really meets these concerns. And you will find that there is broad support in the disability community for the current language and of this bill and that it has safeguards that are built in to ensure that the discussions that occur with people do, in fact, elicit what their treatment goals are, that the -- that the physicians and the advanced practice registered nurses and the physician assistants who will be participating in this pilot will, in fact, have to have some training before they -- they are allowed to do so and that those -- the training will -- will involve quite a bit of emphasis on how to approach these conversations in such a way that you're not steering people away from certain types of things or into other -- into other options.

So we are -- we are actually very supportive of this legislation, and we -- we would urge that you -- you consider it and act favorably upon it. And I don't have anything further to say, but if there's any questions, I'll try and answer them.

SENATOR GERRATANA: Thank you very much for giving your testimony. And, yes, we do on the Committee recognize that there was quite a -- a intensive workgroup going on to address this very important issue. Actually, my Co-Chair, Representative Johnson, has some questions.

JAMES MCGAUGHEY: Okay.

REP. JOHNSON: Thank you so much for your very well-delivered testimony and also, you know, the comparison and contrast between last year's bill and this year's bill. It's -- it's very helpful. One of the things that I've -- I've noticed is that there seems to be in the -- in the bill -- is that there is allowance for someone who has a power of attorney -- a healthcare power of attorney to work with the treating doctor as opposed to having the actual individual make the decision for the treating doctor. Could you speak to that?

JAMES MCGAUGHEY: Well, the only -- the only discussions that we've had about that issue is to make sure that legally authorized representatives would not be cut out of this possibility. There are -- there are times when someone has designated someone to -- to make those decisions, and, in fact, that's a -- that's a practice that's -- that's encouraged.

But the -- the -- I guess the -- the problem can arise when an individual is no longer able to articulate their preferences and to participate in that discussion, but they have now -- they have designated someone and in fact formally done so as their legally authorized representative, their power of attorney as you say.

And so that -- that individual -- we didn't want to deprive people in that circumstance of the opportunity to also have a MOLST, because medical order, this -- this is portable. This will follow the person. It will accompany them when they move from one location to another. And it's a way of making sure that if 911 is called or some other emergency occurs that people are very clear as to what is supposed to happen and what is not supposed to happen.

REP. JOHNSON: Yeah, and I -- I think that that's excellent. I think the way that the bill is presented now addresses that very nicely. I'm -- the -- the focus really, when I was looking at the bill, is when a person say had never had any competency at all and never had advance directives. In that circumstance, it seemed as though that the power of -- healthcare power of attorney conservator might -- might step in.

JAMES MCGAUGHEY: Well, I think that's -- that's, yeah, that's always a difficult situation, but most -- most of those -- it's not so much a healthcare power of attorney. It would be either a conservator or a guardian of a person with intellectual disability in some cases who -- who've been specifically authorized to enter into those decisions usually following some probate proceeding.

But it's always -- those are some of the most difficult things, because it's -- it's -- invariably it's somebody -- somebody who's never had the opportunity to -- to even develop their own preferences much less articulate them, and somebody else is making those decisions usually bringing their own value system into that and trying to -- there's -- there's different theories as to how to go about it and, you know, whether you should put yourself in that person's situation and try to imagine what it's like, but whether -- in the end it's still -- you're trusting somebody else to -- to make -- to make that decision.

I don't think we can solve all the problems through this mechanism, but there's -- there's -- at least there'll be something that will -- you know, when -- when the parameds show up, there'll be something that they know they can count on and not get in trouble if they -- if they act in accordance with it.

REP. JOHNSON: So just briefly, how are those circumstances address today? Are -- are there advance directives or some living wills for people who have developmental disabilities and perhaps wouldn't be able to make their own advance directives?

JAMES MCGAUGHEY: Absolutely, that does happen. There are people who are very clear as to what they want, and they understand what -- what they're deciding. But there -- there's no -- what often happens with the advance directives -- I mean, I -- I certainly have one. I -- I have a will. I have all those things.

That was done 20 years ago, literally, and I haven't looked at it since in spite of the fact that -- I remember the attorney saying, now you should review this periodically and talk to your doctor and so forth, and I think that's the -- the way it is for a lot of folks. It's something -- it's a piece of paper that's on file somewhere, and then, you know, the -- nobody can find it when they need it, or there's some dispute as to whether or not you -- you may have changed your mind in the intervening 20 or 30 years.

S o this is something that is -- that there's recency to it, and also most folks who are going through some kind of a progressive illness that is -- that is terminal will periodically be -- be revisiting their doctors, and it can come up over time. Every time you go back to the doctor they can review the order as they review all the other orders and say, is this still what you want? Is this -- and so there's -- they can actually replace replacement orders. You can change your mind on things over time. So it's -- it's much more apt to be current, and it certainly would be more effective -- recognize the medical environments.

REP. JOHNSON: Thank you so much for your answers, and thank you, Madam Chair.

SENATOR GERRATANA: Thank you. Are there any other questions? Representative Ziobron.

REP. ZIOBRON: Thank you, Madam Chair. Thank you -- good morning -- for being here. I'm reviewing the bill, and -- and I'm curious on a couple things. Can you tell me what the definition of the geographic area is?

JAMES MCGAUGHEY: The -- the -- well, there isn't a -- there -- it's not, I think, specified in the -- in the legislation itself. There's been discussions the Health Department would make that determination, but I think they want it to have an urban area and a rural area for the purposes of conducting the pilot.

So there -- I believe that there is enthusiasm for participating in this in the -- in the New Haven area with Yale and the extended physician network and facilities that are part of that -- that medical groups -- the medical groups and the hospital affiliations there and also in -- excuse me -- in the Windham area as well, so -- so you'll get -- I think that's -- that's kind of been -- those are the tentative decisions that have been made about where it would roll out first.

But it's a pilot, so we want to be careful, I think, and the -- the working group that has -- that has been part of the drafting of this intends to be part of the rollout as well and to watch what's going on, so there'd be a report back. And I believe the one thing that's -- that in this legislation -- let me just mention this now -- that you may get a request to change -- is there is a date at the end of it. And -- and it's -- they're -- they're asking -- that date is like left over from last year's draft of the bill.

So they're asking to extend it one year beyond so the actual pilot would run until I believe 2016, so you'd have time to do that. But you'll hear more from the Health Department on that issue. I think they're taking responsibility for seeing that that happens, but --

REP. ZIOBRON: Thank you, and -- and further, there -- there doesn't seem to be any language in the bill regarding the number of patients. It just talked about a geographic area. So I'm just curious on, you know, what -- what do you believe that will be? I understand it's a voluntary on the patient's part, but I'd like to have an idea of how many patients you're talking about. In the bill, it says that all the doctors in the geographic area are going to be contacted, but it doesn't say anything about the number of patients.

JAMES MCGAUGHEY: I don't think anybody knows the -- knows the number of patients. Obviously, if you're running a pilot, you would hope it would be enough patients so that you would be able to get some sense of does this or does this not make a difference for people? Is this -- you know, you have to have some numbers -- some quantity to -- to validate the -- the idea.

But, you know, the -- the potential for a large urban area is, you know, several hundred at least. In the rural area, it may be, you know, between 50 and 200 people. It's not -- it's not -- I mean, nobody knows for sure. It's more -- it's more to get the practice established in -- in the provider organizations, and, you know, the -- that -- you can't impose this on people right now. We want it to encourage people to participate, so --

REP. ZIOBRON: Okay. Thank you. Thank you, Madam Chair.

SENATOR GERRATANA: Thank you. I don't think there are other questions or comments. Thank you for coming today and giving your testimony. We do appreciate it.

JAMES MCGAUGHEY: Okay. Thank you very much.

SENATOR GERRATANA: Next is Senator Don Williams, followed by Jewel Mullen.

SENATOR D. WILLIAMS: Good morning, Senator Gerratana, Representative Johnson --

SENATOR GERRATANA: Morning.

SENATOR D. WILLIAMS: -- and Distinguished Members of the Public Health Committee. I'm here today to support House Bill 5330, AN ACT CONCERNING THE APPLICATION OF PESTICIDES AT PARKS, PLAYGROUNDS, ATHLETIC FIELDS, AND MUNICIPAL GREENS and to bring to your attention a related issue of significant concern to the public health and our state's parks, playgrounds, and other green spaces.

Let me begin by expressing my support for the underlying bill. Connecticut set an important example for the rest of the country when we adopted a ban on the use of pesticides on the grounds of our elementary and middle schools. Scientific studies have concluded what may seem obvious. Exposure to pesticides is harmful to children's health, and it makes sense to limit the use of these poisons in additional public spaces.

I'd like to draw your attention specifically to the chemical glyphosate, more commonly known by its trade name, Roundup. As an herbicide, it falls under the existing school pesticide ban and for good reason. Studies have shown a link between glyphosate and serious health problems, including DNA damage, premature births and miscarriage, birth defects, multiple types of cancer, and disruption of neurological development in children.

The U.S. Environmental Protection Agency has reported that glyphosate is the most commonly used herbicide in U.S. agriculture and the second most commonly used weed killer for home and garden. Glyphosate ends up in the air we breathe and the water we drink. A 2011 study by the U.S. Geological Survey Office examined air and water samples taken from two states over a two-year period. It found glyphosate present in every water sample examined in Mississippi and in most of the air samples taken.

A new product may soon be marketed in Connecticut unless we take action that will dramatically increase the amount of glyphosate sprayed on soil and introduced into the air, streams, and rivers of Connecticut. Genetically modified and engineered grass seed that is resistant to glyphosate is slated for field testing this spring and summer. Introduction of this product could begin as early as next year.

I respectfully request the Public Health Committee consider adding language to H.B. 5330 that would ban genetically modified grass seed and other genetically modified annual and perennial plants and landscaping plants in Connecticut. As I've already said, glyphosate itself poses health problems. Even worse are the long-term environmental consequences to our state's environment and the Long Island Sound.

Any chemical you -- you spray on the land will affect the chemistry and biology of the land, and the runoff of that chemical will affect the water courses and water quality of our state. Some may claim that increasing the use of glyphosate is not so bad given that it's not quite as toxic as other herbicides such as 2,4-D. I would suggest that's the wrong way to look at environmental stewardship and the wrong way to create a legacy for our children and future generations.

What makes the prospect of GMO grass seed and landscape plants so damaging is that it opens the door to a massive increase in the proliferation of toxic chemicals in our environment. Those who are concerned about the quality of our air, our water, and the viability of aquatic life in Long Island Sound need to be concerned about the prospect of a quantum leap in the amount of toxic herbicides that will be poured into Connecticut's soil and in turn into our waters.

The issue is not just glyphosate. A major corporation is now moving forward with GMO agriculture products that will be resistant to the stronger and more poisonous 2,4-D, which will cause even more damage to our environment. The Wall Street Journal said some of the old pesticides, in particular those called 2,4-D and Dicamba, have a history of posing more risks for the environment than the chemical in Roundup. And that's partly because they have more of a tendency to drift on the wind into neighboring farms and vegetation.

The GMO plants that will survive heavy spring with 2,4-D are being engineered because Roundup-ready plants that use glyphosate have created super weeds, weeds that are resistant to glyphosate. This is similar to the overuse of antibiotics. Initially, everything is killed. Over time, resistance builds, and effectiveness disappears.

The GMO products that promised less use of herbicides have actually resulted in much greater use. And as resistance builds, the GMOs require the use of even more powerful and toxic herbicides. When it comes to lawns, which I think many folks are concerned about, I know from my own personal experience that simply cutting my lawn at a higher setting and using occasional low-strength organic fertilizer is the best way to go in terms of weed control and protecting my lawn against drought and scorching.

Introducing genetically modified seed and large quantities of toxic chemicals is guaranteed to have multiple adverse and unintended consequences. The recent collapse of the honeybee and monarch butterfly populations has been linked to increased use of herbicides and pesticides. The dramatic decrease in the lobster population in the Long Island Sound has been linked to pesticide runoff. Last year, Governor Malloy signed a bill banning the use of the pesticides Methoprene and Resmethrin in coastal areas due to their toxicity to fish, lobster, and other aquatic life.

Glyphosate can retain its toxic qualities in water for between 12 and 90 days. I bring this to your attention because we are at a critical juncture. It is not often that we can so clearly see two different pathways ahead. The question is whether we will have the foresight to choose the right path and recognize that the time to act is now. We can ban GMO grass seed and GMO landscaping plants now before their introduction and stop the guaranteed environmental destruction that will occur over the next five to ten years and beyond.

If we do not take action, next year literally could be too late. I have additional testimony. In the interest of time, I will leave that to you to examine. So for these reasons and the other reasons in my testimony below, I urge the Committee to amend this important legislation in the manner I've described. Thanks very much for your time and support.

SENATOR GERRATANA: Thank you, Senator Williams. Thank you for your testimony. So I just want to follow up. The GMO grass seed would be modified as corn is currently, and that is to make it resistant to pesticides and therefore in our food supply, if you will. So the grass seed that you're talking about would be -- have built-in Roundup, is that correct?

SENATOR D. WILLIAMS: That's -- yes, Senator Gerratana. What would happen is the grass seed and then the grass that -- that grows as a result would -- would be resistant to the herbicide glyphosate, otherwise known as -- as Roundup.

SENATOR GERRATANA: Oh, Roundup.

SENATOR D. WILLIAMS: So you could just, you know, spray indiscriminately --

SENATOR GERRATANA: Right.

SENATOR D. WILLIAMS: -- how many times a year you want it. This lawn with this herbicide with a guaranteed adverse consequence in terms of runoff into streams, rivers, the Long Island Sound, if you think of all the open green spaces that could potentially be affected by this, the potential adverse consequence over future years and decades could be enormous. So if -- and it's so unnecessary when with best practices folks, if they want lawns, can have nice lawns without resorting to massive increases in the application of toxic chemicals.

SENATOR GERRATANA: Thank you, sir. Thank you for your testimony. Are there any questions? Representative Ziobron.

REP. ZIOBRON: Thank you, Madam Chair, and -- and welcome. Thank you for being here --

SENATOR D. WILLIAMS: Morning.

REP. ZIOBRON: -- this morning. I have somewhat -- some experience with glyphosate in my community, but before I discuss that, you know, I have to say I choose not to use any pesticides on my lawn whatsoever. It turns brown mid-summer. I'm a big birder, and one of the first books I read at my grandmother's house was by Rachel Carson, and so I get it. But I'm curious about a couple things.

In my community, we have been hit very hard by the ban on K through eight on our athletic fields. We have children now that have to use other fields, because our fields are -- are not available to be used. That's how bad of a condition they're in, because we have not been able to treat the fields in some way -- in a best practice way. The IPM model is gone. It's a complete ban.

And glyphosate, interestingly enough, has been permitted by DEEP in a number of water bodies, including one in my district to fight lily pads. I'm just curious if you're aware of that, and -- and what would your directive be to DEEP to not allow these sort of permits to go forward?

SENATOR D. WILLIAMS: I -- I think we ought to reexamine that policy of introducing that directly into our -- our ponds, our -- our rivers. I -- I don't think that's best practices. Certainly, the problem is compounded when resistance builds, because this is -- this is not an end solution in and of itself.

By -- by going after weeds, whether it's aquatic or otherwise, with glyphosate, there is a guaranteed outcome that resistance will build, that other so-called super weeds will develop, and then you have to step it up. If you're going to go down the road of herbicides and toxic chemicals, you're going down a road toward ever-stronger and ever-more potent poisons.

REP. ZIOBRON: So would you believe then -- when you talk about extending the ban for GMO grass seed, would you also look to this bill to extend the ban on all waterways that DEEP currently permits? And further, would you also include to extend the ban to all yards, not just municipal but also private yards? Is that something that you're advocating for as well?

SENATOR D. WILLIAMS: Well, I'm -- I'm trying to attack this at the root cause, so to speak. If we -- I mean, you can talk about an outright ban on glyphosate, but I -- I think that if we do not start with a ban on the genetically modified -- modified seed, which is not available now in Connecticut but will be shortly, if we don't start with that, then we won't have the ability to effectively stop the massive increase of the use of that herbicide and down the road, other herbicides like 2,4-D where there are trials already going on in terms of new agricultural products that will be resistant to that and even stronger toxic chemicals.

So what I'm asking the Committee to do is not -- is to ban these GMO-modified seeds for grass seed and landscaping products. I mean, you raise a good point. I would -- I would advocate that the Committee should also look into what you're talking about. But today, I'm concentrating specifically on what I see as a clear and present danger right around the corner, the -- the seed that we need to address today. Yep.

SENATOR GERRATANA: Thank you, Madam. Are there any other questions? Representative Miller.

REP. MILLER: Thank you, Madam Chair, and thank you, Senator Williams. And for you, Madam Chair, I would like to first thank you for your work several years back in starting to help protect our young people with the pesticide-free zones we've now established in pre-K through eighth grade. When I was a first selectman, I came here to testify in favor of that.

My town had on its own gone that route with all municipal properties, and our school board followed shortly. And even to this day voluntarily our regional high school takes care of all their premier fields without chemicals. And for us, it was maybe a little bit easier, because we had already been making compost that we could then use to amend the fields to strengthen the soils to have the very best grasses which would out-compete the weed species.

But when you were speaking of the -- what studies we have on pesticides, glyphosate -- I think of the seven categories that pesticides are evaluated for, their harmful potential, glyphosate is five of those seven, which is pretty severe. But the question I'm getting at, are you aware that -- that here in the Legislature we have the MORE Commission, the Municipal Opportunities Regional Entities, that's --

SENATOR D. WILLIAMS: I have heard of it actually, yeah.

REP. MILLER: Right, and you know too as a former first selectman that many local municipalities have on their own formed alliances for everything from transportation to literacy volunteer to a number of other things. But still, MORE is a good idea, but there's now a subcommittee which is looking at unfunded mandates, and they have apparently invited a number of landscapers who feel aggrieved that this pronouncement where they can't use chemicals leads to conditions where they're seeing playing fields degrade to where there are weed clumps that kids are tripping over that they could fall on now compacted soils and be concussed, that there are clovers and dandelions now blooming, which could conceivably attract bees, which could sting and cause an anaphylactic reaction.

So are you -- I just want to ask you -- are you aware of this -- these efforts right now and apparently new bills which are now being put forward to promote integrated pest management?

SENATOR D. WILLIAMS: I'm aware -- I'm certainly not aware, I'm sure, of everything you're talking about, but I am aware of some of the issues that you raised. I'm also aware of studies that show that the repeated use of glyphosate on the soil tends to, as you described, harden the soil significantly and also harden the area around the roots of plants.

Corn in particular they've noticed where it's not used. In organic corn, you can pull the -- the plant out. The soil behaves as we would expect soil to behave. And in areas where glyphosate has been repeatedly used, the -- the soil is much dryer and is much more hard and compact. So there are some additional adverse consequences beyond the toxicity of the chemical itself.

REP. MILLER: And the last question is you may be aware that the World Health Organization put out a report on February 10th predicting over the next 20 years a 57 percent increase in cancers. They're suggesting we put more efforts into prevention.

And just two morning ago, our Connecticut Public Health Organization was here for their annual meeting, and this is all the venerable health departments in our state, and they are also all about prevention, and they are on board with our efforts to eliminate or reduce exposure to pesticides, particularly for children who are our most vulnerable, so --

SENATOR D. WILLIAMS: Right. I mean, it -- it really underscores the fact that if you don't go down the path in terms of integrated pest management and a more organic approach to cultivating plants -- if you go down the other path, which is the -- the use of toxic chemicals to control weeds, then you're essentially in a never-ending arms race. That's what it is, because resistance will build to whatever chemical you're using.

Glyphosate, we're -- we're seeing it increase in terms of the resistance and the number of weeds that are resistant to this, and you have to step it up. You have to go to a stronger and more powerful poison and then yet a stronger and even more powerful poison. That's not the road we want to go down in terms of leaving a safe and -- and healthy environment for our children.

REP. MILLER: My last question then, are you aware that we have a lot of modern people who do landscaping who many of them have gotten their training at accredited institutions by the very industries that provide these chemicals and such so that we have a lot of landscapers who are kind of averse to old school, if you will, because that's not their tradition anymore perhaps, so --

SENATOR D. WILLIAMS: It's a way that the -- the companies, these corporations lock in the use of their products. And by the way, as they corner market share, they raise the price significantly. The price of soybean and corn GMO seeds has gone up over 50 percent over the last ten years.

REP. MILLER: All right. Well, thank you, Senator, and thank you, Madam Chair.

SENATOR GERRATANA: Thank you, Representative. Representative Johnson.

REP. JOHNSON: Thank you, Madam Chair, and thank you, Senator Williams for being here today and your research on these issues for so long. It's a huge help to this Committee and also to the people of Connecticut for all -- all you've done in this area. And, you know, I -- I just wanted to point out again that the -- if -- if these plants are allowed to come into the -- into the area here in Connecticut, then we will run into difficulty with having to use more and more pesticides.

But if we learn how to manage the grasses and the things that we want to cultivate and make them stronger, then they'll have a natural resistance to what goes on in the environment, which also changes all the time. And if we have one set, a genetically programmed plant, eventually it could be subject to the -- to the -- to different other things in the environment. If you wanted to speak to that, that would be great, but I just want to thank you again for all your hard work on this.

SENATOR D. WILLIAMS: No, thank you, Susan. Yeah, it -- it would be an escalating problem, and it is much easier to nip this in the bud, as it were, before the products are sold and disseminated throughout the state. It's going to be a lot harder to reel it back in five or six or ten years from now when we wake up and realize, oh, my goodness, there is a tremendous problem in terms of the dramatic escalation of the use of herbicides.

And at that point, it won't just be glyphosate. It'll be 2,4-D and who knows whatever else. And keep in mind we're not talking about an annual plant like corn and soybeans. This is a perennial that has the ability to spread and be with us forever.

REP. JOHNSON: Thank you so much, Senator. Thank you, Madam (inaudible).

SENATOR GERRATANA: Thank you. Senator Williams, Representative Ziobron has, I guess, a follow-up question.

SENATOR D. WILLIAMS: Sure.

REP. ZIOBRON: Thank you, Senator. And I'm -- I'm sorry. I know how busy you are. I just wanted to follow up on Representative Miller's line of questioning. I -- I happen to be a member of the MORE Commission on the subcommittee that he referenced, and we certainly looked at a lot of issues.

But I just wanted to bring to your attention that the IPM model is -- is gone. I mean, that's -- what you're talking about is the integrated pest management. There's no ability to do that in the local -- at the -- the K through eight level, because it's a complete ban. And what the MORE Commission was looking at was bringing that capability back.

And so I just wanted to bring to your attention that we looked at it really, really quite deeply, and -- and that was actually unanimous -- one of the first and only unanimous decisions that came out of that commission on the unfunded mandate part, certainly not the public health part.

I also want to bring to your attention when you talk about the landscapers having, you know, gone to school maybe in -- in these places that provide chemical background. I would note that in the state of Connecticut, when they go to take their test, it is heavily on the side of pesticide knowledge. In fact, one of my constituents who would like to be just an organic landscaper kind of balked when he went to take his test and realized that he had none of the knowledge that was required for him to get his license.

So on one hand, we say, you know, that these guys are, you know, too knowledgeable, but on the other, the state of Connecticut requires them to have that knowledge. So, you know, I just wanted to bring that to your attention, because I think it's important to understand both sides of that issue and what we do as the state of Connecticut to -- to mandate them to have that knowledge. So I appreciate your time. I just wanted to point that out to you.

SENATOR D. WILLIAMS: And -- and that's -- I -- I appreciate that, and, I mean, I think that's something we ought to look at as well. You know, I remember my parents telling me how when they were in college back in the 1950s, cigarette companies used to put free cigarettes in the mailboxes of the college students every week as a way of hooking people on cigarettes.

It wasn't that long ago we were looking at healthcare reform and the practice by pharmaceutical companies of providing incentives of one stripe or another to doctors to promote and push the use of their particular prescription drugs. We need to be mindful of those types of undue influence, especially when it comes to the use of toxic chemicals in our environment.

REP. ZIOBRON: (Inaudible).

SENATOR D. WILLIAMS: You're welcome.

SENATOR GERRATANA: Certainly, and thank you. I don't think there are any more questions. Thank you so much for coming today and giving testimony in front of our Committee.

SENATOR D. WILLIAMS: Thank you, Terry.

SENATOR GERRATANA: Thank you, sir. Before I announce the next person, I just want to announce a safety concern that we have. The two doors that come into our room, we have to leave them free so people can come and go. And, of course, if there is any emergency, you know, blocking the doors would be very dangerous. So I ask that please everyone take a seat -- seat if they can, and we appreciate it so much. Safety first. Next is Jewel Mullen followed by Representative Elissa Wright.

COMMISSIONER JEWEL MULLEN: Good morning, Senator Gerratana --

SENATOR GERRATANA: Good morning.

COMMISSIONER JEWEL MULLEN: -- and Representative Johnson. I'm Dr. Jewel Mullen, Commissioner of the Connecticut Department of Public Health, and I'm here to testify this morning on behalf of a number of the Department's bills. First, I would like to take us back to Medical Orders for Life-Sustaining Treatment, Senate Bill Number 413, AN ACT CONCERNING THE DEPARTMENT OF PUBLIC HEALTH'S RECOMMENDATION REGARDING MEDICAL ORDERS OF LIFE-SUSTAINING TREATMENT -- MOLST.

The Department of Public Health supports Senate Bill 413 and would like to thank the Committee for raising our bill. In 1990, under Title 42 U.S.C. 1395 CCA of the Omnibus Reconciliation Act, Congress passed an amendment known as the Patient Self-Determination Act, which gives individuals the right to make their own healthcare decisions and to prepare advance directives.

Medical Orders for Life-Sustaining Treatment, MOLST, is an adjunct to a formal written advance directive and will benefit Connecticut residents with life-limiting illnesses for residents of advanced age who wish to make their choices known by exercising their rights and articulating their choices about the medical life-sustaining treatments they will accept at the end of life.

The MOLST paradigm is an advanced care planning tool that utilizes a structured process of shared decision making so providers can elicit patient preferences about probable medical intervention. The patient's preferences are then translated into an actionable medical order on a highly visible standardized form that travels with the patient across all care settings to ensure continuity of care.

MOLST reflects the patient's current goals for medical decisions that she or he will likely confront within the near future. Currently, there are 15 states with approved MOLST programs, 28 states, including Connecticut, with developing programs, and 7 states without a MOLST program. The bill gives the Department the authority to pilot MOLST to a voluntary program that involves healthcare professionals and institutions in designated areas of the state.

A pilot program will provide opportunity to collect and analyze data on the use, effectiveness, and limitations of MOLST. If the program is successful, the Legislature may elect to implement the program statewide through a comprehensive educational program that targets specific groups of healthcare providers. Thank you for your consideration on the Department's bill.

SENATOR GERRATANA: Commissioner Mullen, I'm -- Mullen -- I'm sorry -- I -- I know there are many questions on this bill. If you don't mind, I know you have, you're going to be testifying on other bills, but we do have some questions, and I have one.

COMMISSIONER JEWEL MULLEN: Uh-huh.

SENATOR GERRATANA: And that is, could you walk us through -- I've been asked so many questions about people -- from people here in the building and outside -- how this protocol would work. And I think it would be helpful for you to give your vision. I know you've worked so very hard on this legislation of how this would work. I understand the pilot would be perhaps in two different geographic areas, but what is your vision on this? I -- I would appreciate your input. Thank you.

COMMISSIONER JEWEL MULLEN: So my vision after over 30 years of medical practice with patients at various stages of wellness and illness would be that we would finally create a system that supports individuals' ability to say how they want to live as they course through an illness that is oftentimes terminal or when they know that they are nearing the end of their life.

And I -- and I put that out there as the first vision, because the vision isn't -- isn't really about the Department or anybody here testifying. The vision is about improving the lives of people and their not having to continue to fear some of what we know happens right now except their wishes aren't known, or even if their wishes are known, they're not upheld and that care providers who always want to do their best not to harm but to -- and to care for people sometimes are left with uncertainty, because they don't know what those patients are.

So with that being my preamble, what I would -- what I would say is that these are the kinds of conversations that people have on a so-called good day. They're not the kind of conversations that I think many of us have experienced when we've had a close -- someone close to us in a hospital or in a situation, maybe even with EMS in their home saying what do you want us to do? And you're faced at that moment with trying to figure out what you remember or realize that you never had the conversation that you've been putting off or saying to yourself -- am I giving you more than you want -- or saying to yourself if I answer the way I know I should, maybe somebody else in my family or in my -- in my circle will be upset, because they disagree. And then all of that removes the focus from the patient.

So when -- when I -- say it's a conversation that you have on a so-called good day. It's because it's a conversation that's initiated between the healthcare provider who knows the patient well and the patient when the patient is able to engage in that discussion or, as you've already heard, when there is a surrogate who is aware of what a patient's preferences would be and would be able to have that conversation on behalf of -- and -- and then it doesn't just become information that's shared between the physician or the care -- and the patient, but it becomes information that others will be able to see and know and uphold, because you do have a form, you have a documentation, and it enables the rest of the conversation with other people close to the patient.

In a statewide work (inaudible) that has a -- a program, we -- we talked about how people could have one in their pocket, on their refrigerator, next to their bed so that if someone calls 911 and EMS arrives, the information is there. The information travels with the patient to any care setting, and it becomes the guide that actually is speaking on behalf of the wishes that the patient designated.

Now I can tell you that any time I've had conversations with patients about their wishes, you know, I've always done what our bill also says, is that no conversation is a final one, so you revisit things, you know. And my biggest example of that is I had a patient that signed out hospice once and lived a lot longer than she thought she was going to.

See, always you revisit things. You revisit things, and -- and that happens with MOLST as well. And -- and because, you know, as I describe MOLST, because I look at MOLST as a document that I will continue to say helps design how people are going to live with their disease and not how to hasten their death, it's -- it's -- it also enables someone to say something like, well, you know, at one point, I would have wanted to have a feeding tube, but I've changed my mind or vice versa. So it's a -- it's a living document with a living person.

SENATOR GERRATANA: I think you articulated that very well. Some of the questions that I have gotten are, would this be applicable to -- this travels with the individual once the protocol is initiated.

COMMISSIONER JEWEL MULLEN: Uh-huh.

SENATOR GERRATANA: Now I had to go to other states to read about the process, if you will, and there are some very good websites -- POLST is one -- that explains that this is -- this is initiated or comes about when the individual, you know, may recognize that, you know, there has to be some sort of advance directive.

I was reading our living will statutes and, you know, the form that is embodied therein also for those individuals who want to, you know, take advantage of that, of the living will so that there's no, I guess, mixed message or confusion or whatever that you were, you know, also describing.

But when we're talking about the individual, it could be an individual at home. It could be an individual in a nursing home. It could be anyone at any point in their life who may want to enact, if you will, a living will of one kind or advance directives. So I just wanted to make that very clear that it could be in a variety of settings, and it could be anyone at any age, if you will, who wants to embark on this advance directive and the management, if you will, of their life decisions, which is appropriate.

The other concern that I've heard is what about individuals? You say that things can change. For instance, somebody leaves hospice, as you used the example, but what about a situation -- and I know I face it -- I take care -- have taken care of my parents, and, you know, that sort of thing as they age -- a situation whereas perhaps somebody lapses into a coma, has advance directives, that sort of thing, and is no longer able to, if you will, participate in making those decisions or changing situations. How do we go about dealing with that particular issue?

COMMISSIONER JEWEL MULLEN: That's -- that's why it's important to -- to differentiate between the advance directive that anybody -- everybody should have that -- that ensures that there's someone that -- who -- who will be a spokesperson for them if they can't make decisions for themselves and can make some of those end-of-life decisions, which is not what -- strictly what MOLST is about as -- as you just articulated.

But when you -- when you've designated someone to act as your proxy or decision maker, they are -- they are in that (inaudible), are representing what your wishes are, what your wishes would have been, which also means people have to have conversations. But I'm so sorry. I'm just using this as a teaching moment for everybody in the room, which is important.

SENATOR GERRATANA: That's what we want.

COMMISSIONER JEWEL MULLEN: Yeah. Okay. So -- so in that -- in that circumstance with that designation, the person who has that proxy status can actually, as Mr. McGaughey also alluded to, be the spokesperson for the person who has a MOLST but no -- can no longer speak to the MOLST.

SENATOR GERRATANA: Okay. Just this morning I was reading The New Yorker magazine, the March 10th issue, and Liz Chaz, who is a cartoonist, if you will, one of the very famous cartoonists for that magazine, did a whole series on how she dealt with her parents and their end-of-life decisions. It was humorous, of course, but also very poignant, so just coincidentally that's what I reading this morning.

COMMISSIONER JEWEL MULLEN: Right, and -- and that's where it's so important not to just -- not to just think of these as end-of-life even though that's how most of them -- of us construe them, because I think most people who are sick, even in hospitals, don't die as quickly as we think they're going to. They just don't. And they're some of the hardest conversations.

And along the way, when they're in those settings, it's not as if they're just there. Things can be done. Interventions can be applied. So -- so it makes it even more important, and that's why I keep talking about this as -- as something that's important to people who are living.

SENATOR GERRATANA: Thank you so much, Commissioner. Does anyone else have questions of the Commissioner on this legislation? Okay. Representative Srinivasan followed by Representative Ziobron.

REP. SRINIVASAN: Thank you, Madam Chair. Good morning, Commissioner.

COMMISSIONER JEWEL MULLEN: Morning.

REP. SRINIVASAN: And thank you for your testimony. And more important, thank you for all the advocacy that you've done on this, which we feel we definitely need in our state. And it's starting, you know, into the first step, the pilot program.

It's just about the right way to go, so we, you know, the -- the entire Committee then, under your supervision, would be able to analyze, you know, what we have accomplished, what we need to accomplish even further, and it's a very, very good first step, and I want to thank you for your support on this. And when we brought up last year, we can move certain places but didn't go all the way, and I'm glad you're back here again to discuss this very important thing which I think our patients in our state definitely need.

COMMISSIONER JEWEL MULLEN: Thank you.

REP. SRINIVASAN: And just one quick question. In the -- in the 15 states, and one of them being where you had worked before coming to Connecticut, and I'm glad you're here, is were there any -- any situations that arose to -- to the best of your knowledge which were -- which were concerning or red flags? Any -- any of that that you're aware of in these states that have this program already?

COMMISSIONER JEWEL MULLEN: Not specifically, and I -- I think -- let me -- I just want to thank everybody who submitted testimony and everybody who affirmed the Department's work, because I read all the testimony last night, and it was actually very touching to me, because I felt as if, you know, what was in our heart last year actually conveyed through our actions in our working with -- especially with the -- the disability community that wanted to be sure that -- that this was not going to be -- MOLST would be a mechanic through which people would not get the cure that they needed.

And to get to the testimony that we received yesterday, I think we established a level of trust. That's really important for us going forward. Reading -- now I'm not -- I can't tell you about everything that's happened in some of the other states, but from reading their testimonies, I think part of what some of our proponents have sited is that there have been more concerns about whether or not medical providers use the order form in -- in a more prescriptive way than they should have or whether or not there were appropriate provisions to ensure equity.

In -- in Massachusetts where we were just starting to pilot it before I left, I -- I did not hear about anything. I talked to the person who led the -- one of the people who led the pilot last year, and she did not report anything. I can follow up again, but thank you.

SENATOR GERRATANA: Oh, certainly. Representative Ziobron.

REP. ZIOBRON: Thank you, Madam Chair, and welcome. Nice to see you again.

COMMISSIONER JEWEL MULLEN: You too.

REP. ZIOBRON: I has asked, well, one of the first gentlemen who came up and testified -- I'm not sure if you were in the room or not, so I'm going to ask you to clarify those two questions. The first was what is the -- I understand the geographic area now, but I'm looking to understand the population of the patients that you're targeting, and then secondly, I also did notice that date of October 1, 2015, and I was curious on such a short window when we were planning on starting, so maybe you could address that as well.

COMMISSIONER JEWEL MULLEN: Right. So we -- we don't have a fixed number, a goal. It's important for us, because the -- the health systems are somewhat different in rural than urban areas to be able to pilot in both, and we know already that there are provider groups and hospitals interested in being in a pilot. So I -- I can't tell you specifically what that number is going to be. I would say that when we come back to you, and I'll get to the date after. I don't think it's just going to be a handful of patients. Okay. Thanks.

Now there were more conversations about the -- what might be an ideal time for the pilot after we had written the bill. And we're certainly open to extending the timeframe from what we had originally said to get the pilot up and going. So that's some discussion that we'll continue to have after. Okay?

A VOICE: Uh-huh.

SENATOR GERRATANA: Thank you. Also, I'm going to recognize Representative Johnson in just a minute, but we do see there is a reporting mechanism in line 82 after the termination of the pilot program. Said commissioner may submit a report in accordance with the provisions and so forth to the governor and Joint Standing Committee of the General Assembly having cognizance over public health.

I -- I don't know how you feel about that, but I -- we'll probably discuss it in screening, but we may want to say that you shall submit a report and a particular date by a, you know, after the pilot closes. I don't know how you feel about that, but I thought I'd ask for your input at this point.

COMMISSIONER JEWEL MULLEN: I am sure we'll be happy to submit a report.

SENATOR GERRATANA: Good, good.

COMMISSIONER JEWEL MULLEN: Well, actually, we'll be proud to submit it.

SENATOR GERRATANA: Proud to submit it. Okay. Thank you very much. Let's see, Representative Johnson.

REP. JOHNSON: Thank you, Madam Chair. Thank you, Commissioner, for your testimony and your good work on this bill, really very much appreciated. It's a dramatic change from what we saw last year, and I do have a couple questions though.

In terms -- I -- I really appreciate your remarks before about the idea of -- the differences between advance directives and MOLST and how perhaps they could work together, or if you have a MOLST agreement in -- in terms of, you know, the -- how the medical profession without advance directives might work with the patient. If you could just compare and contrast that so people would have a real understanding of the differences.

COMMISSIONER JEWEL MULLEN: Well, I think I wrote my first advance directive -- I -- I think I'm like a lot of other people -- maybe when I was 30. And I'm still married to my husband, but, you know, I have to say I haven't really looked at it since, so it's a good thing I'm still married to him, because he's my proxy. And so that's a reminder. Look at your advance directives because things change. I'm -- I'm really respectful of you. I really am. But, I mean, it's -- it's a -- it's a -- it's, I think it's a salient point.

So I know who -- who, if I couldn't speak for myself, would be able to speak for me. And he and I have had lots of conversations. But, you know, I also come from a family where we talk a lot, so I think my -- my siblings wouldn't be suspicious of him or my mother wouldn't be suspicious of him, because, yeah, we -- we have those kinds of conversations. And those are some -- they're some of the hardest things we ever do in life.

But a -- a lot of what the advance directive gets to is so specific about, you know, very end of life and the most aggressive life-sustaining interventions. MOLST -- MOLST, by comparison, is -- is -- and -- and I -- I will keep saying, because people live with terminal illnesses for a long time, and there are so many decisions that they have to make where they might elect to do or not do something, but it doesn't even necessarily mean that decision is going to hasten their death.

But it might start those -- those treatments could change the quality of their life in a way that they would rather not endure. And that's -- that's part of what a MOLST allows, is to really think about the different scenarios that someone might confront, and then have the, well, given where you are and what your condition is now, if you -- if you -- this is happening with you, would you really want this done?

And then it enables you to differentiate between basic hydration, not to become dehydrated, from a -- a -- something like a feeding tube for calories and nutrition and vitamins. Using antibiotics might not, so it's much more specific. And the -- the DNR piece of it or -- or to -- to be resuscitated is another choice. So a lot of times people just skip that question. Is somebody a DNR?

The MOLST actually allows another level of decision making just about whether or not the person would want compression of their heart if it stops beating or to have artificial breathing if they're, if they stop breathing on their own. So it's much more detailed. And -- and to have the individual be able to think those things through -- I don't know if anybody has ever been in a position where a doctor just looks at a family and says, so what do you want us to do? I think that's one of the harshest things a -- a clinician can do to someone. And -- and a -- a MOLST helps remove that possibility.

REP. JOHNSON: Very good. So there's an interaction between the -- the patient and the -- and the provider --

COMMISSIONER JEWEL MULLEN: Right.

REP. JOHNSON: -- so that they come to an agreement, which is the best possible situation and when you're looking at patient care to have the interaction with your provider --

COMMISSIONER JEWEL MULLEN: Uh-huh.

REP. JOHNSON: -- so you make these decisions jointly --

COMMISSIONER JEWEL MULLEN: Uh-huh.

REP. JOHNSON: -- and you move forward with whatever is available. And also as you -- going back to the advance directives or livings wills, some people might be more familiar with living wills than advance directives. They're one in the same.

So when you have those kinds of situations, and as you said, you know, you -- you did yours some time ago, sometimes the language in the living will might need to change because of -- not just because of your changes in circumstances but perhaps because of the changes in the types of care that are available today versus what was available when you -- when you -- did you want to speak to that a little bit?

COMMISSIONER JEWEL MULLEN: Well, I, you know, I think you just said it, but -- but in general, I think, you know, since the Patient Self-Determination act became law, I think the living will, that those type of documents evolved a lot less. I think they've -- I -- it's my opinion -- I don't think they've changed quite as much, so --

REP. JOHNSON: So -- so and then the other thing, so we -- Senator Gerratana was speaking of having advance directives or a living will and then having a situation where someone becomes incapacitated and then needing the family member to work together with the provider and try -- because they're appointed in the living will --

COMMISSIONER JEWEL MULLEN: Uh-huh.

REP. JOHNSON: -- and, or they might even be appointed by the -- the probate court as conservator.

COMMISSIONER JEWEL MULLEN: Uh-huh.

REP. JOHNSON: In those circumstances, talking a little bit first about the advance directive situation where there's a healthcare power of -- durable power of attorney, and in those circumstances --

COMMISSIONER JEWEL MULLEN: Uh-huh.

REP. JOHNSON: -- you would have a guideline. Do you want to talk about the interaction between that guideline and MOLST?

COMMISSIONER JEWEL MULLEN: But -- but I look at the durable power of attorney as a document that assigns, you know, tremendous responsibility to an individual still to -- to make considerations that keep the patient as -- as the primary focus and to act with the information presented about the patient status and the potential benefit or lack thereof of any kinds of treatment and -- and take a real, you know, serious and -- and solemn approach to then what MOLST upholds that patient's autonomy if acting for that patient but also other ethical principles like to -- to do no harm and -- and, you know, beneficence, to really do well by -- by that person.

And -- and, you know, in the situations in which I've needed to work with someone's conservator, I -- I think that the people in those roles have always been careful in their questions about what was going on. And I -- I have to say I -- I haven't felt that they -- that they've imposed their personal feelings on a decision but really tried to act on a patient's behalf.

So, you know, it's very possible that, you know, and I think you alluded to this in -- in the first series of questions with Mr. McGaughey, do you -- there -- it gets much more tricky when you have -- have someone acting on behalf of an individual who perhaps never had decision making capacity. But on the other hand, if that person has had a conservator for a long time, they've had -- they've had that other person who's been able to course through what their life has been for a long time too, and I -- I think there's actually some value and benefit to that as well.

It -- it may actually be a little bit trickier when the -- the conservator ends up being someone who hasn't known the person over a course of a long time. But that's where I think it gets to the individual circumstance. I have some ethical experts sitting behind me, and I have no idea how they're feeling about what I'm saying. Am I doing okay?

A VOICE: You mentioned -- you mentioned that (inaudible).

COMMISSIONER JEWEL MULLEN: But -- but your, I mean, but your questions also reflect that -- that no matter how easily a -- a program might be applied for most of the population, there are going to be circumstances in which it's -- it's more complicated.

REP. JOHNSON: So perhaps -- and I'm thinking this through as you're speaking, because this is very, very helpful -- perhaps in the past, maybe before this legislation and the pilot project and our -- our ability to take a look at this in a more formal way, perhaps these sorts of things were ongoing without MOLST, and now in some ways MOLST will help formalize the -- the situations where people may not have advance directives or capacity.

COMMISSIONER JEWEL MULLEN: Yes.

REP. JOHNSON: And then -- then finally with respect (inaudible), just one of the things that I had noticed when I was an advocate for Medicare beneficiaries, and people would sign themselves into hospice as you -- as you presented in -- in some other testimony you gave, and they would find that if they had to be transported for other circumstances by ambulance, the ambulance provider would be -- would be there and would have to provide the resuscitation whether or not there was a DNR or not.

So did you want to just speak to that and how this would address that? I know the emergency medical services providers, at least many of them, are -- are very happy to see this legislation.

COMMISSIONER JEWEL MULLEN: Because the default action is to treat, and -- and treating is not necessarily what an individual would want. And one of the -- one of the biggest challenges for many people who take it as their primary responsibility to treat and care for people is that it becomes harder for them to see when the best treatment is not to treat.

So for EMS providers and even for people in hospitals to be able to have that guide through a patient's voice actually lets them know that they're administering the best treatment as designated by the patient.

REP. JOHNSON: Thank you so much for your work on this and your wonderful testimony.

COMMISSIONER JEWEL MULLEN: You're welcome.

REP. JOHNSON: And welcome. Glad you're here. Thank you.

COMMISSIONER JEWEL MULLEN: Thank you.

REP. JOHNSON: Thank you, Madam Chair.

SENATOR GERRATANA: Oh, my, one follow-up question, I know.

COMMISSIONER JEWEL MULLEN: Oh.

SENATOR GERRATANA: I'm -- I'm reading about the Patient Self-Determination Act, the PSDA, which was passed in 1990, became law in December of 1991. And my only comment is this is a requirement that certain health institutions, hospices, nursing homes, and so forth, give information to the adult person who may be admitted into that institution for care about the advance directives.

I must say that in taking care of my dad as well as elderly individuals, I don't recall that that was ever disbursed or given to us. It would have been very helpful, I think. So I'm just going to follow up with OLR and ask them to understand how that's being promulgated in our states and if it's indeed a federal law. So --

COMMISSIONER JEWEL MULLEN: Yeah. I -- I think what happens is that it becomes another form that people sign, and they don't even realize what they're signing anymore.

SENATOR GERRATANA: Ah, interesting, yeah. Certainly, I try to pay attention to details.

COMMISSIONER JEWEL MULLEN: Uh-huh.

SENATOR GERRATANA: Well, thank you, Commissioner. Please proceed with the rest of your testimony. I think -- I don't think there's any more questions here, but I know the Committee feels this is a very important issue.

COMMISSIONER JEWEL MULLEN: Thank you.

SENATOR GERRATANA: They all are, but --

COMMISSIONER JEWEL MULLEN: Thank you.

SENATOR GERRATANA: -- this one in particular had a lot of questions attached to it.

COMMISSIONER JEWEL MULLEN: Thank you.

SENATOR GERRATANA: Thank you, Commissioner.

COMMISSIONER JEWEL MULLEN: So I thought you said, oh, my, because you knew that our tech bill was coming next, and it -- I have about ten pages here. So I'm actually going to go through the sections but only just maybe read the first sentence, and then if people have -- if that's okay with you (inaudible) --

SENATOR GERRATANA: Oh, certainly.

COMMISSIONER JEWEL MULLEN: -- in the interest of time.

SENATOR GERRATANA: Certainly.

COMMISSIONER JEWEL MULLEN: Okay.

SENATOR GERRATANA: We'll -- we have our computers, I hope, and -- because we do everything electronically. We can certainly read. I know there's quite a few bills you're testifying on.

COMMISSIONER JEWEL MULLEN: Yes, right.

SENATOR GERRATANA: Go ahead.

COMMISSIONER JEWEL MULLEN: So next, House Bill 5537, AN ACT CONCERNING THE DEPARTMENT OF PUBLIC HEALTH'S RECOMMENDATIONS REGARDING VARIOUS REVISIONS TO THE PUBLIC HEALTH STATUTE. We support House Bill 5537 and thank you for raising it. There is a brief description of each section. I'm going to talk a little bit slowly. That helps.

Section one, outpatient surgical facilities are statutorily mandated by Section 19a-654(c) of the Connecticut General Statutes to submit certain data and information to the Office of Healthcare Access. This data is used by OHA to fill its statutory duties. As it's currently written, outpatient surgical facilities have been accepted, and essentially what we're doing now is looking for them to submit data too.

Sections 2 and 3 contain revisions that expend the voluntary process of acknowledging paternity of a child to cases in which the child has reached the age of 18. Right now, there's not a mechanism to establish paternity for a child that's reached majority age, but, you know, we've learned that there are times when people need to have paternity designated acknowledged, and this is a process to do that. And -- and unless you think I'm being too brief, I'm going to keep going. Okay?

Section 4 amends the child fit immunization registry statute so that school nurses will be able to view -- only view the registry in the Connecticut Immunization Registry Tracking System so that they will be able to see what a -- a student's immunization status is. They'll be able to look at their immunization records and ensure that children are in compliance after entering school.

` Section 5 makes a technical change to the Office of Multicultural Health Statute, essentially changing the name of the Office of Multicultural Health to the Office of Health Equity, which is a -- a much more contemporary name much more reflective of the work that we're doing now and uses language that is much more the -- the nationally referenced phraseology.

Section 6 reestablishes the minimum cover -- cover requirements for burials that were codified in 1949, and essentially this ensures appropriate steps and safeguards that burials are -- are conducted in such a way that there aren't nuisance conditions and that's less likely that graves will be disrupted by animals.

Section 7 requires that a nurse -- a nursing facility management service that is contracted by nursing homes to provide a plan of improvement to the Department if the nursing home's five-star quality rating declines by two stars. This enables us to hold a facility management services company accountable if their services become substandard. And it helps us ensure that quality of care is maintained.

Sections 8, 9, and 10 make revisions to the Childhood Lead Poisoning Prevention Program statutes. Bottom line, it's the reference level for what we consider a -- a lead toxic level or level of concern is lower now. And -- and through these revisions, we're consistent with what the national standard is.

Section 11 requires a nursing home to develop policies and procedures to ensure patient privacy and security when using electronic health records and electronic signatures. Section 12 gives emergency medical service agencies greater flexibility in how they get their vehicles inspected or where they get their vehicles inspected. The proposal would allow ambulances to be inspected by a certified dealer which specializes on the type of vehicle rather than just being inspected at the Department of Motor Vehicles.

Section 13 pertains to the sale, transfer, assignment of water company land. It removes the requirement that class two water company land when being sold also contain class three water company land. And this is a proposal that we're requesting in conjunction with the State Water Planning Council that's underway.

Section 14 requires that each chronic and convalescent nursing home and rest home with nursing supervision complete a comprehensive medical history and medical examination for a patient on admission, but it removes the requirement for a yearly urinalysis, which is currently required in our regulations.

Section 15 specifies the residential care homes' responsibilities in assisting a patient who's being discharged and then finding that patient an appropriate placement. It also clarifies what should be included in a resident's discharge plan.

Section 17 allows DPH to waive provisions of its -- or regulations for any institution defined in Section 19a-490 if the commissioner determines that a waiver would -- would not endanger the health, safety, or welfare of any resident. This gives us more authority to waive regulations that might be outdated and overly burdensome to a facility.

Sections 18 through 25 make changes to the emergency medical services statute, including paramedic intercept services allowing billing for the service and ensuring that services are following applicable statutory requirements. I'm not going to go through the rest.

Section 26 revises the definition of inter-facility critical care to transport to help care for the facility. It allows the healthcare facility to select the transportation services most medically appropriate modernizing the statute, and that also reflects industry practice. It makes sure that patients are transported with the appropriate type vehicle and service.

Section 27 mandates that ambulance services have a contingency plan for potential strike activities. Other healthcare facilities are already required to -- to have such a contingency plan.

Section 28 allows a certified EMS organization to apply to -- to us to allow for billing of non-emergency transport during a disaster for a period of seven days. Given all -- all of the challenges that we've had with storms over the past four years, we found that this has been important to patients and important to the EMS providers who have stepped up to provide transport.

Section 29 mandates licensed and registered direct care staff in a nursing home to complete training and oral health and oral hygiene techniques. Last year, we released a report on the status of oral health in older adults in Connecticut and found that there were a number of people in facilities who have unmet oral health needs. So this -- this provision actually requires some training to help increase the likelihood that patients are going to get the oral healthcare that they need.

Section 30 makes revisions to 19a-14(b) requiring analytical measurement service providers -- laboratories -- and approved radiologic reporting radon results to DPH and require residential mitigation service providers to uniformly report to us the radon mitigation system installation throughout the state. This gives us better ability to track radon where radon has been detected in homes for the kinds of systems that have been installed and ensure that the work that's -- that's being done actually is affording better safety to the -- the homeowners.

Section 31 is really a technical deletion in the statutes related to pneumococcal vaccinations. There's more than one type of vaccine for pneumococcal pneumonia, and we just want to make sure that the wording doesn't restrict us to using only one of those vaccines.

Section 32 revises statutes giving us the authority to continue to utilize existing public swimming pool design guidelines. The guidelines establish minimum standards for the proper construction and maintenance of public swimming pools. And we are able now with this to keep pace with changes in pool equipment and construction technology.

Section 33 relates to our tumor registry and allows us to enter into a contract for receipt, storage, and maintenance of data and files for the Connecticut Tumor Registry. Our national funder encourages registries to warehouse data at a shared data center.

Sections 34 and 35 provide authority for the commissioner of the department to enter into a contract with another state and accept funding for another state. We have situations in which there might be certain kinds of tests that we might want to perform in our lab for another state or vice versa or other kinds of collaborations that we might want to undertake, but right now we're limited in our ability to do that.

Section 36 authorizes commissioners designee to assign waivers of continuing education credits for a position to serve as expert reviewers and physician investigations. When we first introduced or met expert witnesses, the commissioner was going to assign the waiver for something I can also delegate to someone else.

Section 37 authorizes DPH to accept apprenticeship hours completed outside of Connecticut towards meeting optician licensure requirements.

Sections 38, 39, and 40 authorize DPH to accept licensed work experience in lieu of clinical internship hours for clinical sites colleges, professional counselors, and social workers who have been licensed and practicing in other states and who are applying for licensure in Connecticut based on holding an out-of-state license.

Section 41 clarifies that hairdressers must have completed at least a ninth grade education. This is currently the requirement for barbers.

Section 42 clarifies that services provided by an applied behavior analyst in accordance with the General States do not fall in with the scope of practice of a speech and a language -- or -- and language pathologist.

Section 43 amends Section 10a-155(b) to require each student who resides in on-campus housing at a college or university to have documentation of receiving a meningitis vaccine not more than five years prior to enrollment, and that's just adopting a national standard.

Section 44 restores language that was inadvertently repealed during last year's session and will allow appropriately credentialed individuals to continue to perform bone dense optometry.

Section 45 clarifies licensed reinstatement requirements for dental hygienists to be consistent with current standards.

Section 46 revises 19-29(a) to clarify and update current practices of the environmental lab certification program. It's (inaudible) the testing parameters in which certification is not being granted any longer.

Section 47 makes changes to the lead life insurance certification penalty statute, including a revision to reflect the $5,000 per day penalty for violation as required by the Environmental Protection Agency.

Section 48 amends the name of the national organization that has authority for continuing education activities for hearing instrument specialists. The is the tech bill.

Section 49 adds nuclear medicine technologists to the list of professionals are you exempt from having to hold a medical license. Nuclear medicine technologist (inaudible) recognized in our statutes last year.

Section 50 is a technical change related to the repeal of Section 19a-691 of the General Statutes.

In Section 51, which are outdated statutes pertaining to the Department's HIV prevention program -- previously, in 1988, there was a requirement for the composition of an AIDS taskforce. That statute is no longer necessary, because DPH convenes and co-chairs the Connecticut HIV planning consortia that aligns with requirements of the federal funders, the Health Resources and Service Administration, and CDC.

We also request a repeal of 19a-121(c), an outdated statute that requires DPH to establish a public information program for the distribution of material such as pamphlets, films, and public services announcements on HIV and AIDS. And this is largely because with technological advances we have other ways in which we disseminate information. Thank you for listening to all of our proposed revisions to the tech bill. And --

SENATOR GERRATANA: Thank you, Commissioner. You can continue on with your testimony for the other bills, and then we'll come back for questions. Thank you.

COMMISSIONER JEWEL MULLEN: Okay. All right. And I don't intend to read the testimony for the others. I will just mention Senate Bill 414, AN ACT CONCERNING THE DEPARTMENT OF PUBLIC HEALTH'S RECOMMENDATIONS CONCERNING GENEALOGISTS' ACCESS TO VITAL AREAS, which essentially requests that we continue to provide access for doing searches but that we establish an appointment system so that access can be provided at a time when genealogists can get the attention that they need from our staff at the same time that we don't create other burdens for individuals and staff who might be working on confidential information or do -- or -- or be otherwise preoccupied in ways that they wouldn't be able to provide the assistance to the genealogists that they had accessed just throughout the day.

Senate Bill 418 regarding the Department of Public Health's recommendations for medical spas essentially clarifies what cosmetics -- what -- I mean, what cosmetic procedures are and also designates which professionals -- physicians, physicians assistance, and nurse practitioners -- may be the supervising authorities in -- in medical spas and -- and within that authority have the clarity and -- and oversight of which professionals can perform which procedures.

House Bill 5504, AN ACT CONCERNING THE DEPARTMENT OF PUBLIC HEALTH'S RECOMMENDATIONS REGARDING LOCAL HEALTH DEPARTMENTS AND DISTRICTS, requires or requests that local -- municipalities who do not expend their entire per capital -- per capita allocation from our local health administration line return that money to the state.

Our goal is that the funds that go out to municipalities for public health be used for public health improvements in the municipalities. But we understand that there are -- are municipalities that do not use those funds. A provision such as -- as this allows for future possibilities that monies designated for public health will be used for public health someplace in the state even if they're not being used in the municipality that we hoped we'd be using.

Senate Bill 416, AN ACT CONCERNING THE DEPARTMENT OF PUBLIC HEALTH'S RECOMMENDATIONS REGARDING ADVANCED EMERGENCY MEDICAL TECHNICIANS, acknowledges that the certification for AEMTs was originally implemented at a time when -- when the kinds of services in here that would be provided by those providers was perhaps the best at that time period almost 30 years ago. But over time the -- the experience, the expertise, and the -- the services provided have changed in such a way that AEMTs are no longer felt to be a level of care provider that fits within our system of paramedics and emergency medical service providers.

House Bill 5530, AN ACT CONCERNING THE DEPARTMENT OF PUBLIC HEALTH'S RECOMMENDATIONS REGARDING BULK WATER HAULERS. Bulk water hauling is something that's done as a temporary measure to ensure that there is an adequate supply of drinkable water during an interruption of a water service. And what this bill does is actually just spell out that the safety of the water and sanitary conditions and the water quality are going to be upheld. I'm happy to take your questions.

SENATOR GERRATANA: Is that it?

COMMISSIONER JEWEL MULLEN: I hope so.

SENATOR GERRATANA: I'm furiously taking notes here. Actually, I did have some questions. I'm -- we're going to go back to the -- I think it's -- oh, dear, 55 -- is it 27, the technical bill?

A VOICE: (Inaudible).

SENATOR GERRATANA: Yeah. Hold on. 5537, is that it? Okay. Let's see, in Section 14, you are -- or the recommendation is to eliminate the yearly urinalysis in a nursing home setting. And I know we had a bill just to the contrary, and we were somewhat assured that, well, currently when a patient is admitted into a nursing home setting that they do have what I would call, you know, a history and a physical and a workup, and vitals are taken, including certain, you know, lab tests, including a urinalysis.

And why is it your recommendation to eliminate this particularly since I know we -- we've had testimony saying that it should be done on -- at least on a yearly basis?

COMMISSIONER JEWEL MULLEN: Last week, the Centers for Disease Control and Prevention released information on the overuse and inappropriate use of antibiotics in the -- in the population. And a lot of what was cited there was misuse of and overuse of antibiotics in the hospital setting but also in community settings.

One of the examples that they included in how that -- how to actually ensure appropriate use included an algorithm in a scenario around a possible urinary tract infection in an individual. People -- older people, people with certain medical conditions, people in facilities -- sometimes have bacteria in their urine, sometimes have some abnormal cells in their urine, but they don't -- neither of those necessarily reflects that the person truly has a urinary tract infection.

And -- and it's been -- I told you I've been -- I've practiced medicine for over 30 years, so back when I was early in my career, we used to sort of do a lot of routine tests on everybody that -- look at Dr. Srinivasan -- and everybody who ended up in a hospital who came in. And what we find over time is that those aren't necessarily good ways to screen for actual disease.

The urinalysis, the -- the annual urinalysis is one of those kinds of tests where when you -- you think about the ways in which you really are going to identify an infection in someone, it's not going to be by once a year doing a test but following an individual's clinical situation day to day, week to week, month to month. So that's pretty much, it's -- it's outdate medicine.

SENATOR GERRATANA: I see. So you're saying that, for instance, a nursing home should perhaps follow best practices and certain protocols regarding testing or for any particular medical situation so observation as well as doing daily vital signs, you know, the usual protocol.

COMMISSIONER JEWEL MULLEN: Right.

SENATOR GERRATANA: But, you know, one of our concerns is that sometimes in doing the usual and customary in these best practices that certain -- particularly with elderly who may not be able to articulate or for some reason, you know, explain to a person who is their health provider in that setting that, you know, something is going wrong.

And I know with urinary tract infections, very often, you know, these come repeatedly. Certainly someone in a nursing home setting may be more susceptible. So what is the -- what would be the best practices, if you will? I ask you not only as your role as a commissioner but also a physician for the elderly who may be far, far more susceptible to this condition than others.

COMMISSIONER JEWEL MULLEN: To -- to be aware of some of what you said the patient's general status, minding a temperature, other -- other changes that, you know, if we're talking about older people in nursing homes, that might be the manifestation that they have some kind of infection where it might not be, once again, that they're complaining of typical urinary tract infection symptoms like that they have -- they're running a low-grade fever, or their mental status is changing or other clues that something is awry.

And those are, you know, and the yearly test is not going to pick up an acute change in somebody's status. It's going to be more of that monitoring. People might have some cells in their urine that are -- would make somebody want to think, oh, is it an infection, but oftentimes it's not.

There have been situations in which when guidelines weren't followed well, people would act too quickly and put a person on antibiotics. And they wouldn't really be treating an infection, but they would be greatly increasing the risk of antibiotic-associated infections like clostridium difficile or C. diff. Some people have heard of C. diff. which causes an antibiotic-associated inflammation in the intestine which is -- is fatal for -- for some people and causes a lot of illnesses, repeat hospitalizations. So for the individual patient, then it's also important to do the -- the follow up if you have treated an infection but just a routine urinalysis.

SENATOR GERRATANA: I know and -- and sometimes people don't have a temperature but do have, you know, a urinary infection --

COMMISSIONER JEWEL MULLEN: Right.

SENATOR GERRATANA: -- urinary tract infection.

COMMISSIONER JEWEL MULLEN: Uh-huh.

SENATOR GERRATANA: So, hmm, something for us to think about.

COMMISSIONER JEWEL MULLEN: Yeah, so this -- if -- if --

SENATOR GERRATANA: Yes.

COMMISSIONER JEWEL MULLEN: A once a year test is not going to be the way to pick up an infection.

SENATOR GERRATANA: Uh-huh. But any --

COMMISSIONER JEWEL MULLEN: And I'm not trying to say we should do it every week or every day.

SENATOR GERRATANA: -- any change in health status should --

COMMISSIONER JEWEL MULLEN: Right.

SENATOR GERRATANA: -- should set the alarm bell off --

COMMISSIONER JEWEL MULLEN: Right.

SENATOR GERRATANA: -- is what you're saying --

COMMISSIONER JEWEL MULLEN: Uh-huh, exactly.

SENATOR GERRATANA: -- any change at all, physical --

COMMISSIONER JEWEL MULLEN: Right, yeah, uh-huh.

SENATOR GERRATANA: -- behavioral, whatever.

COMMISSIONER JEWEL MULLEN: Uh-huh.

SENATOR GERRATANA: All right. Section 28 you have certified versus licensed EMS organizations. I'm just curious, what are the differences between a -- a certified and a licensed EMS organization? Oh, do we have an expert here on it?

COMMISSIONER JEWEL MULLEN: Yes, I -- I called -- I called Raphael Barishansky.

SENATOR GERRATANA: Oh, yeah, very good.

COMMISSIONER JEWEL MULLEN: I was going to keep a comfortable seat next to me for him.

SENATOR GERRATANA: Just state your name for the record. Thank you.

RAPHAEL BARISHANSKY: I'm Ray Barishansky. I'm the director of the Office of Emergency Medical Services at the Connecticut Department of Public Health. And thank you very much for the opportunity to address any questions. And thank you, Commissioner Mullen. Certified agencies are the -- may bill for emergency transportation, whereas licensed EMS organizations can also transport patients and bill them for the non-emergency transportation.

What Section 28 tries to do is address both planning and the reimbursement considerations for disaster situations and EMS response. As the Commissioner mentioned in her testimony briefly, we've had opportunity within the past few years due to some of the storms that we've experienced where some of our agencies have really stepped up -- our certified EMS agencies -- excuse me -- have stepped up in regard to transporting patients to non-traditional locations such as shelters.

And this gives them the ability which doesn't exist right now to then bill for those transportations to insurance as well therefore being reimbursed for the services they -- they provide when they step up in these unusual situations.

SENATOR GERRATANA: I see, so certified is only for an emergency, life emergency, crisis transport, is that correct, and licensed can do both emergency transport as well as non?

RAPHAEL BARISHANSKY: And bill for those, yes, (inaudible).

SENATOR GERRATANA: I see. And I'm -- without going back to the correction, this would allow certified EMS organizations to bill for non-life-threatening transport.

RAPHAEL BARISHANSKY: Correct, during a disaster situation, so --

SENATOR GERRATANA: During a disaster situation only.

RAPHAEL BARISHANSKY: Exactly.

SENATOR GERRATANA: Okay.

RAPHAEL BARISHANSKY: So what we've done is we've limited it in two different ways. First, we've limited it in regard to a disaster situation, but secondarily, we've also limited it in regard to the time period, so we're not going to allow this to keep going on, but we have a seven-day time period. We felt that those limitations would be appropriate.

SENATOR GERRATANA: Thank you, and thank you for that clarification, only during a disaster. And -- and thank you very much.

RAPHAEL BARISHANSKY: You're welcome.

SENATOR GERRATANA: Commissioner, going back to House Bill 5504 on local health departments, could you, again, explain? I was reading over your explanation. Is this just for a transfer of funds to allow us to go back into our General Fund or --

COMMISSIONER JEWEL MULLEN: Right, so we -- you know, one of -- one of our -- one of -- one of our appropriation lines is local health administration. It's a local health. So departments and districts get a certain per capita depending on -- and it's -- okay. So I know you know the details about that. Right.

Now -- now it's -- it's a local health, and our desire, and our desire on behalf of our local health directors across the state is that the municipalities are -- their municipal leaders are then using those dollars for public health programming within their departments or districts, but not every municipality uses the money. Some have a -- a savings account, so to speak, for accrual of sometimes years' worth of money.

SENATOR GERRATANA: Thank you. Thank you for explaining that. Just want to be clear on that. All right. Does anyone have any questions? Senator Welch.

SENATOR WELCH: Thank you, Madam Chair. Thank you, Commissioner, for your testimony. I -- I'm really not sure what my question is at this point in time. I did read that there is testimony from some speech and language pathologists.

COMMISSIONER JEWEL MULLEN: Uh-huh.

SENATOR WELCH: I don't know if you had a chance to read any of -- of their testimony. And I'm -- I'm not quite sure I appreciate what -- what their issue is yet, but often --

COMMISSIONER JEWEL MULLEN: Uh-huh.

SENATOR WELCH: -- as is the case they will testify later this afternoon, and then I'll probably have some questions for you after that.

COMMISSIONER JEWEL MULLEN: Okay.

SENATOR WELCH: And so to the extent you've had an opportunity to read their testimony and understand what their concern is and -- and maybe have a commentary with respect to that now, I would actually appreciate hearing it.

COMMISSIONER JEWEL MULLEN: Okay.

SENATOR WELCH: Thank you.

COMMISSIONER JEWEL MULLEN: I -- I did see testimony from one individual or organization last night, and I wasn't quite sure what it meant, and I haven't had a chance to talk. Jennifer Filippone is going to tell me. So I -- I haven't heard. I'm not sure.

JENNIFER FILIPPONE: Good morning, everyone. Jennifer Filippone with the Department of Public Health. I think -- I did read the testimony as much as I could last night. There were several pieces of it, I think, that were posted online, and I think we had gotten an e-mail earlier in the week asking us for some clarification. And we'd be certainly glad to speak with anyone from the association who had concerns.

From reading the testimony, I gather that what they think the language is doing is actually adding the behavioral analysis to the speech and language scope of practice, which is not at all what we're looking to do. We had an instance come to our attention last year through a complaint investigation process whereby an applied behavioral analyst was working completely within the scope that's set out for them in the education statutes, but there is some cross-over in some of the modalities that that individual is using into the speech and language pathology scope.

So what our intent with this language is to include behavioral analysts who are working within their defined scope from having to hold a license as a speech pathologist, making sure that it's very clear that if they're working within their defined scope that there could be no question. So we're actually looking to exempt them from that practice.

So I think that -- from what I gathered anyway from the testimony having not spoken with anyone directly, I think that they were thinking that we were looking to do the opposite of what we're doing, so we're happy to have conversations with folks about that.

SENATOR WELCH: Thank you, and -- and if I may just -- maybe you can help me understand a little bit where -- where confusion might arise. Seeing their testimony caused me to kind of look at speech pathology and applied behavior analysts and where there is cross-over, where there isn't cross-over. And it seems like, not necessarily here in Connecticut but at least in other states they tend to kind of butt heads a little bit. And -- and I -- I'm just beginning to appreciate this for the first time.

And so maybe you could tell me a little bit more about the specific example that -- that came to DPH, what issues arose because of that, and then, you know, how -- how does the proposal, I guess, seek to resolve that? From -- from what I understand, their -- their biggest concern is Section, Subsection 6 of 42, which I think is what you just talked about, so if you could elaborate more, that would be great.

JENNIFER FILIPPONE: Sure. I don't have all the specifics with me. I'd be happy to get those back to you all. My recollection of the case is that it was very -- they were very minute kind of tasks working with individual children in a classroom setting. But without having it in front of me, I don't want to portray something that I don't have, and I'm happy to get back to you on that.

SENATOR WELCH: That's fair. Thank you very much. Thank you, Madam Chair.

SENATOR GERRATANA: Thank you, Senator. Representative Srinivasan.

REP. SRINIVASAN: Thank you, Madam Chair. Thank you, Commissioner, for this -- the number of bills that you covered in a relatively very short time. That was phenomenal. Just two questions on the Raised Bill 414 --

COMMISSIONER JEWEL MULLEN: Uh-huh.

REP. SRINIVASAN: -- and lines 26 on, a registrar may grant immediate access or may say you need to have an appointment. Could, I mean, could you elaborate on that a little more and what is happening right now?

COMMISSIONER JEWEL MULLEN: So there -- right now what has been has been more of an -- a granting of immediate access. I'm not sure who's -- who's here, but it's been a much more -- you try to serve people as they come -- come to you. And sometimes that works. Sometimes it doesn't.

We have times that when somebody walks in, there are other more confidential personal issues being handled for an individual when it wouldn't be -- wouldn't really be sort of right for another public person to be there. Do you both want to answer -- introduce yourselves? Okay.

LISA KESSLER: (Inaudible). I think -- I'm not exactly sure it's at the towns. I think a lot of the smaller towns would allow immediate access for a genealogist that came looking to do research. Most of the problem lies in the -- these larger urban offices as well as the Department's office where we have to balance some of our other business needs with having visitors in the office at all times.

DAVID ANTOLINI: Yeah, I would just say it's a way to manage the office in order to -- is it on? Okay. Oh, yeah, I'm Dave Antolini. I'm health program supervisor by the records. It's more of a way to help us manage the office, you know, to do all the various tasks we have to do.

REP. SRINIVASAN: Thank you. Just a follow-up on that. So what would -- what would constitute immediate access? That's the part that I'm not able to get my hands around, because I would think -- I mean, you're absolutely right. The people just walk in and -- and think that you're going to be -- you know, have the time to take care of them right away as opposed to making an appointment when obviously you've already scheduled your day to work around their requests, which seems very fair but is reasonable. But the difference between an appointment and immediate access, that's the part that I'm not able to get my hands around.

COMMISSIONER JEWEL MULLEN: Well, an appointment would be that you would call and schedule, and it might be within, you know, the week or the next week. And immediate access, particularly in the smaller towns, there's, you know, there's no hospital in the town, and, you know, it's not such a busy office. They don't have as many desks or -- and so they may be very able to accommodate someone coming in.

DAVID ANTOLINI: It -- it allows the registrar to make a decision if this person can be, you know, handled right then and there or if they have to have an appointment to -- to do the need -- to do what they need to do.

REP. SRINIVASAN: So as I understand it clearly, the immediate access is more the availability of the person to take care of them. It's not an immediate access in terms of a -- a medical or some necessity that that person needs to be taken care of right away.

COMMISSIONER JEWEL MULLEN: Right, it's a -- it's a convenience. You walk in, and we can conveniently accommodate your request right now.

REP. SRINIVASAN: Thank you.

COMMISSIONER JEWEL MULLEN: You're welcome.

REP. SRINIVASAN: And if you could just comment on Raised Bill 416. My second question is I see this emergency medical technicians and advanced emergency medical technicians. If you could just expand on that and the difference between the two, and what are we trying to accomplish here by saying that we do not need them to be in a different category is how I understand this bill. They would all be a part of the emergency medical technicians.

COMMISSIONER JEWEL MULLEN: Right. I'll -- I'll -- I'm going to let Ray give you a -- a more articulate explanation than I would.

RAPHAEL BARISHANSKY: I will certainly do my best. Thank you for the question. The AEMT level or advanced emergency medical technician level has been around for about 30 years. As the Commissioner mentioned before, some of the utility in having that model initially developed was in regards to specific trauma patients and the outcomes that we were expecting.

Clearly, medicine and medical practice has developed in the last 30 years, and the AEMT level has developed as well. The current level being utilized in the state of Connecticut is not current with the scope of practice -- the national scope of practice regarding EMS education. So currently, the two major elements of the AEMT level are an advanced assessment set -- advanced assessment skill set and the establishment of an IV line, intravenous line. Those are it.

Approximately probably between eight and ten years ago, there was a lot of discussion in regard to coming up to the current scope of practice, and the physician medical directors who did take clinical care for EMS providers in Connecticut called the CEMSMAC. The Connecticut Emergency Medical Services Medical Advisory Committee came to the conclusion that the AEMT was not functioning at the level that they wanted it to.

There was some discussion about bringing it up to the current scope of practice or this current national education model, but unfortunately right now, the -- we have been advised by our educational entities that they are so busy with the assuring of appropriate education for the paramedic level that they simply cannot do this at this time. Therefore, what you're seeing in front of you is 416. And clearly, I've tried to summarize the issue, and you can see the testimony at greater length.

REP. SRINIVASAN: Thank you. Thank you for that, and you obviously made that very clear, and I appreciate that. So would the take on that be that if they're -- they have, you know, gone through the paramedics, that education part, and if time and funds permit, would you be reinstating the -- the training for these advanced emergency medical technicians?

RAPHAEL BARISHANSKY: I think making a promise like that would certainly paint me in a bad light if something like that wasn't to occur in the future. However, I will tell you that having been with DPH for approximately a year and a half, I can tell you that I've tried to look at every element of the EMS system to see what we can improve and what's functioning well. This clearly would be no different.

REP. SRINIVASAN: And my final question to -- to you through the Commissioner is right now who -- who establishes the IV lines or the intravenous lines in our system?

RAPHAEL BARISHANSKY: Both the AEMT level as well as the paramedic level.

REP. SRINIVASAN: Thank you. Thank you, Madam Chair.

SENATOR GERRATANA: Thank you. I think -- was it -- okay, Representative Conroy followed by Representative Ziobron? Okay.

REP. CONROY: Thank you, Madam Chair. And thank you, Commissioner, for being here. I just wanted to ask a couple questions on two bills, and I'll start with following up with what Dr. Srinivasan just was talking about with 416. I have a lot of concerns in my district. I've met with my ambulance societies. We're volunteer ambulances, and we do currently have -- many of our ambulance people are the advanced EMTs. We have paramedic intercept in our area, and they've been telling me that, you know, this is something that we really need to keep in our -- our towns. You know, if it's one life saved, that's one life that's well worth keeping saved.

I do have the concerns that, you know, I -- I know you were just speaking to that it's kind of onerous or onerous on the DPH for the educational issues. But from my understanding, this scope hasn't, or the education hasn't been upgraded since 1985, and there are new standards since 2009. I'm just wondering if it's such a valuable resource to our communities why we would think just because there's, you know, resources and educational pushback, why we would take this away.

COMMISSIONER JEWEL MULLEN: I -- I received some letters last year regarding this issue like that the elimination of the AEMT category has been discussed for a while. And so we -- we talk about resources. We talk about the best resources and best not being a value statement but a -- a statement of -- of what kind of treatment capability and response capability should be afforded to the public and what skill set needs to be delivered by -- by that.

So -- so there are a couple of things, one of which is, you know, has already been reflected in the -- what's, I think, relatively sort of less contemporary or somewhat outdated skill set. At the same time, that while we understand that rural areas in particular might have some extra challenges in terms of the numbers of providers available, we want to make sure that the providers who are deployed have the same skill level as the providers in any other part of the state.

And -- and part of that skill comes from the numbers of -- of responses that they -- they actually do. So when you're not practicing with the most contemporary skill set, and you're also not responding to as many calls, you even -- have even less time to keep the skill set you had as honed as they ought to be, and I'm going to let Ray (inaudible).

RAPHAEL BARISHANSKY: Thank you, Commissioner. There were two things that I wanted to speak of in regard to a direct point if that's okay. First, it was the sponsor hospitals that's the hospitals who assist us in medical oversight of the EMS system who have actually told us that they don't have the resources to provide adequate clinical practice opportunities in regard to remediation of the potential deficiencies in the skill competency.

But I also wanted to let you know that it's the EMS -- it was the EMS training institutions through our training and education committee of the advisory board that indicated that they have inadequate clinical training sites available to actually educate the AEMTs to the national standard without negatively impacting our paramedic education. So this isn't a decision or determination that -- or a request that we've entered into lightly.

As you can see from the testimony, this is something that's been discussed for many a year. Additionally in the testimony, we see that this is something that we're looking at for the beginning of 2017. So not only is it not something we're entering into lightly, it's also not something that we're looking to rush or rush anybody into, and nobody would lose a certification. They would simply be subsequently certified as EMTs as opposed to AEMTs. I felt those things are necessary to point out.

REP. CONROY: Okay. Thank you for your response. And do you know what our neighboring states do? Do they -- they have the advanced EMTs in place?

RAPHAEL BARISHANSKY: Some do, and some do not.

REP. CONROY: All right. Thank you for your response. And then on 418, the med spa, I just have a question, because I was reading some of the testimony, and there'll be -- just like Senator Welch said earlier, you'll be gone, and we'll get these questions. There's some testimony in there concerning about designating it as a facility. And I see you want that out of the language. Can you tell us if you have any concerns that others that will come in before us saying that there won't be oversight because it won't be termed a facility? Can you address that?

COMMISSIONER JEWEL MULLEN: Yes, we can.

REP. CONROY: Thank you.

MARIANNE HORN: Good morning. My name is Marianne Horn. I'm the legal director at the Department of Public Health. And your question was if the term facility is eliminated from the medical spa --

REP. CONROY: Correct.

MARIANNE HORN: -- the medical spa, will there be concern about how the facility is regulated?

REP. CONROY: Correct.

MARIANNE HORN: Yes. We had a -- a very large taskforce that discussed these issues, and the -- the spas are -- do not perform the kinds of services that would be included within the meaning of facility for our institutions that are licensed by the Department of Public Health. These are not entities that perform the level of medical services that would require licensure from the Department of Public Health.

And I think inserting facility might lead both the public to assume that the Department of Public Health is regulating them as a facility and the -- the operators of a medical spa to think that they are required to get a license. The regulation comes through the individual practice license of the practitioners. So that, I think, is the response to those questions.

REP. CONROY: Great. Well, thank you very much. Thank you, Madam Chair.

SENATOR GERRATANA: Very good. Thank you. Representative Ziobron.

REP. ZIOBRON: Thank you, Madam Chair, and I just have a quick couple of questions, if you don't mind. Going back to Bill 5537, on Section 5 you talk about the technical changes to the multicultural health statutes. And I had the opportunity to hear from one of the staff of DPH who I have a lot of respect for at an appropriations meeting. I'm sure you've heard about our exchange.

And at that meeting, I had gotten an e-mail from one of my constituents who happens to be an employee of DPH who had received a program announcement through the auspices of the Multicultural Health Office that was quite concerning to me. And the invitation was for an engagement at Connecticut State University, and it was being promoted to DPH employees under the offices of this program, and the name of the program was White Privilege and How It's Affecting America.

So I ask you now if you could explain to me -- now that we've seen this change in the Multicultural Health Department -- exactly what they are doing and how I can, you know, how -- will they be promoting this sort of material in the future?

COMMISSIONER JEWEL MULLEN: First, I have to say -- I'll always say as Commissioner, you never know everything, so I don't know anything about the exchange you had with my staff person, but I didn't hear about it from you, so hopefully it -- it wasn't a bad thing.

A VOICE: (Inaudible).

COMMISSIONER JEWEL MULLEN: Right. Then I probably would have heard about it from you. So the Office -- the Office of Multicultural Health is a (inaudible) -- has been within the Department for a long time. And we -- we collaborate with a number of organizations across the state.

Let me just go back to the invitation to a -- a program on white privilege. I don't know what the issue was other than perhaps the person who saw it took offense to a term that is -- is well embraced, written about, and described in the sociology -- sociological literature, not having as much to do about race per se but a term that really gets people to think about what we talk about a lot when we talk about equity in the same way that we talked about it even with MOLST, is that individuals who have differences always have questions about how in their life those differences either put them in a better or worse circumstance with regard to something that they're experiencing.

So -- so, you know, I didn't attend the session, but, you know, we are asked to send out information through -- I (inaudible) a little while ago -- Connecticut Health Foundation, the Connecticut Multicultural Health Partnership, all kinds of organizations that touch on us that are opportunities for people to have discussions. So I'm actually glad that you asked, because I'm not sure whether or not you -- you link the two with some question about the work that's being done at DPH.

REP. ZIOBRON: Well -- well, I did, frankly --

COMMISSIONER JEWEL MULLEN: Okay.

REP. ZIOBRON: -- because the constituent who sent it to me --

COMMISSIONER JEWEL MULLEN: Uh-huh.

REP. ZIOBRON: -- was actually very offended by --

COMMISSIONER JEWEL MULLEN: Uh-huh.

REP. ZIOBRON: -- by the program and that it was -- and I see your colleague here, and -- and she and I spoke about it again after the meeting, and she understands, you know --

COMMISSIONER JEWEL MULLEN: Uh-huh.

REP. ZIOBRON: -- kind of where I was coming from. But, you know, what I had said to her after that meeting was I think this is an -- an example of how sometimes the Public Health Committee up here is not aware of some of these opportunities.

COMMISSIONER JEWEL MULLEN: Uh-huh.

REP. ZIOBRON: And what I had asked was in the future if a mass e-mail like that was going to go out to the state of Connecticut employees, I certainly would have appreciated knowing that ahead of time, and so, you know, when you're talking about what the Multicultural Health Office does --

COMMISSIONER JEWEL MULLEN: Uh-huh.

REP. ZIOBRON: -- and if that's part of their purpose, I think we should also make sure that, you know, that legislators are getting --

COMMISSIONER JEWEL MULLEN: Right.

REP. ZIOBRON: -- some of these notifications as well.

COMMISSIONER JEWEL MULLEN: Okay.

REP. ZIOBRON: So -- and then the other question I had on 5537 is -- and when I look through all the testimony --

COMMISSIONER JEWEL MULLEN: Uh-huh.

REP. ZIOBRON: -- myself, I see a lot of testimony on naturopaths. I'm sure you must have noticed it too. There's -- there's dozens and dozens. And I know that you went through a scope of practice review process. I don't have a lot of that information. So I just am curious, because you're not going to be here when all these people come to testify, what your position is, and -- and I'm hoping I'm going to hear that the conversation is continuing in some regard on your level.

COMMISSIONER JEWEL MULLEN: So thanks. I think it was two weeks ago I testified on the Governor's bill regarding the elimination of the Collaborative Practice Agreement requirement for nurse practitioners. And what I said about the Department's scope of practice review process is that we convene parties and present a report to the -- the Committee, but we don't make a decision. We don't recommend legislative action. And that's the same circumstance for naturopath.

I did happen to see a lot of testimony attached to Bill 5537, and the scope of practice changes that they asked are not part of our bill. The scope of practice changes for nurse practitioners is part of a Governor's bill.

So my position is that like with any other scope of practice request, once the information is delivered to the Committee -- and I know you've received finally a draft version. And the Committee -- people who were on the Committee that would convene to look at the pros and cons of the changes that were requested are weighing in and getting -- getting feedback to us so we can get the Public Health Committee the final version of the report.

After that, I think it's going to be determined by the Committee whether or not it wants to raise the bill. You know, I'd be happy to -- if you want to meet sometime next week and talk about what's in there, I would be happy to do that. You -- you heard the tech bill testimony, and I -- I understand that there was hope that, you know, maybe we were going to be referencing that.

You know, we take scope of practice really seriously. I read you a number of sections and somewhere in the middle joked about these are our technical changes. A scope of practice change like that isn't a technical change and deserves to have the whole conversation, so --

REP. ZIOBRON: Thank you so much, and I just want to say for the record I always appreciate the fact that we can have these kind of frank discussions. And sometimes they seem to be uncomfortable, but I think that that is always pushing us to really understand great -- how great policy comes to shape. And I always appreciate your frank answers, and I just want you to know that, so thank you.

COMMISSIONER JEWEL MULLEN: Well, back at you. Likewise. And -- and, I mean, I try to tell my staff that all the time when we walk out of here. These are conversations, and -- and I, you know, I'm still smiling, and, you know, I don't always smile. I really don't. But, I mean, it's so important. It -- so thank you. Thank you.

SENATOR GERRATANA: And I thank you too. Are there any other questions? Oh, Representative Johnson.

REP. JOHNSON: Thank you, Madam Chair. And thank you so much, Commissioner, for being here, and we have had a wonderful conversation this morning, and I -- I want to just continue it a little bit longer. So -- so in any event I -- I was just wondering about the -- the change for the advanced medical technicians and -- and going to emergency medical services exclusively instead of having that -- that carry forward. What do you think about maybe phasing something like that in over time? Do you think that that would be a -- a way to do that?

COMMISSIONER JEWEL MULLEN: I think -- I -- I believe that having this become effective in 2017 is the way to do that, because it also allows time for people to then say, okay, I'm going to go ahead, and, you know, they can avail themselves of the opportunity to become an EMT rather than an AEMT. And it along the way allows for ongoing conversations even, you know, in areas where Representative Conroy is saying that she's heard a lot of concern.

REP. JOHNSON: Yeah, so have I. I think we all have had some concern, and certainly we appreciate the work the Department has done in many, many areas of emergency medical services, and we want to make sure that we -- we are recognizing the wonderful work that our emergency medical service providers do, and we're not trying to do anything that would get in the way of that work or their great accomplishments with respect to their certifications and training.

Then I go into the Bill 5537, and I just wanted you to -- if you could go into Section 2(d)1 and just tell me the reason again -- perhaps I missed it in your original remarks -- but the reason again for these -- this modification.

COMMISSIONER JEWEL MULLEN: Lisa, do you want to come back? I mean, technically, this gets back to the issue around the -- the ability to designate paternity for someone who has reached age 18. And there are circumstances in which we find that people who aren't minors still have that as a necessity.

LISA KESSLER: (Inaudible).

SENATOR GERRATANA: Please -- please put your speaker on.

LISA KESSLER: Sorry.

SENATOR GERRATANA: Identify yourself for the record, please.

LISA KESSLER: Lisa Kessler of the DPH. So we've made this proposal, because we've had many requests over time for people to establish paternity for a child that's already reached adulthood. And the statutes for establishing paternity in the Superior Court are very explicit that it only applies to persons under 18 years of age.

And I believe that the probate court -- although the laws aren't explicit -- they interpret that restriction as being applied to, you know, their jurisdiction, so they won't do it for anybody over 18 also. So this is the mechanism that will allow people that want to establish paternity for a child that's already reached adulthood to be able to do it.

REP. JOHNSON: Thank you so much for your updating me, and I appreciate that. Commissioner, also in 4(d), the reporting requirements for the school nurses, could you just go through a little bit of the history and how that came into -- just how your recommendation came into existence?

COMMISSIONER JEWEL MULLEN: I think this -- you know, one of the holdups for children being able to get, you know, get back to school, get into school is verification that they've had all of the mandated childhood immunizations and that they're up to date.

You know, parents are asked to show immunization records, you know, electronic data that has -- gives the right people the appropriate level of access, makes, you know, for an efficient, more efficient pathway to document that shots are up to date. School nurses are usually the people in the schools that have to verify shot status, and this gives them a way of looking into the registry to do that.

REP. JOHNSON: Very good. And finally, in 5537, Section 12 there's some language changes on emergency medical services, and I just wondered why the changes. And if you could just tell me a little bit about that too. Thank you.

COMMISSIONER JEWEL MULLEN: My -- my simplest answer is that right now we -- we rely on DMV to do the inspections, but there are other entities that can be certified to inspect these type vehicles. It helps keep our responders out on the road and -- and not in line, and that's not a commentary on DMV. It's really not. But, you know, it -- it takes time, and this just helps create a more efficient system by expanding the number of places where the inspections can happen.

REP. JOHNSON: Very good. Thank you so very much for your testimony. I really appreciate your taking the time and your great explanations.

COMMISSIONER JEWEL MULLEN: Thank you.

REP. JOHNSON: So thank you, and --

COMMISSIONER JEWEL MULLEN: Thank you.

REP. JOHNSON: -- thank you, Madam Chair.

SENATOR GERRATANA: Commissioner, I -- I think -- you've been here quite a while -- I think we're all set.

COMMISSIONER JEWEL MULLEN: Great. Thank you very much, everybody.

SENATOR GERRATANA: Thank you so much for coming.

COMMISSIONER JEWEL MULLEN: Thank you.

SENATOR GERRATANA: I know there's quite a few of your bills on -- on the agenda today to be heard.

COMMISSIONER JEWEL MULLEN: I can't believe this is a short session.

SENATOR GERRATANA: I know. Long bills and many of them in a very short session. Right now, of course, we've surpassed the first hour of testimony, so we're going to alternate now, and we're going to members of the public. The first to testify, I understand, is Monica Minionese, I believe, principal of Mary Morrison School, and Richard Calvert, Child and Family Agency. I understand they're coming up together to testify on Senate Bill 415. Turn the microphone on, and just identify yourselves. Thank you.

MONICA FRANZONE: Good morning. Thank you, Madam Chair.

SENATOR GERRATANA: Good morning.

MONICA FRANZONE: My name is Monica Franzone. I am principal of Mary Morrisson Elementary School. I'm here on behalf of Groton Public Schools. I believe you have written statement of support for the S.B. Number 415, AN ACT ESTABLISHING ADDITIONAL SCHOOL-BASED HEALTH CENTERS. I would be the recipient of one of these school-based health centers within my district. And if I may just read you part of the statement from my superintendent, Dr. Graner, and then I have a few more things to say at the bottom if that's possible.

Please accept this statement as an expression of my strong support for the establishment of two additional school-based health centers to serve the children of Groton Public Schools. The additional health centers are needed to provide much needed support for schools that service the large military community located near the U.S. Naval submarine base in Groton. The services provided by the school-based health center will greatly assist these children whose lives are frequently disrupted due to military transfers.

Each health center will also include a clinician to provide mental health services to this very at-risk population. Highly mobile families who experience frequent disruptions due to military transfers and deployments are a particularly vulnerable segment of our community. The mental health clinicians will provide much needed support to these families. In addition to servicing children of active duty service members, the population of both of our schools contain large segments of children who are eligible for free and reduced lunches. Approximately 40 percent of the students at our schools qualify for free or reduced meals.

Groton Public Schools takes great pride in servicing all of the children in our community, including dependents of our active military members as well as children from the economically disadvantaged families. The additional school-based health center would be an enormous asset to our school community and would greatly enhance our ability to meet the needs of the children and their families. On behalf of the children of Groton Public Schools, I urge passage of this bill, signed Dr. Michael Graner, superintendent of our schools.

I have worked for Groton Public Schools for 24 years, and in my current role as an elementary principal, I see a great need for families to have one place to go and to feel comfortable to be able to obtain services for their family. They are in states of transition, which are very challenging, as you know. Often a safe place to learn and be healthy is an important community resource.

SENATOR GERRATANA: Thank you. And I know the bell has rung, so I know Mr. Calvert we have your testimony here online in front of us. In fact, I'll just make a real quick announcement that all public hearing testimony written and spoken is public information, and as such it will be made available on the CGA website and indexed by Internet search engine so just so you know. So perhaps you could summarize for us, Mr. Calvert, instead of reading your testimony.

RICHARD CALVERT: Yes, absolutely --

SENATOR GERRATANA: Thank you.

RICHARD CALVERT: -- and certainly will try to not overlap and appreciate the opportunity to integrate and coordinate our testimony. What I would essentially add is that even with recent improvements in the availability of healthcare coverage, barriers to actual care on the ground remain, and this is an arena where school-based health centers as a barrier free service delivery mechanism have huge -- huge advantage across the state over the past 30 years. A couple quick bullets under that.

First, primary care practices in our particular area are typically saturated, and many go through significant periods of not being able to accept new patients. And the result, especially for working families, working parents, is significant delay in terms of being able to access critical services such as school entry physicals and immunizations. And I think the last thing that we want is to see children withheld from starting school because of that kind of an access issue.

That issue is particularly accentuated in the Groton community because of the high percentage of children of military families that our school-based health centers serve. And the percentage at Mary Morrisson Elementary where Ms. Franzone is principal is actually 61 percent military attached to the Navy base, so that kind of delay in school entry is of great concern, and we're concerned about expanding our presence as the school-based health center provided to address that issue.

The only second issue that I would emphasize is on behavioral health services side of school-based service delivery. With recent post-Newtown initiatives in particular, the system building outline in Public Doc. 13178, while those initiatives will likely make improvements in early identification and referral, the capacity to provide then the ongoing mental health services after identification and referral gets to the matter of ease of access and service capacity. And so school-based health centers, again, offer that and really plug that gap.

MONICA FRANZONE: Yes.

RICHARD CALVERT: Thank you.

SENATOR GERRATANA: Thank you. Certainly, we couldn't agree more. We identify school-based health centers as being an open portal, if you will, and once a child, a student, goes through there, whatever kind of care they receive is what they receive, and no one knows what that would be other than the professionals inside. So they're certainly very affective that way. That was something that we identified in our taskforce, the bipartisan taskforce on school safety, and, of course we addressed extensively, you know, some of the mental health components. So thank you very much for your testimony.

RICHARD CALVERT: Thanks so much.

SENATOR GERRATANA: Is there any questions? If not, thank you for coming up today and testifying on the bill.

RICHARD CALVERT: Thank you.

SENATOR GERRATANA: Next is Representative Elissa Wright and Senator Andy Maynard.

ELISSA WRIGHT: Thank you, Co-Chairs Senator Gerratana and --

SENATOR GERRATANA: Good morning.

ELISSA WRIGHT: -- Representative Johnson, Members of the Committee. I thank you for the opportunity to testify in support of Raised Bill 415, which would establish additional school-based health centers in -- in two communities, including Groton, which we represent. Senator Maynard is here with me and joining me in this testimony.

For the record, my name is Elissa Wright. I represent the 41st District, which includes portions of Groton and New London. In our community, Groton's school-based health centers have proven to be very effective in the delivery of preventative and primary healthcare, mental health, and behavioral healthcare to children and adolescents in the town.

More than 1800 students currently are enrolled in the five school-based health centers in Groton at two of the seven elementary schools, both middle schools, and the high school. As currently configured, the five school-based health centers do provide a continuity of excellent care for students from Claude Chester Elementary School, Catherine Kolnaski Magnet School who then attend the middle schools and eventually the high schools.

So by this request, which would establish new school-based health centers at Pleasant Valley Elementary School and Mary Morrisson Elementary School, students attending those elementary schools, which include families from the military community, would provide that same continuity of care. And as you know and previous members of the community have testified, Groton is home of the largest military installation in Connecticut.

Fully 61 percent of students attending Mary Morrison and one-third of students attending Pleasant Valley are from military families, and those -- the life of those military families frequently are disrupted when a parent is deployed on active military duty. And they depend on school-based health centers to care for their children.

These proposed new facilities would be ideally situated to meet those needs. And we thank you very much for raising this bill. And thank you for your long-time interest and -- and support for school-based health centers throughout this state. Be happy to answer any questions you might have, and I'll turn this over to Senator Maynard.

SENATOR MAYNARD: Thank you, Representative Johnson, Senator Gerratana, and -- and Members of the Public Health Committee. I think we're at the point where everything that needs to have been said has been said, and just not everyone has said it, so I --

I won't repeat what my colleagues have said, except to also say that I've submitted written testimony. We know your long-standing support for this, and I just stand here in solidarity with the community that would benefit so much from these two additional school-based health centers, particularly the in school systems of such particular need and, and so impacted by the presence of the military families.

So, thank you very, very much for your consideration.

SENATOR GERRATANA: Thank you, Sir. Representative Johnson has a question.

REP. JOHNSON: Thank you so much for being here and for your testimony. This, I believe, is a very, very important service that we need to provide to the community, and one of the things we recognize is the difficulty that many military families face in the loss of loved ones and also the fear of the loss of loved ones when they are deployed. So, this is, I think, an excellent proposal. So, thank you for being here and thank you for your good remarks.

Thank you, Madam Chair.

SENATOR GERRATANA: Thank you. Representative Ziobron.

REP. ZIOBRON: Thank you, Madam Chair. And welcome, thanks for being here.

Senator, I had the opportunity to read your testimony, and I know you've been very familiar with eastern Connecticut for a long time. And it was a surprise to me to know that we even had Community Health Centers in eastern Connecticut and that, you know, I'm familiar with New Haven and that area. Can you tell me what other -- are there other Community Health Centers outside of the Groton area that you're -- I know you're not an expert, but you may be familiar with.

SENATOR MAYNARD: Sure. Yes, New London, certainly, and also in the Norwich and soon to be -- well, it's there in Jewett City, United Health Services. We're hoping for an expansion of their work. That's one of my most economically impacted communities up in the Jewett City, Griswold area. So, they have limited access now, but hopefully more (inaudible).

SENATOR GERRATANA: Thank you both for coming today and testifying. I don't think there are any other questions or comments. Thank you so much.

SENATOR MAYNARD: Thank you very much.

A VOICE: Thank you, (inaudible).

SENATOR GERRATANA: Next is Deb Poerio followed by Deputy Commissioner Kathleen Brennan.

Good morning.

DEBBIE POERIO: Good morning.

Good morning, Senator Gerratana, Representative Johnson, and members of the Public Health Committee. My name is Debbie Poerio. I'm President and CEO of Integrated Health Services that runs a school-based Health Center Program in East Hartford, Connecticut. We currently have five DPH-funded school-based Health Centers in East Hartford, Connecticut, and I'm here in support of Senate Bill 415, A Proposal for Supporting School-based Health Centers in East Hartford, Magnet Schools Administered by Goodwin College.

There are three programs at Goodwin College, two in the high school population, one in the early elementary school population, the preschool population, and the need there is as great in magnet schools as it is in the East Hartford Public Schools because the magnet schools are representative of communities that have the same demographic as the community in East Hartford and as represented in such need. However, they don't have the services. They have actually even bigger barriers to care because, since the magnet schools are open longer hours and there's transportation issues to different communities, the challenge to access care is even more difficult.

So, I'm here to encourage the support of this, not only for the medical and the dental, but absolutely in support of the behavioral health services. There aren't enough providers for behavioral health services, as we know, statewide as it is. Access is limited. But the more important thing that I realize is in the preschool population that is not covered by the current mental health legislation, the preschool population currently -- and we have been consulting with our school readiness program in East Hartford for almost eight years just as consultants to the teachers.

We've seen 150 percent increase in not only the referrals, but the severity of the referrals in preschool. Within one year of that, we saw a nine percent expulsion in kindergarten. There is a high correlation. There is also a correlation to the impact of academic success, involvement in criminal justice system long term, and huge cost to the system. We need to -- we need to invest in the preschool population. We need to invest in behavioral health services in the younger age groups, not just the nine through 17-year-olds.

So, I'm encouraging you to support the school-based health center. You know the importance of school-based health centers. You certainly understand the significance. And if I can ask -- answer any questions, please feel free to ask.

SENATOR GERRATANA: Thank you.

Are there any questions? Oh, Representative Johnson.

REP. JOHNSON: Thank you, Madam Chair. And thank you for your testimony.

You had talked about a nine percent increase in the need for behavioral health services in the pre-K population?

DEBBIE POERIO: No, there is 150 percent increase in the number of referrals that we've received in 2011 to our school readiness population in East Hartford. The following year it was reported that there was a nine percent expulsion rate in the kindergarten class.

REP. JOHNSON: Thank you for that clarification. So, expulsion in a kindergarten class, it seems to me, to be fairly severe. Why -- what do you suppose the precipitating cause of some of these behavioral health issues that perhaps weren't an issue 20 years ago?

DEBBIE POERIO: I think we're seeing a lot -- a lot more underlying issues in families. So, we're seeing challenges in families, economic, personal, criminal, substance abuse issues. We're seeing families that are separated for a variety of reasons. We're seeing homeless families. We're seeing an increased severity. I think the media has a certain play in this as well. I think there's a variety of different factors that are basically causing issues in the population, but I think what we're seeing is the escalation in the severity of what we're seeing.

So, the older issues that we had with, "He called me a name," or "She touched me and shouldn't have touched me," is now we have kids -- preschoolers who are bringing in weapons and threatening other children with them. We have preschoolers who are throwing chairs at teachers, throwing furniture, biting to very deep levels, and we're seeing hyper-sexual issues as well.

So, I think we're seeing issues that are extremely significant and very different from those issues that we saw, you know, 10, 15 years ago.

REP. JOHNSON: That's very stunning, but it certainly demonstrates the need for more behavioral health services and to have those services available within a school-based health center right on campus. So, thank you for taking the time.

Thank you, Madam Chair.

SENATOR GERRATANA: Thank you. And thank you for coming today to present your testimony. I did notice -- are you submitting any for online testimony or --

DEBBIE POERIO: I can submit a -- Goodwin College submitted testimony, but I would --

SENATOR GERRATANA: Oh, they did.

DEBBIE POERIO: Yes.

SENATOR GERRATANA: Okay.

DEBBIE POERIO: I would be more than happy to submit some.

SENATOR GERRATANA: Thank you so much.

Okay. Next is Deputy Commissioner Kathleen Brennan followed by Leah Lucarelli.

Welcome.

DEPUTY COMMISSIONER KATHLEEN BRENNAN: Thank you. Good morning.

SENATOR GERRATANA: Good morning.

DEPUTY COMMISSIONER KATHLEEN BRENNAN: Good morning, Senator Gerratana, Representative Johnson, and distinguished members of the Public Health Committee. My name is Kathy Brennan and I am the Deputy Commissioner of Administration at the State of Connecticut Department of Social Services. I am before you today to testify on House Bill 5529, An Act Concerning the Definition of Medical Necessity. We have submitted written testimony, so, I'll just take the opportunity to quickly summarize.

This bill seeks to amend the definition of medical necessity for the purposes of the Departments Connecticut Medical Assistance Program as well as Commercial Insurance and Group Commercial Insurance Programs. The Department has significant concerns about this proposed legislations, which are detailed in the testimony.

First and foremost, the bill removes credible evidence published in peer-reviewed medical literature as a source criteria for the determination of medical necessity and, therefore, limits the sources to the views of physicians' specialty societies, individual clinicians or any other relevant factors. However, the science of the community, including a large majority of physicians, broadly acknowledge that credible evidence published in peer-review literature is the best standards for medical and scientific evidence. Continuing to emphasize the high standard of medical evidence is particularly critical as medical errors are rapidly becoming the leading cause of injury and death in the United States.

Secondly, the existing statutory language already has flexibility in defining health services that meet generally accepted standards of medical practice. The current statute specifies four factors for the clinical reviewer to consider when determining whether a requested health service meets the generally accepted standards of medical practice. The Department has consistently applied and interpreted the statutory language and has, when appropriate, approved requested services that are not necessarily based on scientific evidence published in peer-reviewed medical literature if there are other factors present as appropriate for an individual medical condition. However, that flexibility has been the exception.

When determining a health service means the generally accepted standard of medical practice and may therefore be medically necessary, the general standard remains a credible scientific evidence based on peer-reviewed medical literature should be the first determining factor because it is the most important. Regardless of whether it's first or last, it should definitely not be deleted.

For these reasons, the Department opposes this bill. We believe that the care provided to HUSKY Health should be of the highest quality and built upon the strongest evidence base, and the current statute supports this critical priority.

Thank you.

SENATOR GERRATANA: Thank you very much for giving your testimony today. I think Representative Johnson has some questions for you.

REP. JOHNSON: Thank you, Madam Chair. And thank you for taking the time to be here today --

DEPUTY COMMISSIONER KATHLEEN BRENNAN: Thank you.

REP. JOHNSON: -- and providing your testimony. I have a question. In terms of when we talk about evidence-based, isn't it -- can the treating physician make a determination as to what's evidence-based or scientifically-based information as opposed to having someone other than a treating physician do that?

DEPUTY COMMISSIONER KATHLEEN BRENNAN: Representative, if I may, I might ask Dr. Robert Zavowski, the Department's medical director, as I only play a doctor on TV, so.

REP. JOHNSON: Welcome, Doctor. Please state your name for the record.

DR. ROB ZAVOWSKI: Yes, good morning. I'm Rob Zavowski. I'm the medical director for the Department of Social Services.

Many physicians, we hope all physicians would use the best evidence to make a medical decision. But, frankly, the state of the art is changing hourly, daily at this point. And, so, knowing what the best possible standard might be is difficult for people to, to continue and to keep up with. Unfortunately, there are many providers out there who don't choose to do that. They, they have other motivations for practice and, unfortunately, we have to be cognizant of that.

The Agency for Healthcare Quality and Research actually puts out a journal every month that I would recommend folks look at because it looks at the standard of research and it compares different types of practices. And one of the, one of the articles that appeared this past month is a study that was done at for-profit versus not-for-profit dialysis units, and it determined that the cost of dialysis in a for-profit center is actually considerably higher. And in large part the cost -- that higher cost is due to the use of various medications, including things like Erythropoietin, et cetera. And it's not that the protocol doesn't recommend using those medications. It's just that they use them at much higher doses and more frequently in the for-profit dialysis centers than the not-for-profit.

I'll leave it to your imagination as to why that might be. Unfortunately, the outcomes are considerably better in the not-for-profit centers.

REP. JOHNSON: So, you are speaking of -- as a representative from the Department of Social Services. If you look at the reimbursement rate for some of these, these medications and the -- how practice is made, can you draw any parallels between those types of cases where insurance is making the reimbursement versus where the State is making reimbursement at a lesser -- at a lesser reimbursement rate?

DR. ROB ZAVOWSKI: I think my point is that people's motivations vary, and that depending upon how you set your, your reimbursement up, et cetera, people behave in different ways. What we would like to see when we make a determination of whether something is medically necessary is that, number one, we look at the current research, that that is the information. That is the -- that is what we would all aspire to, hopefully be practicing. And I think it's all -- what all of us around this table would aspire to in our own healthcare. I don't, I don't think any of us would want to be using the -- what they learned in medical school 20 years ago and haven't changed their practice. We would want the best and the most current.

And, frankly, as you're -- one of the things in the Affordable Care Act is that's slowly getting off the ground is an emphasis on setting up a Center for comparative research in, in the Federal government. And there's a number of programs around the country that have started doing that, and it's a science of looking at the research and comparing one set of research to another to determine what's the best practice.

I sit on a group that's looked at the breast cancer screening for dense -- for women with breast dense tissue. And if you look at that research, you become rapidly very confused. But what people are doing is they are looking to see what research, what's out there, what's the best practice. If you rank the sorts of things where, you know, what kind of research is the best, most accurate, most valuable, it's a double-blind controlled study. And then they grade them on down the list, and the very last standard that you would use when there's no other research is an expert opinion or a professional opinion. You want the double-blind. You want the random. You want the person doing the research not to have an interest in the outcome.

REP. JOHNSON: Well, the treating doctor has an interest in the outcome because the treating doctor, of course, is -- first of all, has a duty to the patient. And, so, that is -- and the treating doctor by and large are doctors -- I believe, are up to date on this, on the research that, that applies to the patients for whom they are treating. So, I think that we're looking at something that -- you have research, though, on the other hand, that's done, as you say, with all competing types of determinations. And, so, the treating doctor has to be able to take a look at the, at the patient and make a determination as to which, perhaps, set of studies that might best apply.

How is it that someone who has never seen the patient, an administrative service organization that administers the Medicaid program, can make that decision better than the treating doctor?

DR. ROB ZAVOWSKI: We can't, but we can help with it. At the end of -- at the bottom of that definition is a requirement that the individual consideration for that particular patient be taken into account. Very often we bring information to the treating clinicians that they were not aware of. And not infrequently, the final decision is made by them saying, "Thank you, you're right, we didn't see this information and we'll make the adjustment."

Very often we hear information that we say, "Okay, we understand now. Go -- please, go forward." Needs to be a conversation, needs to be a dialogue. But when it is left purely for somebody to make a decision based upon, not the research but other factors, that's when you run into trouble.

REP. JOHNSON: I believe -- I think that when you read the, the definition, medical necessity, and you take a look at that, the treating doctor has a duty to keep up to date on what the research is in terms of how they, how they make these decisions. And, again, having someone who has never seen the patient try and apply a number of studies that might have competing final analyses are certainly problematic. And you could see where there might be determinations, and there have been determinations on either the insurance side or the Medicaid side that would, would perhaps hold up the care that might be very beneficial to a person and override what a treating doctor has made a determination about.

DR. ROB ZAVOWSKI: Having practiced pediatrics for 25 years, I do understand that point of view. Having been a Medicaid Medical Director now for six years, I understand both sides and I think we're trying to accommodate both sides. We have a duty to make sure that our, our recipients get the very best medical care and share that duty with the clinician. But at the same time, we need to make sure that that, that care is maximally safe.

REP. JOHNSON: Thank you so much for being here and helping us out with this. Really appreciate it.

Thank you, Madam Chair.

DR. ROB ZAVOWSKI: Thank you for your time.

SENATOR GERRATANA: Yes, Representative Srinivasan.

REP. SRINIVASAN: Thank you, Madam Chair.

Thank you both for being here this after -- yes, it's afternoon now, and for your testimony. We appreciate that very much.

I understand that the main reason for opposition for this bill is line 1551 where we talk about based on credible scientific evidence published in peer-reviewed medical journals. Is that the, the main reason for the opposition?

DEPUTY COMMISSIONER KATHLEEN BRENNAN: Yes. The Department's position is it's not necessary to remove that language from the statute.

REP. SRINIVASAN: Right, right.

DEPUTY COMMISSIONER KATHLEEN BRENNAN: That's correct, Sir.

REP. SRINIVASAN: And the fact that it is removed in this bill is, is the reason why --

DEPUTY COMMISSIONER KATHLEEN BRENNAN: That's correct, Sir.

REP. SRINIVASAN: -- the opposition appropriate. And, and, you know, in going what you said and as our Chairwoman said, that a practicing physician obviously knows the patient best and, in an ideal setting, should be aware of the latest information that there is. And I agree with you 100 percent, unfortunately that does not happen. That does not happen. There could be a gap either because you are not just current or you didn't even bother to be current, either/or. And, so, this system where, you know, somebody being there monitoring and saying, "Hey, you could do this, you know, this is the research, look at it," and then decide what is appropriate and applicable to that particular patient is what, as I see that in real life and clinical practice, one more pair of eyes being there for you and, by and large, supporting you and saying, "These are options you should consider as well," and leave it to obviously the practicing physician who knows the patient best what is going to be most appropriate in that particular situation. Thank you.

Thank you, Madam Chair.

SENATOR GERRATANA: Yes, Senator Welch.

SENATOR WELCH: Thank you, Madam Chair.

I understand your concern at one level and I'm hoping you can help me understand it at another level, and that is what -- I mean, what do you foresee being the horrible consequences that would come out of it, a change like this? I mean, are you looking at millions and millions of dollars that you foresee you'd have to pay for services that you wouldn't under the current statute? I mean, what, what are we talking about here?

DEPUTY COMMISSIONER KATHLEEN BRENNAN: I mean, personally we're not -- I believe we are not looking at this from a financial -- from a fiscal perspective at all.

SENATOR WELCH: Okay.

DEPUTY COMMISSIONER KATHLEEN BRENNAN: That's not the basis of our concern here. Our opposition to the bill is that the definition of medical necessity now includes four factors. It's not an all or nothing. Not all of them have to be met. It's an opportunity to determine that the procedure, the health services are medically necessary. So, in that regard, to remove just one of the factors -- again, not a -- the sole determining factor, just, quite honestly, doesn't make sense to us in the big picture of providing the best care possible.

SENATOR WELCH: All righty. I guess, I guess I'm, I'm struggling now even more with, with your answer. So, under, under kind of your view of how this law would change, it sounds like you're saying that there is a component that you as DSS seems -- deems critical to patient care, which is now going to be removed, and it's going to allow patient -- or doctors to prescribe services or tests or whatever it might be now that you just, as DSS, don't seem prudent for patients that receive payment from DSS. Is that --

DEPUTY COMMISSIONER KATHLEEN BRENNAN: It applies not only to the DSS program, but this also applies to both the -- to the commercial insurers as well.

SENATOR WELCH: And I get that, and none of them are here today saying this is horrible and the world is going to end type, if we make this change. And I'm not saying that's what you're saying at all either, but they're not here, and I scratch my head at that. So, if -- I mean, what, what exactly -- so, you're not here saying this is going to cost the state of Connecticut millions of dollars. You're, you're legitimately here to say that, We think that there is going to be unnecessary treatments or unnecessary tests which are going to harm your clients. Is that, is that kind of what I'm hearing?

DEPUTY COMMISSIONER KATHLEEN BRENNAN: Yes.

SENATOR WELCH: Okay.

DEPUTY COMMISSIONER KATHLEEN BRENNAN: And with 100 percent, this has nothing to do with this goal and everything to do with clinical assessments.

SENATOR WELCH: Now, in, in -- and I appreciate that answer.

DEPUTY COMMISSIONER KATHLEEN BRENNAN: Uh-huh.

SENATOR WELCH: Do -- are there other states that have made this change that had -- gives, essentially gives you credible evidence that this would be a bad change? Or is this -- I mean, are we just in anecdotal world here because no other states have done this?

DEPUTY COMMISSIONER KATHLEEN BRENNAN: I'm not aware, Sir. I could take a look, but I am not aware. I don't know, Dr. Zavowski, if you have any --

DR. ROB ZAVOWSKI: When this legislation was originally passed four years ago, there was a group that looked at the definitions of medical necessities from around the country and they are as short as one sentence and as long as three pages. To be able to generalize would be difficult.

I guess the concern I have is I'm afraid of seeing the headline in the newspaper saying that Connecticut passes law that says that the current research is not to be used to make a decision about healthcare. And I just -- I think that sends a message that I would feel a little uncomfortable with. It's -- and, frankly, I think Representative Srinivasan was clearly a lot more eloquent about this than I was and, so, I would defer to him on this. I think he spoke very well, said it much better than I could.

And I think the best of all worlds is that we are an extra set of eyes and we have some of the wherewithal to be able to do a lot of the research and to know what's been published on everything more quickly than, than a lot of practicing providers can. And we don't micromanage every little thing. We're not in every examining room, but we're cautious. And with types of procedures that are dangerous, that are costly, that are -- you know, you know, those are the things that we look at, you know.

For instance, we look at a CT scan. We actually don't look at it specifically because of the cost. We look at it because of the exposure to radiation. CAT scans are an incredible source of radiation right now, and if you're not monitoring especially folks who go different places the amount of radiation they're receiving, they're at risk for long-term outcomes, especially if it's a child because you're talking about lifetime risk. And, so, if I were a practicing physician, I ordered a CT scan not knowing that the child I just saw had one two weeks ago, I would change my therapy. So, it's -- hopefully it's a dialogue and I, and I appreciate Representative Srinivasan's words.

(Inaudible).

SENATOR GERRATANA: Well, thank you.

Are there any other questions?

If not, we thank you very much for coming in and testifying today.

DEPUTY COMMISSIONER KATHLEEN BRENNAN: Thank you very much.

SENATOR GERRATANA: Next is Leah Lucarelli followed by Chief James Brown and Ann Diamond with the UConn Health Center.

Hello, Leah.

LEAH LUCARELLI: Good afternoon.

SENATOR GERRATANA: Good afternoon.

LEAH LUCARELLI: Senator Gerratana and Representative Johnson and members of the Public Health Committee, thank you very much for the opportunity to testify concerning school-based health centers.

My name is Leah Lucarelli and I am a Nurse Practitioner currently working in two school-based health centers in Middletown. Both are operated through the Community Health Center. I also serve as the Regional Director for school-based medical services for Community Health Center, and I'm here to testify in favor of S.B. 415, the Act Establishing Additional School-based Health Centers.

The issue of expertise in running school-based health centers dates back over 20 years when we first opened our very first school-based health center at MacDonough School in Middletown. Since then, schools across the state have asked CHC to run school-based health centers in their schools. In 2013, we were able to serve 12,000 students for all school-based services across the state. For mental health services alone, CHC has providers in 38 schools, mostly clinical social workers, and those schools cared for 1,800 students ranging from kindergarten all the way through seniors in high school. Adding this to the medical and dental services that we provide, we've had a very positive impact on students across the state.

Research is clear. Students are more likely to participate in treatment in school-based settings than they are outside of the school walls. We remove waits and delays, eliminate the barriers of access, and respond to requests from teachers and school administrators for help. This can be especially important when communities experience a trauma like Sandy Hook did last year or the current issues around drug overdoses in East Windsor. These situations, school-based health centers can provide services for not only the students but the whole community.

We know that early recognition of problems and prompt treatment is essential. Having medical and mental health professionals right in the school is effective and efficient. We urge you to support the expansion of school-based health centers across the state whether as part of a comprehensive school-based health center or as centers providing one specific service. We operate both models based on the community and the school district's wishes. CHC is available to assist additional communities either as an external advisor or by running school-based health centers fully integrated within our statewide network of health centers. Working together, we can do a better job of identifying, treating and helping school children with the medical, mental health and oral health issues they have.

Thank you very much for your time and your support.

SENATOR GERRATANA: Thank you very much for taking the time and coming up and testifying today. I don't think anyone has any questions, so, thank you so much.

LEAH LUCARELLI: Thank you.

SENATOR GERRATANA: Next is Chief James Brown with Ann Diamond, I believe, from the UConn Health Center, and to be followed by Dr. Helen Newton.

Good afternoon.

JAMES BROWN: Good afternoon.

Good afternoon, Senator Gerratana and Representative Johnson and members of the Public Health Committee. My name is James Brown. I'm the Fire Chief of the University of Connecticut Health Center Fire Department and with me today is Ann Diamond who is the Interim Chief Executive Officer for the John Dempsey Hospital. Like to thank you for raising House Bill 5503, An Act Concerning Emergency Medical Services for Certain State Facilities.

As you are aware, the Health Center is a very large facility consisting of 37 buildings with over 2.2 million square feet situated on 200 acres. We have 5,000 employees and we annually see about 500,000 patients. With this in mind, you are aware that we do have a Fire Department on campus that provides emergency medical services as well.

As we share with the Committee, we have a history of serving the Farmington Valley with our emergency medical services and we are one of the first paramedic services in the state. Sixteen of our firefighters also serve as paramedics and we provide this service to our campus. Our personnel can be on scene within about three to three-and-a-half minutes, and under current law we are required to contact a private ambulance service to move the patient to the emergency room, which could be literally yards away. Having to call an outside provider to transport the patient to our emergency room, even after our first responders have stabilized the patient, is inefficient, has the potential to create a significant delay in patient care.

We've seen a significant increase in patient contacts over the years. Four years ago, we saw about 56 patients on campus and we're up to 206 in the past calendar year. This past August we made an attempt to negotiate with our current ambulance provider to get this service on campus. We conducted meetings over about four months and we had very negative results at the end, really not very cooperative. We are -- also have been made aware through the Public Service Area Task Force that other instances of particular public service areas have been designated by commercial providers, particularly in the Middletown area. Hunters Ambulance has designated the Pratt and Whitney facility as a first response area or a primary service area. So, it can be done.

Unfortunately, like I said, the negotiations from the ambulance provider have been non-fruitful, so, we have once again pursued a legislative remedy to this situation.

Thank you for attention, and we ask that you support House Bill 5503. If I can answer any questions --

SENATOR GERRATANA: Thank you very much.

Does anyone have any questions? Senator Kane.

SENATOR KANE: Thank you. Thank you for your testimony.

Can't yourselves and AMR or whoever it may be come to an agreement without legislation?

JAMES BROWN: We've tried that. We sat at a table and negotiated with DPH and they claimed profit margins were very thin. They said they couldn't entertain that type of an agreement.

SENATOR KANE: And tried that, as in recently, or for a long period of time or --

JAMES BROWN: This began in August of 2013 and we concluded in approximately November, December of the same year. So, we spent about three or four months discussing it back and forth.

SENATOR KANE: And what brought you two here today to propose legislation?

JAMES BROWN: We had --

SENATOR KANE: Was it UConn or --

JAMES BROWN: Excuse me?

SENATOR KANE: Was it UConn that -- who advised you to propose legislation?

JAMES BROWN: We had proposed this last year and were asked to delay it until this year after the public's Primary Service Area Task Force was able to, to do their work as well.

SENATOR KANE: Okay. Thank you.

SENATOR GERRATANA: Thank you. Thank you so much for taking the time to be here -- oh, oh, Representative Perillo. Thank you.

REP. PERILLO: Madam Chair, thank you.

Just one quick question. As I read the language as it is currently drafted, it says "each State-owned facility or campus having acute care hospital on the premises that employs or contracts with a provider."

I know in this particular instance for you folks that you obviously -- you know, you're employees. But I could see a scenario where down the road, or if there were to be another facility at some point in time that met these criteria, that another private ambulance service could be contracted with. And I could see where that may create some confusion with multiple private operators working in the same municipality. Is it necessary, from your perspective, that those words "or contracts with" be included in this legislation?

JAMES BROWN: I don't see it as necessary. We actually drafted the language with the help of Department of Public Health, and certainly opened the suggestion. We tried to keep it very, very narrow just to specify the Health Center Campus. That was our intent. So, I guess --

REP. PERILLO: And I -- and thank you. I noticed it was pretty specific. I just -- it's just something that popped out at me as something that may not necessarily be necessary in your particular case, but could open up a can of worms down the road. But thank you.

JAMES BROWN: Our intent was to keep it very, very focused on the Health Center itself. So, if there's language changes proposed --

REP. PERILLO: Thank you. I appreciate it.

JAMES BROWN: Okay, thank you.

REP. PERILLO: Thank you, Madam Chair.

SENATOR GERRATANA: Thank you, Representative.

Oh, yes, thank you. Representative Zoni.

REP. ZONI: Thank you.

Thank you for your testimony here today. I just want to ask one simple question. Do you anticipate a savings in -- financial savings for the university as a result of this effort?

JAMES BROWN: We have actually been under a budgetary constraint proposed by the Governor's Office and the Legislature from last year and again for the next fiscal year to save $400,000 specifically aimed at the Fire Department and the overtime budget. We have made some staffing changes. We have come up to full staff. We have made some progress towards that goal. This would allow us to generate some additional revenue to address that $400,000. And it -- indeed, yes, it is a patient safety issue as well. We don't have a patient (inaudible) sitting around.

REP. ZONI: Thank you so much.

REP. JOHNSON: Okay. So, just to clarify, the issue is now there has to be a wait for -- go to that process once more just so that there is clarification in terms of what it is now and how the change will help healthcare delivery.

ANN DIAMOND: Yes, good afternoon. My name is Ann Diamond. I'm the Interim Chief Executive Officer at John Dempsey.

From my perspective, this is a patient safety issue. We've heard from the financial component, both on the for-profit side and -- and at UConn. But I'm here to provide the patient safety perspective and the patient centric perspective. Right now, the patient is stabilized by our Fire Department and their EMTs. Their response time is wonderful. They're there within minutes, but then they are not able to transport that patient literally feet to our Emergency Department.

One example is our Ambulatory Surgery Center. We had a very healthy 29 year old gentleman that was in there for a routine procedure. He had a bad reaction to the anesthesia, became combative and then lost his airway. We stabilized him and then we waited 45 minutes for the private ambulance to transport him to the Emergency Department. Now, if I was that patient or their family -- minutes matter. The standard of care is to provide the more advanced life-saving treatment in the Emergency Department as soon as possible. And, so, passage of this bill would positively impact that patient's safety on our campus.

REP. JOHNSON: So, when you would have it you would, you would be able to transport the person right within the campus area --

ANN DIAMOND: That's right.

REP. JOHNSON: -- as opposed to waiting for some outside assistance?

ANN DIAMOND: That's correct, Ma'am.

REP. JOHNSON: And if somebody for outside -- who is outside assistance can go deliver the patient right to the campus now, right to the Emergency Room?

ANN DIAMOND: Right now we have to wait for the private ambulance to come and respond. Their average response time is 10 minutes, but they do have outliers that, that I can speak to that have been much, much longer than that. The 10 minutes by itself is already two minutes above the national average. What we have now with our Fire Department is two-and-a-half to three-minute response time, which obviously does make a difference in patient care.

REP. JOHNSON: Certainly. So -- but in terms of -- so, there's nothing -- this isn't a situation where you would have a reversal where there might be an opportunity for the private ambulance to come, but you would take over at a certain point. It's only, only with respect to where the patient is within the area of the campus and you would be able to transport that -- am I understanding this correctly?

ANN DIAMOND: You're understanding that correctly. That's what we're seeking.

REP. JOHNSON: Okay. Yes, Representative Betts.

REP. BETTS: Thank you, Madam Chair. And thank you for your testimony. Just a couple of clarifications.

Could you give the Committee an idea as to the numbers that have occurred in 2012, 2013, or over the last year-to-year comparison of, of responses you've made with people who become sick or in need of medical service on the campus alone?

JAMES BROWN: It was included in the testimony. We have -- from 2009, we had a total of 56 and in 2013 it's up 206.

REP. BETTS: The reason why I think that's important is obviously we don't know what the reason is, but a 10-minute wait strikes me to be a very long time for a patient that's waiting to get additional medical care. And my understanding of this bill is that it's limited just to the campus itself and nowhere else. So, I thank you for your testimony, and I do support the concept of doing this.

Thank you.

REP. JOHNSON: Thank you.

Any additional questions?

Thank you so much for taking the time and being here and for your very excellent testimony.

JAMES BROWN: Thank you.

REP. JOHNSON: Next person on the list to testify is Dr. Helen Newton.

Is Dr. Newton here?

Okay. I'm moving down. Deb Migneault.

DEB MIGNEAULT: Good afternoon.

REP. JOHNSON: Good afternoon. Please state your name for the record.

DEB MIGNEAULT: Yes. Senator Gerratana -- I'm sorry, she's not here. Representative Johnson, my name is Deb Migneault. I am the Senior Legislative Analyst for the Connecticut's Legislative Commission on Aging and I'm here to provide comment on House Bill 5535.

As you know, the Connecticut's Legislative Commission on Aging is a nonpartisan public policy office of the General Assembly devoted to preparing Connecticut for a significantly changed demographic and enhancing the lives of present and future generations of older adults.

We are here today to provide our support for H.B. 5535, An Act Concerning Notice of Patients Observation Status and Notice Concerning the Qualifications of Those Who Provide Healthcare and Counseling Services. We are very much grateful for this Committee to raise this bill and try to address a growing problem for Connecticut's older adults specific to observation status, and we are here to support it, as I said.

We've been following this issue very closely with our partners and friends, national experts, the Center for Medicare Advocacy. They've been doing a lot of work on the national level with the observation status and, in fact, filed the class-action lawsuit to challenge this illegal practice. I believe you will be hearing from the Center for Medicare Advocacy in a little while, and that's wonderful because they really truly are experts. And if you have any questions, they can answer anything and everything Medicare related.

As you are aware, increasingly hospital patients are finding they have been in the hospital under observation status, and what that means is they are in a hospital bed receiving care from hospital physicians and nurses, eating hospital food. People are coming to visit them in a hospital room, and yet they come to find out that they're actually not admitted. They might have been there for two days, three days, five days, even as much as 14 days, and for billing purposes they have not been admitted.

They are considered observation status. And what that ends up meaning is that some of their benefits under Medicare don't come into play for coverage of -- coverage in the hospital, things like prescription drugs that they might be taken -- taking for chronic illnesses like hypertension or diabetes. They will be responsible for paying. Medicare won't pay for those in the hospital. They also might be paying -- have to pay for physician visits or testing that's being done in the hospital but is not covered under Medicare because they're not considered inpatient.

Also has an effect if they're released to a skilled nursing facility for rehabilitation. Coverage of a skilled nursing facility under Medicare does not come -- does not begin until they have a three-day hospital stay, inpatient hospital stay. And, so, they could have been in the nursing -- in a hospital for three days, but then are released to a skilled nursing facility and, in fact, they were never actually admitted to the hospital. So, they're, they're -- they are not covered for skilled nursing facility coverage which, as you know, is extremely expensive.

Medicare does not require hospitals to notify patients of their status. Many times, patients believe they are inpatients because they're in a hospital bed in a hospital and they don't realize the potential effects that it has on their Medicare benefit. So, again, we are here to support this bill. Providing this information to patients while they're in the hospital is really important for them to understand how their status affects their coverage and their benefits.

We do have some -- a little bit of suggestions just to strengthen the bill. The intent is great and we just have few little, small suggestions to strengthen it. We would suggest that the notice to patients includes information about what it means to be considered observation status, particularly that patients may be responsible for cost of medications and skilled nursing facility coverage, if needed. And we would also suggest the notice include that questions regarding their status in addition to their health insurer and the Office of Healthcare Advocate be directed to the admitting or primary physician.

So, it's just a couple of suggestions just really to strengthen it. But, again, we're very supportive of Section 1 of this bill and are very grateful that you are trying to address a very, very challenging problem here in Connecticut, but across the country nationally.

REP. JOHNSON: Thank you so much for your testimony. Have you run into any, any people personally through your organization, in your work who have had this situation happen to them?

DEB MIGNEAULT: Certainly. We have received phone calls into our office about this, and we always direct to the Center for Medicare Advocacy because they are a wonderful resource and will advocate on behalf of that patient to try to, to manage the, the situation. So, what we do is refer to experts, which is the Center for Medicare Advocacy. We're very lucky to have them in our state. They're national experts, but they are located here.

But, yes, it's certainly something that we've heard of, and we also know of really horror stories nationally about bills that come in after they've been in the skilled nursing facility for a couple weeks, and then all of a sudden they are left responsible with thousands of dollars of medical bills because Medicare, in fact, is not paying -- will not pay.

REP. JOHNSON: Great, thank you so much for your testimony.

Any questions? Yes, Representative Klarides.

REP. KLARIDES: Thank you so much for coming in today. I'm not as -- that familiar with, with how this works, but how does -- how is it decided if somebody should only be there for observation or be called, you know, under observation?

DEB MIGNEAULT: Yeah, there are, there are -- well, basically it's when somebody comes into the hospital and they're, they're assessed. Usually they come in through the Emergency Room. They're really too sick to return home, and then they're admitted into the hospital. They sign all the paperwork, but they are not actually admitted and that -- that is because they -- the hospital feels they're too sick to return home but they need -- so, they need to observe them and perhaps do further testing or things like that. And, so, it's, it's really a billing procedure that happens with the hospital.

It's Medicare rules that determine that and there is legislation in Congress that's trying to kind of correct some of these challenges with Medicare. Obviously, it's a Federal issue. So, it's not so much that the hospitals are doing anything that they shouldn't be doing. They're using -- it's Medicare rules. It's just that these Medicare rules are making it quite cumbersome and difficult for inpatient medical stays. And, so, this is a trend that is becoming increasingly -- happening more and more here in Connecticut and nationally.

REP. KLARIDES: Well, I mean, that makes sense to me, I guess, if it were a day or two. But, I mean, you used an example of a couple of weeks.

DEB MIGNEAULT: Yes, uh-huh.

REP. KLARIDES: And, so, I guess that's what the concern is, I would assume.

DEB MIGNEAULT: Yes, and that is when -- especially concerning a skilled nursing facility, when somebody is released to skilled nursing facility. If somebody has been in a hospital for three days inpatient then they are covered under Medicare for skilled nursing facility rehabilitation for a certain length of time. However, what's happening is somebody may actually be in the hospital for three or more days but under observation status, and then they are released to a skilled nursing facility. But because they have been under observation status and not inpatient, Medicare does not pay for the rehabilitation in nursing facility.

So, it's a billing practice. There are certain guidelines through Medicare that distinguishes whether somebody is inpatient or observation status and that -- those problems with those billing coding and rules are causing these lengthy stays that aren't actually -- they're not inpatient and they really don't look anything different than, than -- you would go visit somebody, you would not be able to tell. A person in the hospital bed would not know unless they specifically asked. In fact, I have had the experience several times over the last year or so with family members and me advising, "Make sure you find out. Please ask are you observation status because unless you know, you could be stuck with some really significant bills." And that's the time that you potentially could advocate for a change in status if that's possible.

REP. KLARIDES: Thank you.

DEB MIGNEAULT: Uh-huh.

REP. JOHNSON: Very good. Are there any additional questions?

Thank you so much for being here, for your testimony. It's very much appreciated.

DEB MIGNEAULT: Thank you.

REP. JOHNSON: Next on our list is Jim Iacobellis.

JIM IACOBELLIS: Good afternoon. My name is Jim Iacobellis. I'm the Senior Vice President of Government and Regulatory Affairs for Connecticut Hospital Association. It's a pleasure to be able to testify here this afternoon on House Bill 5535 and three other bills and I'm going to try to do that in three minutes.

With respect to H.B. 5535, it's broken down into two sections and I'll take the first section first. It has to do with observation stays, and we applaud and thank the Committee for trying to figure out a way in which we can clarify what is going on. But to pick up where the last testimony left off, we have patients, doctors and hospitals caught between this complicated Medicare regulatory scheme. The Medicare Recovery Audit Contractors and the False Claims Act, these are all intersecting here at the same time. Medicare rules define when you can be an inpatient and when you can't be an inpatient.

So, a physician has to certify that you are an -- that you are an inpatient. And as the last woman just, I think eloquently spoke about, there are situations when you're in the hospital and you think you're admitted, but under the billing status you are in observation. That does impact your paying what is covered under Medicare. It impacts if you need -- if you need further care. We have concerns over this bill and I've had conversations about it and we're going to try to look at where some other states have gone to made sure that we don't complicate this any more.

I think as we've heard, there are bills in Congress that are trying to straighten out what is observation status. There's conversations about trying to deal with ways in which we deal with short stays with what we're talking about. There are lawsuits and there are actions by Recovery Audit Contractors and they all intersect.

So, I want to say that we are interested in working with this Committee to make sure that what we do doesn't complicate an already complicated problem, but it is one that we know we have to address because patients are caught in between, doctors are caught in between, and hospitals are caught in between. And one of the most, I think, troubling aspects is three years after somebody leaves the hospital, a Medicare Recovery Audit Contractor can change their status.

Quickly, Section 2 is a bill that is -- is a section that's directed I think at those types of outpatient settings which are not regulated currently by the Department of Public Status -- Public Health as drafted. It includes emergency departments. I don't think it means to include emergency departments or other hospital clinics which are regulated by the Department of Public Health. We've added some language in our testimony I think to straighten that out.

The second bill, An Act Concerning Hepatitis C Testing, we support. We've added some technical clarifications. One, the bill refers to a nurse practitioner. I think the bill needs to refer to an APRN. That's the licensure status. Two, in lines 17 and 18 it requires the physicians to provide a hepatitis C test. In most cases the physician is not going to provide it. He is going to give them documentation in order to go get a blood test. So, I think it's technical, but highly important.

And lines 28 to 33 statutorily mandates the conversation or the next steps between the physician and the patient, and we feel pretty strongly, to the best that we can, we should not put in statute what a physician has to do when he receives a test result, what that conversation should be like. So, consider looking at that section and either modifying it or deleting it.

We support the Senate Bill 413, the MOFLT bill. We are part of that working group and we look forward to working with the Department and implementing that.

And with respect to 5537, the DPH revision bill -- and I bring this up, we have written testimony on it because I want to talk about it publicly. We've asked for a section to be added. We have a section in Connecticut statutes which governs access to laboratory records. We are always waiting for the Federal government to come in and do their Federal regs on clinical laboratories and HIPAA. They have now done so. It is a way in which I think goes exactly where we want to go as a state, giving patients access to their lab results. Our language hopefully just conforms those two so we're on the same page so there's no confusion, but the result is exactly where we wanted to go for a number of years and the Federal government has just caught up with us.

Took longer than three minutes.

REP. JOHNSON: But you covered so much ground. Very nice.

So, yes, I think the Committee is definitely willing to work with you on, on the language issues that you raise, and the fact that -- you mention in your testimony regarding House Bill 5535 Section 1, the fact that other states have passed legislation that are similar to what we're proposing here. And, so, I think the state of New York has certainly done that and I, I respectfully ask you to take a look and make sure that, you know, we're not doing anything that will complicate the issue, but just make sure that the patient and the family of the patient understands the circumstances that they're in and the change, although there's no regulatory change, no statutory change in how Medicare is supposed to operate with respect to the provision of healthcare services and the payment. There is administrative changes that have occurred that will have an impact.

And there are so many times when people say, "I've heard Medicare was changed," but, you know, really quite, quite truly it's not the law itself that changes but the way it's being administered. And I think that this has been going on not just for the last ten years, but it's been a way for perhaps some bureaucrats who are administering the program, who are doing the audits, a way for them to figure out a way to save money on the Federal level. But what does it do here in the state? It creates a situation where people will have to have -- either pay from their own pocket or go onto the Medicaid program, which -- that was not the vision of the, of the folks when they, when they crafted the Medicare program back in 1965.

JIM IACOBELLIS: I couldn't agree with you more. I think we have -- we had the Centers for Medicaid and Medicare Services come out (inaudible) with the regulation. They immediately delayed it for six months and they immediately delayed it again. It's known as the Two Midnight Rule. And how can we clarify when and when you're not in observation status?

Congressman Courtney has a piece of legislation which we support and have been working with him on which would deal with a small part of this as it relates to observation days, and then care in long-term nursing homes, to count those as, as the three days.

Part of what -- and we will check with our colleagues in these states where something like this has been implemented to make sure we don't do anything that makes this more complicated for the patient. We may have to deal with some part of it whether this notice's intent deals with the fact that maybe a year or two later an auditor may go and change a status, and whether that notice provision would require the hospital to go back and try to track someone down a number of years later to do that. But that, I think, is part of the conversation when we see how it's working in New York, but I welcome that conversation because this is an area that's critically important to patients, doctors and hospitals.

REP. JOHNSON: It seems like it's just mushrooming because of the administrative difficulties and, so, the hospitals have tried to implement policies that are really inconsistent with the intent of the Medicare law. So, thank you so much for being here and working with us on the legislation.

JIM IACOBELLIS: Thank you.

REP. JOHNSON: Any questions? Yes, Representative Srinivasan.

REP. SRINIVASAN: Thank you, Madam Chair.

Thank you very much for being here this afternoon for your, for your testimony. Two questions, one on 5535, the observation status. Am I to understand that you feel that with whatever is going to happen hopefully soon at the type of level that your involvement with Congressman Courtney, that to wait to see what happens before we institute this in our state, is that how I am reading you?

JIM IACOBELLIS: I don't think Congressman Courtney's specific bill addresses the notice provisions of this bill in the state of Connecticut. His bill specifically addresses what is -- a problem is if you're in observation status then you go to long-term care, those days don't count, so you, the patient, have different financial responsibilities. His bill treats the observation days as something that will count towards the three days to go in there. So, his bill won't do that.

My concern is, is the new regulation coming down from CMS and how they define what is observation and what isn't observation may put different parameters around this notice requirement. So, I just want to make sure that we are coordinating everything and we don't do anything that complicates it. My conversation with Representative Johnson is that this was modeled after New York, and we're going to make sure that we have conversations with them and this Committee to make sure that what we do doesn't complicate an already complicated area because we don't mean to do that because it is important for the patients to know, first of all -- and this is a billing issue -- what their financial responsibilities are. It's very important.

REP. SRINIVASAN: Thank you very much for sharing that. And I definitely agree, the last thing we need to do is complicate it and make it even more difficult to comprehend by everyone. But I also feel that patients in the Emergency Room, by and large, to whom this applies, you know, should be aware as to whether they are in observation or not because obviously it's going to impact them, not only in their long-term care which is a different issue altogether in the number of days counting, but in the hospital itself that -- you know, because a lot of people don't know what's happening. I mean, you know, the doctor, the nurse comes in to check them every so often and they, they assume that (inaudible) there that they are going to be automatically admitted only to find out, "No, you've been in observation status this entire period and now you're ready to go home" or whatever medical decision is made.

So, that information -- you're right, we've got to do it correctly. Look at New York and see how -- so that we learn from them. But informing the patient, informing the patient's relatives, the appropriate relatives that the person here is not being admitted but under -- is under observation status, would be very useful information as far as the patients are concerned. But you've got to do it right.

JIM IACOBELLIS: You know, I think -- I think you're absolutely right, because the patient has -- has the right to know what and how this -- how this status is going to impact them. And I think we need to do everything that we can do to make sure we do that. But, again, the thing that -- and we may have to deal with this bill, how do we deal with the fact that maybe six months, a year, three years later an Audit Contractor will come in and change someone's status, which doesn't impact anything to do with their care, but how does this notice requirement -- and I think we can figure out a way in which, in which to deal with that.

It is appropriate for the people and the patients while they're in the facilities to know what they are and this notice appears to be focused in that direction as opposed to some retrospective type of issue, but I look forward to working with the Committee to actually straighten that out.

REP. SRINIVASAN: And a second question is on, on your Bill 257 which (inaudible) the hepatitis C screening. And what I kind of gleaned from you was that the testing obviously is being -- is being offered at the M.D.'s office, but the test would be done at the laboratory. And when the results come in, that was the part that I missed or couldn't comprehend. When the results come in, you're saying not to put in the statute that this conversation has to happen between the physician and the patient and just leave it like any other thing where obviously when the results come in, whether it be a CAT scan or blood test or whatever it is, and we are not mandating that or requiring that a CAT scan result has to be discussed or a bone density is to be discussed.

So, this would be no different is what I'm understanding from what you're saying. The tests are in, the results are in, and obviously it is the responsibility of the physician to discuss those results, A, and to discuss option B, and then leave it to the patient to decide what they want to do.

JIM IACOBELLIS: Exactly.

REP. SRINIVASAN: Thank you. Thank you.

Thank you, Madam Chair.

REP. JOHNSON: Thank you so much.

And just, just as a -- one of the things I heard you say was that you have to figure out a way to deal with something that occurs between the hospital and the Medicare agency and the auditors. That's a separate issue from what occurs between the hospital and the patient. Those are two separate things. They shouldn't be confused or connected in any way. The -- under the Medicare certification requirements, whether it's through the hospital -- between the hospital and the patient, between the, between the patient and the skilled nursing facility or patient home care provider, the patient and the treating doctor, they all have a duty to tell the patient whether or not at the time of the visit there is coverage. And if there is not coverage then the patient has that responsibility of payment.

So, this isn't something that, that was ever intended that down the road, if the hospital has made an error in the determination of whether coverage exists or not, that the patient should somehow be responsible.

JIM IACOBELLIS: No, I didn't -- and I think a lot of times when we talk about the hospital or the physician making an error, part of the whole problem is, is the disagreement over whether or not the -- an auditor is coming in, deciding whether somebody was inpatient -- should be an inpatient or an outpatient. We have these judgments and it is I think you rightly putting -- that's a debate going on between the, the hospital and the physician and the Recovery Audit Contractors. It shouldn't impact the patient.

I just want to make sure that the notice actually reflects that and it is different from that.

REP. JOHNSON: So do I. We're in agreement.

JIM IACOBELLIS: We are.

REP. JOHNSON: Thank you. Thank you so much. I really appreciate it. I just want to make sure everybody understands that we're not trying to meld the two and I want to be very, very clear about that.

JIM IACOBELLIS: And my concern is to make sure that the notice doesn't do exactly what we are agreeing.

REP. JOHNSON: That's right.

JIM IACOBELLIS: Thank you.

REP. JOHNSON: We don't have any desire to do that.

Thank you so much.

Representative Wood. Welcome, yeah.

REP. WOOD: Or happy Friday or --

REP. JOHNSON: Well, we'll see how, how long it lasts.

REP. WOOD: Yeah.

Good afternoon, Senator Gerratana, Representative Johnson, Senator Welch and Representative Srinivasan. I'm Terrie Wood, State Representative for the 141st District, which is Darien and Norwalk. I'm here to testify in opposition to Senate Bill 416, An Act Concerning the Department of Public Health Recommendations Regarding A-Level EMTs in Connecticut.

I represent a district that relies heavily on the skills and training of the A-advance level emergency medical technician. Our EMS service is staffed and run by Darien High School students. The students participate over four years and many continue on to be graduate reserves. As sophomores, the students take the State certified EMT course and the requisite State exams when they turn 16. After two more years of service and experience, many of the students go on to take the AEMT course. The A-level training is the culmination of four years of training for them.

In addition to the students, there are adult volunteers who staff the ambulances during the day while the students are in school. These adults are virtually all AEMTs. These AEMTs are able to provide a higher level of support in emergency care that can make a life-saving difference in the care of the critically ill. One example of this is the ability to start and run an intravenous line. This additional training also provides better care with advanced assessment before the paramedics arrive on scene or before arrival at the Emergency Department at one of two hospitals.

This is training that is vital to our community as high-quality and cost-effective care. It is also a logical training step between basic level EMT and the requirements of the full paramedic course. Advanced EMTs undergo over a hundred hours of additional training to the curriculum required of the basic level EMTs. They also must complete 48 hours of continuing medical education every three years to maintain their certification of AEMT. This is a significant contribution to public health and safety.

Thank you for hearing my testimony. I hope that you will give serious consideration to opposing this bill. Please continue to support the training and certification for the A-level EMT. I would be happy to answer any questions.

REP. JOHNSON: Thank you so much for that testimony and your perspective on it. That's something that we have some concerns about, the people have received this certification and now there is a recommendation that it be phased out. So, we're looking at -- it doesn't occur till I think 2017.

REP. WOOD: '17, right.

REP. JOHNSON: But, you know, we are trying to make sure that everybody who has gone through the training is, is recognized and acknowledged.

So, with that, do we have any questions? Yes, Representative Srinivasan.

REP. SRINIVASAN: Thank you, Madam Chair.

Thank you, Representative Wood, for being here this afternoon and good to see you here. Thank you for your testimony. And I share your same concerns and I, I cannot comprehend the logic between eliminating or saying this is not necessary when this is a different level of service that they are capable to provide. And I'm not sure if you were here when DPH was testifying on that. And if memory serves me right, I think it is, as Senator Gerratana said, that even if you save one life that this person is able to do, it is well worth it.

REP. WOOD: Right, and it is increased training. And it's also -- many of these A-level EMTs are volunteers, so, they are providing tremendous support in a very cost-effective way to our community. I mean, the most important point is they're trained. It's further training.

REP. SRINIVASAN: Right. So, our concern is that, as Representative Johnson said, we are looking at this as eliminating this component totally, is that -- I mean, (inaudible) reasons that they believe they could not continue to do this. And I feel this is a service that our state needs. And if they need to be certified and re-certified and ongoing education, it's got to be a part of what our services should be so that, A, our constituents, B, our state is served well with the, with the expertise and the added information and knowledge that this group of people have which others may not have.

So, we are taking away what we have, and that doesn't make any -- any logical sense at all. So, I do appreciate your bringing this -- your opposition to this bill in front of us and obviously we will be giving all due consideration to that. Thank you for being here this afternoon.

REP. WOOD: Thank you very much.

REP. SRINIVASAN: Thank you, Madam Chair.

REP. JOHNSON: Thank you, Representative. And thank you. I was just wondering, do you have some recommendations on how to perhaps make this legislation that would work better from your perspective that might be helpful to us? So, we're certainly willing to work with you on that.

REP. WOOD: Thank you.

REP. JOHNSON: So, whatever ideas you have, please bring them forward to us in the next, you know, couple of days.

REP. WOOD: Next two days.

REP. JOHNSON: Next two days --

REP. WOOD: No rush, but next two days, right?

REP. JOHNSON: Exactly.

REP. WOOD: Okay. I will ask -- I represent them. I am not an A-level EMT, although I do have a son who is and two kids who are full EMTs, so, three all together. So, I do have a lot of perspective on this. And I will ask the group of adults and see the graduate reserves -- how they would like to see this managed because it does save -- ultimately, it does save money and it saves lives. So, it's a win/win. So, thank you. I will take you up on that.

REP. JOHNSON: Great, thank you. Look forward to it. Thanks so much.

REP. WOOD: Thank you again.

REP. JOHNSON: Any other questions?

Okay, thanks so much.

REP. WOOD: All right.

REP. JOHNSON: Next person I have on the list is Jean Rexford.

JEAN REXFORD: (Inaudible) need to -- sorry. The need on this to --

REP. JOHNSON: I'm doing it. Just for the record, so that -- when you don't have the microphone on, we don't get the recording. So, if you could just, just recap briefly your name and we'll start all over again.

JEAN REXFORD: Thank you so much.

Jean Rexford, Executive Director of the Connecticut Center for Patient Safety, in strong support of allowing patients to know if they are on observation status, but it is the beginning of the need for patients to know cost.

There is nothing that I get more questions about right now than the problems of affiliation charges when someone has a colonoscopy. I just walked out into the, into the atrium and someone said, "Oh, my God, I was just charged $500 for two Advil." As we are expanding healthcare, patients are putting much more skin in this game. And to be informed patients means we will make decisions on cost.

I have done it. The dentist says, "You need to have a full set of X-rays." I say, "No, I don't," because I know what that cost is. And I believe that it will be a more responsible, a more accountable system when we provide transparency of costs of all procedures so that patients can and will make decisions based on those.

So, thank you for your time. Thank you for your work. I haven't been testifying before Public Health in a few years and I realize -- you know, I love all the issues and you do such important work. But as we make radical changes to our delivery system, if we remember the patient needs to come first, I think that some of those decisions will be easier to make.

Thank you.

REP. JOHNSON: Thank you so much. And, also, as we make changes in the delivery systems but also has -- science makes changes and the different types of medical techniques and -- we also probably need to look at the laws that were put into place more than almost 50 years ago now and take a look at that and bring things up to date because the one thing that hasn't changed is the cost of medical care has continued to increase. So, we need to make sure people are covered as they -- as we move into these new areas.

JEAN REXFORD: I had this -- the paradigm thought the other day that 20 percent of -- almost 20 percent of our economy is healthcare costs and yet most of us are really, really healthy people. So, what does that mean on, on how we are spending money? It is probably not all patient centric money. It is -- these are industries that manage to churn and we're paying them. So, thank you.

REP. JOHNSON: Thank you so much.

Any questions? Representative Srinivasan.

REP. SRINIVASAN: Thank you, Madam Chair.

Thank you for being here this afternoon and for your testimony. So that I'm clear, I know you are supporting House Bill 5535 because that -- is it the observation status that you were referring to?

JEAN REXFORD: Yes.

REP. SRINIVASAN: Or for the Section 2 where it talks about in the private offices?

JEAN REXFORD: It's the observation status. It is such a huge expense, particularly for people who are on limited income that -- there's a fairness issue on observation status, but I think I heard you particularly say with critical.

REP. SRINIVASAN: So, the transparency inasmuch as informing the patient and the family that this person is on an observation status at this point in time.

JEAN REXFORD: Yes.

REP. SRINIVASAN: And eventually either a decision to go home or to be admitted will be made. So, that is what you want to make sure happens.

JEAN REXFORD: Absolutely. Thank you.

REP. SRINIVASAN: Yes. And the other comment was, I'm not sure where they'd fit it in where you talked about the dentist and, you know, his saying that you need X, Y and Z, and then you feel -- obviously you have the background, you have the knowledge, you're able to do that and say, "I really don't need a full set."

JEAN REXFORD: Right.

REP. SRINIVASAN: "And a partial is good enough." But once again, going back to the average Joe, you know, who goes for the dental workup or any other workup, like the colonoscopy you were just mentioning as you were in the corridor, and they have to go with whatever the physician or the provider tells them because obviously they feel that is in their best interest.

JEAN REXFORD: Absolutely. And, so, I think what you said is just critically important. So, what if the patient is getting a colonoscopy could say, "What is the total cost of this procedure?" and that could be provided, that patient will make those decisions. There is a fecal test that England uses that is probably 100th of the cost of the test that we use in this country. So, that whole movement that we're seeing towards informed decision making, shared decision making I think will help expose the cost of care.

REP. SRINIVASAN: You are absolutely right. And I definitely concur on that because patients then -- patients and families in limited budgets or limited health access that they have can then decide, you know, what is appropriate for them and what they do not need at that point in time.

JEAN REXFORD: Yes. Thank you.

REP. SRINIVASAN: Thank you very much for your testimony. I appreciate that.

Thank you, Madam Chair.

REP. JOHNSON: Thank you so much. Thank you so much.

The next person -- any additional questions? No?

Next person is Representative Berger. Welcome.

REP. BERGER: Welcome.

REP. JOHNSON: Thank you.

REP. BERGER: Good afternoon, Madam Chair and Committee members. Thank you for having this hearing on a Friday afternoon at 1 o'clock. Hopefully your day will be short.

For the purposes of the record, my name is Representative Jeffrey Berger representing the 73rd Assembly District in Waterbury. As a way of an observation, Madam Chair, before I get into my testimony, I, I have not appeared before the Public Health Committee very often. But having a doctor on Public Health is very, very comparable to having an economist on Finance Committee, so.

I am here in support of House Bill 5537, An Act Concerning the Department of Public Health's Recommendations Regarding Various Revisions to the Public Health Statutes. I have submitted before you a -- additional change in Section 20-71, the licensure without examination physical therapist and physical therapist assistant sections of that, of that bill. Included in that is a new section, Section E, which has -- which has notwithstanding language. I will also, before I comment on the genesis of this language to the Committee members, also would like to make an observational change that I would like the additional language which you see in the blue section effective upon passage of House Bill 5537 as amended.

The genesis of this language comes from constituents, a constituent concern, and also a concern that ended up being a, so to speak, far reaching and encompassed other individuals in an anomaly related to a change in the legislation which you see in section -- in Section D which allowed for licensure of individuals under certification and having experienced some training of April of 2006.

It came to my attention from a constituent of mine and also then in drilling down and looking at other individuals who came forward that individuals fell through the crack, so to speak, and being able to be grandfathered in under that window time frame that the Legislature allowed for. This language will rectify that, allow for those individuals that may and are currently are unemployed because of losing the ability to fall into that grandfather clause and have served in capacity and many instances 10 and 12 years as physical therapist assistants having, again, qualifications and experience and training.

I also note there is one individual that also has fallen through this grandfather time frame that was a veteran of the United States Army, received certification and training as a physical therapist assistant and, and before being deployed and serving in the Army before his honorable discharge.

So, with that, that's the background and I would appreciate the Committee's support in this very, very important clause in addition to the licensure section that we as a Legislature have the ability to make a right -- a wrong a right.

Thank you.

REP. JOHNSON: Thank you so much, Representative, for bringing this to our attention. It's a very important thing and I think that in terms of how our Legislature has been writing legislation to help veterans obtain, you know, jobs and certifications, this fits in very nicely with that. So, we're very pleased -- also, the fact that the proposal gives the Commissioner the complete discretion to make a determination as to what the qualifications are of a person. So, briefly, in this circumstance you're, you're -- the person that brought this to your attention was highly qualified.

REP. BERGER: Yes, yes. And the answer to the question, yes, Madam Chair, certain for the Committee member, certainly very, very qualified and employed for roughly 12 or 13 years in the field. So, that does not become an issue.

REP. JOHNSON: Very good.

Any questions?

Well, thank you so much for being here --

REP. BERGER: Thank you.

REP. JOHNSON: -- and taking the time. Really appreciate it.

REP. BERGER: Thank you, Madam Chair, and thank you, Committee members.

REP. JOHNSON: Okay. The next person I have on the list is Terry Berthelot. Welcome, and please state your name for the record. And I might not have pronounced it just right. I'm sorry.

TERRY BERTHELOT: Thank you.

My name is Terry Berthelot. I'm a Senior Attorney with the Center for Medicare Advocacy. The Center is a national not-for-profit law firm. Our mission is to ensure that the elderly and people with disabilities have access to Medicare coverage and to ensure access to quality healthcare.

I'm here today to express our strong support for Raised Bill Number 5535 spoken about earlier. It is the bill that would require that hospitals give notice when patients are put on observation status. At the Center, we know firsthand how terrible being put on observation status is for a patient. There are very, very serious financial and health consequences. Financial consequences, the biggest is that when a person is on Medicare and she's put on observation status, she will not have the required three inpatient days as an inpatient for her subsequent care at a skilled nursing facility.

At the Center, I personally represented someone who was put on observation status for 12 days. After 12 days of being in a hospital bed, anybody will need the kind of care that one can only get in a skilled nursing facility. The cost of care in a skilled nursing facility in Connecticut can be as much as $15,000 a month. So, to be put on observation status because of a crazy billing rule can have dire financial effects but also health consequences, because most people don't have $15,000 lying around. Many people are forced to go home and not get the necessary care. Those folks, sadly, will often fail and end up back in the hospital in much more serious medical condition.

Getting this notice will not solve all the problems, but it will go a very long way for helping people and families to advocate for themselves. I speak nationally on this issue and locally and was recently at a community center where a woman spoke up and said they formed a committee. Their rule was friends don't let friends end up on observation status.

Reality is if you have knowledge, you can advocate for yourself. You can ask the treating physician, the admitting physician what your status is and why you're on that status. You can get your community physician involved to advocate for you because, in reality, medically there's no such thing as observation status. It's a myth. It's a billing issue and it's an issue that is extremely complicated and being made often -- the decision to put a person on observation status by the Utilization Review Committee, often overruling the initial admitting physician.

I've seen in discharge summaries where, where treating physicians are writing over and over again, "This person should have been admitted." So, we have financial and we have medical concerns when people are put on observation status. So, it will be a great service to the people of Connecticut if they could get notice from the hospital when they're on observation status.

The other issue is when you're on observation status, your medications will not be paid for by your Part D Plan. This can be very, very expensive because folks are forced to pay whatever it is the hospitals charges for these medications. So, an Advil can truly be very, very expensive. Most people do have chronic conditions, things like high blood pressure or diabetes. They need these medications while they're in the hospital.

The other issue is that folks will be responsible for their Part B cost sharing. That's the 20 percent that Medicare beneficiaries usually pay when they see a physician. The other issue is that many folks don't have Medicare Part B. So, these folks, when they are hospitalized, will have literally no insurance and have to pay the entire hospital bill out of pocket.

We do have a few suggestions we'd like to make to make the bill stronger. We would like to see language added encouraging patients to talk to their treating physician and possibly their community physician about their status. Because this is a medical decision, these are the folks who are best able to possibly change the person to an inpatient.

The other thing that would be a great help would be if hospitals were required to allow folks to bring in their medications from home and that the notice would tell folks that they could do this. We see some hospitals in Connecticut already doing this. This could save Medicare beneficiaries especially quite a bit of money.

The other thing that could be improved is the notice. The language of the notice could be a bit stronger. It should -- often when folks are admitted to the hospital they are overwhelmed. They are frequently confused because of medications or possibly even a head trauma. It's very important that the notice be given to a capable recipient and, further, that the notice be given in a language that the person can understand or with the presence of a translator.

And additionally, being somebody who needs reading glasses, to make sure that if the person can't read it herself -- lots of times when folks go in an ambulance, they don't remember their glasses -- if somebody reads the notice to her.

The last thing that we would add is, though I think most hospitals will comply with this willingly, as we heard earlier, there seems that there needs to be some sort of, um, sanction if hospitals don't comply. Whether financial sanction or other, that certainly seems to be something that could make this strong -- a stronger bill going forward.

Thank you.

REP. JOHNSON: Thank you so much for those recommendations and taking the time to be with us today. Just -- you said that you had a number of cases that you have been dealing with. Go a little bit through the procedure in terms of how the case comes to you, the appeals process, and what the patient might have to do in order to get skilled nursing facility coverage or Part D Medicare Prescription Drug Coverage if one of these is -- if, in fact, they are just observation status and then transferred from the hospital to the skilled nursing facility.

TERRY BERTHELOT: Often folks call us after the fact generally because they're not getting notice. So, just yesterday one of my colleagues took a phone call where her father had been in the skilled nursing facility for two weeks and the skilled nursing facility and the family had just been given notice that he had never been admitted to the hospital.

Fighting these cases is -- after the fact is enormously challenging, largely because even though there may be a right to appeal on one level, there is no process for appeal.

The other issue is that because of the administrative process for Medicare appeals right now is extremely backlogged, our cases are taking about two years at best to get a decision from an administrative law judge. And because these are so complicated, not all of the cases make it all that way.

Regarding the prescription drug medications, again, there is a right to have them billed to a Part D Plan, but there is no official process. And I've not seen somebody successfully do that yet. The hospital is -- will be out of network. So, even if the Part D Plan agrees to pay for the medications, the person will pay at a higher rate than she would have had she been -- had she brought in her medications from home.

REP. JOHNSON: So, when you look at the scheme that you have and the regulations for Medicare, they have something called the Waiver of Liability. So, if the hospital or the skilled nursing facility, some provider does not provide notice then the patient doesn't have to pay. How does that work when someone goes into a skilled nursing facility and they've had an observation status situation?

TERRY BERTHELOT: That's an excellent question. The Waiver of Liability provision only applies when the question is whether or not the care is custodial or skilled. It doesn't apply when it's a technical denial, and lack of a three-day inpatient stay is a technical denial. So, that particular provision that would hold the skilled nursing facility rather than the family or the patient financially responsible does not apply.

REP. JOHNSON: Very good. So, so, for sometime the patient could be on observation status, go to a skilled nursing facility, and be continuously on the unawares of, of the financial burden they've been incurring?

TERRY BERTHELOT: Exactly.

REP. JOHNSON: And thousands of dollars later, and if they have any resources like a home or any of those things, then at that point in time the, the -- those assets are in jeopardy.

TERRY BERTHELOT: Indeed. I fielded one phone call from a woman who was on Medicare because of disability who paid with a credit card to get into the nursing home and quickly was looking at 21 percent interest. People are, are making enormous sacrifices in order to get the care they need including, sadly, putting their, their homes and all of their assess -- assets in jeopardy.

REP. JOHNSON: So, by your comments, you have a two-prong situation here. Perhaps they have to absolutely be in the skilled nursing facility after having been in the hospital with an observation status for three days or more. And in that circumstance they have to find a way to pay, but they won't necessarily know that they'll -- that they'll have to find a way to pay.

In terms of -- are you familiar at all with the Medicaid process?

TERRY BERTHELOT: Um, not an expert, but somewhat familiar.

REP. JOHNSON: So, in, in a circumstance where the lady had used her credit card, if she was medically needy under the Medicaid law, she might have used that if she had had proper assistance through the nursing facility.

TERRY BERTHELOT: It is possible, and it's a good thing that we have such a strong Medicaid program here in Connecticut. But one of the consequences of observation status is the shifting of liability from the Federal government to the State government for care that should be being paid for by Medicare.

REP. JOHNSON: And then the other circumstance might be where if there was a chance someone had the observation status might know of, of a way to provide around-the-clock care at home instead of the skilled nursing facility, that might be another avenue if they had a family member or something that would be able to save the cost to --

TERRY BERTHELOT: That is true -- that is true. Some of us are lucky enough to come from families that do have enough people who are -- who don't have to work and are able to be with us around the clock, but unfortunately that's not everybody.

REP. JOHNSON: Very good.

Do you have any questions? Yes, Representative Srinivasan.

REP. SRINIVASAN: Thank you, Madam Chair.

Thank you very much for your testimony. You gave us a lot of insight. And even though I am in the medical world, I mean, there are a lot of things about this that I was not aware of and appreciate -- the entire Committee appreciates that very much.

You know, when a patient goes on observation status, to the best of your knowledge, is there a limit in number of days that the person, he or she could be? I thought there was, and you said -- you gave an example of somebody being on observation for 12 days and not being admitted, and that is astounding. And I wasn't sure if there was any rules on that -- on that aspect.

TERRY BERTHELOT: Observation status is only addressed and defined in policy by the Centers for Medicare and Medicaid Services, and there it's suggested that it shouldn't be more than 24 to 48 hours. But in reality, folks are frequently on observation status for many, many days.

REP. SRINIVASAN: Thank you. And that's what I thought all along that you would -- you know, because the condition of the patient is stable, unstable, stable, unstable. Still you want to keep them under observation, but typically would -- I would guess by 48 hours you will know what to do, that they would admit them or send them home. Thank you for that clarification, but that's what I thought all along and I was absolutely shocked when you said this person was on observation for 12 days and obviously didn't know about that fact of it at all.

I want to thank you for all your recommendations. They are very, very practical and, and I'm glad some of the hospitals are already complying. And, obviously, we need to make sure that getting the medications from home, which will save these people a ton of money, and obviously they don't have it. Nobody does, and definite this group does not have the extra money when the medicines are already paid for as an outpatient.

And my last question is I'm trying to figure out what would be the rationale if a physician says in his notes over and over again that this patient's status as such is labile and, you know, should be admitted in the hospital, and then the hospital does not do that. Utilization or whatever it is, does not admit the patient and continues to keep them in an observation status?

The only occasion or the only scenario that comes to my mind is, you know, in Medicare if you get readmitted within a certain period of time, I mean, the hospital obviously has, has a penalty to pay. It's done. There's, you know, red flags go up, and so on and so forth. So, other than that, what would be the motivation or the reason? I'm hoping not financial, but what would be the reason that the hospital, in spite of the physician's recommendation to admit, continues to keep the patient in observation status?

TERRY BERTHELOT: You asked a question that I'm frequently asked, and lots of folks assume that the hospitals must be making a lot of money on observation status and that's why they're doing this, but that's not true at all. They're losing money when they put people on observation status.

The reason they're putting people on observation status was alluded to earlier. The Recovery Audit Contractors, often known as the RAC, I think of them as the Spanish Inquisition. They're literally bounty hunters who are using criteria that are far more limited regarding what should be covered by Medicare than what the actual law is and they're doing this retroactively. And if you are overturned -- if you're a hospital system and you're overturned too frequently, you will be investigated for fraud and you'll definitely end up on the front page of the local paper, and no hospital wants to be there.

So, I'm afraid they're, they're -- they're feeling forced into this even against their own physician's wishes. And doctors are told -- if you're a nerd like me and you look at -- you Google things and you find PowerPoints that are being taught in hospitals, you'll see that doctors are being told -- promised that regardless of what status their patient is on, the patient will get the same kind of care, and not to worry about it. But what, what the doctors don't know often is the later ramifications.

REP. SRINIVASAN: Thank you very much for all those clarifications. We appreciate that.

Thank you, Madam Chair.

REP. JOHNSON: Thank you, Representative.

Any additional questions?

Thank you so much. We want to work with you on some of your recommendations and really appreciate having this conversation. So, thanks so much for being here today.

TERRY BERTHELOT: Thank you very much for the opportunity.

REP. JOHNSON: Okay. The next person on our list testifying for House Bill 5330 is Jerry Silbert, followed by Tara Cook-Littman.

JERRY SILBERT: Thank you very much.

REP. JOHNSON: Welcome. Thank you, and please state your name for the record.

JERRY SILBERT: My name is Dr. Jerry Silbert. I'm a physician, I'm trained in pathology, and I'm testifying for Bill 5330, and I want to thank the Committee for raising this bill. And I -- it would be the right thing if you're voting for this bill as well because you may never know the children you are helping. But rest assured, you'll be saving lives and you'll (inaudible) saving suffering to the Connecticut's children.

I think the evidence is clear. There is independent science in peer-reviewed journals talking about the health effects of pesticides on children. Neurological effects, brain tumors, lymphoma, leukemia, birth defects, asthma, behavioral disorders -- all of this can be related to wide a variety of different pesticides, many of which are lawn pesticides.

In term of -- you'll be hearing testimony here that, that grounds keepers need to use these pesticides in order to maintain fields. You'll be hearing testimony that these fields deteriorate and are a danger to children because of compaction, because of clumps of crag grass and they're going to trip. But I would say this, I've had personal experience with consulting with towns on nontoxic turf care and they've been quite successful. Their fields are perfectly playable.

And in addition to that, in terms of IPM, there are letters from the principal authors of a book that was put out by the American Association of Pediatrics. They were the principal authors, and they have a letter which is attached to my testimony which praises Connecticut for banning pesticides and saying that IPM is not as good as the pesticide ban. There is also attached to my testimony a letter from Dr. Landrigan who is one of the international experts on children and environmental effects, also praising Connecticut for its pesticide ban and saying that this is far better than IPM.

So, we have two circumstances. We know that pesticides can cause harm and we know we don't need them in order to maintain perfectly playable fields.

I would say I think those who say those -- that these pesticides must be used and they can't maintain fields without pesticides, I don't doubt their sincerity in, in their wanting to protect children and their having -- wanting to protect children. But I can tell you there's a tremendous amount of misinformation that's been given out to a number of committees and I would be happy to answer questions and let you know about what you're going to hear and what the true story is.

REP. JOHNSON: Thank you so much for your testimony. I'm just -- given your experience with this issue, did you tell us some of perhaps the patients you have encountered who have had reactions to pesticides?

JERRY SILBERT: I'm a pathologist. I don't deal with patient care.

REP. JOHNSON: Okay. So, what exactly -- in terms of your knowledge from scientific studies have you --

JERRY SILBERT: These are peer-reviewed literature that I am quite capable of looking at and interpreting. And it's very clear that there is an increased risk of many of these diseases that I spoke of when children are exposed to pesticides. So, that's, that's where I'm coming from.

REP. JOHNSON: Okay. Any questions? Yes, Representative Widlitz.

REP. WIDLITZ: Thank you, Madam Chairman.

Good afternoon, Jerry. Nice to have you here. Jerry is a constituent of mine, and I would appreciate it if you'd share a little bit of the local experiences we've had in treating fields in Branford and Guilford and, and if, if a person is knowledgeable on how to do this and stays with it what the results could actually be, and what we've experienced it at home.

JERRY SILBERT: Right. Two particular cases in Branford and in Cheshire, they've gone beyond the mandated pesticide ban. In Branford, all their fields are treated nontoxically. And in Cheshire, I believe all their fields are as well and including the high school fields. They have perfectly playable fields. In fact, in Branford, I've been doing this for -- since 2005 basically, I started in Branford, and they progressively increased their nontoxic care of fields. And I can say that the soil there -- because I've actually been, been testing the soil and taking samples, and so forth -- has improved dramatically. The, the resilience of the field is really good. In other words, the ground is not compacted.

In Branford, for example, we've had grub problems, which you'll be hearing of and they'll say there's nothing, you know, really that they can do about grubs. In Branford, they had a very bad grub problem. They had up to 20 of these oriental beetle grubs per square foot, which is very high. They treated them with nematodes. It stopped it cold. Damage was limited. They re-seeded heavily over the damaged spots. These, these grubs generally attack in April -- sorry, April, August. And by the time Fall came around and Fall playing was there, everything looked fine. There wasn't any problem.

So, I really believe that the problems that you're hearing about in terms of fields deteriorating are due to lack of knowledge or lack of motivation. And I'll give you an example. Let's say you wanted to do a nontoxic lawn and you tried your best, but it wasn't working and your lawn started to be full of weeds, it wasn't looking good, but your neighbor was also doing nontoxic care and his lawn looked fine.

So, wouldn't you think you would ask your neighbor what they were doing right to see what was going on so you could do it better? I don't think that's been going on. Really, even though there have been training programs, they've been relatively poorly attended. And even when they've been attended, I don't think the people are really following up in terms of doing the kind of care that's necessary to maintain fields, because I've seen really perfectly playable good-looking fields with nontoxic care for over five years. So, I think that's a nonargument in terms of a we-can't-do-it type of thing.

In terms of the cost -- because this is something else you're going to hear, that it costs too much -- I have two cost studies attached to my testimony which show in one that it actually costs less than conventional care. And in the other one it shows it costs more than conventional care to begin with, but then as you improve the soil the cost actually decreases. So, actually, you'll be saving money in the end in terms of doing nontoxic care properly.

But basically, this is not about grass. This is about children's health. And because I'm a physician, that's why I got so interested in this. I got interested in grass because I knew that if we couldn't maintain lawn -- the turf well, you get all sorts of complaints. And I remember a quote, a quote from someone as the head of the Legislative Committee way back when of the Connecticut Recreation and Park Association. And as he said, "Perhaps despite our best efforts, our fields will have to deteriorate so the Legislators will see the error of their ways."

And you've been hearing lots of testimony, but in my personal opinion I don't think they've been making "their best effort." I think they're sincere in wanting not to harm children. I think I'm sincere in wanting to see them have very good, perfectly playable fields, but I think the problem is the knowledge and the motivation to do it.

REP. WIDLITZ: Thank you, Madam Speaker. If I may.

I think, I think the Guilford green has also gone green, if I'm not mistaken.

JERRY SILBERT: That's right.

REP. WIDLITZ: And, you know, that was out of concern. In the summer we have concerts. We have little kids rolling around the green and learning how to ride their, their first set of wheels. And because of all of the activity, family-oriented activity on the green, I know our Park and Rec Department has made that commitment --

JERRY SILBERT: Right.

REP. WIDLITZ: -- to have a green Guilford Green --

JERRY SILBERT: Right.

REP. WIDLITZ: -- which is the pride of our town. It's a beautiful historic green --

JERRY SILBERT: Right.

REP. WIDLITZ: -- and we want it to look good.

JERRY SILBERT: Exactly.

REP. WIDLITZ: And it does. So, I just really appreciate your coming and your testimony.

JERRY SILBERT: Right.

REP. WIDLITZ: Thank you, Madam Chair.

JERRY SILBERT: And I want to make it look better. I'm working with Rick Maynard, who is head of Park and Recs, and I think we can even do better than we have been doing even though it looks very good now.

REP. WIDLITZ: Good. Thank you very much.

Thank you, Madam Chair.

REP. JOHNSON: Thank you.

Any additional questions? Oh, yes, Representative Srinivasan.

REP. SRINIVASAN: Thank you, Madam Chair.

Thank you, Dr. Silbert, for coming here and sharing your knowledge and your expertise on the subject matter. Obviously, as you very correctly said, it's not about the grass, it's not about greenery, it's about our children.

JERRY SILBERT: Correct.

REP. SRINIVASAN: And obviously, when you look at that, it is -- that is our priority, our children and our grandchildren.

JERRY SILBERT: Right.

REP. SRINIVASAN: One of my questions was, and I want to thank you for already addressing that, was the cost factor. And you were very clear in your one analysis and the other analysis where at the end -- at the end of the day, over years, you -- regardless whether you went with the first study, the second study, you still came ahead.

JERRY SILBERT: Right.

REP. SRINIVASAN: And, of course, you still keep coming ahead, at the same time taking care of our children and grandchildren, which is the best of both worlds.

JERRY SILBERT: Right.

REP. SRINIVASAN: My question to you is -- and this is what I've heard. I'm sure we'll hear it later on in the afternoon as well, is that when a lawn or a ground has an acute infestation and it is acute -- I mean, we're not talking about routine. We're not talking about chronic. We're not talking about maintenance. At that time it is better served with the pesticides rather than the nontoxic care at that time, just to get over the hump, whatever the hump is. A couple of applications maybe, I'm not sure. I'm not -- I don't know too much about that. And then get on to the routine maintenance.

So, what would your comment be if -- if a playground were to be -- had an acute kind of a disturbance?

JERRY SILBERT: Right. Well, as, as one says, the devil is in the details. And one of the things to do is to monitor early on so you get some idea of, of whether there is a potential problem of an acute infestation. Sometimes a good, strong turf can tolerate more grub activity than a turf that's weak, okay. Use of pesticides and high nitrogen fertilizers plus play -- frequent play on the field really stresses the grass out a lot. And if you look at the root depth of the grass, it's usually about two or three inches, okay.

In a, in a nontoxic field, once you start getting that soil restored to its normal health and ecology, you'll find that the grassroots go down five, six -- I've seen them as deep as fifteen inches in a soccer field in Haddam where there was a -- what do they call it when the ground sort of collapses when there's a cavity underneath, you know. When they build fields sometimes they fill it in with boulders and stuff, and it collapses and you can see the whole soil profile down to about three or four feet. And the roots there on a tree -- on a field that was treated nontoxically were fifteen inches. That's the deepest I've ever seen it.

So, you can make a field by treating it nontoxic more resistant to grubs. You, you monitor early so you know whether you have a problem or not. You identify the kind of grub that's there so you know what the most appropriate treatment is, the most -- two most common grubs in Connecticut are Japanese beetle and oriental beetle, both of which are treated by nematodes. And we've done nematodes twice in Branford because they had a grub -- and as I say, it stopped them cold. You do a heavy overseeding over the damaged areas, and by Fall it's filled in and, and it's not a problem.

One of my colleagues, Patty Wood, I know she's going to be testifying here, but she's spoken to grounds keepers who have done nontoxic care in New York State which had a ban from K to 12. Their grounds keepers say that they haven't seen a field that's more than 15 percent affected by grubs. It doesn't destroy the entire field. In Branford, I think the most that we ever saw was maybe five percent, and that was handled mainly by nematodes and overseeding. So, I don't think it's a problem.

You hear that field are going to be destroyed. It's hard for me to conceive, knowing what I've had through my own personal experience and observation, that that's the case.

REP. SRINIVASAN: Thank you very much.

Thank you, Madam Chair.

REP. JOHNSON: Thank you.

Any additional questions?

Well, thank you for your very complete testimony and your very good answers. Much appreciated.

JERRY SILBERT: Thank you, Madam Chairman, and I thank the Committee.

REP. JOHNSON: Thank you. The next, next person on the list is Lori Cook-Littman followed by Roberta Silbert. I guess it's not, not an L, it's a T, Tara. Sorry.

TARA COOK-LITTMAN: That's okay.

So, my name is Tara Cook-Littman and I'm most importantly a mother of three young children. I'm also the Chair of ConnFACT, Connecticut Families Against Chemical Trespass, the organization that grew from the roots of GMO Free CT, and our mission is to educate the residents of Connecticut about the toxic chemicals that they're being exposed to without their knowledge daily.

And last year, through my experience with the GMO labeling battle, I developed a new respect for democracy and believe it can work because all of you heard your constituents and took steps to give us a transparent food system. And it is my hope that you will all support H.B. 5330 and put the interests and health and welfare of the citizens of the state in front of the corporate profits.

So, when writing this testimony, I really struggled because it really does seem so self-evident that we should not be putting toxic chemicals where children play. I do everything I can in my home to keep toxic chemicals away from my children yet I never thought I'd have to protect them from toxic chemicals on playgrounds and on fields where they are playing.

This past summer I took my children to a playground and they were on the slides and swings and then left that area to go run on the grass. And I called out to them, "Don't play in the grass." I literally had to tell a ten-year-old, eight-year-old and six-year-old not to play in the grass because I was concerned of the pesticides that may have been used on that playground. I shouldn't have to do that. My children should be free to play without me worrying that they're being exposed to toxic chemicals that could severely impact their health. And Dr. Silbert gave you some examples of things that could really happen when they're exposed to pesticides.

I'm really not sure how perfectly manicured grass became the norm in this country. I personally really enjoy my dandelions every spring, but I do understand that there are some places like playing fields where you need a perfectly manicured grass playing field. However, there are very good alternatives to toxic chemicals. It is just my fear that the pesticide industry really doesn't want us to know about what those alternatives are.

So, I also just want to, um, mention that I support Senator Williams' amendment that he suggested earlier today to include a ban on the sale and use of all genetically engineered grass and other genetically engineered, um, landscaping plants. This is something that is coming and if we don't stop it before it's here, it will be too late.

Thank you.

REP. JOHNSON: Thank you so much for your well-timed testimony.

Are there any questions?

Thank you so much for being here.

TARA COOK-LITTMAN: Thank you.

REP. JOHNSON: Much appreciated.

The next person on the list is Roberta Silbert followed by Bill Duesing.

Welcome, and please state your name for the record.

ROBERTA SILBERT: Thank you. My name is Roberta Silbert, I have an advanced degree in public health, and I'd like to talk in favor of 5330.

If children fell (inaudible) on grass of a pesticide maintained athletic field after a game of soccer, we'd have a lot of press coverage. But it can take over 20 years from the time of exposure until the time of diagnosis of disease. Because I've been in healthcare field, I know of battles, publicized tragedies, like a mother taking her child with leukemia to the hospital for chemotherapy, the high school athlete just about to start college who has been diagnosed with lymphoma, or the parents helping their child adjust to life with severe asthma. This much is clear to me, that pesticides and children don't mix.

Just to show you what Dr. Silbert showed you, this book is just some of the peer-reviewed scientific articles about the adverse effects of pesticides on children. And I'd also like to show you these 12 pages of pictures of children being treated with leukemia and their stories, many who have died.

In introducing your bill, your Committee has shown that you are following the precautionary principle. Because of the cognizance that pesticides can cause potential harm, you are taking action from a duty to prevent harm. We need to protect children wherever they play.

I've worked in the healthcare field for many years with extremely ill patients, and I can tell you this. When disease strikes, they don't care what grade you're in, what your age is, or your economic status. The ugly news is that a billion-dollar pesticide industry wants to protect their market share on the backs of our children and the environment. One wonders what goes through the minds of people who advocate pesticide use when they hear of a child in their town that gets cancer.

Some people here that are pro-pesticide and pro-IPM will tell you here and complain about their deteriorating turf and the weeds on their fields, but this is not about turf and it's not about grass. It's about these children, these 12 pieces of children, many of who have died. It's about children with leukemia, children with lymphoma, children with sarcomas. It's about the water we drink, the food we eat, and the air we breathe.

I would like to say that if I -- as an advocate for these children, I would like to ask the Committee in their name three questions, if I may, or if someone will be kind enough to ask me what these children will say, I will continue my testimony.

REP. JOHNSON: We'd love to hear more about this. We'd love to have you summarize at this point, though. And if anybody here has questions, we'll move on from there. Thank you so much.

ROBERTA SILBERT: Any questions?

REP. JOHNSON: No, I ask that. You tell us the summary.

ROBERTA SILBERT: Okay. My summary is just the three questions that these children will ask. What kind of society do we live in where money for corporations that manufacture toxic chemicals is valued over the health of our children? And as elected officials, don't you have an obligation, a moral obligation to all our children and future generations to make sure that we would have a toxic-free legacy? And the last question that these children would want to know is if you will vote in your Committee in their favor or in the favor of corporate greed?

Thank you.

REP. JOHNSON: Thank you so much for your compelling testimony.

Are there any questions?

Thank you.

Bill Duesing followed by Beth Beisel.

BILL DUESING: Good afternoon, Senator Gerratana, Representative Johnson, members of the Public Health Committee. Thank you so much for raising House Bill 5330. I am testifying on behalf of the over 800 members of Connecticut NOFA, the Northeast Organic Farming Association of Connecticut, in support of H.B. 5330 to ban the use of toxic lawn care pesticides on Connecticut's parks, playgrounds, athletic fields, and municipal greens. This ban will help protect the health of children and other living things who use these facilities.

Since 1990, Connecticut NOFA members have been involved in managing landscapes organically without the use of toxic pesticides. The benefits in terms of soil health, worker health, and public safety have been clear for over 20 years. Since 2000, the NOFA Organic Land Care Program has educated thousands of land care professionals in organic methods in response to both the professionals and the public who ask for nontoxic lawn care. And you can learn more about that program on organiclandcare.net.

Many of the resources that were there were supported by the U.S. EPA in order to protect Long Island Sound from the effects of lawn care chemicals. Almost every month we learn about another way that toxic pesticides interfere with human health. We have very little knowledge of all the negative effects of individual pesticides and know even less about their effect in combination. For example, a recent study on bees found that it was combination of fungicides that make them more vulnerable to diseases and it has been thought that fungicides designed to kill fungi wouldn't have any effect on bees.

In my testimony, I pasted an essay describing a situation in Beardsley Park in Bridgeport where I took a whole bunch of school children there for the end-of-the-year picnic. And at the time the town was applying a mixture of fertilizer with three different herbicides to this park -- beautiful parkland, and to the detriment of the trees, to the detriment of the water that was right nearby, to the detriment of the children who were playing on it. Really stupid behavior.

Reluctant communities, toxic chemical companies, and recalcitrant maintenance people need the wisdom of H.B. 5330 in order to keep our children safe. Our town parks and especially town greens shouldn't be sprayed with poison. We shouldn't put poison in the middle of our communities.

I also would like to support, very quickly, Senator Williams' amendment to ban GMO grasses. One of the basic tenets of creating a good lawn in any case is to use three or four different kinds of grasses so that they respond differently to the different seasons through the year. With GMO grass you can only plant one kind of grass designed to be sprayed with a chemical that we're learning, almost every day, new toxic ways that it interferes with our gut intestines, with the soil life, with many other things.

So, my 40 years of experience in organic and pesticides has realized that the chemical companies keep pushing these pesticides there. We keep learning the dangers that they pose to us, and we also keep learning the value of organic management of our beautiful planet to maintain the ecosystems and maintain the biodiversity on which our very lives depend.

So, please, support H.B. 5330.

REP. JOHNSON: Thank you so much for your thorough and impassioned testimony. I will ask a, a question, though I think I also asked Senator Williams. And that is when you have -- and you mentioned it in your testimony, you alluded to it, the fact that you -- in order to have a, you know, healthy lawn you plant different types of grass so that they have a complete -- different types of genes in their, in their makeup.

BILL DUESING: Yes.

REP. JOHNSON: And that they will develop the ability all on their own, in most instances, to resist other types of pests, whether they are herbal in nature or -- you know, like nematodes or something like that.

BILL DUESING: Yeah. Um, well, what, what organic theory is and what we've seen in 4 billion years on this planet is that it's biodiversity which builds health, which increased resistance to diseases and, and insects, you know. We're surrounded by, by dangerous diseases, but if we're healthy and we lead a good life-style, we usually don't get those, and the same thing applies to other living systems.

REP. JOHNSON: Are there any questions? Yes, Representative Miller.

REP. MILLER: Thank you, Madam Chair. And I thank you, Bill, for your testimony.

My question is that for the layperson who might be viewing this testimony or hearing this who might be interested in not using toxic chemicals on their own lawn, especially if they have young ones at home. In a nutshell, in lay terms, what is the -- are the features of organic or sustainable lawn care that you could briefly give us information on?

BILL DUESING: The first thing I would recommend is that people get a soil test. Our great University of Connecticut does a wonderful job of testing the soil. And the main thing you want to look at that is the pH and you would like the soil to be somewhere between 6 and 7 in the pH to grow good grass.

The next thing you want to do is to get some organic matter in there. Mulch the grass clippings into the lawn. Mulch the leaves in the Fall because that is food for the organisms in the soil which will nourish the soil and make that healthy sod that Jerry was talking about, because his fields work very well because they have that leaf compost. We've returned the leaves to the soil to nourish the organic matter there.

You want to cut the grass high. Three inches high or so will prevent many of the weeds from growing. If you have bare spots, you want to sow grass seed because grass seed is one of the best -- is very cheap and certainly nontoxic, and one of the best things to grow a healthy lawn. So, those are the simple.

Test your soil, adjust the pH, mow high, sow good grass seed. And if you have a few little weeds, either learn their benefits. Many of them are very valuable for our health as food or as medicine. And otherwise, you can just -- they're easy to spot-remove with a shovel or some -- there are a few organically approved herbicides, but you really don't need those if you cut the grass high.

REP. MILLER: And my last question is, I understand most of the soil in most of Connecticut, except for the far western areas where you have those limestone and marble soils --

BILL DUESING: Uh-huh.

REP. MILLER: -- is very acidic typically. And, so, when you can balance that potential of hydrogen, you can grow the very best grasses that outcompete the weeds. Could you tell us --

BILL DUESING: Yeah, that is -- that's what the pH is. And actually, to adjust the pH, we take some of that marble from northwestern Connecticut, grind it up, and apply it as limestone on our soil. And that raises the pH and also encourages the good organisms and makes the, the nutrients that are in the soil available.

REP. MILLER: Thank you for your answers.

And I thank you, Madam Chair.

SENATOR GERRATANA: Thank you, Sir.

Are there any other questions?

If not, thank you very much for coming today.

BILL DUESING: Thank you very much.

SENATOR GERRATANA: Next is Beth Beisel followed by Erica Fearn.

BETH BEISEL: Good afternoon --

SENATOR GERRATANA: Good afternoon, Beth.

BETH BEISEL: -- Senator Gerratana and members of the Public Health Committee. My name is Beth Beisel and I'm here today in support of H.B. 5330.

First of all, I want to say, um, how thrilled I am that Senator Williams suggested the amendment, and I thoroughly, thoroughly support that amendment.

SENATOR GERRATANA: Thank you for that, yes.

BETH BEISEL: As a mother of three children, I do support this bill. I support any bill that serves to protect our children and, for that matter, anyone who utilizes school grounds, parks and other public areas from toxic chemicals. A few weeks ago I had no idea that the grass many parents sit on when they watch their children play various sports was potentially covered in chemicals. I shutter to think about all the times in the last 20 years I have taken our children to the park and let them play and picnic in the grass. I never thought about it.

I didn't think about resting my hands on it and then eating something, or the fact that our skin absorbs everything we touch. And I always taught my children, "Don't put anything on your skin that you wouldn't eat because your body absorbs it." And, unfortunately, when you eat -- when you put something on your skin, it goes right in and it doesn't have the benefit of being detoxified in your liver like when you eat something, you at least have the liver to detoxify it.

I didn't question if it was safe for my children to roll down a grassy hill or sit on a public lawn and watch fireworks. It just wasn't on my radar. Once I learned about our current law which covers schools from day care through grade 8, I decided to look into what is sprayed on my town's school grounds. These are the grounds where my children and my friends' children have been playing sports since they were in kindergarten. These grounds are where we walk and let our dog run free.

Last year alone, three chemicals were applied to several of the high school sports fields, all known to be harmful to health and/or the environment. One chemical was also sprayed under the bleachers, the bleachers where the children love -- the little ones love to sit and play while their parents are watching the older siblings play their sporting games. It may take 20 to 30 years to learn the detrimental effects of these chemicals on our body.

Included in my submitted testimony is a link to an article that discusses safety testing. When they test the chemicals, they only look at the one ingredient. They don't look at the adjuvants or what they call inert ingredients that can make these chemicals up to a thousand times more dangerous and more toxic. And I'll finish up there.

SENATOR GERRATANA: Thank you, Beth.

BETH BEISEL: Thank you.

SENATOR GERRATANA: Thank you so much for coming today and testifying and also for your support for Senator Williams', if you will, amendment.

Are there any questions? No?

Thank you so much.

BETH BEISEL: You're welcome. Thank you.

SENATOR GERRATANA: Next is Erica Fearn followed by Ellen McCormick.

Hello. Good afternoon.

ERICA FEARN: Good afternoon, Senator Gerratana and Representative Johnson and members of the Public Health Committee. I'm Erica Fearn and I think I am your first person testifying in opposition of House Bill 5330.

I'm Executive Director of the Connecticut Environmental Council as well as a mom of two girls that are 13 and 10 years old. And I hate to say that I would be opposing something that could potentially harm my children and, so, I am in opposition of this bill.

Connecticut Environmental Council is a membership organization that represents the Connecticut Grounds Keepers Association, the Connecticut Tree Protective Association, the Connecticut Pest Control Association, the Connecticut Irrigation Contractors Association, and the Association of Golf Course Superintendents.

In 2005, our organization supported legislation that permitted pest controls to be applied on public and private schools grade 8 or under if the plan adhered to an integrated pest management plan. Since the July 2010 sunset, we've seen our school grounds fall into disrepair. We've seen children with cases of poison ivy that have been so bad that -- so severe that they've had to be treated with steroids, poison oak. And my personal family -- in my personal life, my family has an instance of Lyme disease that has been very devastating to us, and we have no control of the lyme, the edges of those fence lines to control the ticks, and I'm concerned about that.

The ban has left licensed and professional applicators without the ability to use all of the EPA registered tools at their disposal. While your bill allows for EP registered tools, it does not allow for the synthetic tools that, because of the public's demand for safer products, companies are providing those to us and we are unable to use those, such as Acelepryn for grub control.

Connecticut --

SENATOR GERRATANA: You can summarize. Thank you.

ERICA FEARN: In summary, our organization as well as over 20 municipal organizations support the use of integrated pest management and being able to use those registered EPA products using sound science and the methods that monitor, identify, determine the thresholds and utilize pesticides in a thoughtful prescriptive manner.

Thank you.

SENATOR GERRATANA: Thank you, Erica. Thank you for your testimony.

Are there any questions? No?

T hank you.

ERICA FEARN: Thank you.

SENATOR GERRATANA: Thank you for coming today.

Next is Ellen McCormick followed by Randy Collins.

ELLEN McCORMICK: Good afternoon, good Legislators of Connecticut. Thank you for this opportunity to support H.B. 5330.

My name is Ellen McCormick, and my testimony is in support, obviously, of H.B. 5330. I live in Weston, Connecticut, and I am here more as a grandmother of five young children, but I also represent ConnFACT. I think you might remember our members. We had approximately 12 to 15 here today, which I thought was extremely supportive. They're a group with a tremendous amount of perseverance and information on pesticides and chemicals, as many of them have been affected by these chemicals which has spurred them on to fight the invasion of unwanted chemicals, at least -- oops, I've adjusted that.

In Section 1a and 1b, I would encourage you to strengthen the language about the use of integrative pest management. We all know that's a marketing term for using less pesticides, but it isn't always properly used because of a lack of training or perhaps common sense.

What constitutes an application of pesticides to eliminate an immediate threat to human health? How will that be determined, and will that application be put in the record so there is a control of who used it? How much of a chemical was applied? Where was it used and why?

Mothers now have over 280 chemicals, at a minimum, in their blood that is passed along to their newborn. Protecting our mothers of child bearing age and our children from toxic chemicals is really urgent, and what better place to do that than on school grounds, parks, playgrounds, athletic fields and municipal greens where they walk, take their pets and children to play. Is it right that play should result in the insidious intake of chemicals that will harm children and pets and mothers-to-be for life and into future generations?

This is not a decision that should languish in our Legislature, and it is not something that is up for debate any longer. This little book has traveled through many of us today, but it is so, the science studies prove it, and now it is your job to pass this bill to protect them. They are in your hands.

There is a 20 percent rise in children's brain cancer and leukemia since the 1970s -- oops, okay. You have my testimony. I would also like to just add that I am also in support of Senator Williams' amendment about the GMO grasses.

SENATOR GERRATANA: Thank you.

ELLEN McCORMICK: Thank you.

SENATOR GERRATANA: Yes, I was following you along with your testimony.

ELLEN McCORMICK: Okay.

SENATOR GERRATANA: But we do appreciate you coming here today and testifying.

ELLEN McCORMICK: Thank you very much.

SENATOR GERRATANA: Thank you. Next is Randy Collins followed by Greg Foran or Foran.

Hello.

RANDY COLLINS: Hello. Thank you very much. My name is Randy Collins. I am Senior Legislative Associate for the Connecticut Conference and Municipalities, and I just wanted to speak very briefly in opposition to Senate or House Bill 5330.

The current ban -- to expand the current ban on use of pesticides to our high school fields, municipal parks, it is going to be a very costly and unfunded mandate that our municipalities are going to have to assume -- absorb. And it's not just about the money for our municipalities. We truly believe that if there was an effective, truly effective and cost efficient way to use organic, a truly organic model, I think we would look at that. But as of right now, all the grounds keepers that we have talked to, my municipal town managers, mayors, First Selectmen, have repeatedly said that they just don't have something effective to use for the treatment of grubs, poison ivy, and numerous other invasive species. And we're not talking about perfectly manicured lawns. That's not what our municipalities are about.

If there's a few dandelions, okay, but there is true safety concerns that when you see invasive species like crab grass and others and grubs, it affects the density of the turf, will make these fields much harder to play on, which can increase the rate of concussion, ankle injuries, knee sprains. These are concern that we have to deal with.

A number of towns, yes, have gone all organic. I know that Greenwich is one of them. I've talked to the Park and Rec officials from Greenwich and they have five synthetic fields that they have access to, which allows them to rotate, allows them to spend significant amount of money on their other fields, and they still expect total field failure periodically where they have to completely tear a field up and start over again. Not every municipality has the resources to, you know, to implement a program like that.

How do we not, you know, provide the same quality playing fields for our distressed municipalities as we do for a town like Greenwich? CCM is in strong support of the recommendations that came from the Moore Mandates Working Group, we worked with Representative Sayers on, to create a pest said Advisory Council within DEEP that will allow us to really scientifically look at these on a yearly basis so we're not coming back, you know, every few years and looking for what works and what doesn't work.

Thank you very much and I appreciate the opportunity to comment.

SENATOR GERRATANA: Thank you, Randy. Did you submit testimony?

RANDY COLLINS: I did.

SENATOR GERRATANA: Okay. I couldn't find it.

RANDY COLLINS: I talked to the Clerk. It was --

SENATOR GERRATANA: Yeah.

RANDY COLLINS: We had a little bit of an issue with it I think coming through.

SENATOR GERRATANA: Okay, no problem. I'm sure we will get it.

Okay. I don't think there's any questions.

RANDY COLLINS: Okay. Thank you.

SENATOR GERRATANA: But thank you for coming today.

Next is Greg Foran followed by Mike Papa, I believe.

GREG FORAN: Hi, Senator Gerratana, members of the Committee. Thank you for having me today. My name is Greg Foran. I'm with the town of Glastonbury and I'm representing CRPA, the Connecticut Recreation and Parks Association, and the Connecticut Association of Schools and the CIAC are in support of my testimony which is against House Bill 5330.

I submitted testimony already, but I'm going to deviate from it because, honestly, I take umbrage with some of the things that were said here today. I'm offended personally and professionally by the implications that I lack the knowledge or the motivation to embrace organic care methods. There has been a lot of use of the term toxic pesticides. Organics are toxic. There's no sense putting something down unless you're trying to control something. And when we use IPM, we use all the cultural methods that are endorsed by the organic people. The only thing we do differently than them is we have those pesticide tools at our disposal if needed, and we select them in a judicious manner with the least toxic means of control being selected first. That's IPM. It's not a misnomer or an excuse to use pesticides.

There is something called the World Food Prize that was given out in 1997 to scientists for their humanitarian work to increase the quality and quantity of food available on the world market because of IPM. IPM has become a dirty word over here at the legislative office building. I don't know why. UConn embraces IPM. Cornell, Purdue, Ohio State, Texas A & M, every major agricultural university in the United States and around the world advocates for integrated pest management as the best management practices that can be used whether you're growing food or horticultural crops. And I would ask you to please let the science rule.

Talk to the folks at UConn, the experiment station, the Department of Ag, the folks in the Environmental Protection Agency both nationally and statewide. They will tell you that IPM is the way that you can legislate and let professionals and scientists then look at the arsenal of what's out there and ban DDT and Chlordane and Dursban and the bad actors and embrace things like Acelepryn that have such low toxicity that they don't even have a signal word on them. They have such low toxicity that Branford, who was -- it was testified by Dr. Jerry Silbert here today that Branford is wholly organic. Branford used Acelepryn two years ago on their fields. He implied that we don't talk to our neighbors. I only know this because I called Branford and said, "Hey, I have a grub problem and I heard you're organic over there. What are you doing?"

"Oh, well, we had to use Acelepryn," was the answer.

So, that's where you need to delve into the testimony and find out what's being misrepresented. And my profession is being misrepresented over and over and over by testimony from my opposition.

I am also against pesticides and for safe fields where they're not needed. I maintain 600 acres for the Town of Glastonbury, 250 are in turf, and the last 16 years that I have been there, less than 50 acres of those acres have ever had pesticides put on them.

SENATOR GERRATANA: Mr. Foran, could you, could you please summarize your testimony?

GREG FORAN: The summary of my testimony -- thank you --

SENATOR GERRATANA: Okay. Thank you.

GREG FORAN: -- is that I'm for IPM.

SENATOR GERRATANA: I do have -- I have a quick question. You say the bill neither protects the public nor preserves our fields and recreation areas. The bill as written would eliminate the use of a DEEP, Department of Environment and Energy Protection, I guess, approved list of nontoxic pesticides. What is a nontoxic pesticide?

GREG FORAN: A nontoxic pesticide -- there is no such thing. I -- excuse me for using that language.

SENATOR GERRATANA: Oh, okay.

GREG FORAN: Nontoxic materials is what it should say because --

SENATOR GERRATANA: Not nontoxic what, what?

GREG FORAN: Nontoxic materials --

SENATOR GERRATANA: Oh, materials, I see.

GREG FORAN: For instance, something that can be used on the fields that many people use the term nontoxic, which is what made me slip into that, is vinegar, acetic acid. And you can use acetic acid at the rate of five percent and eight percent because it has what they call a 25v exemption. It's ineffective until you get to 20 percent.

SENATOR GERRATANA: I see.

GREG FORAN: At 20 percent it can cause blindness.

SENATOR GERRATANA: Okay. Well, thank you very much for your testimony.

Representative Sayers?

REP. SAYERS: Thank you. And thank you for coming to testify here today.

We heard some of this testimony at the Moore Municipal Mandate hearing, and one of my concerns was that what we heard is that because of the increased use of organic pesticides we have an increased problem with runoff and phosphorus in a lot of our streams and waterways. Could you just maybe comment on that?

SENATOR GERRATANA: I believe that is a fire drill. So, if everyone will please exit the room. Both sides are exit doors and --

REP. SAYERS: (Inaudible) Mr. Foran did not have an opportunity to respond, so if he remembers the question, I --

SENATOR GERRATANA: If not, you can certainly repeat it for him.

REP. SAYERS: All right. Thank you. And one of the questions I had is we had a lot of testimony, as I said, in the More Mandates Committee on this very issue, and one of the things we heard

is the increased problem we're having with algae and everything growing in our -- our ponds, our -- our lakes and streams, and part of that is the runoff from using more organic materials, and if you could just respond to that, please?

GREG FORAN: All right. Am I on now? Thank you.

SENATOR GERRATANA: If you would, just repeat your name, so we know who's talking.

GREG FORAN: My name again is Greg Foran.

SENATOR GERRATANA: Thank you.

GREG FORAN: And the question was about runoff and phosphorus, and the answer to that is that IPM again takes all those things into consideration. One of the problems with the organic solution to treating the fields is there's a lot of recommendations for the use of compost. Compost is a great product. If you keep a vegetable garden, you can't help but understand that. But most compost, and in fact every compost that I have found, has phosphorus in it. And right now there is existing legislation that says if you are fertilizing an athletic field, you cannot use a fertilizer that has phosphorus in it unless you show by the use of a soil test that it is necessary. The reason for that is that tens of millions of dollars, if not billions of dollars, have been spent to try to reduce nitrogen and phosphorus in Long Island Sound. And so all sources of phosphorus are being monitored.

Those sources of compost that have high phosphorus can't be managed. So when we talk about going back to a time when biology was -- was in balance with itself, one of the things we're doing when we add natural compost is we're adding phosphorus. Commercial fertilizers allow us to pick and choose the elements that we're adding. So we use both, but we're primarily using phosphorus-free, commercial fertilizers on our fields.

And, you know, there's just two things I want to say real quickly. Emerald ash borer -- you've probably heard a lot about it; it's an invasive pest. It will kill all of our ashes. It's here now; it's in Connecticut. There is no solution to that without pesticides. We have schoolyards already where we have lots of ash tress that can't be treated, and now we're going to have parklands. We don't have a rose garden in our parks, but if you have a rose garden, you're not going to be able to take care of the pests with this proposed legislation.

So again, in summary, my testimony is science, science, science. Connecticut values education and technology and science. Let's be informed. Let's eliminate as many pesticides as we can, but let's do it based on science through IPM. Thank you.

REP. SAYERS: You mentioned the federal government, and one of the other testimonies that we heard is that federal government has actually banned some organic materials because of the danger from E. coli as part of that, and if you could comment on that please.

GREG FORAN: Well again, that -- that just goes into IPM inputs in management, and if you're not careful in what you're putting in, just because something's organic does not mean that it's safe. And just because something is synthetic does not mean that it's overly dangerous or more toxic than some organic alternatives, and things like E. coli -- I don't need to speak to you folks; you could educate me in a heartbeat on that. And we know what happens with gray water. It's a great idea to save irrigation. We're lucky that we don't need it here in Connecticut, but where they use gray water, they have to be cautious of that as well.

REP. SAYERS: Thank you.

GREG FORAN: Thank you.

SENATOR GERRATANA: Thank you. Are there any more questions? I don't think so. Thank you.

GREG FORAN: Thank you.

SENATOR GERRATANA: Next is Mike Papa, followed by Kathleen Kraczkowsky. Welcome, Mr. Papa.

MIKE PAPA: (Inaudible). Okay, my name is Mike Papa from Stamford, Connecticut, and you know, I'm an agro-ecobiological landscaper, and I may consider myself between the organic and the -- and the synthetic people here. Actually I understand both, and I think we should work together instead of trying to jumping to conclusions. You know, this is -- this -- the environment is something that it doesn't really care what you think. It just follows divine guidances, and so observation, I think, is key, you know. So what we've got to do is -- I did bring a lot of papers over here from -- you know, I'm very patient, so I usually travel all over the country to learn from different scientists, and from Connecticut, and from Norfolk from the organic people, so you have to be very intuitive about the problem, and being able to do a lot of observation, and then solve the problem according to what kind of situation you're up against. Okay, that's exact the solutions.

So we know that we're supposed to be the caretaker of nature, so basically we know that nature is a -- is a -- there's no waste in nature. But even though we say there's no waste in nature, but there's about 70 per cent of what we put in that goes into the river or riverway, so there must be a solution there.

So the idea is to know exactly the way nature works managing through the biological, chemical, physical, and also the geological, you know, point of view. And also follow also the nature laws. You know, there's a lot of nature laws that we as a people have to follow, whether it's organic or not organic, because if you don't -- you just do a shotgun approach, and then you are up to a lot of problems. But the fact about the pesticides is basically that is I don't see there is any need of it. You know, basically, the way I see things is when you play baseball, you have to leave base one to go to base two. You can't just stay at base one, so if you want to go forward, you got to leave the pesticide, the potions behind, and you concentrate on the nature laws, the way nature works, you know, so follow the nature laws and then whatever it needs, you do. If it doesn't need, you don't do, you know. So you have to do things right. So there's a lot of things I'd like to say, so if anybody wants a lawn over here, I even have something from Einstein. He says the intuitive (inaudible)is a gift of nature; the rational brain is its servant. We (inaudible) create a society that worships the servant and is forgetting about the gift of the intuitive. So the idea is that we have to be very intuitive and we have to stop fight; we have to work together, you know, the pesticides and the -- but the pesticides -- I don't think there's any need for pesticides.

SENATOR GERRATANA: Thank you, Mr. Papa. Can you summarize your testimony? We --

MIKE PAPA: Well, to summarize the testimony, actually I did it right here, you know --

SENATOR GERRATANA: You did, yeah.

MIKE PAPA: Yeah, the summary --

SENATOR GERRATANA: I -- I wanted to ask you: Do you have a copy of that for all of us, or -- ?

MIKE PAPA: Oh yes. I have -- I left (inaudible) of copies over there.

SENATOR GERRATANA: Oh, good, good.

MIKE PAPA: Because I wanted -- you know, you're doing a helluva job to listen to all these people. I don't know how you do it. I have a hard time just to (inaudible) how to deal with nature over here.

SENATOR GERRATANA: That is our job.

MIKE PAPA: If we work together, probably we could do it, you know, so the idea we have to follow -- not a thin about --

SENATOR GERRATANA: That's our attitude, too.

MIKE PAPA: Another thing that I put in is a suggestion, I did it with the farmers. We have to put the scientists, the farmers, and the school together to grow a farm next to the school so that the kids could be able to -- to bring the farm level up to the next level --

SENATOR GERRATANA: Yes, yes.

MIKE PAPA: -- you know, by learning different things, and then also they could be enjoying the (inaudible) schools and everything else that will save it from bankrupting this country from chronic diseases. That's what we got to say.

SENATOR GERRATANA: Thank --

MIKE PAPA: We've got to stop fighting over there, organic versus non-organic, because we have to get --

SENATOR GERRATANA: Hopefully there's a better way. Right.

MIKE PAPA: We have to give a lot of credit, also for, you know, the groundkeepers association. I attended and I learn a lot from the scientists about the cell walls, membrane, and about the rain garden, but I didn't like the idea that they spend a lot of time with the pesticides and people asking questions after the fact, and all the people there don't even ask one question. So 500 people not asking one question, just to go over there to get the license for the pesticide.

SENATOR GERRATANA: Okay.

MIKE PAPA: That's it, ma'am.

SENATOR GERRATANA: Well, thank you very much. Are there any questions? Comments? If not --

MIKE PAPA: If you want a (inaudible), I'm the guy.

SENATOR GERRATANA: Thank you for -- okay. We'll note that. Thank you for coming today, sir. Thank you.

Next is Kathleen Kraczkowsky, followed by Margaret Miner.

KATHLEEN KRACZKOWSKY: Thank you. Great job on my name. Most people mispronounce it.

SENATOR GERRATANA: I'm from New Britain.

KATHLEEN KRACZKOWSKY: So am I.

SENATOR GERRATANA: All right!

KATHLEEN KRACZKOWSKY: My name is Kathleen Kraczkowsky, and I support the bill. However, I think it needs more research, more work, and some clarification.

I am here as a volunteer with Elizabeth Park Conservancy. We work together with the City of Hartford, and the City of Hartford is represented today by Elizabeth Maran who is one of the city gardeners, and the president of the Conservancy is Laura Berman. And we maintain many of the gardens and the grounds, especially the rose garden. And we're here to report that we are going to be getting off pesticides and herbicides, and we are going organic, so we support the bill.

SENATOR GERRATANA: Thank you.

KATHLEEN KRACZKOWSKY: But there are some things that we have questions on. And there are many bio-safe products out there. This bill seems to say that you can't use anything. It says what you can't use, but it doesn't say what you can use. And we suggest that you set up some guidelines around what we can use.

SENATOR GERRATANA: Uh-huh.

KATHLEEN KRACZKOWSKY: Because it's really -- we have 15,000 rose bushes to take care of, as well as 100 acres of a park, and we have to have some guidelines on this.

The other question I have is -- and this is a personal question -- is why are golf courses exempt, and where's this going to end? Will eventually farms and orchards not be able to spray, because even -- no matter where you spray, it's going to get in the water; it's going to get in the ground. So I don't understand why golf courses are exempt from this, and I'm sure the golf course people will want to scream at me when I leave. But children play on golf courses, too. They're out there playing golf. They come after hours and run on them. Most golf courses are in residential areas. So that -- that is all I have to say. I'd like to -- like I said, I'd like to have more clarification on what we can use. And I'm done before the bell.

SENATOR GERRATANA: Well, and we appreciate all of your efforts including your brevity here. There's the bell. But I thank you very much for your thoughtful testimony and input. I cannot find it on line. Had you submitted anything in writing to us?

KATHLEEN KRACZKOWSKY: No, but I will.

SENATOR GERRATANA: No?

KATHLEEN KRACZKOWSKY: Do you want me to type it up?

SENATOR GERRATANA: That's good, only because sometimes we like to, if we get the chance to give you a call to elaborate a little bit more about what you're suggesting, but you can leave your contact information with our administrative staff over here if you would be so kind.

KATHLEEN KRACZKOWSKY: I will type it up.

SENATOR GERRATANA: Is there any questions? No? Thank you so much for taking the time. Congratulations to Elizabeth Park.

Next is Margaret Miner followed by Terri Eickel.

MARGARET MINER: Thank you, Chairman Gerratana --

SENATOR GERRATANA: Thank you.

MARGARET MINER: -- and the members of the committee for the chance to testify on this bill. I submitted two bills. This main one for our testimony is 5330. The -- the other one is, I think 5537. We submitted electronically in both cases with Maureen Westbrook, and that is an Act -- that is a small change to the Class I, Class II statutes --

SENATOR GERRATANA: Yes.

MARGARET MINER: -- which, over three years, we have checked with practically everybody in Connecticut, and everybody is fine with that change.

SENATOR GERRATANA: Oh, good; good to hear.

MARGARET MINER: I think it was a mistake to begin with. The -- on -- I'm testifying in favor of 5330. It's, you know, I attached to my testimony the American Academy of Pediatrics Review, and also the letter from those doctors. I must say, in my mind, my daughter worked as a landscaper for a few summers and became increasingly cautious and wearing more and more clothes, even in the summer, because of the products that she was using.

The Courant ran an article which -- a Courant editorial -- about a month ago saying Connecticut has got to get a handle on its pesticide use. We are -- we are dumping thousands of pounds, or applying thousands of pounds of these pesticides. The science is -- is terrible. A US Geological Survey has found pesticides in all of our streams, so as a person trying to protect water, and salamanders, and turtles, that's -- those -- those are leading the die-off of species. I support Don Williams' amendment. I think that's -- GMO grass is just about the worst idea I've heard of in, oh, maybe hours.

The IPM -- you know, IPM used to -- people used to be very interested in it. We used to be very interested, but over the years there's been no rules, no enforcement. There are guidelines, but it pretty much amounts to okay, do better, do -- do what you can. I have been to, you know, Freedom One events where IPM and DEP turn up with some wonderful guidelines and ideas, but nothing that can be enforced.

And then finally I'll say I have some questions about the definitions of controlling authority and public notice, and I think Citizens Campaign for the Environment shares some of those things, so going forward I'd like an opportunity, if that language is going forward to -- to work on being sure it's -- it's clear.

SENATOR GERRATANA: Thank you. And thank you so much for your testimony. Did you submit testimony?

MARGARET MINER: I did submit testimony --

SENATOR GERRATANA: Good.

MARGARET MINER: -- electronically on both bills.

SENATOR GERRATANA: Okay. Thank you very much. Okay, are there any questions?

Representative Miller.

REP. MILLER: Thank you, Madam Chair, and thank you for your testimony. My question is, as far as that -- that term "the controlling authority," because it's not spelled out, do you think an appropriate person might be the -- the health director of the health district, or the local district perhaps, something like that?

MARGARET MINER: I certainly think -- of course, as is many things, it's fragmented authority. DEP deals with some aspects of pesticides. The Public Health Districts deal with others. I think what the legislation is trying to do is to enable somebody who's on the scene to act quickly. Let's say you find ground bees -- to act quickly, and then to provide notice. So definitely as early as possible, I would like to see someone with a medical or toxicology background and expertise making the decision or at least validating the decision, being sure the proper warnings are posted and that it's properly reported to the State because we have no -- how many? I don't know, 11,000 different approved pesticides for use in this state, and we don't know where they all are.

So, yes, with controlling authority, I think it's some -- you have to find a balance between the person who's on the site who could act, and the person who has the best expertise to make the decision. They probably both need to be involved and there need to be better notice about what was done and why, who was in the vicinity of the pesticide. Some of those pesticides for stinging insects and fleas and things can give you quite a severe reaction. I know because I had one once. You could end up in the hospital. So you would want to have good notice.

REP. MILLER: Okay. Thank you for the answer, and thank you, Madam Chair.

SENATOR GERRATANA: Certainly. Thank you. And thank you, again, for your testimony, Ms. Miner.

MARGARET MINER: Thank you.

SENATOR GERRATANA: Take care.

MARGARET MINER: You, too.

SENATOR GERRATANA: Next is Terri Eickel followed by Elaine Titus.

TERRI EICKEL: Good afternoon. I'm Terri Eickel. Thank you so much for the opportunity to submit testimony. I am here in sort of two roles. I am the Executive Director for the Inter-religious Eco-Justice Network. We're a faith-based environmental organization. We believe we have a moral, ethical, spiritual reason to protect the planet and protect all of its inhabitants. And I'm also here as a cancer survivor. I've been here at the capital for a couple of days now testifying on different toxin bills because I was diagnosed three and a half years ago. I found my lump when I was 36 years old. I was a total health nut. I didn't have any family history. I ate my vegetables; I exercised; I didn't drink; I didn't smoke; and I still had advanced breast cancer. I had found a tumor so big that I didn't think it was cancer because I couldn't figure out where it started and where it ended. I went to the doctor just because I'm a good student. You know, I'm a good do-bee and I do that stuff, and she didn't even have to give me a biopsy to say, Terri, this is malignant and you have cancer, and I'm telling you now so that you can make your plans.

I had a six-year-old niece at the time. She's now almost ten, but I remember thinking like, I have to beat this. If I die now she will not trust the universe as a safe place to be. I did 18 months of chemotherapy, and surgery, and radiation, and after that I developed a very comprehensive survivorship plan. And I've read so much about diet, lifestyle, toxin exposure, and I am convinced, as are many of the different oncologists that I've consulted, including people that treated me, and then people I just went and met with, that toxic chemicals, the environmental link, is extremely clear with the rising cases of cancer.

A lot of times people talk about cancer and the increase and they say well, you know, we've got better screening, and there's so much more awareness, and people are living longer, but what we're also seeing is people in their twenties and thirties with advanced cases of cancer, Stage III, Stage IV, other people that, you know, no family history, totally healthy; children, obviously I've already heard the statistic, 20 percent increase in children's leukemia, children's brain tumors. These are not people that are benefiting from better screening. These are people that came in with symptoms, you know, and I have -- I submitted my testimony, but I don't know if you have it yet, but a national toxicology program study found that we're exposed to about 3500 to 7500 chemicals daily, and even though potentially all of them are in the safe level, when combined together it's like 35 to 75 times the dose considered safe.

Yeah, so, I support H.B. 5330. I've done a lot of work with other cancer survivors and patients to help them reduce their risk of recurrence and -- and do well during treatment, and one of the things that we always talk about is chemicals and how we can reduce our exposure.

SENATOR GERRATANA: Thank you for your testimony. Are there any questions or comments? No? If not, thank you for coming today.

TERRI EICKEL: Thank you.

SENATOR GERRATANA: Next is Elaine Titus, followed by Louis Burch. Is Elaine here?

A VOICE: No.

SENATOR GERRATANA: No. Oh, okay, so she's not -- okay, Louis Burch?

LOUIS BURCH: Good afternoon, Senator Gerratana, Representative Miller, and the rest of the distinguished members of the Public Health Committee. For the record, my name is Louis Burch. I'm the Government Relations liaison for Citizens' Campaign for the Environment. We have over 80,000 members in Connecticut and New York working to protect our public health, and our natural environment. We're here today to testify in support of House Bill 5330.

I don't need to go into the science. You all have been convinced all ready the science is clear. Exposure to pesticides absolutely increases children's risk of developing cancer, and a number of other health problems which is why this Legislature passed a prohibition in 2005 on using chemical pesticides on grades kindergarten through six. That was expanded in 2007 to include middle schools, grades 7 and 8, and then expanded again in 2009 to include daycare facilities.

I view this gradual expansion as a progression -- demonstrating a growing body of knowledge among the health scientist community as well as the Connecticut General Assembly, and it is our view at Citizens' Campaign for the Environment that the next step in that progression is House Bill 5330 that you all have proposed. So we absolutely applaud you for introducing this important children's health protection.

I think it also needs to be said that in 2010, after we passed that legislation and expanded upon it, New York State passed what's called the Childsafe Playing Fields Act, which is a comprehensive K through 12 ban on using chemical pesticides, and I think it needs to be said that we haven't seen the same pushback here -- in New York State as we have here in Connecticut, and we even have a letter from the Senate sponsor of that legislation in New York to that effect. They had implemented natural turf care with measurable success in over 100 districts in New York State, and have been able to demonstrate not only effective pest management, but in many cases cost savings as well.

And I hope that you'll ask me questions about integrated pest management and why it's not appropriate for short-grass playing fields.

SENATOR GERRATANA: Well, actually I had a question on national turf care. Did I hear right?

LOUIS BURCH: Natural turf care.

SENATOR GERRATANA: Oh, natural. Okay. He thought it was national turf care, too. I thought maybe there was some protocol.

LOUIS BURCH: I may have misspoke.

SENATOR GERRATANA: No, or I misheard. Thank you for that clarification. Okay, so I'll ask you about the integrated, or the ICM protocol.

LOUIS BURCH: Absolutely. So integrated pest management was designed absolutely to reduce the use of dangerous pesticides. And we, I just -- to touch on a statement that was made a little bit earlier, we absolutely recognize the value for integrated pest management in certain situations, including agricultural uses and indoor purposes. However, integrated pest management is not scientifically defensible for short-grass playing fields. I think it needs to be said that we do not have tick problems on short grass. There -- there is no need to address those kinds of things with dangerous chemicals, especially when there are nontoxic approaches to dealing with things like brown patches, weeds on -- on playing fields, and grubs.

Integrated pest management is designed for use in places where exposure levels are low. So, for example, it would be appropriate to implement an IPM policy in a kitchen, or in a basement of a school building, something to that effect, but we have a problem, and frankly there -- there is one issue -- Margaret Miner testified on this before -- there's one issue with the definition of controlling authority as this bill is written, where it would really leave that determination of what is a significant public health threat up to the -- the authority, whoever is in charge of maintaining that field. And our recommendation for this body is that that definition be amended to -- to require, at the very least, a qualified -- a qualified toxicologist or a representative from the Health Department. Because, once again, I mean if -- if you give that decision-making power over to someone, and it's not a slight against the groundskeepers, but we can demonstrate that there have been many training opportunities afforded to groundskeepers in the state since we passed this legislation, and attendance has been abysmal, whereas in New York State those training opportunities were required by law. So that may be another thing that you all look at moving forward.

SENATOR GERRATANA: I see. Well thank you very much for that. Are there any questions further? No? Thank you. Thank you for your testimony.

LOUIS BURCH: Thank you for the opportunity to submit.

SENATOR GERRATANA: Next is William Cooke followed by Martin Mador.

WILLIAM COOKE: Good afternoon. My name is William Cooke and I'm here representing Grassroots Environmental Education. We had hoped to have our Executive Directory, Patty Wood, appear, but she was unable to, so I got a call this morning to get over here because of the importance of this proposal and this committee. I appreciate the opportunity to appear before you.

I want to start with science, science, science. We heard that earlier. Here's the science. Here's the peer-reviewed published science on pesticides and their impacts on our children, our families, and our future. Grassroots supports 5330, if amended, to address the area of concern that is in the definitions section, and we believe the controlling authority's definition should be changed to designate the Public Health Commissioner, or the Commissioner's designee, or the Commission of DEEP, or his or her designee, as the controlling authority.

There's one other little minor thing, when dealing with bait, it should be in tamper-resistant containers.

I want to talk about natural lawn care, and Grassroots has trained hundreds and hundreds of lawncare professionals in New York and Connecticut at no cost to ensure that they could comply with the law in Connecticut and New York and, as was said earlier, in New York there has not been one phone call to one of the prime sponsors of this legislation in a number of years expressing concern about the ability to do it.

Natural lawn care is doable. All you have to do is understand it's not rocket science; it's soil science. But to suggest that it's important to protect our children from a sprained knee, and we should use toxic chemicals that are associated with an increased incidence of cancer because we're worried about a sprained ankle, I find that outrageously offensive, and I would think that they would have come up some sort of better line than that by this time, but apparently not.

I applaud what Connecticut has done to protect our children. I believe it's appropriate to move forward and expand this law. The science could not be clearer. If we are not protecting our children's health, what is it we're doing?

I'm not going to sum up. If you have questions, that's fine. If not, (inaudible) folks.

SENATOR GERRATANA: Fine. Thank you very much. Are there any questions?

Representative Miller.

REP. MILLER: Thank you, Madam Chair. Thank you for your testimony. Again, could you just give us your synopsis on IPM and -- and what are its strengths and weaknesses?

WILLIAM COOKE: Integrated Pest Management is something I'm very familiar with. I have been on Cornell University's Citizens' Advisory Committee on IPM for years. We are still, around this country, trying to figure out what the definition of IPM is, but I'll set that aside. Integrated Pest Management is a tiered approach to addressing a threat from a least-toxic to most-toxic rating. You start at the bottom.

You first look at the threat. You then look at how you address it, and then you look at the cost-benefit so to speak. If you're dealing with malaria, you're probably going to pull out some chemicals. But you know what? You don't have much choice. If you're dealing with rat infestation; if you're dealing with a public health outbreak, it is a reasonable, reasonable way to look at it. The problem is, as soon as you get on the short grass, you can't use IPM, and to suggest you can is either to basically say you don't understand what IPM is, or worse, you do.

You can't do a balance between the risk of the pesticides being used and the benefit. We're not talking about protecting from malaria. We're talking about grubs. We're talking about being attacked by clover. To suggest that an outbreak of clover represents a threat so significant that we should use IPM is to not understand IPM. You can't defend IPM on short grass. You can't defend it medically because of the chemicals that would be considered for use and the risk to our children, and you can't defend it as a reasonable practice because there's no need to get the IPM.

We obviously can manage turf naturally. They're doing it next door in the state of New York for years without one complaint to the Legislature. But for some strange reason, when we cross over the Connecticut border, it becomes almost impossible to maintain short grass without toxic chemicals related to an increased incidence of cancer.

If somebody tells you IPM should be allowed on short grass, wow. They either don't get it, or they're lying to you.

REP. MILLER: Thank you for your answer. Thank you, Madam Chair.

SENATOR GERRATANA: Certainly. Thank you. Thank you for coming today.

Next is Martin Mador followed by Charlie Ortiz.

MARTIN MADOR: Good afternoon. I'm Martin Mador. I'm the Legislative Chair for the Sierra Club in Connecticut. I'm here representing our 8000 members.

Why is the Sierra Club here? Because the knowing and intentional introduction of toxics into our environment is very much an environmental issue of concern, and that's really what we're talking about here. You've heard a lot of testimony about the effects of pesticides, the consequences of their use, about the exposure to children. I'm not going to walk through all that again; you've heard all that.

The question is why do we still use toxic pesticides knowing what we know about them? Here is the reason I think we do it. Because we are the land of steady habits. Long-established practices persist despite bountiful evidence that they can and will do harm. We have to learn that when the way we did something yesterday is harmful to us, we have to stop doing that. So perhaps a resolution renouncing our unofficial state motto might really help us get to where we want to get to. I think the land of steady habits does a lot of harm in getting us to much better places.

We also have to look at commercial interests, what they do, the times they add significantly to our quality of life and to our economic health, which is great, but at times commercial interests simply protect their own economic interests, and you really need to think about this as you hear about their recommendations.

The Sierra Club strongly endorses Senator Williams' suggestion that we include GMO seed in here, because the nexus of GMO crops and pesticides is very strong. The whole point of doing the GMO engineering is to increase resistance to pesticides so we can use a lot more of them. So it makes a lot of sense to include the GMO grass seed in this bill as well.

One aspect of IPM that should be noted is it may be a good prescriptive to use when you have a very motivated land owner who really wants to reduce their use of pesticides. If not, what you have is a system where the applicator is essentially free to do whatever they like, unregulated and unmonitored, and it's just a recipe for having uncontrolled application of pesticides. IPM just does not work for us.

Connecticut has followed a --

SENATOR GERRATANA: Can -- can you summarize, Martin? Thank you.

MARTIN MADOR: -- (inaudible) in recent years working to protect its citizens from unnecessary exposure to toxic substances. We still have a ways to go. This bill is the next step in the campaign to keep us safe from toxins. Thank you.

SENATOR GERRATANA: Thank you, sir. Are there any questions or comments? If not, thank you for your testimony.

Next is Charlie Ortiz followed by Ann Targonski. Is Charlie here? Charlie Ortiz? He did sign up to testify, he or she. Okay, then Ann -- Ann Targonski. There she is. Followed by Richard Holmes.

Good afternoon.

ANN TARGONSKI: Good afternoon, Senator Gerratana, and members of the Public Health Committee. My name is Ann Targonski and I'm a licensed funeral director with the New Britain Memorial Funeral Home.

I'm here to express support for Senate Bill 434, AN ACT CONCERNING FOOD BEVERAGE SERVICE IN THE FUNERAL INDUSTRY.

This bill is an outgrowth of a taskforce formed by the Legislators last session to study the provisions of food and beverages in the funeral homes. I was privileged to serve as a member of that taskforce which held a public hearing on this issue to help inform its -- and its recommendations. It was an informative and productive experience.

Senate Bill 434, which reflects the unanimous decision of the taskforce, would allow funeral homes to serve non-alcoholic beverages and packaged food to client families during pre-arrangements and arrangement planning. The State has been operating under a ban on food and beverages for far long in my opinion. This bill represents a small but positive step toward helping our industry evolve with the marketplace in Connecticut and the rest of the country.

The taskforce recommendations met with a positive response from our client families and we look forward to having the opportunity to put it into practice should this bill -- bill be approved.

I hope you will support Senate Bill 434. Thank you for the opportunity to testify.

SENATOR GERRATANA: And thank you, Ann.

ANN TARGONSKI: Thank you.

SENATOR GERRATANA: Thank you for serving on the taskforce, also, and coming here to give testimony. I was reading through all the testimony and it looks like everyone is on the same page, so that's really excellent.

ANN TARGONSKI: Thank you very much.

SENATOR GERRATANA: Excellent to hear. Thank you. Are there any questions? No? Thank you for coming today.

ANN TARGONSKI: Thank you.

SENATOR GERRATANA: Next is Richard Holmes; yes, followed by Dr. Marc Eisen.

Mr. Holmes.

RICHARD HOLMES: Good afternoon, Senator Gerratana, and the rest of the committee. My name is Richard Holmes. I am a member, past president, and a legislative committee representative for the Connecticut Funeral Directors Association, and I along with Ann, who just spoke, ask that you support Senate Bill 434, which will allow funeral homes to offer non-alcoholic beverages and prepackaged food to families that come in to make arrangements, or what we call pre-arrangements.

Currently there is a Public Health Regulation 20-211-28 which prohibits funeral homes from having food or beverages. We feel that the -- having an amendment to the current regulation that would allow us to offer food, non-alcoholic beverages, and prepackaged food to families that are coming in at usually a stressful time would hopefully make them feel a little less stressful and relaxed.

So at this -- on behalf of the Connecticut Funeral Directors Association, I would ask that the committee members support Senate Bill 434, and I would be happy to answer any questions anyone may have.

SENATOR GERRATANA: Yes, Representative Cook has one for you.

REP. COOK: Thank you, Madam Chair. Thank you for your testimony.

With the changes that are being proposed, does that also allow a family to -- if somebody goes out to get something from McDonald's or a fast food restaurant, can they also, under this legislation, bring that in an eat, or is that part of a no-no?

RICHARD HOLMES: Now actually there was a paragraph in my testimony I forgot to read. To clarify, this bill would only allow non-alcoholic beverages and packaged food or prepackaged food in funeral homes during small meeting situations. So someone coming in -- if someone were to come in to make arrangements, they brought in a cup of coffee or something, that's fine. But this bill does not allow people to bring food or beverages, or allow funeral homes to serve food or beverages during a wake, a funeral service, any type of a large gathering. It would strictly be a small gathering situation.

REP. COOK: So during the work of the taskforce, was that conversation had about being able to bring food in? I mean because if you're -- if you have a wake, those can be five or six hours long, and I -- I understand that you all currently cannot, so if somebody -- if a family member brought some food in, or had food there, they would not technically be allowed to consume it within your -- your building? But was that discussed as we move forward to try to fix some of this?

RICHARD HOLMES: The way the current regulation reads is that food and beverages are not allowed to be served. Okay? The taskforce -- the majority of the taskforce members interpreted that as people could not bring food into the funeral home. Does that answer your question?

REP. COOK: It does, and is that something that you all would be opposed? If we could strengthen this and let food be brought in during those times, would the funeral home owners be opposed to that, or would you be in favor of that.

RICHARD HOLMES: There was a survey taken by one of the taskforce members of the funeral homes in Connecticut. The majority of them, close to 80 percent of the people that -- of the funeral homes that responded to the survey, were opposed to allowing food and beverages in the funeral home during a public service or any kind of a public gathering.

REP. COOK: And your opinion on that?

RICHARD HOLMES: My personal opinion? My personal opinion is I think at this time I -- you would have a difficult time getting the majority of people to accept that, but I think society being the way it is, and the way it's changing, somewhere down the road I think that would be beneficial.

REP. COOK: Thank you. Thank you, Madam Chair.

SENATOR GERRATANA: Thank you.

RICHARD HOLMES: Any other questions I can help with?

SENATOR GERRATANA: Yes, Representative Sayers.

REP. SAYERS: I'm in line with Representative Cook. I find it very difficult that -- you know, food is one of those comfort measures, and in time of stress and time -- difficult times during a death in a family, it's really difficult, and I see more and more wakes that go from mid-afternoon to -- into the evening and -- and depending on the size of families, it sometimes can go to eight, nine, ten o'clock, and it doesn't allow the family any breaks or time even to have something. And not to be able to take that break and -- and do that, I just find it very difficult. And why they would oppose it, it doesn't make sense at all to me. I don't know what the reason was, because there certainly is no legitimate reason for that.

RICHARD HOLMES: Representative, if you have access to our report, there is a page in the summary that gives reasons pro and con for allowing food in the -- in the funeral home. Years ago, when I first started working in the funeral home years ago, it was very common to have a wake for a couple of hours in the afternoon, and then a break, and then a wake for a couple of hours at night. One of the reasons you had that break was for families to be able to go get a bite to eat, and get off their feet, and then come back to the funeral home.

Nowadays it's very common for everything to be all at once. Unfortunately a lot of funeral homes are not set up to be able to -- to serve food or beverages, or have a place where people can go to have food or beverages. One of the reasons for -- in the taskforce, one of the reasons for not allowing food and beverages in the funeral home is they didn't feel many members -- most members feel that it is not respectful to have food and beverages in a room where you have a deceased person and you're trying to have a dignified setting.

Again, if most funeral homes had a room or a place available where people could go, then that would probably be a different story. But a lot of funeral homes don't have that.

REP. SAYERS: And actually, most funeral homes do have a place where the family can have a room to themselves if they need to take a break. So there -- I think that maybe if they looked at that and because I don't have the space doesn't mean I should stop somebody else from doing something that is just good practices and, as I said, food for most people is a comfort measure, and this is the one time when families do need every bit of comfort that they can get.

RICHARD HOLMES: And that was brought up during the -- during the taskforce. The compromise at this point was allowing people to have food and beverages while they are in a small group atmosphere, and making arrangements or pre-arrangements, and that is what this S.B. 434 is trying to acknowledge, and as a member of the Funeral Directors Association and taskforce, that was one of the recommendations we had was to have you pass it.

REP. SAYERS: Thank you.

SENATOR GERRATANA: Thank you. Are there any other questions? If not, thank you so much for coming today --

RICHARD HOLMES: You're welcome.

SENATOR GERRATANA: -- and giving your testimony, and thank you for your service and work on the taskforce, too. We appreciate it.

Okay. I did call Dr. Marc Eisen on House Bill 5529, and then I understand one of our officials is here, Dr. Helen Newton, to follow.

DR. MARC EISEN: Thanks for having me. My name is Marc Eisen and I -- I'm an ear doctor, but I think I'm representing the eye physicians. In common we have our patients' best interests in mind, and I come in favor of 5529 concerning definitions of medical necessity. I just -- we support the idea that medical necessity is important to determine because it tends to drive how the third party payers make their decisions regarding payment for procedures and other medical things that happen with the physician.

So the one concern we have about defining medical necessity is that the language of the bill does not include using the medical literature as a determinate, and we're just a little worried that you don't want to take away the opportunity to use the medical literature to make a decision about medical necessity. It's important to determine, and I think that physicians who are in practice, they're the ones who get together and make these decisions, but it just doesn't have language allowing the medical literature to be used.

SENATOR GERRATANA: Are -- are you suggesting we should not delete that particular?

DR MARC EISEN: You should not delete it, and you should be able to use, you know, you don't want to take it (inaudible).

SENATOR GERRATANA: Right. I -- I know, I read the bill, too. I didn't understand why not since my understanding of evidence-based science is that ongoing debate and discussion, so --

DR MARC EISEN: Absolutely.

SENATOR GERRATANA: -- and, you know, but ultimately, at least in my opinion, should be left to the healthcare providers making those decision with the patient, you know, to decide -- decide the best course of action, so, okay it's good to hear that you said that. And please continue, I'm sorry I interrupted.

DR MARC EISEN: I was done.

SENATOR GERRATANA: Oh, you're done.

DR MARC EISEN: I think that's it.

SENATOR GERRATANA: Oh, okay. Excellent. Does anyone have any other questions or -- no? Well, thank you. Thank you for coming today and giving that testimony.

And now we go to Dr. Helen Newton, Commission on Health Equity. That's correct. Welcome. Thank you.

DR. HELEN NEWTON: Good afternoon, Senator Gerratana, and distinguished members of the Public Health Committee. First of all, thank you so much for the opportunity to testify today on Raised Bill 5337.

I'm Dr. Helen Newton. I've practiced in the state of Connecticut for the past 11 years, and I've practiced in general for about 25 years. I'm presently the Executive Director of the Connecticut Commission on Health Equity, and on behalf of the Connecticut Commission of Health Equity, we support the work of the Department of Public Health, Office of Multicultural Health.

Other than the very close name association between the Commission on Health Equity, and the Office of Health Equity, and the inevitable name/function confusion, we enthusiastically support the presence of the office in the Department of Public Health. We support the mission of the Office of Multicultural Health, which is to improve the health of all Connecticut residents by working to eliminate differences in disease, disability, and death rates among ethnic, racial, and other population groups that are known to have adverse health status or outcomes.

We are also very supportive of the Office of Multicultural Health's provision of resources for the use of culturally and linguistically-appropriate services in the state.

According to State Statute, Section 38a-1051, the mission of the Commission on Health Equity is to eliminate disparities in health status based on rate, ethnicity, gender, and linguistic ability, and improving the quality of health for all state residents. State Statute Section 38(1)-1051(j)mandates the Commission on Health Equity to make a determination as to whether the duties of the Commission are duplicated by another state agency, office, bureau, or commission, and shell include information concerning any such duplication or performance by any other state agency, office, or bureau. We are requesting clarification on Section 5c-3 of Bill 5537 which states that the office shall assist the Department in its efforts in the following areas: To assess the effectiveness of State programs in eliminating differences in health status. We'd like to know whether these State programs are programs that are sponsored by State Agencies, or State programs sponsored by the Department of Public Health.

In State statutes section 38a-1051e(5), the Commission on Health Equity is specifically mandated to evaluate the policies, procedures, activities, and resource allocations to eliminate health status disparities among racial, ethnic, and linguistic populations in the state, and have the authority to convene the directors and commissioners of all State Agencies, who purview is relevant to the elimination of health disparities, including but not limited to DPH, DFS, DCF, DDS, Education, DMHAS, DOL, DOT, and Housing Finance.

In addition, the Commission on Health Equity is in the process of rolling out the CLAS, which are culturally and linguistically-appropriate services statewide. We have seven agencies that have handed in Stage I paperwork which includes a health equity plan, health equity policy statement signed by the commissioner, and an impact statement.

Stage II encompasses an organizational chart, SWAT analysis, demographics of the clients that are being served, and identification of a champion.

The training for the rollout will be conducted by Johns Hopkins Center for Health Disparity Solutions which will be offered on March 18th, April 15th, and May 20th, with a special session for agency heads and commissioners.

With limited staff, the Commission on Health Equity is presently offering this training to the seven agencies that have handed in paperwork which includes the Office of Healthcare Advocacy, Department of Public Health, Department of Children and Families, Department of Energy and Environment, Department of Mental Health and Addiction Service, Department of Corrections, and the Connecticut State Department of Education.

We will start with the actual assessment on April 7th with the Office of Healthcare Advocacy. The Commission is aware of the cost of the program, but the benefit of finding a solution will greatly outweigh the initial cost investment.

Although there appears to be an overlap of mission and/or responsibility, this can have an additive or even a multiplicative effect with multiple organizations and agencies working toward the same goal. The area of concern is more in duplicated effort in assessing state agencies and the associated duplicated course related to health disparities.

State Statute Section 38a-1051e(2)requires the Commission on Health Equity to review and comment on the Department of Public Health's Health Disparities Performance Measures which would include their Office of Multicultural Health, and directing the implementation of policies, procedures, activities, and resource allocations to eliminate health status disparities in the state. As a result, with the clarification of Section 5c-3 from Raised Bill 5537 to ensure that this does not represent a duplication of the purview of the duties of the Commission on Health Equity, we would support the changes to the State Statute language presented in this bill. Thank you.

SENATOR GERRATANA: Thank you, Dr. Newton. I am trying to find your testimony on line so we -- I did make a note 5c-3.

DR. HELEN NEWTON: Yes.

SENATOR GERRATANA: That is the section of the bill?

DR. HELEN NEWTON: Yes, it is.

SENATOR GERRATANA: Okay. And you are in what section of the bill? Your reference with the name change?

DR. HELEN NEWTON: Well, yes, the section that we are questioning is Section 5c-3 of Bill 5537, and --

SENATOR GERRATANA: Okay, so Section 5 of the bill?

DR. HELEN NEWTON: Yes.

SENATOR GERRATANA: Okay. And you did -- you did submit testimony.

DR. HELEN NEWTON: Yes, we believe that it was submitted upstairs, yes.

SENATOR GERRATANA: Okay. I just got from our administration who said it was submitted a little late.

DR. HELEN NEWTON: Yes.

SENATOR GERRATANA: But we'll get to look at it because, of course, we want to address your concerns.

DR. HELEN NEWTON: Absolutely.

SENATOR GERRATANA: Okay. Thank you so much.

DR. HELEN NEWTON: Thank you so much.

SENATOR GERRATANA: I don't know if anyone has any questions. I guess not. Thank you for coming and testifying.

DR. HELEN NEWTON: Thank you again.

SENATOR GERRATANA: Okay, we're going back to House Bill 5529, and next is Matt Katz, Connecticut State Medical Society. And to follow Matt is Vic Vaughan.

MATTHEW KATZ: Senator Gerratana, Representative Johnson, and members of the Public Health Committee, my name is Matthew Katz. I'm the EVP CEO of the Connecticut State Medical Society, and I'm here today representing not only the State Medical Society, but the Connecticut Chapter of the American College of Physicians, and a number of other medical specialty societies actively practicing in the state of Connecticut.

We appreciate the intent of House Bill 5529; however, we have concerns associated with the removal of language that presently we believe functions effectively when it comes to peer review and peer review of literature. Though we recognize the interest and intent of including mental health and related issues into the bill which we think would be helpful, the concern is eliminating anything that has been effective would be problematic, we believe, for physicians and patients.

So we again recognize the -- the intent and appreciate the Committee's efforts, but are concerned about elimination of language tied to peer reviewed literature that could have an unintended consequence for those patients that need medically-necessary care that physicians determine is in their best interest based upon the peer-reviewed literature that they review.

Finally, I do remiss not to mention Bill 5535. Real quickly, Section 2 we think has significant concerns for us because it provides an undue burden on physician offices having at each visit to provide information to patients about who provided care and what care was provided which could differ on every patient encounter. So we ask the Committee to look at that section again, and thank you very much. And I'll take any questions.

SENATOR GERRATANA: May I -- I know Representative Johnson has questions and I apologize. Were you only testifying on 5529? Did you just include -- ?

MATTHEW KATZ: I -- I -- we did not submit 5535, but I just wanted to raise it to the Committee's attention that Section 2 of that bill has some, I think, language -- we have some language concerns with because it may be overly broad to cause a patient to receive information at every visit, at every encounter that may be different for each patient.

SENATOR GERRATANA: Oh, I see. Okay. Thank you very much.

MATTHEW KATZ: You're welcome.

SENATOR GERRATANA: Representative Johnson.

REP. JOHNSON: Thank you, Madam Chair, and thank you for providing testimony today. And so I appreciate your remarks with respect to evidence-based, peer-reviewed materials, but I'm not sure that's the exact language in the medical necessity statute. I'm not sure it says peer-reviewed, evidence -- it's just evidence-based language, so maybe we should add the language peer-reviewed then? And you don't have to make that determination now. I'm willing to work with you on the language, but I do think that we need to have mental health parity in both medical necessity statutes, and I think that that's important. And also, of course, as you -- as you mentioned, the reason for this is to make the treating physician (inaudible) and not a third party that doesn't share the same, you know, credentials as the treating doctor.

MATTHEW KATZ: I wholeheartedly agree with everything you said. I -- I think the -- the language that is in statute came from the settlements that the Medical Society engaged in in the mid -- mid 2000s, and the intent was to deal with scientific and peer reviewed. If the language does not state that, we are more than happy to work with this committee and both chairwomen to -- to address that. With the mental health issue, absolutely there needs to be parity, and if -- if it is not being done, tied to mental health conditions or mental health and behavioral health issues, as well as substance abuse, it needs to, and I think we'd want to make sure in all cases that the individuals that need care tied to those conditions are equally represented by their practicing physician.

REP. JOHNSON: So the -- the only other thing is that in terms of these determinations are made by third party administrators, or by administrative service organizations or insurance companies, they're made by people other than who have had a chance to, you know, work clinically with the patient, and so they -- they're overriding these clinical determinations by the treating doctor, and by having the doctor be the key figure in making the health care determinations based on the doctor's clinical examination of the patient, and also applying -- applying peer-reviewed studies to the actual care of the patient is -- is what we're trying to get at here. So any way we can do that we're -- we're working at trying to do that.

MATTHEW KATZ: And thank you. We again wholeheartedly agree that the physician and patient in a -- in a process of that physician-patient relationship is where that decision should be made, and you shouldn't have a third party that is not engaged in the care of that patient making that decision and it needs to be again, a physician who is well qualified, well informed, and who has provided that care to that patient. So we agree 110 percent with regards to that. The concern was just eliminating some of the language that has been used effectively to advocate for patients and patient care over the last few years, and we wouldn't want that aspect taken out of statute, but we do agree with the other things being proposed to add in.

REP. JOHNSON: So one final quick question is how would you make a distinction between two peer-reviewed scientific studies that came out with opposite opinions.

MATTHEW KATZ: And that happens often when it comes -- because there's always a new piece of literature coming out that may -- may address aspects of the -- of the previous piece. I think in this case, it should always rest ultimately with the physician's medical judgment and making that determination as to what constitutes medical necessity, and the medically-necessary care for the patient. So as long as we recognize that the ultimate arbitrator of -- or decider should be the physician providing that care to that patient in consultation with that patient, I think we're doing a good job. So if we can make sure that there's language there that allows the physician and the patient to reach towards that peer-reviewed scientific research that highlights the necessity for care in their situation, I think that's a good thing. The moment we start putting that in front of what a physician believes is best for that patient, then that's a bad thing.

REP. JOHNSON: Thank you so much for being here. Thank you, Madam Chair.

MATTHEW KATZ: You're welcome.

SENATOR GERRATANA: Thank you. Are there any other questions? If not thank you very much for coming today --

MATTHEW KATZ: Thank you very much.

SENATOR GERRATANA: -- and giving your testimony.

Next is Vic Vaughan, followed by Sheldon Toubman.

VIC VAUGHAN: Good afternoon, Chairman --

SENATOR GERRATANA: Good --

VIC VAUGHAN: -- Chairpersons Gerratana, Jefferson, and Johnson. I applaud you for your patience and your stamina.

My name is Vic Vaughan. I'm a member of the public policy committee of the Connecticut Physical Therapy Association, and I'm here to testify in support of House Bill No. 5529, with some caveats.

One of the -- the definition of medical necessity for physical therapists has been a significant issue, especially the alteration of the definition of physical therapy -- or of medical necessity, and our ability to care for patients. We've had some third party administrators that have decided to lower the bar on that, and that's created some problems.

We do have -- we do share the concerns of some of the other providers regarding the removal of the use of peer-reviewed literature, and we would ask that that no be removed, and that be continued to be included, and in fact we would ask that it would be strengthened and use it with the work "current" peer-reviewed literature. One of the problems that we run across is that some of the -- the criteria that's used to make decisions on medical necessity for our patients is based on dated literature, and therefore is hardly appropriate anymore.

We do strongly support the insertion of the language regarding requiring the -- the assessment of an individual as a factor in making medical necessity determinations by -- by a provider. We think it should actually go a little further, because in physical therapy our major issue is helping patients return to function, and many of our -- of the -- of the administrators -- third party administrators are using impairment-based data which is not related to function, and therefore cutting off patients prior to their ability to return to a meaningful functional level of life. So we would love to see that some criteria be established, within the medical necessity definition, that would allow the use of function -- or the determination of function as part of that criteria.

One of the major issues that we've run across is that some of the utilization review companies have actually reduced the -- the concept of medical necessity to where 80 percent of normal is good enough, and that then cuts off patients prior to their ability to return to that meaningful level of function. I've included a story about a patient in my testimony that is very real, and happens to pretty much all the outpatient providers across the state on almost a weekly basis, and so there are -- there is plenty of evidence that we've run across that has demonstrated the inability of the therapists to provide adequate care for their patients.

So in closing, I'd simply like to say we would really appreciate the opportunity to work with you on this bill, and -- and also appreciate the opportunity to testify.

SENATOR GERRATANA: Thank you, Mr. Vaughan. I could not find your testimony on line. Have you submitted it?

VIC VAUGHAN: It has been submitted.

SENATOR GERRATANA: It has? Okay. So we will look for that, because it's important for us to either get in touch with you, or at least read what you suggested for the bill. We thank you.

Are there any questions?

Representative Johnson.

REP. JOHNSON: Thank you, Madam Chair, and thank you for being here and waiting and providing testimony. I know that 80 percent of recovery is not really good enough in so many circumstances. You find that somebody could really improve their potential by going to 100 percent. So could you just expand a little bit on that part of your testimony to let us know exactly what's happening here, and why they seem to be -- the administrative service organizations and the insurance companies seem to be cutting short the -- the chance for people to be able to have 100 percent in terms of their -- their chance for recovery, and this includes physical therapy?

VIC VAUGHAN: Well, I think the why is relatively clear. I think it comes down to saving money. The -- the way they -- the way they administer it is when we see a patient we are -- for the very first time, for our initial examination, we submit a request for authorization to the third party administrator companies. The authorization is generally provided almost -- almost 100 percent of the time at six visits. Those six visits, when you -- when you go through those six visits, you then are required to resubmit for an additional number. It doesn't matter how many you ask for, you get six. Once you get finished with your six visits, you ask for some more. Almost always it is four or five, and then when you get finished with those, you need to go back and ask for more. When they -- the determination appears to be these companies have set up criteria that they -- internal criteria that they use to decide what is -- is sort of the end point, and there can be sort of three reasons why they would -- why they would discontinue or no longer authorize further care. You would either have achieved your goals, and the patient would have gotten better, in which case we generally don't ask for more authorization. The patient is either not getting better fast enough, and that fast enough number is kind of arbitrary; it's not really clear what that is. Or, the patient has hit this 80 percent point, and the 80 percent point is based upon this criteria that they've established, and this is where I made reference to the outdated literature. What they've used to establish those criteria is this old -- either old peer-reviewed, or textbooks that are -- that can be considerably out of date.

So at that point then the patient -- they -- the 80 percent number becomes 80 percent of sort of impairment, so 80 percent of normal range of motion, 80 percent of normal strength, 80 percent of normal gait speed, or pain levels. They -- you could still have pain, and they would consider that that doesn't matter, that it's good enough, and you've gotten as well as you can get.

I mean if I were going to make an analogy about how this would be determined it's as though they look at a patient who has had a fractured femur and they say well your bone is 80 percent healed; that's good enough, and they're not going to authorize you to see the orthopedist any more. Or your pneumonia is 80 percent cured, so we're not going to give you any more antibiotics because that's -- that's close enough to normal. I think most of us would -- would find that sort of reprehensible if that happens. And that's the method.

REP. JOHNSON: So -- so, if you have people in varying degree of age and type of injury, and in terms of whether it was a broken bone, or someone who had suffered a cerebrovascular accident, or something of that nature, we have people sometimes with multiple medical conditions that are, you know, trying to get enough therapy so that they can either be independent, or go back to work, do you see that this kind of rule-of-thumb of 80 percent achievement of, you know, possibly getting better is impeding people in either returning home from a skilled nursing facility or some other such facility, or impeding someone's ability to get back to the normal day-to-day routine in their life?

VIC VAUGHAN: Well, it wouldn't impede people in skilled nursing because it wouldn't -- these criteria are not applied to them. It's only in the outpatient world that we're seeing this. However, well maybe that I see you shaking your head now, it may be. In our case, though, what I deal with is primarily outpatient.

So it certainly impedes people getting back to normal. The problem is that oftentimes there's -- you're not getting better fast enough or -- and we all know people get better at -- at different rates. I mean it's just, it's not all -- there's not a set standard of improving and restoring function, and if you add additional co-morbidities on top of this, that adds considerable -- can considerably add length to time. So it absolutely prevents us from being -- allowing patients or assisting patients to get back to that level of function that they could get to, and they're sort of left to their own devices if they can't pay for it on their own, which is really unfortunate.

SENATOR GERRATANA: Very good. Thank you so much. Any additional questions? Okay.

REP. JOHNSON: Madam Chair, thank you. Thank you.

VIC VAUGHAN: Thank you.

SENATOR GERRATANA: Thank you very much.

Next is Sheldon Toubman. Sheldon was here before. If he comes back, we can always go back to him.

Let's see, we'll go on to Senate Bill 257. Reverend Michael Christie, followed by Gloria Swenson. No.

CATHERINE LUTZ: I'm not Reverend Christie.

SENATOR GERRATANA: No.

CATHERINE LUTZ: I know. I can't feel a lot of surprise coming around the table. My name is Catherine Lutz, and I represent AVIA Research Biopharmaceutical Company. We've been working with a large coalition of public health providers and disease advocacy groups who had been here today in support of 257, and they had to leave to attend to some childcare and personal care. And I'm not going to be giving their testimony because it's been submitted and you have it.

SENATOR GERRATANA: Thank you.

CATHERINE LUTZ: But they -- yeah, I figured you'd like that would be good news.

SENATOR GERRATANA: Well -- but I -- I -- now I know what's going on.

CATHERINE LUTZ: And so what they just asked me to do was to put their names and their organizations on the record, and to -- to say that they were here and were here to support the bill. Reverend Christie from the Union Baptist Church in Stamford. There were two patients actually currently battling hepatitis C, one representing the Mid-Fairfield AIDS project, Stuart Lane, and a patient from COPA Coalition on Positive Health Empowerment, Gloria Searson. A hepatitis C advocacy manager with the Harm Reduction Coalition, Hadiyah Charles. You should have all of their testimony. I'm sure when you read the stories, you'll understand why they, as a group and individually, were here to urge you to support Senate Bill 257, AN ACT CONCERNING HEPATITIS C SCREENING.

So thank you for letting me articulate their names, and their organizations for the record. As I said, you should have all of their testimony. I believe there are other folks here as well to testify if you have any questions.

SENATOR GERRATANA: No, other than I was reading the Connecticut Hospital Association. They were in here earlier and testified. They had a variety of suggested changes. If you would take a look at their testimony and let us know. I think they're fine, but --

CATHERINE LUTZ: Okay.

SENATOR GERRATANA: -- if you would like to do that.

CATHERINE LUTZ: We will do that.

SENATOR GERRATANA: Does anyone else have any questions? No.

CATHERINE LUTZ: Thank you very much.

SENATOR GERRATANA: Thank you so much for coming. Now I have -- I do have just one followup.

CATHERINE LUTZ: Sure.

SENATOR GERRATANA: And I'll see; I don't know whether all of these people are not going to testify: Reverend Michael Christie, Gloria Searson.

CATHERINE LUTZ: Reverend Christie, Stuart Lane, Gloria Searson, Hadiyah Charles.

SENATOR GERRATANA: And Hadiyah Charles. So the rest are here. Okay, I -- I'm just trying to.

CATHERINE LUTZ: Yeah, they are the folks that left.

SENATOR GERRATANA: Stuart and Hadiyah Charles. Okay. So we would go next to Dan Munson, Mussen. Sorry. Dan Mussen? Thank you very much, Catherine.

DAN MUSSEN: Good afternoon.

SENATOR GERRATANA: Good afternoon.

DAN MUSSEN: I'm here as a representative of the Connecticut Academy of Physician Assistants. Committee Members, thank you for your time today.

I'm going to actually summarize on three bills and try to save some time for you today if I can real quickly. My testimony is already submitted.

SENATOR GERRATANA: We left you out, huh?

DAN MUSSEN: No, you did not. So I want to, first of all, iterate that physician assistants are members of the health care team. We still are very devoted to that -- that role model, and as part of that role, as part of the health care team, I want to summarize ConnAPA's, Connecticut Academy of PA's position on three bills.

One is 257, hepatitis C, where primary care providers will be needed to be tested for hepatitis C. We feel that physician assistants should be part of that bill. As of right now, they are not included in that legislation, so we just -- we feel that as primary care providers that if there's a requirement for testing, PAs should also be there.

I'm going to jump to the Medi-Spa bill which is 418, and I'll just say that ConnAPA was very involved with the development of that legislation. We're very much in favor of compromised language that was presented with that package, and so we are very in favor of that bill as well.

And finally, I'd like to comment on House Bill 5537, the Department of Health Revisions. In Section 43 -- I know you don't have it in front of you, but in Section 43, there is a section that allows for primary care providers to give exemptions for college students receiving meningitis vaccines. So it will be required that all students receive meningitis vaccines, but physicians and PAs should be included in that section, to be allowed to provide that exemption to the college students when applicable.

That's a summary of our positions on all three bills and I wonder if there's any questions.

SENATOR GERRATANA: Thank you. No, you summarized it very well. Are there any questions? No, but thank you for coming and thank you for covering all three pieces of legislation.

Next is Shawn Lang, followed by Carol Steinke. Is Shawn here?

A VOICE: (Inaudible.)

SENATOR GERRATANA: I'm sorry?

A VOICE: He left.

SENATOR GERRATANA: Okay, so Carol, I thought it was s-t-e-i-n-k-e, I believe?

A VOICE: Yes.

SENATOR GERRATANA: And she is followed by Carol Jones. Two Carols. Welcome.

CAROL STEINKE: Good afternoon, Senator Gerratana and Representative Johnson, and members of the committee. I appreciate the opportunity to testify before you today to lend my support to Senate Bill 257, AN ACT CONCERNING HEPATITIS C TESTING.

I'm a public health nursing supervisor for the City of Hartford under the Health and Human Services Division. We're what they call a PSCI model -- Program Collaboration and Service Integration. We cover STD, TB, hepatitis, and HIV. We provide hepatitis C screenings to our clients in the STD Clinic, and also in a mobile health van that goes out throughout the city. We're identifying high-risk patients, but also including the baby boomers now since that's one of the newer recommendations from the Centers for Disease Control.

The 2010 census - U.S. census indicates that there are 1,000,019,042 baby boomers in Connecticut. Baby boomers disproportionately represent 28.5 percent of Connecticut's population, therefore placing Connecticut among the top five states with the highest baby boomer population. Based on these estimates, the Connecticut Hepatitis C Virus Registry has captured 44 percent of the baby boomers exposed to hepatitis C. Therefore, approximately 12,090 still remain; that's 30 percent. 36 percent of the baby boomers still need to be identified.

In our small clinic in Hartford alone, in the last nine months, we've identified 42 hepatitis C individuals; 36 percent of those were baby boomers.

Hepatitis C is a silent killer, where most people have no symptoms, don't know they're infected, and don't seek treatment. We counsel newly-identified hepatitis C individuals and try to help them determine how they might have contracted the disease. It could have come from a blood transfusion prior to the screen that has been improved since 1992, whether they used a one-time drug use back in the early sixties and seventies, or unregulated tattooing that we see.

I, myself, know an individual who had -- was undergoing chemotherapy for leukemia, and was having difficulty managing the drugs, and he came to found out when he did some more testing he also had hepatitis C which he was not aware of, which complicated his -- his treatment and -- and actually caused him an earlier death than they anticipated.

So please support the passage of Senate Bill 257. This will ensure that more individuals are tested for hepatitis C and lead to care and treatment. Thank you.

SENATOR GERRATANA: Thank you. Thank you very much for giving your testimony today. We appreciate it. Are there any questions? No. Well, thank you.

CAROL STEINKE: Thank you.

SENATOR GERRATANA: Next is Carol Jones, followed by Jonathan Raymond. Is Carol Jones here? She is? Is Carol Jones here? Okay. She was with the City of Hartford. I see; okay.

Jonathan Raymond, followed by Stephen King.

Senate Bill 435. Hello; welcome.

JONATHAN RAYMOND: Thank you. Good afternoon --

SENATOR GERRATANA: Good afternoon.

JONATHAN RAYMOND: -- Senator Gerratana, Representative Johnson, and distinguished members of the Public Health Committee.

I, myself, am a member of the Connecticut Funeral Directors Association, and I also served on the food and beverage taskforce, and was honored to do so. I'm also a licensed embalmer at New Britain Memorial Donald D. Sagarino Funeral Home in New Britain, Newkirk, and Whitney and Benjamin J. Callahan Funeral Home in East Hartford, and Glastonbury Funeral Home in Glastonbury where I've worked for the past ten years.

I am here today to testify on S.B. 435, which I believe was intended to prevent non-licensed individuals, specifically consultants, from holding themselves out to be licensed directors, a laudable goal we in the industry can all understand. However, I have some serious reservations about the language as proposed, as I believe it is overly broad and would have some unintended consequences for our industry.

As I read it, if the bill is adopted as it is, it would require that most all tasks conducted routinely in funeral homes across the state, even those as simple as calling a celebrant to conduct services, filing the necessary paperwork to obtain a burial or cremation permit, and filing a death certificate would require a funeral director's license. This would be an extremely costly, devastating blow to the funeral service industry which is already faced with a serious shortage of licensed professionals.

I also have serious concerns about the provision dealing with cash advances. In 2004, the FTC issued an interpretation of the Funeral Rule 16-CFR-453.1, Section B regarding cash advanced items. The rule does not require that funeral providers make cash advances, nor does it require that any particular item be designated as a cash advance item. The rule simply requires that when a funeral provider states or implies that it will make a purchase on behalf of the consumer, that it provide -- that the provider disclose that it charges for its service in buying that item. Compliance with this requirement is intended to dispel any impression created by the provider that the consumer will be charged the same amount as the provider paid for the item. That comes directly from that interpretation.

Finally, while this proposal may be well intended, as currently drafted it has some serious flaws. I respectfully urge the committee to reject this bill as written, and to re-examine its substance. As currently crafted, this proposal would make it nearly impossible to serve the needs of the families in a manner they have so richly -- they so richly deserve and have come to respect.

And I thank you for you consideration and opportunity to testify today.

SENATOR GERRATANA: And we thank you, too. Thank you for your service on the taskforce, also. Did you submit your testimony?

JONATHAN RAYMOND: It's upstairs.

SENATOR GERRATANA: It is upstairs. Okay. Good.

JONATHAN RAYMOND: You will have a (inaudible.)

SENATOR GERRATANA: Because I know you made some suggestions. I didn't write them all down while you were making them, but I appreciate that.

Does anyone have any questions? No? If not, thank you for coming today and testifying.

JONATHAN RAYMOND: Thank you for the opportunity.

SENATOR GERRATANA: You're welcome.

Next is Stephen King on Senate Bill 435, to be followed by John Quinlavin.

STEPHEN KING: Good afternoon --

SENATOR GERRATANA: Good afternoon.

STEPHEN KING: -- Senator Gerratana, Representative Johnson, and the distinguished members of the Public Health Committee. My name is Stephen King and I am the owner and operator of the Mystic Funeral Home in Mystic, and I currently serve as the president of the Connecticut Funeral Directors' Association, otherwise referred to as CFDA, which represents 220 out of the 290 licensed funeral homes here in Connecticut.

CFDA supports and thanks the committee for raising Senate Bill 435, AN ACT CONCERNING THE DEFINITION OF FUNERAL DIRECTING AND DISCLOSURES OF FUNERAL SERVICE COSTS. This bill effectively fills in the details of the duties of licensed funeral directors. This includes various aspects of funeral directing in order to provide for both burial and/or cremation services to families who call upon us in their time of need. The current statute is general, and CFDA feels that there is an imminent need to address the full scope of funeral directing in the interest of the consumer. This bill provides the necessary descriptions and specific definitions of funeral directing.

The language before you in Senate Bill 435 is modeled after Massachusetts statute, and will provide for greater consumer protections. CFDA has found an increasing number of unlicensed internet concierge services, memorial planners encroaching upon the practice of funeral directing by offering funeral services, and goods, and pre-planning services and goods without the necessary consumer protections.

Funeral directors, not memorial planners, are highly regulated by the Departments of Consumer Protection and Public Health. These concierge services offer none of these consumer protections. In addition, CFDA is currently aware of an insurance company that has its agents sell insurance policies with funeral language in the contract. These insurance agents are not employees of funeral homes, and are not licensed by the State as funeral directors.

Furthermore, insurance contracts containing funeral language that is sold by these insurance agents, will likely not be accepted for Medicaid Title 19 purposes, since there is not a funeral services contract with a licensed funeral home. We feel that these individuals hold themselves out to be funeral providers, and unknowing consumers may call upon them in their time of need.

Because of a time constraint, I'm going to skip over this next paragraph dealing with licensing requirements of a funeral director, but I'd be glad to answer any questions at the end.

SENATOR GERRATANA: Actually I think -- I thank you Mr. King. Did you submit your testimony also?

STEPHEN KING: Yes, we did.

SENATOR GERRATANA: You did, okay. It isn't online, and I -- I was, you know, just making sure that you would do so. And I assume you heard the previous person testify, too.

STEPHEN KING: Yes, I did.

SENATOR GERRATANA: And I guess there's some work to be done.

STEPHEN KING: There is.

SENATOR GERRATANA: Yeah. It sounds like the intent is good, but just ironing out those little details.

STEPHEN KING: The CFDA -- we would like to work with the Committee on clarifying any language --

SENATOR GERRATANA: Good.

STEPHEN KING: -- or revisions to the bill.

SENATOR GERRATANA: Good, good. Okay, very good. Thank you. Any other questions? No? Thank you for coming today.

STEPHEN KING: Thank you for your time.

SENATOR GERRATANA: All right.

Next is John Quinlavin. Connecticut EMS Advisory Council, I guess; followed by -- that's -- that's on House Bill 5503, and then we go to Senate Bill 414, Nora Galvin. Mr. Quinlavin, am I saying that right?

JOHN QUINLAVIN: Yes, you are. Thank you very much.

SENATOR GERRATANA: Thank you, sir.

JOHN QUINLAVIN: Thank you for the opportunity. I'm here as the chairman of the Connecticut EMS Advisory Board to share with you the position of the board. These positions were established after a vote at our meeting this past week. We are here to support Raised Bill 5503 with the understanding that this is a bill that was crafted with very narrow focus to identify specific purpose at a very specific location, and we ask that this in no way be misinterpreted to change our position on 5542, which does not support recommendation 5. That's not -- not up here for you today, but just as a future comment.

Moving on, if you don't mind, I'd like to just comment on a few other bills. Thank you very much. We are here to support 413, the MOS bill. We are also here to support 416, the Advanced EMT bill.

A couple of points on that bill: That has been in the works for over a decade. I would ask that the committee members try to separate the emotional arguments from the medical and patient care arguments. We've done a lot of work and tried to identify from the science perspective any clear impact on patient outcomes from that level of care which is provided and we failed to do so. We've asked proponents of that bill, not of the bill, but of maintaining the level to produce anything, even anecdotal, that would support that lives have been saved, and shy of one episode, we've not been able to do that.

So again, the medical community stands firmly behind the removal of that level, in that all the care provided by that level is available through existing providers to the paramedic level.

And I see my timer went off, so 5537, the Department's Tech Bill, we support as well.

SENATOR GERRATANA: Thank you. Thank you very much. That's all very, very helpful.

JOHN QUINLAVIN: Thank you for the opportunity.

SENATOR GERRATANA: Thank you, sir. I don't think there's anyone who has any questions. Okay, good.

We move on to Senate Bill 414, Nora Galvin, followed by Thomas Howard.

NORA GALVIN: Good afternoon. I'm Nora Galvin from Bridgeport. I'm testifying on Senate Bill 414, AN ACT CONCERNING THE DEPARTMENT OF PUBLIC HEALTH'S RECOMMENDATIONS CONCERNING GENEOLOGISTS' ACCESS TO VITAL RECORDS, and I oppose the legislation.

Madam Chairman and members of the committee, I'm a professional genealogist. I own a business, and I earn my living by doing research for other people. Access to Connecticut's large collection of Vital Records is critical to the success of my business.

Except for births that occurred less than 100 years ago, Vital Records are public records in Connecticut. It is the job of the Registrars of Vital Statistics to make the records available to the public when the office is open for business, otherwise they are not public records.

I must confess that this proposed bill mystifies me. DPH testimony says the bill is intended to minimize interruptions in the regular business operations of Registrars' offices. I contend that making records available for research is a regular business operation. There does not seem to me to be a problem with too much research traffic. In my eight year career, I have seen at most two other genealogical researchers in any Registrar's office I have visited. Usually I am the only one there. There are many more people researching property titles than there are genealogists. My experience has shown me that genealogists are accommodating to the needs and rights of Registrars, and vice versa.

The wording of this proposed change is so vague as to be meaningless. Allowing closure of the records at the Registrar's discretion could create a patchwork of hours and days of access that would become a nightmare for any Connecticut researcher. People plan vacations around genealogical research. Imagine flying to Connecticut from say California, and being denied access to vital records. We already had two City Registrars of Vital Records who have declared themselves exempt from the current statute, New Haven and Bridgeport. Is this legislation an attempt to legitimize their restrictions, or the DPH itself which only allows four appointments a week in their office?

In closing, I submit the proposed legislation is vague, open-ended, impossible to define, unnecessary and wrong-headed. I ask you to keep Connecticut in the vanguard of open vital record states, and to vote no on this proposed change. Thank you.

SENATOR GERRATANA: Thank you, and thank you for your testimony today. Are there any questions?

Senator Welch.

SENATOR WELCH: Thank you, Madam Chair. I guess I'm a little bit confused. I don't know if you have the statute or the bill in front of you. What -- what is the language that you -- you contend would deny you access to vital records?

NORA GALVIN: What they're saying is that rather than being able to do research any time the office is open for business, a Registrar could decide on their own discretion that they couldn't allow that on any particular day, and would require a genealogist to come back at another time when there's an appointment -- to make an appointment and come back later.

SENATOR WELCH: Okay, but if -- if you go ahead and -- and schedule an appointment and you have an appointment, it doesn't seem like --

NORA GALVIN: But you don't know -- if you go to the office, they can either let you go in and research at that time, or they can say, I'm sorry, you can't come in today. You have to go home and come back some other time.

SENATOR WELCH: And so under the -- under the current law, you feel you could walk in any time and look at anything you want, and then walk out. Under this change you feel like you won't have that ability.

NORA GALVIN: Well, yes.

SENATOR WELCH: Okay.

NORA GALVIN: And apparently, according to the testimony today, this is mainly in the cities. We don't really have too much problem in town clerk offices.

SENATOR WELCH: Thank you.

SENATOR GERRATANA: Representative Srinivasan.

REP. SRINIVASAN: Thank you, Madam Chair. Good afternoon, and thank you for your testimony this afternoon. What confuses me in -- in what -- what you're opposing is: Yes, if you go to the office and a Registrar happens to be busy, and other things are happening in the office at that particular time, he or she may not have the time available for you to do your work and to take you there. But if you make an appointment, like everybody else, every other thing that we do in life, you know, then where -- where is the problem? Can this appointment be made over the phone? Or you have to go there physically to make the appointment?

NORA GALVIN: Well, that's not made clear, and I will say that if you do try to call certain Registrars' offices, it's next to impossible to get through to a person, and even if you leave a message, they don't always receive it. That has happened to me in Hartford when they did require appointments, and I called and tried to make an appointment and left a message with the Registrar and she said she never got the message. This was on phone mail. So, I mean I think that's a real serious concern.

REP. SRINIVASAN: Well that is a serious, if you're not able to make a phone appointment --

NORA GALVIN: Right.

REP. SRINIVASAN: -- and then come at the appropriate time --

NORA GALVIN: Right.

REP. SRINIVASAN: -- like we do in other walks of life.

NORA GALVIN: Right.

REP. SRINIVASAN: You know, we don't go there physically to make the appointment to come back a week later.

NORA GALVIN: Right.

REP. SRINIVASAN: We do it over the phone and then you show up a week later or five days later, or whatever. So what you're saying is when you try to make these phone appointments, you're not going anywhere.

NORA GALVIN: This was when Hartford required appointments and since one of my colleagues, who will probably address this issue, had an attorney write a letter to the City, they had their attorney read the statute and decide that they had been in error for the number of years when they had required appointments, so now they are open whenever -- whenever the office is open, we can go in.

I must say that when we go to Hartford, for example, or New Haven, which continues to restrict to three days a week, you go in; they check your I.D., you go in and then you have access to the vault, and you're not requiring attention from anybody in the office. It's just simply once you get past, you know, the identification stage. There are -- because there are restrictions on access to certain records, more recent records with Social Security numbers, certain -- sometimes some records are restricted, so it all depends on the setup in the office. But in my case, I don't usually require any help from anyone in the office.

REP. SRINIVASAN: Okay. Thank you. Thank you for the clarification. Thank you, Madam Chair.

SENATOR GERRATANA: Thank you again. I don't think there are any more questions. Thank you. Thank you for testifying. By the way, I'm sorry, Nora, did you submit your testimony.

NORA GALVIN: I did this morning.

SENATOR GERRATANA: Okay, good, good. Very good.

Next is Thomas Howard followed by Antoinette Spinelli.

THOMAS HOWARD: Excuse my coat. I still feel the chill from our field trip.

Senator Gerratana, Representative Johnson, members of the committee, especially my neighbor from the 60th District, given that in the 61st you all know that our Representative passed away and very sadly; we will miss her.

I speak against Senate Bill 414 because it's a bad idea. Actually it makes a good bill -- it makes a good law worse. Genealogists are targeted; that's why I don't like it. They're second-class citizens. As Nora already mentioned, we do some very important bit of research that will help people understand their medical history, that will clear up some of the mysteries of their life, and much, much more.

The problem is the statute as you have it before you addresses something that isn't broken. It's not a problem for 98 percent of the towns. It's not a problem for genealogists. I am a historian as well as a professional genealogist. I helped to bring a conference to Hartford in 2007. I was co-chair, that resulted in about a million dollars, it's estimated by the Chamber, to our economy. I grew up to Hartford and was proud to do it. Genealogy is a great field, and Connecticut is the best in the country for doing research.

The proposal focuses on -- on the purpose of -- that is for the purpose of conducting genealogical research. That's new. Now why? I do historic research, but when has history not included people? We have to do genealogy whenever we do people, and this -- does this open up a new area for me when I'm a historian going and researching a Concord stagecoach from 1857? Do I have to sign in to read land records and probate records? They don't -- I don't need their help finding them, and lawyers don't sign in when they do it, or title searchers. But we have to jump through hoops as genealogists. They have our card, our driver's license on record, and that's only if we need a vital record. This legislation --

SENATOR GERRATANA: Thank you. Thank you, Mr. Howard. Can you summarize for us please.

THOMAS HOWARD: Yes.

SENATOR GERRATANA: Yes.

THOMAS HOWARD: This -- this legislation rewards noncompliance. The cities that want a change have been for two decades not compliant. By changing the law, it makes what they've done legitimate. It's not a good change. I think, you know, the rule of doctors "do no harm"? This is a deterrent to bringing people into Connecticut, the tourist dollars, and I don't think it's going to help us, especially as we try to bring the 2017 conference to Hartford. 2007 was the first one in 25 years in Hartford. Now we have to wait ten years as the cycle for regional conferences plays out. We hope we can really attract them to Hartford in 2017. This won't help.

SENATOR GERRATANA: I agree. Well thank you so much for your testimony today. You certainly made your point and we appreciate that very much. We have your written testimony; it is online.

THOMAS HOWARD: Yes.

SENATOR GERRATANA: I was following along. Does anyone have any questions? If not, thank you so much for coming today.

THOMAS HOWARD: Thank you for your time and your endurance.

SENATOR GERRATANA: Thank you.

THOMAS HOWARD: It's a long day for us.

SENATOR GERRATANA: Antoinette Spinelli, followed by Dr. Robert Rafford.

Is Antoinette Spinelli here? No? All right, then we'll go on to Dr. Rafford.

DR. ROBERT RAFFORD: Good afternoon. I am not she.

SENATOR GERRATANA: No, no. I assumed as much.

DR. ROBERT RAFFORD: Senator Gerratana, Representative Johnson, members of the Public Health Committee, thanks for having me before you today.

I want at the very beginning to say that we as genealogists are highly respectful and thankful to our Town Clerks, our Registrars of Vital Records, the Department of Public Health, and others who protect, preserve, and make available our records.

The question that this committee should be asking today, rather than this legislation is, first of all why don't Registrars of Vital Records know what the law is? Secondly, why don't they follow it? And thirdly, what is the recourse? How do we get Registrars of Vital Records to follow the laws?

I can address those questions later. Today, though, I want to state that genealogists are outraged and appalled by the Senate Bill 414 which would isolate us among all the groups and professions that there are around. It would isolate one particular group from all the others for adverse treatment at Town Halls. This is appalling.

The proposed legislation is wrong, and it should be rejected by this committee and by the Legislature for the following reasons. First of all it would gut the existing provision regarding access to genealogy. That provision was put into the law in 1996. I was there; I helped to write that legislation. Town Clerks helped us with that legislation, as well as professional genealogists. We put that provision in there that said during all normal working hours because, at that time, we were being treated as second-class citizens. If a mother came and wanted three birth certificates, we would have to step aside. We would have to wait for other people to be served because we were considered to be doing something frivolous, whereas the business of other people, other members of the public, was serious.

Secondly it would demand that all genealogists contact the Town Hall before we went there to make sure we didn't have -- to make sure that they didn't require an appointment. Yesterday I telephoned the Hartford City Hall to see if I could get an appointment, or if I could even talk to somebody. The numbers are right there in my report. I could not get through to anybody. This is true about every major city in Connecticut. Registrars simply do not make themselves available and accessible.

The most egregious part of this bill is that it isolates one group. How is this even legal in this day and age, and in this state of Connecticut in 2014, to isolate one group for adverse treatment? I've listed all the other occupations, the agencies, and other people that come to this state, that come to our Vital Records Bureaus and ask for help with the Registrars, but they are not being touched by this bill at all. Genealogists alone are being targeted for adverse treatment. I ask why?

SENATOR GERRATANA: Dr. Rafford, could you please summarize your testimony?

DR. ROBERT RAFFORD: And in summary, this whole thing can be cleared up if people from the Department of Public Health that testified before Dave and Lisa -- I know them; I research next to them almost every week. If they had approached us as genealogists, and if they, and the Town Clerks association would sit down with us, we could work out these problems rather than spending the entire day up here wasting our time and your time. This is bad legislation; it should have been avoided long before.

SENATOR GERRATANA: Well thank you, sir. We do have your testimony which is extensive and makes some very good points, and we appreciate very much that you did take the time to come up and share your opinions with us. They are important.

Any other questions or concerns? If not, thank you very much. Have a very good weekend.

Just making one detour onto Senate Bill 413, Stephen Mendelsohn.

STEPHEN MENDELSOHN: Thanks for the accommodation there.

SENATOR GERRATANA: Certainly, understood.

STEPHEN MENDELSOHN: My name is Stephen Mendelsohn. I'm from the Second Thoughts Connecticut. I also serve on the MOLST steering committee regarding Senate Bill 413. Senator Gerratana, Representative Johnson, members of the Public Health Committee, we in the disability community have a motto: Nothing about us without us.

Last year we opposed the bill to establish the MOLST pilot, in part because of policies that affected not only our lives, but also our deaths as being made without our input. I am happy to say that the Department of Public Health got the message, and has fully included us in the process. I want to thank Suzanne Blancaflor in particular for her support of our concerns. I am also happy to say that we are here to support Senate Bill 413, condition on new language in the bill.

I'll summarize the rest of my testimony. I also want to refer to the testimony of Cathy Ludlum, and also of attorney, Jason Manne, on whom the new language is based. Some of the concerns that we have found is the news that this bill now limits the use of MOLST to people who have an end-stage -- approaching an end-stage condition, or have advanced, chronic progressive frailty, unlike New Jersey, Nevada, and a number of other states. Those two states allow up to people with five years, and the danger of that is of non-stable treatment orders where somebody might fear a lingering death check to refuse the treatments on the form, wind up having a car accident and anaphylactic shock the next day, and they wind up dying. We don't want that.

We also mandate that people be informed of that risk before they get a MOLST. This pink form is very powerful. You know, advanced directive might not be powerful enough. This might be a little too powerful. We want people to know exactly what the risks and benefits are, just like anything else in medicine. We also have the problem of unilateral physician completion, so we require the signature of the patient. I cite, and Jim McGauhey cited a course from California's Protection and Advocacy Agency where that -- where that happened prematurely, killing a patient. We require -- we actually require that there be a conversation about goals for care before we actually use this form, because otherwise what ends up happening is a checklist.

We also have issues with steering people away from burden -- basically so much of the literature tends to demonize, or stigmatize things like feeding tubes, BiPAPs which are used by members of our own organization for long term to live productive lives, and such; I had a bunch of things there.

I cite John Kelly's story in Massachusetts where he was presented with -- he and others who were presented with a form involuntarily. Yet we do want to solve the over-treatment problem, but, you know, there's the clutch factor. There's the problem of the -- the research is not -- the research does not -- is not entirely, so we need -- that's why we need to pilot this, and I also suggest three changes -- three particular changes to improve the bill there.

SENATOR GERRATANA: Oh.

STEPHEN MENDELSOHN: I'd be happy to answer any questions.

SENATOR GERRATANA: Thank you. Yes, we have your four pages of testimony here.

STEPHEN MENDELSOHN: Yes.

SENATOR GERRATANA: And I appreciate all the links also, the hyperlinks --

STEPHEN MENDELSOHN: The links, yes.

SENATOR GERRATANA: -- you know, if you will. And -- and you have in your testimony a couple of recommendations, some tweaking, if you will, to the language?

STEPHEN MENDELSOHN: Yes, there's one type -- there's one thing that's clearly a typo. I'm on the autism spectrum; I correct errors. That's, you know, that's how I am.

SENATOR GERRATANA: Okay. All right. Very good.

STEPHEN MENDELSOHN: Yeah.

SENATOR GERRATANA: All right, and of course we very much appreciate both your work with the department --

STEPHEN MENDELSOHN: Yeah.

SENATOR GERRATANA: -- that is very appreciated. I'm so glad that you were tapped to do that.

STEPHEN MENDELSOHN: This is -- if it still is going to set a role model for the nation to fix many of the problems that we've seen in -- in the other states --

SENATOR GERRATANA: Yes.

STEPHEN MENDELSOHN: -- in so many of the areas that I've cited here.

SENATOR GERRATANA: Yes, yes. It offers protection. It does. You're absolutely right. Thank you, sir. Are there any questions?

Yes, Representative Srinivasan.

REP. SRINIVASAN: Thank you, Madam Chair. Good afternoon, and thank you for your testimony.

STEPHEN MENDELSOHN: You're welcome.

REP. SRINIVASAN: Am I to understand that the -- your recommendations will be incorporated -- is that what you've suggested that we do with the new language, that you're saying, in this bill --

STEPHEN MENDELSOHN: Yeah.

REP. SRINIVASAN: -- the new language that you're -- that you're suggesting?

STEPHEN MENDELSOHN: The additional things -- the additional recommendations at the end of my testimony, you're referring to?

REP. SRINIVASAN: Right. Correct.

STEPHEN MENDELSOHN: Yeah, I think Jim McGauhey mentioned the last one about the pilot needing -- needing to go -- needing to be two years instead of one.

REP. SRINIVASAN: Right.

STEPHEN MENDELSOHN: I mean we're dealing with people -- we're dealing with people who have a life -- the target for this is people who have a -- roughly a life expectancy starting with about 6 to 12 months. We don't want to go through the problem again. As I said before, if you go, you know, too far, then you're having these -- these refusal orders on people who cannot possibly have stable treatment preferences. But we want to have a situation where we can have, you know, people go through that part of the lifespan, and also have enough time to train new people. It's going to take a while to get this up and running properly. It's a very complex and difficult issue. It's not just, you know, people will say it's just about choice and, you know. It's very -- these are very complicated and difficult issues.

REP. SRINIVASAN: Thank you.

STEPHEN MENDELSOHN: The one about religion. Let me just ask that. I don't know if it -- some people -- as I noted particularly in the Catholic world, there's been a lot of -- there's been a lot of controversy. I know people see in the Catholic Medical Association's white paper which opposes this paradigm, it's been very controversial. But, I mean they do -- a number of the concerns we got were actually -- were actually listed in there. What we're seeing -- what we're trying to see is if we can actually fix them. This is -- this will -- what we are trying to do here in Connecticut is to see whether the problems that many of the critics have said are -- are actually fixable. And in order to -- one of the things that we need to understand is, you know, some religious people, for instance, were having difficulty dealing with the checkbox format where you have to check things off ahead of time when, you know, their faith would say it really depends on the situation. So how do we make this compatible? And that's why I think religion belongs in that list along with, you know, race, and language, and disability, and people who tend to have serious issues of undertreatment.

REP. SRINIVASAN: Thank you. Thank you, Madam Chair.

SENATOR GERRATANA: Thank you.

Representative Johnson.

REP. JOHNSON: I want to thank you for your testimony and work on this very important legislation. I think your testimony is very, very excellent, and I just want to thank you for all your -- all your work. Much appreciated.

SENATOR GERRATANA: Thank you, Representative. Any other questions or comments? If not, thank you very much.

STEPHEN MENDELSOHN: I do want to mention one thing though. I just wonder, though, where -- where's compassion and choices on this. They always say they're for choice at the end of life, and they seem to be AWOL on this, and you might want to check out Arielle Levin Becker's article today in CT Mirror.

SENATOR GERRATANA: Thank you. Thank you for coming.

STEPHEN MENDELSOHN: Yeah.

SENATOR GERRATANA: And testifying.

STEPHEN MENDELSOHN: You're welcome.

SENATOR GERRATANA: Okay.

Next, we're on Senate Bill 418 now. Mac Hadden -- Haddow, I'm sorry. Mac Haddow, followed by Dr. Patrick Felice. This must be MedSpas.

MAC HADDOW: Yes.

SENATOR GERRATANA: All right.

MAC HADDOW: Senator Gerratana and Representative Johnson, thank you for this opportunity, and members of the committee. I represent the International Aesthetics and Laser Association, and we strongly support S.B. 418 as it was developed by the Governor's Taskforce.

We believe that it provides a balance that protects the safety of Connecticut residents who seek cosmetic medical procedures and allows consumer access to those procedures to be reasonably available.

The key issue is the training that's required in the legislation for the medical professional who makes the initial patient assessment, and then follows with the treatment that is provided. Those training requirements provide equally to a physician, a physician's assistant, or an advanced practice nurse who conducts the initial assessment and then administers the procedure.

Notices will be provided in each facility describing each practitioner who will provide the medical procedure so that consumers are adequately provided the information that will help them make an informed decision.

You will hear the deliberations of the taskforce characterized in some cases as a compromise from the previous legislation, but I think that misstates what actually occurred. There was an exhaustive examination as to what the standard should be that apply to Med-Spas in the administration of cosmetic medical procedures. The final product that was provided greatly refined the original proposal, and it does, today, provide the right balance between those required qualifications that are necessary for the medical professionals who assess individuals seeking cosmetic procedures and those who ultimately administer those procedures.

This refined proposal is now before you, and we believe it merits your support because it strikes that appropriate balance. Thank you so much, and I'd be glad to answer any questions.

SENATOR GERRATANA: Thank you. Thank you so much. Does anyone have any questions or comments? No. Oh, Representative Johnson.

REP. JOHNSON: Thank you, Madam Chair. Thank you for your testimony. I just was wondering: You started out your testimony by saying that it's -- it's imperative that the person who does the initial evaluation had a handle on the overall condition of the patient, and the type of service that will be rendered in the MedSpa?

MAC HADDOW: The protocol that a -- a medical professional uses to evaluate a -- a consumer who seeks these procedures has to examine the medical history of that patient and evaluate them for the appropriateness of the procedure that they're seeking. So, that's in the bill, and we think it's an important element for that assessment to be made in order to maintain the safety that's necessary for those -- for those consumers.

REP. JOHNSON: We've also included notice provisions for Med-Spas, so people will know who they are receiving care from, and what's available in the MedSpa.

MAC HADDOW: We think that's an important part of the -- of the bill because it does allow for an informed consumer to evaluate who's actually going to provide those treatments. And they are allowed a choice as to whether they want to proceed or not.

REP. JOHNSON: Great. Thank you so much. Thank you, Madam Chair.

SENATOR GERRATANA: Thank you, and oh, yes, I just wanted to make a comment. I don't see your testimony here online, but did you submit it.

MAC HADDOW: Well I tried and I apparently failed, but I'll make sure I follow through on that.

SENATOR GERRATANA: No, we really appreciate it, and I use the testimony actually quite a bit --

MAC HADDOW: Great.

SENATOR GERRATANA: -- as I craft legislation. We all do.

MAC HADDOW: I sent it from an airplane and it obviously didn't send properly, so I'll make sure I follow through.

SENATOR GERRATANA: Oh dear; we won't go there.

Representative Srinivasan.

REP. SRINIVASAN: Thank you, Madam Chair. Good afternoon, and thank you for your testimony today.

Would a medical spa require a medical director, who would the medical director is, or can the medical spa just have A, B, C, and D as their employees, whether they be physicians, PAs or PRNs, and who is the one who oversees the medical spa?

MAC HADDOW: In the legislation, you will see that the medical director can be either a licensed physician, or a licensed physician's assistance, or an advanced practice nurse, and within their scope of practice which is appropriate for the level of services that are provided under cosmetic medical procedures that are provided to consumers, that's an appropriate level of intensity of care and training for the individuals responsible for that.

REP. SRINIVASAN: Thank you for that information. If the medical director happens to be a physician's assistant, would that automatically imply that there would have to be an MD in that -- in that system, because physician assistants need to be supervised?

MAC HADDOW: As a medical director for a medical spa under this legislation, it does not require them to be a physician. Within the scope of practice, and I think this was what the Governor's objection was last year to the legislation that went through, was that for cosmetic medical procedures, the appropriate level of intensity for training can be held by any of those three within their scope of practice because they are licensed medical professionals in the state of Connecticut.

REP. SRINIVASAN: Just by clarification, yes, you're talking about scope of practice, but as we speak right now, unless things change, the -- an APRN has a collaboration with a physician. I'm not sure what's going to happen at the end of the session.

MAC HADDOW: Right.

REP. SRINIVASAN: A PA always has to be under the supervision of a physician.

MAC HADDOW: That's correct.

REP. SRINIVASAN: So it is confusing to me how, in a medical spa, that suddenly a physician's assistant suddenly has a scope of practice where there is no MD that he or she is -- is attached to one way or the other in terms of -- in terms of a supervisor.

MAC HADDOW: The relationship between both a physician's assistant and the collaborative agreement with an advanced practice nurse covers a broad spectrum of services that they provide to patients, and what we looked at in the taskforce was what's the appropriate level of medical training that's needed for a person that would be at a medical spa, given the kinds of procedures that are administered there. And based on that, the recommendation in the legislation is that that medical director, for a MedSpa can be either a licensed physician, licensed physician's assistant, or the advanced practice nurse, all of which have specific requirements under their licensing and training requirements under the -- the various sections of the code that apply to them.

REP. SRINIVASAN: And my final question is, so in these procedures, and I'm not sure of the list of the procedures that are done at a medical spa, but I will go and look it up, in these -- all the procedures that are done in a medical spa can be done by either of the three professionals, whether it be an APRN, a PA, or an MD.

MAC HADDOW: With one caveat, with the proper training, and that's within the legislation requiring the training where the specific kind of procedures.

A physician can go through medical school and never touch a laser for example. They need training in order to do this. So with the license that's provided, that gives them that authority, they then have to have the additional training that's specific to the procedures that are being provided to a customer in a MedSpa.

REP. SRINIVASAN: Thank you for the clarification. Thank you, Madam Chair.

SENATOR GERRATANA: You're welcome. Are there any other questions? If not, thank you very much for coming today and giving your testimony, and I know for your help with the taskforce, also.

MAC HADDOW: Thank you.

SENATOR GERRATANA: Thank you, sir.

Next is Dr. Patrick Felice, followed by Dr. Donna Aiudi.

Welcome. Your microphone is not on. I'm so sorry. Could you just identify yourself into the microphone. Thank you.

DR. DONNA AIUDI: Donna Aiudi.

SENATOR GERRATANA: Thank you.

DR. DONNA AIUDI: I'm a board certified dermatologist, a board eligible internist, and I'm the current president of the Connecticut Dermatology and Dermatologic Surgery Society. I've been in private practice for 18 years. My practice is both general and surgical dermatology, and I do have a small cosmetic practice. I also employ three nurse practitioners within our practice.

At this point I'm offering testimony supporting Senate Bill 418 AAC, with the Department of Public Health's recommendation concerning medical spas as a first step in protecting patients.

I support it with some reservation, and I think my reservation lies with the points that Representative Srinivasan made regarding the role of a medical director, and whether that medical director can legally, or should legally be a nurse practitioner or a PA.

I know our -- our Society was in support of the original bill that was submitted last year requiring a medical director to provide direct supervision of medical spa facilities, but because this board -- this bill was vetoed, we feel that the current bill provides the next best provision for safety.

I realize that the Department of Public Health as well as my colleague, Dr. Phil Kerr, spent numerous hours kind of going through and coming up with a bill that would best meet the requirements, while not limiting the scope of practice of the APRN and the PAs.

I think it's in part problematic because there really are no standard -- standards of care for physicians, PAs, or APRNs in the practice of -- of this -- of this cosmetic medical dermatology. Within my training I did receive, I received training on laser safety, proper use of lasers. I received training in cosmetic procedures. I go to our yearly meetings and update my knowledge in both anatomy, physiology, new techniques. I know within our Academy that those -- those courses are limited to physicians within the practice of dermatology.

The degree of training that different people can have is varied. You can be trained by a pharmaceutical representative in the administration of some of these substances, so we don't have good -- good guidelines at this point, but in light of the lack of any certification or regulation, I think that this bill at least provides a modicum of some of the safety issues, as well as transparency issues to the patients and consumers who will be utilizing these services.

So it should be clearly delineated what specialty a physician is practicing in, what -- whether they are an MD, an APRN, or a PA, and I also -- I think that's basically about it. I think it's imperative amongst our specialties of dermatology: plastic surgery and ear, nose and throat, to continue to monitor outcomes, because as we see in the literature, many of the complications that have occurred, 70 to 80 percent -- I have some written testimony from our American Society of Dermatologic Surgery -- they occur in unsupervised settings. So I kind of feel like we're in the wilderness as far as these medical spas are concerned. I feel like it's a currently evolving field, but that this bill does provide a first step.

SENATOR GERRATANA: Right. Dr. Aiudi, I would agree. I think it is evolving and we shall see. I am glad to see the language in front of us. At least we're addressing it which I think is what your testimony basically says, you know, in support, and that this is really a concern and something that we have to get a little handle on. There is no -- I don't believe there's any designation of a medical director. I think that was in the old language.

DR. DONNA AIUDI: That was in it, uh-huh.

SENATOR GERRATANA: Right? And that was taken out. But we did put in Lines 33 to 35: Any cosmetic medical procedure performed, and we define what that is in the bill, at the medical spa shall be performed in accordance with the provisions of Titles 19a and 20 of the General Statutes which are our Practice Acts. So all other consider, you know, all the law remains the same, but that we also put in there the requirement for additional training. You can't do any of these things unless you have that additional training, and also subject to the Medical Practice Act. So I think that's very appropriate.

I thank you very much. Do you have a question for her?

Yes, Representative Srinivasan.

REP. SRINIVASAN: Thank you, Madam Chair. Thank you, Dr. Aiudi for coming out here and testifying in front of us today. Could you tell us what the experience is, or the training, the one that Chair, Senator Gerratana just referred to, that if I was an MD, you know, an MD just practicing family medicine or internal medicine, and then one fine day I decided, you know what, let me go into this cosmetic surgery. Let me get trained, obviously get trained first, and after training, open up my own business, or whatever. The fact that I'm an MD, I'm a PA, or an APRN, when that person gets the idea that let me do this, could you just educate us as to what the training would involve, so that at the end of the day I can open up a shop and tell my patients now I am training in cosmetic surgery?

DR. DONNA AIUDI: Well that's the problem. I think there is no standardization of training. I think you can purchase a laser and be trained by the laser company. Oftentimes it is a nurse trainer who will come in and go over just the operational part of the laser, and -- and they do go over safety and some basic guidelines, but it's usually an afternoon of hands-on training with the equipment. In addition, the representatives from the various fillers, Botox, neurotoxins, they oftentimes will have a nurse -- it oftentimes is a nurse practitioner, nurse trainer, who will come in and train somebody. It's usually a session of a couple of hours.

So, I mean you really could go out with very, very limited training and perform these procedures under the scope of a medical license. You can also take it much further. I know within our Academy there are courses on anatomy. There are courses on technique. There are hands-on training courses, but there is no actual standardization or certification process at this point, and I think that's what makes it so problematic. We employ three nurse practitioners and we do hands-on training with them. We have them -- we observe them -- we observe their technique. We observe, you know, to make sure that they're knowledgeable of any complications that can occur before we will sign off on them performing a given procedure like Botox or a filler. In our practice we don't allow them to progress to something more substantial until we would feel they're ready, and -- and we place limitations on -- on some of the things that we feel they're capable of doing, particularly since they're under our license and our malpractice -- they're under our malpractice.

REP. SRINIVASAN: Thank you very much. So if I glean from what you're saying, you have a couple of hours training one afternoon, a Friday afternoon, or a Monday afternoon, or a Saturday morning. One of us, or any of us, you know, with the background of the three professions could become a cosmetologist, or whatever you call them.

DR. DONNA AIUDI: Right.

REP. SRINIVASAN: I mean minimum. You're right, as you said, you could go on and go to anatomy and all of that or the other, but if I chose not to do all of that, just in one afternoon and another morning, I could be able to do these -- these procedures. Is that -- ?

DR. DONNA AIUDI: That's correct.

REP. SRINIVASAN: Thank you. Thank you, Madam Chair.

SENATOR GERRATANA: Thank you. Are there any other questions? No? Thank you for your testimony.

DR. DONNA AIUDI: Okay.

SENATOR GERRATANA: Next is Donna Montesi, followed by Donna Sanchez.

DONNA MONTESI: Hello. Senator Gerratana --

SENATOR GERRATANA: Yes.

DONNA MONTESI: -- Representative Johnson, and members of the Public Health Committee, thank you for hearing this bill.

My name is Donna Montesi Enters. I'm an adult nurse practitioner working in the New Haven area. I provide care to geriatric patients residing in their homes and in skilled nursing facilities. I am testifying in support of Raised Bill No. 1 -- of 418, AN ACT CONCERNING THE DEPARTMENT OF PUBLIC HEALTH'S RECOMMENDATIONS CONCERNING MEDICAL SPAS.

As a clinician, I appreciate the extent of effort that was directed at reviewing the 2013 bill and drafting this bill. I was present during the MedSpa taskforce meetings as a representative from the Connecticut APRN Society.

The new definition of what constitutes a cosmetic medical procedure will provide safer practice. Under this legislation, it will now be necessary for each client to have an initial physical assessment performed properly by licensed personnel before undergoing a cosmetic medical procedure as defined in the law.

Consumers will be protected under Raised Bill No. 418. This is a good bill. The bill will also allow current APRN-owned medical spas to stay open in Connecticut. It allows APRNs to maintain the ability to work to their full scope of their practice in accordance with existing practice acts.

I urge you to support this bill. Thank you.

SENATOR GERRATANA: Thank you very much. Are there any questions? I guess not. Thank you for coming and giving testimony.

I hear Doctor -- well, I did announce Donna Sanchez, and then after that I hear Dr. Felice might be here? Yes, good. Go ahead, Donna.

DONNA SANCHEZ: Good afternoon, Senator Gerratana and Representative Johnson. My name is Donna Sanchez and I'm a certified registered nurse anesthetist, and on behalf of the Connecticut Association of Nurse Anesthetists, we support the Senate Bill 418.

The current language of the bill, Senate Bill 418, does much to ensure the welfare of Connecticut's residents. This language comes forth from the working group of healthcare professionals who spent many hours discussing line by line what best to serve and protect Connecticut's residents. We believe the original intent of the bill was to put some structure and -- and uniformity to the facilities that label themselves as MedSpas, and to ensure that the petitioners who practice the procedure have some accountability to our Connecticut residents.

The bill was also designed to add a level of safety for those pursuing by ensuring that the procedures were done by qualified personnel and that the people who are receiving them were indeed healthy enough to undergo these procedures, especially in light of the fact that these were not things that would improve, preserve, or enhance their overall physical health, or their physical functioning. These procedures are not lifesaving, nor are they medically necessary.

During the workgroup we discussed many of the issues that came up from this bill. We defined what exactly is a MedSpa, who can call themselves a MedSpa. We outlined the types of procedures that would be done, even to the detail of the percentages of the chemical peels to be used, the layers of the skin that would be interrupted or worked on, and even -- even who can and what can -- what devices that we could actually use to achieve the end.

So I think that we've done our duty by making sure that these facilities protected the Connecticut residents from harm. Furthermore, as the bill is written, it does its due diligence and by clearly identify who would be responsible to perform these -- these procedures by virtue of their licensure and their training. It also identifies who is accountable to perform the needed physical assessment prior to the start of the procedure, all key factors in ensuring that these procedures were made as safe as possible.

Bill No. 418 provides the Connecticut residents with transparency by knowing just who was performing these procedures they seek by legislating that the facility must provide updated information on the credentials of their personnel, not only on their web sites, but on their advertisements.

I believe it is unrealistic to think that law can mandate by their very virtue of existence anything or everything possible that can go and harm Connecticut's residents, but I believe this bill can at least eliminate some of the common elements that lead to the potential for harm.

Thank you for the opportunity of talking to you today, and also for the ability to work -- be part of the workforce group on this issue.

SENATOR GERRATANA: Thank you very much, and thank you for your testimony. I don't think anyone has any questions, so that will be fine. Okay.

Dr. Felice, to be followed by Christine Zarb.

DR. PATRICK FELICE: Good afternoon, Senator Gerratana and Representative Johnson, distinguished members of the Public Health Committee.

I'm Dr. Patrick Felice and I am here today as the president of the Connecticut Society of Plastic Surgeons, and on behalf of the Connecticut State Medical Society to speak on S.B. 418, AN ACT CONCERNING THE DEPARTMENT OF PUBLIC HEALTH'S RECOMMENDATIONS CONCERNING MEDSPAS.

You may remember that I was here last year testifying -- I think it was about 1 o'clock in the morning, so this is much better.

I spoke about this issue. I discussed the explosion of MedSpas around the country, and the variety of injuries and even deaths that have occurred in these facilities. I felt grateful that we were able to pass this important legislation last year overwhelmingly in both chambers. Our original bill would have established standards and safety provisions that we believed were critical. Unfortunately that bill was vetoed by the Governor, referencing among other issues undue burden on small business.

At the Governor's request, a workgroup was created in an effort to reach a compromise. I would personally like to thank Senator Terry Gerratana, Anne Foley from the Governor's staff, and Wendy Furniss from GPH for their involvement in this sometimes difficult process. In my mind compromise is difficult when talking about patient safety.

To be clear, MedSpas are facilities where surgical and nonsurgical procedures are performed. Currently there are no licensure requirements in Connecticut and therefore there is no regulatory oversight by the Department of Public Health, no facility inspections, no infection control requirements, or other patient safety and quality of care guidelines as we have in place for hospitals and ambulatory surgery centers.

Several states have moved to regulate these facilities, with our neighbor Massachusetts requiring licensure as a clinic. Understand that currently in some MedSpas procedures are performed without supervision -- physician supervision, and without patients being seen or evaluated by a physician. This fact will not change under S.B. 418. While we did not favor the language, an actively-practicing physician medical director was also eliminated from the bill before you today.

Please understand that in my own practice I have seen patients who have been treated in facilities without physician oversight and have needed corrective intervention. The DPS -- DPH has documented a number of proceedings filed against designated providers in MedSpas for inappropriate or illegal actions.

The bill before you today looks at MedSpas in office setting, and therefore only provides licensed providers to provide services. No need for physician oversight. This hardly raises the bar for safety. Remember, this very committee passed legislation to address safety concerns in physician office settings several years ago when you required physicians' offices that provided certain levels of anesthesia to become licensed as outpatient surgical centers. Who is checking and who is responsible under this bill? I'm not sure that issue has truly been addressed and the public wants to know where does the buck stop?

In summary, I have attached language that we had suggested after our last working group meeting in an effort to address one aspect of our concern with this proposal. As you review it, I ask you to ask yourself how could more disclosure to the patient be a bad thing.

I hope with this added language to S.B. 418 that we will be improving the safety and well being of patients that access care in Connecticut's MedSpas. I'm not just -- I'm just not completely convinced that short of licensure and physician oversight that this will occur.

As a final thought, a mentor of mine once said to me when I finished my training: We need not fear the conscientious providers who know what they don't know. We must be fearful, however, of providers who do not know what they do not know, and that really goes to training and who is doing these procedures.

Thank you for your time.

SENATOR GERRATANA: Thank you, sir.

DR. PATRICK FELICE: We've also, by the way, included in the packet, a CBS News article on -- they did -- they did a survey of medical spas around the areas and documented some problems with those MedSpas and various complications that have occurred. There's also, in your packet, the -- the California regulatory site that has had issues with MedSpas, and there are several questions they ask the public to ask when they are going to MedSpas --

SENATOR GERRATANA: Right.

DR. PATRICK FELICE: -- and I think that's a great site.

SENATOR GERRATANA: I didn't see, though, attached to your testimony alternate language. Did you submit that electronically? Maybe I --

DR. PATRICK FELICE: Yeah, we had submitted -- we feel it's very important to -- although it's not required under Statute, we require that the medical director component stays, so those of us who are medical directors would recognize that.

SENATOR GERRATANA: Okay, so did you put something in writing regarding that?

DR. PATRICK FELICE: Yes.

SENATOR GERRATANA: You did? Okay. Now I do have your testimony, and I -- should I extrapolate from your testimony the points that you think should be included in the bill, or -- I'm confused. I thought you said you had attached something to this testimony, but we don't have that. That's what I'm looking for, and that was the changes -- but, it was submitted?

DR. PATRICK FELICE: I think Lisa is bringing it up there now.

SENATOR GERRATANA: Okay. Very good. So long as we have it. I just wanted to make sure it's not embedded somewhere in your testimony. It was actually sent. Okay. Very good.

Are there any questions?

Representative Srinivasan.

REP. SRINIVASAN: Thank you, Madam Chair. Good afternoon. Thank you for your testimony this afternoon. Just for our clarification, you're going to submit some language which is on its way suggesting improvements, or suggesting how we should alter Raised Bill 418, because the concerns that you have are exactly the concerns that I have, and that was what I was trying to get to to the people who spoke ahead of you on this bill in terms of oversight, in terms of experience, in terms of, you know, how they learn these procedures, so on and so forth, and I mean it's appalling that you could be in a -- in a half-day session, or a one-morning session, one afternoon or one morning, you could suddenly be a -- I mean, you could have the technique and the knowledge to do these, and I'm not so sure how you would handle the, you know the complications which, you know, unfortunately can and will occur in any medical procedure.

Could you comment on the fact that one -- one of our colleagues earlier on in the testimony who didn't like the bill all the way, but at the end of that said that this bill is a reasonable bill, a good first step, and to move on? Is that how you also feel, that this is a good first step? Or without -- without those changes, this would not be a good first step?

DR. PATRICK FELICE: No I feel the bill that the Chamber passed last year was a good first step. Taking out the medical director does nothing but lower the bar. Now although we can't require, through Statutes, everyone to have a medical director, I still think the very thought that anybody can be a medical director but a physician is ludicrous. There's no hospital in the nation that a medical director is not a physician. I don't think we should just throw that term around lightly. Being a medical director requires a lot of training and aspects of medicine that physicians have, and we felt that if the statutes require -- or do not require the use of a physician in a medical spa, why is the medical director being removed when those of us that do run medical spas, that are medical directors, should be recognized by the public for such. We're not saying that they have to require it for everyone, but through transparency and what we put into this bill through the workgroup, I think we agreed on the majority of things. We made transparency a very big issue through advertising, through the websites, through conspicuous places in the waiting room, and the person that's responsible for that MedSpa has to answer to those patients. If they don't want a physician medical director for that added security, that's fine. But why take it out when a medical director in other facilities is there? So we want the medical director component to stay.

REP. SRINIVASAN: Thank you, and if I may one more followup question. Thank you, Madam Chair. How do you feel when our colleagues -- physician colleagues, who are not in this particular field of specialization -- they're not dermatologists, they're not plastic surgeons, say for example, somebody like me, an allergist, takes a course and then says, you know what, on the side, along with my allergy injections, I'll be doing Botox, and I'll be doing that as well? Are you comfortable with that, or even in your opinion, that training is not adequate, even though the person providing the service happens to be an MD?

DR. PATRICK FELICE: Well I think you know, the MDs, irregardless of their specialty, certainly we feel that dermatologists and plastic surgeons are specifically trained in this area for the same reason that I don't do brain surgery; I don't go off and do endoscopies and things that, you know, I'm not trained to do. However, for a medical spa community, physicians at least have extensive training through medical school and residency where they're doing, irregardless of our specialties, from primary care throughout, we do a pretty extensive residency to where you do a number of procedures; you do a lot of basic science toward these things that -- that you have a better understanding of -- of what's going on. I think with regard to complications and how to treat them, you get a better understanding of those type of things. Our feeling was, with regards to even the basic medical knowledge of evaluating the patient's suitability for these procedures, I think a physician can do that. And it's not that an APRN or PA can't evaluate that, but I think there's a different level at the MD level that we've done residencies; we've done extra training, and I think the majority of them can pick it up pretty quickly by being trained by plastic surgeons or dermatologists. And that's -- that -- I don't really have a problem with that.

REP. SRINIVASAN: Thank you very much. Thank you, Madam Chair.

SENATOR GERRATANA: Are there any other questions? Dr. Felice, before you go away, I thank you for submitting your language. Unfortunately, it's very similar to the language that the Governor vetoed last year, and I ask you this sir: Would you be in favor of the legislation that we have before us, or would you rather have no legislation.

DR. PATRICK FELICE: No, it's not similar to what the Governor vetoed. The Governor vetoed the requirement for a medical director.

SENATOR GERRATANA: And that's in here.

DR. PATRICK FELICE: What we're -- what we're asking is that the medical director component stay as -- as someone that -- a facility can have a medical director. It's not required, but it can -- they can have a medical director. So in our advertising or our disclosure to the public, we can say our medical director is Dr. so-and-so.

SENATOR GERRATANA: Well, in essence the bill that we have before us doesn't specifically say a medical director. You're just using may be a medical director, but the bill that we have before us actually does provide for similar situation that there would be the list of who it is, who would be doing what, contained in the -- in the advertisements, so that would be disclosed. When you say credentials, does that mean -- ? Actually, I would have to ask what do you mean by a list of their credentials in this language.

DR. PATRICK FELICE: If I were to go to a medical spa, I would want to know what are the credentials of the individual that is going to treat me?

SENATOR GERRATANA: What do you mean by that?

DR. PATRICK FELICE: What's their training? What's their board certification? What's the board certification in? Where did they get their training to inject my face?

SENATOR GERRATANA: Okay. So are you saying it would be for instance: Jane Smith, MD, board certified in gastroenterology?

DR. PATRICK FELICE: Correct.

SENATOR GERRATANA: I see, and the same thing with an APRN.

DR. PATRICK FELICE: See, the part --

SENATOR GERRATANA: So you feel that the advertisements and the information that would be there wouldn't be sufficient? It says each medical spa facility shall post notice of the names of any specialty areas and so forth and so on. That's not sufficient?

DR. PATRICK FELICE: We -- we would like to see -- we -- we essentially compromised during the workgroup on the need -- or the requirement --

SENATOR GERRATANA: The need for disclosure so that when people -- when people go there, they will know who the healthcare professionals are that is rendering the service --

DR. PATRICK FELICE: Right. Right.

SENATOR GERRATANA: -- or the people who are involved. Okay.

DR. PATRICK FELICE: I -- I was getting back to the medical director component.

SENATOR GERRATANA: Uh-huh.

DR. PATRICK FELICE: We -- we agreed that we won't require it, but the Governor vetoed it because he felt that was an undue burden to require a medical director. We said well, under the Statutes, independent, whatever they -- they can practice under their Statutes, we would agree to that; however, we felt that the medical director, if available, should still maintain some position in medical spas.

SENATOR GERRATANA: Right, and if you recall during the taskforce that it was very difficult to define, at that point, what the medical or who the medical director would be given the other considerations that we were discussing. So to go back to that reference to a medical director, even if you say that maybe it should be -- or I think you say here, the physician whose license pursuant to Chapter 370 of the General Statutes may be a medical director.

I don't understand why we would even have to put that into the language of the bill.

DR. PATRICK FELICE: Because that's a physician's -- that's what the physician holds in -- in this bill. The physician holds that they can be a medical director. While -- while others may open medical spas, the public needs to know that a medical director is a physician. And I don't see any problem with leaving that in the bill, because essentially what you're doing is taking away a title from a physician. We've earned that title as medical director. And it's fine with us if other people do not want to use a physician/medical director, but why would that be taken -- why would that be an issue?

SENATOR GERRATANA: No, no. Your -- your language is -- it's incidental if you learn my way I interpret it. I just didn't understand why it would be incidental that way to put into Statute. But I appreciate your testimony very much. Are there any other questions? If not, thank you, sir --

DR. PATRICK FELICE: Thank you.

SENATOR GERRATANA: -- for coming today and giving your testimony.

Next is Christine Zarb, followed by Mark Ginella.

CHRISTINE ZARB: Good afternoon --

SENATOR GERRATANA: Good afternoon.

CHRISTINE ZARB: -- Senator Gerratana, Representative Johnson, and members of the committee. My name is Christine Zarb, and I'm a nurse practitioner, and owner and operator of a small boutique MedSpa in Wilton, Connecticut. I am here today to declare my support for bill number 418.

To quote my first medical director upon entering the aesthetic medical field: Aesthetic medicine is a marriage of art and science. She understood that it is not enough to merely know how to do a procedure. One must also have an aesthetic sensibility, know when you can or cannot achieve a certain result, excuse me, and know when the work is completed.

Not any one discipline of medicine owns the franchise on aesthetic acumen. I truly appreciate the combined efforts of -- of Legislators, the American Society for Dermatologic Surgery Association, and the Connecticut Society of Plastic and Reconstructive Surgeons for originating the original bill to make our industry safer.

Although I didn't agree with the original bill because it conflicted with the APRN Practice Act, I agreed with the intent of it. I appreciate the Governor's efforts to bring together the various professions that make up the aesthetic industry. As a result of this collective taskforce, the language has been revised in the current bill to include important definitions, and recognize the expertise of other providers that perform many of these services in this industry, specifically NPs, RNs, and PAs.

My observation over the past ten years working in the aesthetic medicine field has been that it is collegial. The first course I took to learn how to inject was taught by an RN, and my fellow classmates included physicians. During the course -- during the course of my aesthetic medicine career, I've not only honed my skills under the tutelage of NPs, RNs, and MDs, but I have trained others, including physicians in a formal professional capacity, as well as informally during the course of practicing in the York office.

This past fall I was privileged to attend one of the medical spa workgroup meetings held to write this bill. One of the concerns voiced by a physician in the group was regarding training and continuing the education of providers who are not dermatologists or plastic surgeons. It occurred to me that perhaps there is a knowledge deficit about the vast amount of training available in aesthetic medicine. To help clarify, I have assembled a short list of professional organizations that offer professional membership and certification tests, and it's attached to my testimony.

I care about my industry, and I care about public safety. If I could be of service to the committee on matters of aesthetic medicine as this bill moves forward, it would be my pleasure to serve you, and thank you for this opportunity to testify in support of Bill 418.

SENATOR GERRATANA: And thank you, Ms. Zarb. It's -- it's very appreciated that you actually list the professional organizations, and the certifying exam and so forth, and that was what we were talking about in the legislation. I wasn't even aware of that. Okay. Thank you so much. Are there any questions? No.

Thank you for coming today and giving your testimony. Next is Mark Ginella, followed by John Lynch.

MARK GINELLA: Senator Gerratana, Representative Johnson, and members of the committee, I apologize for my sartorial splendor. I didn't think I'd be given public testimony today. I thought I was going to be in the gallery.

A little historical perspective: Last year Bill -- by the way, I'm sorry -- the managing partner of Radiance MedSpa in Avon, Connecticut. Last year, when Bill 1064 was crafted without input from the various stakeholders who provide a bulk of the noninvasive cosmetic services in Connecticut, the MedSpa owners, APRNs, RNs, and PAs were made aware of the bill, and we organized a veto request from the Governor's office on the basic fact that it did trample on the Scope of Practice Statutes in the State of Connecticut. The Governor, in his wisdom, saw it that way, and in fact did issue the veto.

I had the privilege to serve on the Governor's taskforce which was called upon to craft legislation with all of the aforementioned stakeholders, as well as the plastics and the dermatologists. One of the first questions the taskforce dealt with was assessing the number and severity of injuries that have occurred in Connecticut MedSpas. Again, not MedSpas in Florida or California, or anywhere else in the country, but here in our state. And there were none. There was no data.

We asked Wendy Furniss; we asked all the appropriate people that would have that data and -- and there just -- there wasn't any there. You're going to see the term "wild west" used in some of the testimony before you to describe the MedSpa industry in our state, but we have some of the stringent Scope of Practice standards of any state in the union. We took an informal survey of the eight or nine MedSpa owners that, you know, I was representing, and thousands and thousands of procedures have been performed: filler injections, Botox, laser hair removal, and none of us have had a single claim against our medical malpractice insurance.

We had in-depth and frank discussions on patient safety, and we believe that the language before you will be more than adequate to ensure that Connecticut will continue to be one of the safest states to receive cosmetic treatments in a medical spa environment, and it will also ensure consistent application of scope of practice across all the medical industry. Thank you.

SENATOR GERRATANA: Thank you so much, Mark. I call you Mark, because I got to know you with our work in the taskforce, and I appreciate very much that you -- you came up here. I was very impressed during the taskforce that you were the one who constantly challenged and pushed back a little bit, because you're out there working in reality in this field. So that was a very valuable contribution.

MARK GINELLA: Well if I can just say to the committee, having been here since 11 o'clock, I have a new-found appreciation for what our Legislators go through. I would never do it. You guys are great.

SENATOR GERRATANA: I think -- I think when you first came in you thought, oh, a State Senator.

MARK GINELLA: This is unbelievable, what you guys go through, fire drills and all (inaudible).

SENATOR GERRATANA: This is out job, so thank -- thank you, sir.

Yes, John Lynch, thank you, followed by Susan Yolen.

JOHN LYNCH: Senator Gerratana, Representative Johnson, and members of the Public Health Committee, on behalf of ProHealth Physicians, its 351 primary care providers and its over 350,000 patients, thank you for the opportunity to testify today.

My name is John Lynch. I am vice president for research at ProHealth. I am here today to support passage of Senate Bill 413. We applaud the Department of Public Health and the Governor's Office for bringing forward this legislation that will provide our patients an opportunity to discuss their desires for life-sustaining treatment with their primary care provider well in advance of crises of a life-threatening situation, and to have their desires be part of their ongoing medical record.

In this patient-centered medical home environment, more and more of our patients are expressing a desire to avoid spending their final days hooked up to all kinds of medical equipment in a critical care unit. They would rather spend their final days in their home, surrounded by family and friends, in a warm and comforting environment.

The MOLST would be a portable document, both paper and digital, that would accompany medical records, and allow the patient to choose medical treatments they want to receive, as well as medical treatments they do not want. These documents will provide healthcare providers directions during serious illness, and allows healthcare providers to know, and to honor wishes for end-of-life care. These documents will transform the patient's treatment plan into actionable medical orders, to be followed regardless of the patient's healthcare setting.

I would recommend one minor change to the proposal. Limiting the pilot to one year is extremely short. It will take time for the Department of Public Health to develop regulations, and for pilots to be selected and gear up. If the results of the pilot work as good as we expect, we wouldn't want to deny the opportunity to patients while waiting for the next legislative session to approve full deployment.

Please provide sufficient time for the pilot and the opportunity for the Legislature to reconvene and pass followup legislation. We are willing to work with the Department of Public Health to develop mechanisms to make the most documents workable and flow smoothly with our electronic health records. We have attached to this testimony a model MOLST document that is used in Massachusetts, to provide members of the committee with the best idea of what these proposals could look like if implemented.

Thank you for your time and attention, and I hope you can support Senate Bill 413.

SENATOR GERRATANA: Thank you very much for your testimony today. I have gone online also just to see what some of these forms look like, if you will, so that is very helpful that you attached it.

Does anyone have any -- yes, Representative Sayers.

REP. SAYERS: Thank you, doctor. I'm just curious. How is this different from what we have now for Advanced Directives, or a Living Will?

JOHN LYNCH: This goes beyond those, in that this is a situation where a physician and a patient can sit down, not even just a physician, but primary care, practicing APRNs, PAs, et cetera, can sit down in a conversation with the patient well in advance. If you look at the sample forms, for example, it talks about, you know, are you willing to -- do you want intubation? Do you want noninvasive ventilation? Would you like dialysis, artificial nutrition, et cetera? So I think it goes well beyond many of those other aspects.

REP. SAYERS: And one of the reasons why I asked the question is I do some home-care nursing, and one of the things I find, because on the Oasis, which is the Federal form for -- assessment form, it asks them if they have made these decisions or filled out any of these forms, and I find most people have not. And, in fact, when you ask them the question on the Living Will, the response I get is, "I know who my money is going to, but I haven't written it down yet." So it tells me they truly don't --

JOHN LYNCH: Right.

REP. SAYERS: -- even have an understanding of what the question that I'm asking them. So I'm just wondering, that was one of the reasons why I'm asking --

JOHN LYNCH: Yes.

REP. SAYERS: -- why is this different. And we're not really -- we're not seeing, and yet I know frequently, when I go to health fair, sometimes from the AG's Office I'll get copies of the information for making those out, and they -- they disappear because people are interested in looking at that, but they just --

JOHN LYNCH: I think they're looking for education.

REP. SAYERS: -- they don't take it to the next step.

JOHN LYNCH: They're looking for education. I think they're looking to express their patient-centered opinion, and I think that's what this bill potentially opens up is that opportunity to have that frank and honest discussion about what they want.

REP. SAYERS: Then I think maybe the next question: Do you -- do you think that most physicians are comfortable having this discussion, because I think that is somewhat -- could be somewhat problematic.

JOHN LYNCH: I -- I can't say that physicians are all comfortable, but I -- I do know that we have a number of physicians that are very interested in this bill because they believe in it. I know we're having a lot of new discussions going on with nursing homes, home care, et cetera, how do we work better together, and this is one example of where -- how do we help each other out in that whole process between primary care, nursing home, home care, et cetera. We've got to work -- work these things out and be able to allow the patient to express their opinion so that all of us understand what it is, across the continuum is traditionally tough to follow.

REP. SAYERS: Yeah, and I know from past legislation we've done around Do Not Resuscitate orders in nursing homes, it's problematic when you have someone that is 98 years old and at the time. A lot has since changed. The EMS comes and has to do CPR on someone who's really frail and really not a candidate to do CPR, because it's not in their best interest, so thank you.

SENATOR GERRATANA: Thank you very much.

Next is Susan Yolen followed by Carin Van Gelder, Dr. Van Gelder.

A VOICE: Dr. Van Gelder had to go to work.

SENATOR GERRATANA: Oh, well.

A VOICE: (Inaudible.)

SENATOR GERRATANA: Okay, and I don't see Susan Yolen.

Tracy Wodatch. Is Tracy here? She's not here either. Okay. I know their testimony is online. Cathy Ludlum would be the next person, and she had to go home, also. Okay. Christopher O'Brien. Okay; you're up.

CHRISTOPHER O'BRIEN: Does that mean we went from the beginning of that list to the end already?

SENATOR GERRATANA: There you go.

CHRISTOPHER O'BRIEN: Before I begin my testimony, I did send a copy of the MOLST form from Massachusetts for your review if you need to. I know Senator Gerratana, you already looked at that.

SENATOR GERRATANA: Thank you.

CHRISTOPHER O'BRIEN: Good -- good afternoon. How are you feeling today? It's a nice day, and we're all sitting in a comfortable setting. Does anybody here feel that they need antibiotics today? I'm sure you feel fine, so you'll probable decline. How about an I.V.? Does anybody in the room need an I.V. today? No? What about next month? What about next year? Probably not, but I ask you that question because --

SENATOR GERRATANA: Mr. O'Brien, I'm sorry, could you identify yourself (inaudible).

CHRISTOPHER O'BRIEN: Oh, I apologize, I'm sorry.

SENATOR GERRATANA: So sorry. I didn't hear that.

CHRISTOPHER O'BRIEN: My name is Christopher O'Brien. I'm a certified paramedic.

SENATOR GERRATANA: Thank you.

CHRISTOPHER O'BRIEN: Thank you. I had had asked you if you would like an antibiotic, or an I.V. today, or see a foreseeable need that you might in the next year or two. Many of us can't answer that question because we don't know what will happen as our health progresses. Many of us are optimistic, so we'll probably say no, we won't. But that might change. At some point in the future we might get sick; we might have an infection. If we are achy or have a fever, certainly we would want to have that type of medical intervention.

I ask these questions because that's the type of question that will appear on a MOLST form that we're discussing today under S.B. 413. I was strongly opposed to the proposal last year, but see that much progress has been made to improve this program that's proposed today.

There is some utility in a MOLST form, covering a very limited number of foreseeable medical procedures such as CPR or ventilation, but at the -- these should probably only be used -- but going beyond that should probably only be contemplated at the very last stages of chronic disease. I believe that the overall effort is overbroad. We have seen instances where healthy persons have been enrolled in the MOLST process in Worchester at assisted living facilities. Fraudulent documents were drawn up in California, and the program in Delaware was suspended for at least a couple of years.

As a paramedic I'll testify that the best interest of any patient lie on a Durable Power of Attorney which already exists under Connecticut State Law. Most of the time such healthcare advocates can be reached within a reasonable amount of time in an emergency and can make the decisions in the best interest of the patient that cannot be reduced to a checkbox document such as a MOLST form.

As I testified then, I remain very concerned that the MOLST implementation can trump rules for informed consent, and in order to have true informed consent, or conversely refusal of medical interventions a patient does or doesn't need, must make medical decisions within the context of a medical problem. For instance, hydration. The human body is composed of approximately 65 percent water and fluids. When this percentage is altered, various activities are thrown off including cognition, awareness, and proper absorption of medications to relieve pain. Antibiotics are also inappropriate, I believe, to be used on this form. When a Hospice patient develops a fever, as I witnessed one day, family members and nursing home employees out of the hospital setting are unable to determine what's causing it. Could it be a UTI, or a treatable respiratory infection? Or would it be the continuation of sepsis of the underlying disease which might be extraordinary means for that -- for that family to decide to pursue.

I have witnessed patients that have been -- that have been denied fluids because they signed a Living Will long in advance of foreseeing that. This one patient I had, she had very parched lips, chapped, almost bleeding. You could tell through her eyes she understood what was going on. She had a Power of Attorney that lived in Florida who was not able to be reached, but she had a family member nearby that tried to have to go to different hospitals, including to a Catholic hospital, but because of the legal ramifications, they were not able to do that, so --

SENATOR GERRATANA: Mr. O'Brien, could you please summarize for us?

CHRISTOPHER O'BRIEN: Absolutely.

SENATOR GERRATANA: Thank you.

CHRISTOPHER O'BRIEN: EMS providers will tell you that there's a lot of misinformation out there regarding end-of-life care. Sometimes documents such as DNRs are misplaced, or Living Wills are misplaced, and the public is not well educated sometimes in the biological sciences, and are sometimes unprepared to handle end-of-life decisions, even when they are in the context of lengthy illnesses.

At the same time there are families that are very well prepared and handle them very well. Those families often are very well -- very engaged on a daily basis within their care and investigating their options.

I think I'll just reiterate that I believe that is a good document when it's very limited, but I think that overall I'd be very careful moving forward on how many different interventions the MOLST program will include. Thank you.

SENATOR GERRATANA: Thank you, sir. Are there any questions? If not, thank you for coming today.

I do have one. Did you submit your testimony to our committee?

CHRISTOPHER O'BRIEN: I did, just within the last hour.

SENATOR GERRATANA: Okay. Very good. Thank you so much.

Okay, we'll go onto Senate Bill 416. Arthur Grouf, or Group? Groux? Maybe it's G-r-o-u-x? Ge-roo? Okay, sorry.

ARTHUR GROUX: Groux, that works.

SENATOR GERRATANA: There you are. Groux works. All right.

ARTHUR GROUX: (Inaudible). It's 5 o'clock, I'll answer, so.

SENATOR GERRATANA: All right. Thank you. Thank you for waiting, too.

ARTHUR GROUX: Thank you very much, members of the committee. I did submit my written testimony so I'm not going to re-read that. I think you can all read it probably better than I can re-read it, so.

I do want to touch on a few things that were brought up by DPH when they were up here doing their testimony in regards to the elimination of the AEMT level. The AEMT level currently is outdated. We're in 100 percent agreement with that. The National Scope of Practice study brought it up to a new level of care. We're asking that that be implemented. We've asked DPH that that be followed. Our neighboring states have all done that, New Hampshire, Massachusetts, Maine, Vermont. They all have transition programs out there. They've all started the training. Some of them have completed the training. So it's not a matter of having to recreate the process. They all went from the same level of care that we have up to the new level of care.

And the point of going to a National Scope of Practice study was to bring all of the EMS providers throughout the nation into a unified process and scope. So we think that that should be followed.

And also when they mentioned that people wouldn't lose anything, there's 742 AEMTs in the state of Connecticut; 25 percent of all the providers that are licensed or certified to provide ALS-level care in the state of Connecticut are AEMTs. So you would lose 25 percent of those providers as of 2017 or 2015 as the Advisory Board wants to go.

There has been no communication back to those providers or the services that hold primary service area designations at those levels about how that transition would work, or what's going to happen. As the Chief of Suffield Ambulance, I hold one of the four PSAs in the state at the AEMT level. If I wasn't actively involved in looking at legislation, we would have no idea that this was coming forward.

Those 742 people that are certified at that level paid for that certification. They paid for that class. They will lose that class. They had to take the AEMT class, then they had to pay to become an AEMT. They would go back to being EMTs as DPH stated. They would lose what they paid to be certified at that level. They would lose that certification. Now regardless of whether the skill set can be used uniformly throughout the state or not, it's an additional level of training. I've worked as a paramedic for 22 years. During that time there's any day that I would love to have an AEMT available to assist me on critical calls. Whether they can do all the skills that they're certified to or not, I know that they understand what the next step is.

And obviously there's more; there's plenty in my testimony. I'd entertain any questions that you may have.

SENATOR GERRATANA: Actually I do have some, sir, if you don't mind. In your testimony you state, "We are not asking that the 1985 standard be kept, but that the state move to the same standard that all our neighboring states are moving to, in fact most of the states in the United States are moving to." What is that standard?

ARTHUR GROUX: They did a National Scope of Practice study in 2009.

SENATOR GERRATANA: Who did?

ARTHUR GROUX: It was --

SENATOR GERRATANA: Who did a National Scope of --

ARTHUR GROUX: -- it was through a grant through the Federal Government; I forget the name of the group that was formed to do it.

SENATOR GERRATANA: Oh, okay.

ARTHUR GROUX: But it is under the -- if you go to the National Transportation -- I'll get it right, NTSB's web site, it's under there. It spells out what the scope of practice is. That was to be rolled out nationwide, so --

SENATOR GERRATANA: And is this for Advanced Medical Technicians, or is this --

ARTHUR GROUX: It's for every level of EMS provider.

SENATOR GERRATANA: For every level of EMS?

ARTHUR GROUX: Exactly.

SENATOR GERRATANA: Okay.

ARTHUR GROUX: And the state has made the transition to bring the -- what we used to call the MRT, is now the EMR, or Emergency Medical Responder --

SENATOR GERRATANA: Right.

ARTHUR GROUX: -- up to that new standard.

SENATOR GERRATANA: Okay.

ARTHUR GROUX: It brought the EMTs up to that standard. They're bringing the paramedics up to that standard, but the AEMTs, instead of bringing them up to that standard, they're asking that that level be removed.

SENATOR GERRATANA: Right. So you're saying that A -- AMTs, Advanced Medical Practice, or Advanced Emergency Medical Practice, should be moved up to that level, also.

ARTHUR GROUX: Yes, and if we remove them from this -- if -- if the legislation passes, and they're removed, that leaves the -- now the state can't move to that new level unless they come back and have new legislation passed. I understand that they're not at the point where they can move them up right now, but I think that relatively quickly, if they look at the models that all of our neighboring states have already implemented, those can be utilized to bring them up. So I just don't want to see legislation passed that eliminates the level.

SENATOR GERRATANA: Okay, so you want to keep the AEMT designation --

ARTHUR GROUX: That's correct.

SENATOR GERRATANA: -- but you want an AEMT to be able to do the same thing as an EMT?

ARTHUR GROUX: No, we want the AEMT to stay in Statute. The transition up to the new level is an issue with DPH that -- that needs to be addressed with them. But if the AEMT level is removed from Statute, then they can't be brought up to the new -- the new scope of practice. I know a little bit confused there probably, right?

SENATOR GERRATANA: It is a -- I'm sorry. It is a little confusing to me. Now I'm trying to understand if all emergency medical personnel are being held to a particular standard, what is the difference between them?

ARTHUR GROUX: Well there's all -- there's different levels of training, so the basic --

SENATOR GERRATANA: Ah.

ARTHUR GROUX: -- a basic EMT goes through about 150 hours of training.

SENATOR GERRATANA: So the standard, if you will, scope of practice is that an AEMT can do this, could be trained to do this --

ARTHUR GROUX: Exactly.

SENATOR GERRATANA: -- and then an EMT, and so forth.

ARTHUR GROUX: Yeah.

SENATOR GERRATANA: And currently, as I understand it, AEMTs are trained at a particular level, that 1985 level if you will?

ARTHUR GROUX: Yeah, the 1985 level.

SENATOR GERRATANA: I see.

ARTHUR GROUX: Which is the EMT training plus another 120 hours or so of training on top of that.

SENATOR GERRATANA: Thank you. That's very, very helpful for me, and good to know.

All right, I think you're -- okay, Representative Johnson.

REP. JOHNSON: Thank you, Madam Chair, and thank you for waiting so long and your excellent testimony making some of this more clear for us.

I'm just wondering, so if we keep the AEMT designation, and of course we have the EMTs, they -- they will not have to aspire to be AEMTs. They will go on to the next level that we -- that we will do because it's a change in practice -- the scope of practice that has been recommended on the national level? Is that -- am I understanding your testimony?

ARTHUR GROUX: Yeah. What -- what we're looking is if you look back through my -- my written testimony that we have, I mean just in Suffield, we had 6000 hours of volunteer level at the AEMT. If that stays, most of our AEMTs will take the additional training to bring them up to the current, you know, the new scope of practice. It's -- it's not realistic to think that a bunch of these AEMTs, who the majority of them are volunteers, are going to take 2000 hours of additional training from EMT to become paramedics. So if that middle level is removed, they're not going to advance their training within EMS which ultimately is not what we want. I mean we want the best possible provider that we can get in a cost-effective healthcare, you know, delivery system, and that's not happening if we're removing that whole middle level and leaving that -- that big gap that currently are being filled by the AEMTs.

REP. JOHNSON: So -- so in the future -- I'm just trying to ascertain --

ARTHUR GROUX: Yeah.

REP. JOHNSON: -- how to move our existing system into the future, so what do we do with the EMTs that are -- they're certified; there's several of them, and do you think that they'll want to, you know, become -- what do we call the new scope of practice, the new emergency medical service provider? What will we call them? Have you -- what's the vision?

ARTHUR GROUX: Well currently we're bringing the first responders up, the EMRs up, to the new scope of pactice. The current EMTs are being brought up to the new scope of practice. The current paramedics are being brought up to the new scope of practice. The vision that we would like to see is that the AEMTs also be brought up to the new scope of practice. That's an issue that is dealt with through training at DPH. You know, I'm -- we're not asking for legislation that -- that requires it. All we're asking is that the AEMT level be left in Statute so that this way that training can take place. And there was a concern from DPH about training facilities. I will say that was from the training committee of the advisory board that didn't go back to all the EMS instructors in the state, and all the organizations that do training. Because at Suffield Ambulance, we do training. We have an AEMT class going on right now to the old standard. We want to do the new standard. We have a sponsor hospital that wants to support the new standard.

So it's not everyone that's said this, but rather a small group associated with the advisory board that was never brought back to all of the providers to see where that actually fell.

REP. JOHNSON: So that's -- so, I'm just trying to still understand what will happen. Just let's take the existing EMTs --

ARTHUR GROUX: Yep.

REP. JOHNSON: -- and bringing them up to the -- when do you -- when does this whole new Scope -- what's the vision for implementation?

ARTHUR GROUX: It's -- it's already been started, so --

REP. JOHNSON: It's been started, so when -- so the existing EMTs will have to become -- will have to go through this whole new training process?

ARTHUR GROUX: Well during their three-year refresher -- we all work on a three-year refresher cycle, so during that three-year refresher cycle that they're in, you know, it started just about a year ago, they're coming up to the new standard. So over the next three years they'll all be transitioned up to that new standard during their refresher programs. The same with the paramedics; the same with the first responders. So that process is there.

REP. JOHNSON: And then the EMTs and the Advanced EMTs will be on the same level.

ARTHUR GROUX: Well, no. The new EMTs are at a lower level than the Advanced EMTs. So the State is saying that as we get rid of the Advanced EMTs, we're going to move them back down to the EMT level, and I apologize. It would probably be easier with a white board, but -- so -- so what they want to do is move them from Advanced EMT which, say as you know, the middle of the tree so to speak, and move them further down to EMT training. So that -- that's what the proposal is before you. And we're saying leave that middle section there.

REP. JOHNSON: Okay. Thank you so much for your testimony. Are there any other questions?

Yes, Representative Srinivasan.

ARTHUR GROUX: I hope it's a little clearer for you. I apologize.

REP. JOHNSON: Well, that's okay. Maybe we'll get the white board later. Thank you.

Representative Srinivasan.

REP. SRINIVASAN: Thank you, Madam Chair. Thank you very much for your testimony. It is very clear, I think, with or without the white board, you know, the way you went from all the way from the first responders, all the way up to the Advanced -- Advanced Emergency Medical Technicians.

My question to you is, you know, obviously we heard DPH's testimony, and obviously we are hearing yours, and in this new standard, this national scope from 2009, what would it take for somebody like you, or whoever you're training right now in the class that's going on right now, to become the state of the art, the current as per the protocol by the National Scope. Are we talking about days of training, hours of training? What kind of training is involved?

ARTHUR GROUX: It's hours. Most of the neighboring states that have done the transition program, most of them are looking at about 100 hours of additional training. So it's not a, you know, it's by no means a, you know, spend a couple of evenings in a class and be done, but what, you know, some of them have done, you know, month-long trainings where you come in for one or two evenings a week for a few months. They've done them in a couple of different formats. You know, the only difference to that is New Hampshire allowed self study, and one opportunity to pass their recertification test with self study and not have to do any classroom. They're the only ones who have done it, but there are models out there with about 100 hours of classroom work, and some clinical work to get up to that standard.

REP. SRINIVASAN: Thank you, and so what you're suggesting is, which is the right thing to do that, you know, you don't bring anybody down; you move everybody up.

ARTHUR GROUX: Exactly.

REP. SRINIVASAN: To me it doesn't make any sense. Why would we eliminate this whole group of people who are -- who are going to provide services which are very, very critical to that particular family, that particular patient, so removing that group doesn't make any, you know, logic at all. But this 100 hours of training -- this 100 hours of training would be done by DPH. Is that what your vision is? That's where it's done in other states?

ARTHUR GROUX: Well the way it's done is DPH comes up with a -- with a training curriculum, and then the emergency medical services instructors, so that's another level of certification that people get. They go out and they do the training based on DPH's standard. So DPH doesn't actually do the training. They set the standard for the training; they approve the training program, but it's up to -- in most cases services, you know, will hire someone to do their training, or they may have an instructor that can do it based on DPH's standard.

REP. SRINIVASAN: And DPH would come with these standards on their own, or they would take the National Scope Standards, and just kind of -- and then use those standards as a benchmark?

ARTHUR GROUX: We would certainly hope they would use the National Scope standards. That's what they've been doing in all the other levels on, you know, again to bring that National Practice together. You know, when they originally did the study, there were 37 different levels of EMS provider in the United States, so -- and, you know, if you crossed a state line, what you got was completely different, and that's one of the problems. You know, as a bordering -- you know, we border the state of Massachusetts in our service area. It's difficult, you know, when you're providing one level of care, and we're transporting to Massachusetts on a regular basis, if they're not on the same page, because when you hand off care it's difficult to make that transition, you know. It'd be one thing, you know, as a physician, if you were handing off care to, you know, a physician that had a completely different skill set, you know. That's getting that standardization in, to make it much clearer as to what we can and can't do.

REP. SRINIVASAN: Thank you very much for your testimony. Thank you, Madam Chair.

SENATOR GERRATANA: I do have a couple of followups. Dr. Wolfson who I think serves as a medical director for OEMS did submit testimony. He says the State's EMS Medical Directors felt that to optimize the EMS system in the state, resources should be put into the MRT, which is First Responder, EMT-B, and paramedic level responders, and to eliminate the AEMT. In addition, as community paramedicine develops across the country, with paramedics checking on patients outside the EMS system, which is interesting, a paramedic level provider is required, and an AEMT is not authorized to perform such services anywhere.

And then it's interesting because he says the decision to eliminate the AEMT certification was made over several years with a great deal of thought, debate, and input. Were you part, or was the AEMTs part of that thought, debate, and input?

ARTHUR GROUX: The -- the AEMTs were to the extent that when this came forward from the Medical Advisory Board to the EMS Advisory Board, I became aware of it. I went back to the services in the State of Connecticut, asked the service chiefs if they had heard of it. Most of them had not. I provided a survey -- you know, we put a very quick survey together to get information back to the advisory board. That survey was overwhelming when they went back to their members, because what we were being told was that at that point, most AEMTs would not be willing to go through the training to get up to the new level. So we asked them that, and they were originally saying this may take up to 400 hours to do. We asked the services to go back to their AEMTs and overwhelmingly the AEMTs were willing to do it. The services were willing to support that transition.

We provided that information to the advisory board, and at that same meeting that we provided it, they voted to eliminate the AEMT level. So as far as being involved in the discussion, yes, at the last minute we were -- we were involved in the discussion.

SENATOR GERRATANA: Thank you. Excuse me. And the AEMTs, are they considered First Responders?

ARTHUR GROUX: In the sense that every EMS professional is, but normally it's the EMR, or Emergency Medical Responder, that's considered the first responder in the EMS system.

SENATOR GERRATANA: Right, right. So what is it the AEMTs specifically do, and how do they respond?

ARTHUR GROUX: Well currently they're part of ambulances. Normally -- normally they're part --

SENATOR GERRATANA: They're like part of the crew so to speak?

ARTHUR GROUX: They're -- they're part of the crew so to speak. Yeah, yeah. And they provide some -- they get some additional patient assessment training and I.V. insertion training at this point in time, and Dr. Wolf talked about the expanded, you know, the scope of practice change with community paramedicine, and actually that -- that's a good point because in the beginning of the Scope of Practice study it talks about community paramedicine, and talks about the ability of using all of the levels in that process.

As community paramedicine starts to roll out, and it's been tested in other parts of the country, when a paramedic arrives and determines that a person doesn't need the full level of care that a paramedic meets, in some of these systems, they're putting the patient over to an AEMT. That's a resource when, you know, when a service is paying an AEMT $16 or $17 an hour and a paramedic $25 per hour, is it cost effective in the healthcare system to turn around and say everybody now that needs some level of advanced care has to go with that $25 an hour resource.

And there's a limited number of paramedics. Wouldn't it be better off to utilize them to the best of their ability, and utilize the levels and so forth, and the scope of practice talks about doing that, exactly what Dr. Wolf was referring to.

SENATOR GERRATANA: Well thank you very much, and thank you for giving your testimony today. We do appreciate it, and answering all these questions.

ARTHUR GROUX: Thank you very much.

SENATOR GERRATANA: Thank you.

Next is Don Miner, to be followed by Skip Kosciusko.

DON MINER: Good afternoon, or I should say almost good evening, Senator Gerratana, Representative Johnson, members of the committee. My name is Don Miner. I am Deputy Chief of the Suffield Volunteer Ambulance. I also serve as president of the Suffield Volunteer Ambulance Association which is the governing body.

I am one of those AEMTs that you all have been trying to understand what we do. Let me try to explain currently. There are four levels of EMS provider today and perceived in the future. EMR, which is about 50 hours of training, typically first responder, that's what they teach the police officers in the Police Academy, really what to do in the first ten minutes of a medical emergency. EMTs are kind of the backbone of -- of an ambulance service. They can put somebody on a backboard, provide oxygen, splint broken bones, control serious bleeding and that kind of thing. An AEMT, in addition to being able to do that currently can start I.V.s and under certain situations do advanced airway management, and that's probably another 100 hours of classroom, and maybe another 50 to 75 hours of field training beyond EMT.

The next step is paramedic which is about 2000 hours of training. I would love to be a paramedic, but frankly with my professional responsibilities, I have a full-time job, and my family responsibilities, I don't have the time to go to school almost fulltime for the next year and a half to do that, as a volunteer. And that's true of most of the volunteer -- most of the volunteers in Connecticut. We have a handful of volunteer paramedics in Suffield. We're one of the few services to try to employ that. Most of the small services either operate at EMT level, or the AEMT level, particularly some of these remote towns in the rural areas of the state. AEMTs are all they've got. There aren't a lot of paramedics around.

The National Scope of Practice suggests that that skill set would increase by adding breathing treatments, perhaps for an asthma patient; Narcan for a narcotics overdose; and treatment for somebody experiencing a serious diabetic low blood sugar reaction. Those, at least the -- we don't see a lot of drug overdoses in Suffield, but the other two things we see quite a -- quite a bit of. Currently they would require a paramedic. We don't necessarily always have a paramedic available.

Perhaps I can give you two personal quick stories to illustrate the value of this. A couple of years ago, about 3 o'clock in the morning, we responded to a sick person who had been vomiting. Well, actually he had been vomiting significant amounts of blood for -- for some time. We got him in the back of the ambulance, and his blood pressure started to drop significantly. Fortunately I was able to start an I.V. just before -- before we met paramedics to go the rest of the way to the hospital. At the point where I started the I.V., his blood pressure was 43/20. I don't believe that if I -- if we had waited another even five minutes to get him that fluid, that he would have survived the ambulance trip.

The other sort of personal story, and -- and illustrates what else the AEMTs do is -- is on a very critical call can provide another level of care assisting a paramedic, and another personal story. Actually my daughter was critically injured about seven years ago when she was hit by a car while running. Fortunately the crew that responded to that included a paramedic and two AEMTs who were able to provide -- the AEMTs were able to start I.V. lines and -- and do those kinds of things, while the paramedic managed the airway and provided advanced assessment. The result of that good pre-hospital care is that she made a full recovery, although she was -- it was almost a life-threatening injury.

So most of the -- I'm sorry, that's --

SENATOR GERRATANA: I was going to say --

DON MINER: I understand we're on time.

SENATOR GERRATANA: We thank you; no, but we thank you, and understand your service, and deeply appreciate it, and also thank you for coming here today to testify.

I didn't see your written testimony. I see you don't have any in front of you, but that's quite all right. We keep a transcript.

DON MINER: I will provide some. Okay.

If I could, I would like to acknowledge one of my colleagues who is here today --

SENATOR GERRATANA: Sure.

DON MINER: -- but not testifying. Our Assistant Chief, Stanley S. Wicke, with 32 years of service for us. He's been invaluable. He serves at the EMT level, but he has been invaluable, and he has sat here and listened all day long to understand the issues.

SENATOR GERRATANA: Thank you. Thank you very much. Oh good, you brought your Chief with you. Thank you. Okay. Thank you, sir.

DON MINER: Thank -- thank you very much. Are there any questions?

SENATOR GERRATANA: I don't know. Does anyone have any questions?

Senator Welch has a question for you. Hold on.

SENATOR WELCH: Thank you, Madam Chair. Thank you for your service, and hopefully your daughter got through that.

DON MINER: She made a complete recovery.

SENATOR WELCH: So I -- I just -- I guess I want to understand how you perceive the impact of this bill on -- on your ability to serve. So I guess what I'm hearing is is there are certain things you can do as an AEMT such as, with respect to airways and I.V.s.

DON MINER: Right.

SENATOR WELCH: And as you perceive this bill, you will no longer be able to do that; that would have to be a paramedic who could only then provide those types of services.

DON MINER: Yes.

SENATOR WELCH: And you essentially would be an EMT>

DON MINER: Back to a basic EMT, yes.

SENATOR WELCH: Okay. All right. And do -- do you have an idea as to what the policy might be behind the proposal before us?

DON MINER: I have no -- I simply do not understand the reason we want to do this. It makes no sense to me.

SENATOR WELCH: All right. Thank you. Thank you, Madam Chair.

SENATOR GERRATANA: Thank you, sir.

I don't think there's any other questions. Are we all set? Thank you for coming today.

DON MINER: Thank you for your patience today listening to all of this testimony.

SENATOR GERRATANA: You're welcome. You're welcome.

Skip Kosciusko, followed by Suzanne Letso, I think; L-E-T-S-O.

Mr. Kosciusko, welcome.

SKIP KOSCIUSKO: Thank you. Thank you very much for listening to all the testimony you've heard today.

SENATOR GERRATANA: Of course.

SKIP KOSCIUSKO: It's a bunch.

My name is Skip Kosciusko. I'm a -- I serve currently as a Captain on the Cornwall Volunteer Fire Department in the little town of Cornwall up in the northwest corner. We are a volunteer department. We still provide all of our services at no charge to any of our patients, and we rely heavily on the two interventions that are allowed at the Advanced EMT level that are now allowed at the basic level. It allows us to start I.V.s, and it allows us advanced airway management that we would not have at the basic level.

We are very remote. We -- we rely on paramedics to intercept us, but usually those paramedics are somewhere between 25 and 35 minutes away from us in the best of conditions, and -- and may times there is no paramedic available at all, and so we're on -- we're on our own. We -- we rely on being able to establish that line for fluid resuscitation. I've got a couple of calls in the last week -- I'm not even sure if I'm allowed to present a patient's chart. It has all the identifying information blacked out, but I have chart, you know, charts from the last two weeks where we've had young kids injured at the ski area that were trending in a disastrous direction. Their -- their blood pressure was plummeting and their -- their pulse was skyrocketing to the point of vascular collapse, I would dare say, and an I.V. was used to help stabilize those patients en route to the hospital. We're out in the sticks, and it usually takes a while to get there.

To lose -- to lose that intervention, we would not have been able to provide that line or to help stabilize, like I said, I can think of two patients in the last week and I brought in a written copy to document how an I.V. did stabilize, you know, one of the kids that was injured at Mohawk Mountain. We have about 15 advanced AEMTs on our squad. They have gone to tremendous lengths to obtain that certification, and to maintain that certification, all at great cost to them. You should see how far we have to go to get our training.

In -- in summation, I would like to say, it would -- it would be disastrous for the morale of my department to not be able to provide this level of care that we've been providing for decades. It -- it greatly enhances the care we can provide patients. It greatly improves our paramedics' ability to do what they need to do when they don't have to worry about establishing that line or maintaining that airway because Cornwall's already done that, and it's just hard to imagine how a remote, rural community like Cornwall would do without being able to provide this service to our patients. We've been doing it for decades, and -- and I hope you'll defeat this bill so we can continue to do that.

People have noted the encouragement to move to an upgraded standard, and Cornwall fully supports that, and we would -- we would go on, you know, take any additional training required to attain the new standards.

SENATOR GERRATANA: Thank you.

SKIP KOSCIUSKO: Thank you very much for listening to me.

SENATOR GERRATANA: Thank you very much for testifying in front of our committee. We do appreciate it.

SKIP KOSCIUSKO: Do you have any questions for me?

SENATOR GERRATANA: Actually Representative Johnson has one.

REP. JOHNSON: Thank you. Thank you, Madam Chair, and thank you for your testimony, and you raise a very interesting issue because Connecticut geographically is so diverse, and when we get into the areas where -- where you have --

SKIP KOSCIUSKO: Did you know we have a Cornwall?

REP. JOHNSON: Why I have an idea, but in any event, I'm in the eastern part of the state, and I'll -- I'll give you a test about those towns. But in any event, I just -- I think that it's important for us to understand that when you have large distances, that you have to have the -- the emergency medical services, and people equipped with -- with the expertise to be able to deliver those services.

So you're -- you're out there in that area and I think that you raise a very important issue, and I think we've heard that. If you wanted to go a little bit on about that, that would be appreciated.

SKIP KOSCIUSKO: Oh, I would love to. If you consider, though, the three levels of care we're talking about: the basic EMT, the paramedic EMT, and where we stand at the Advanced EMT. If you eliminate, as this proposed, if you eliminate that middle section, you're saying okay Cornwall, now you can only provide a basic level of care. Our -- the help that's coming toward us, or the hospital that we're responding to is a long ways off. Care is greatly delayed, and then when we get to the definitive care, be it a paramedic or a hospital, then they've got to worry about establishing the lines, and establishing the airway that Cornwall has, you know, aggressively and very effectively is establishing now. And, you know, to eliminate that middle level of care, you know, knocks us down, and like I said, the morale to the providers, the confidence to our patients, and to our community, I'd think would be devastating to remove that level of care that we've been safely, and effectively, and proficiently providing for decades. It's hard to imagine.

REP. JOHNSON: Well thank you so much for that. Thank you, Madam Chair.

SENATOR GERRATANA: And thank -- thank you for coming today. I just want to say Cornwall has a wonderful pottery. I don't if this -- Cornwell Bridge Pottery. I have to get that in there. But I've been there. They have an anagama pottery kiln.

SKIP KOSCIUSKO: Uh-huh.

SENATOR GERRATANA: Anyway, which is very ancient style of producing pottery.

SKIP KOSCIUSKO: It's all handmade and kiln -- and kiln-dried in Cornwall.

SENATOR GERRATANA: Yes it is, and I have one right on my counter at home. I have one of their pots.

Representative Srinivasan.

Well I had to get that in there.

REP. SRINIVASAN: Of course then, he just stopped laughing. Thank you, Madam Chair. Thank you very much for your testimony. Just a hyper -- a hypothetical question: In case our resources at DPH here are not able to give you that advanced training that you need to be current as per the 2009 standards, would Plan B be to go to the neighboring states, whether in New Hampshire by, what do you call it, mail, or Massachusetts, get the appropriate training and be certified in Connecticut. Is that an option?

SKIP KOSCIUSKO: I'd think there would be several options. This entire level of care came about when local -- there was no statewide standard. Local hospitals said, you know what, these guys out in the sticks here, they could really use this level of care; why don't we train these guys, and that's how this started. So you could go back to a similar -- to a similar, you know, scenario and say, okay, here's the standards we want you guys to be trained to, that you'll be allowed to practice to, and give those to the hospital, and -- and our medical control, the doctor that oversees it and say, this is what these guys need to get. You can provide it; you can hire, you know, outside resources to come in; you could go to a neighboring state; you could get online. There'd probably be several ways that that training could be obtained.

We certainly have many models to choose from. Of -- of the 45 states in the country that have an Advanced EMT, every other state has -- has selected a model and -- and is making some accommodation to keep their Advanced EMTs, and to keep them practicing. So we have 44 other models. Connecticut is the only state that's looked at the Standards and said we can't do this; let's get rid of it; let's get rid of this level.

So like New Hampshire was mentioned. Georgia has a very progressive model where they've taken people and given the practitioners ways to, you know, incrementally get the training they're going to need by a certain date so they can get up to the new standard so they can be, you know, trained appropriately and provide appropriate care.

I have not heard -- of course, Connecticut would like to eliminate the level, so we haven't heard much about how they would proceed if this level was to be preserved, but I think that we have many models that we could choose from and find one that could be very applicable to the State of Connecticut and to us.

REP. SRINIVASAN: Thank you very much. Thank you, Madam Chair.

SENATOR GERRATANA: Thank you, sir. I don't think there are any more questions. Thank you for coming all the way from Cornwall.

SKIP KOSCIUSKO: Thanks. Thanks for having me.

SENATOR GERRATANA: We love it. We love it.

Okay, let's see. Next is House Bill 5537, and the first one is Suzanne Letso, followed by Ashley Bates.

Ah, you're here already. Good evening.

SUZANNE LETSO: Good evening, Senator Gerratana, Representative Johnson, and the rest of the committee. My name is Suzanne Letso. I am the parent of a child with autism. I am the CEO of the Connecticut Center for Child Development which provides services to people with autism, both adults and children. I am also a parent advocate, and I'm here today to give testimony very different from what I thought I was going to be talking about when I got up this morning.

We are here because of Section 42[6] in this bill which, to our eye, appeared to expand the scope of practice for speech/language pathologists. It's our understanding from the testimony this morning from DPH that that actually wasn't their intention. In fact, their intention was quite the opposite. Their goal was to ensure that board-certified behavior analysts, which by the way I am also one (I think I forgot to say that) have the right to practice, and they wanted to include the language that's included already in Public Act 09, I'm sorry, 10-76ii. They wanted to include that in the statutes relative to speech/language pathologists because of a situation that's occurred, and they wanted to make it clear.

Unfortunately I think the language that's been proposed is confusing. There has probably been somewhere between 80 and 100 pieces of testimony submitted with people expressing concerns that, like me, they think that this language expands the scope rather than clarifying the roles of behavior analysts. So what I would propose, if it's possible, is to change, and this was done at the back of the envelope in the cafeteria, to change number six to state something to the effect that: Not withstanding Chapter 399 of the Connecticut General Statutes, which is the statute that delineates the Scope of Practice for speech language pathologists, that BCBAs (board-certified behavior analysts) may practice behavior analysis services in accordance with the scope of practice in Section 10-76ii.

I think language to that effect would accomplish what the Department of Health is trying to accomplish and will help speech language pathologists avoid potential conflicts of interest where -- not conflicts, some ethical dilemmas where they may be asked to provide services that they're actually not trained to do.

SENATOR GERRATANA: Suzanne, thank you very much for coming and testifying. I was reading your testimony on Section 42[6]. You did give us some suggestions; I'm sorry I couldn't write fast enough, and I don't see it attached to this testimony. Could you submit in writing your suggested language to correct this?

SUZANNE LETSO: Yes, I would be happy to. I'm sorry. It's not on there because we didn't know at the time that we submitted what the issues were for DPH. We found out this morning after they gave testimony.

SENATOR GERRATANA: Now we understand and she said that in the beginning.

SUZANNE LETSO: I would be happy to -- I can write it up and send it to you, certainly.

SENATOR GERRATANA: Thank you so much. Are there any questions for Ms. Letso? No. Thank you very much. Thanks for coming.

SUZANNE LETSO: Thank you for your time.

SENATOR GERRATANA: Next is Ashley Bates followed by Solandy Forte -- For-tay, or Forte.

ASHLEY BATES: Thank you members of the committee for hearing my testimony. Like Suzanne I submitted my written testimony which is also very different from what you're going to hear today, for the same reason. I am -- my name is Ashley Bates; sorry if I didn't say that already. I'm a Senior Behavior Analyst at the Connecticut Center for Child Development. I'm also a Connecticut certified teacher in special education.

As Suzanne stated, we realized the intent of -- of Bill 5537, Section 42[6] is -- is not to expand the Scope of FLP services to include applied behavior analysis, but we do oppose the wording that is -- that's currently in place and would like to see that changed.

If anybody in this room has a relative or acquaintance with autism, you would know that they have very unique and multidimensional needs and can benefit from services in several different deficit areas. Some of you might also be aware that applied behavior analysis is the cornerstone of behavior reduction and skill acquisition for these individuals. While behavior analysis and FLPs work with the same population for the most part, and do provide measurement and treatment of different skills, some of which, a large amount which includes social skills, we think it is very important not to blur the lines between these two disciplines.

You've received a lot of testimony from different speech pathologists who do agree with our stance that they do not agree with expanding the scope of their services to Applied BA, and as Suzanne stated, this would put them in -- in some ethical dilemma. I actually work with some great FLPs and have over the years that have chosen to pursue an additional certification in Applied Behavioral Analysis, as they realize these disciplines are separate and have different requirements.

Currently the requirements for becoming a board-certified behavior analyst, other than holding a Master's Degree in Applied Behavior Analysis, or a related field such as special ed or psychology, we have to complete 225 classroom hours as well as 1500 supervised field work hours in the science, just as the FLPs have to do in their discipline. We just want to ensure that there will not be any detrimental effects on either of these disciplines and that we will maintain the highest level of care for our clients.

SENATOR GERRATANA: Thank you very much for -- for your testimony. Are there any questions? If not, saved by the bell. Okay. Thank you.

Next is Solandy Forte, or Forte, followed by Missy Olive. Meredith is not testifying; she is no longer on the list.

SOLANDY FORTE: Hello.

SENATOR GERRATANA: Hello; good evening.

SOLANDY FORTE: Good evening. My name is Solandy Forte. I am a board-certified Behavior Analyst in the state of Connecticut.

SENATOR GERRATANA: I'm sorry; you are a board-certified what?

SOLANDY FORTE: I'm a board-certified behavior analyst.

SENATOR GERRATANA: Oh, behavior analyst. Thank you.

SOLANDY FORTE: Yes. And I am also the president of the Connecticut Association for Behavior Analysis.

As you have already heard from Suzanne Letso and Ashley Bates, my testimony, I submitted it I believe a couple of days ago, and it's probably going to be a little different today. Originally I was opposed to the Section 42, Part 6 of H.B. 5537. I believe that that Section, I would ask that the Public Health Committee definitely modify or clarify the language proposed in that section to protect the Scope of Practice for speech and language pathologists, as well board-certified behavior analysts.

As I had mentioned before, I am the president of CTABA, and I just want to let you know that the Connecticut Association for Behavior Analysis is a professional organization that seeks to assist in the development and advancement of the field of Behavior Analysis within the state of Connecticut through research, education, and dissemination of information. CTABA represents board-certified behavior analysts in Connecticut with a current membership of over 400 persons certified by the Behavior Analysis Certification Board, and is affiliated with various chapters including Association for Behavior Analysis International, and the Association of Professional Behavior Analysts.

I just want to reiterate that ABA (Applied Behavior Analysis) is not -- does not fall within the Scope of Practice of speech and language pathologists. In order for us to become board-certified behavior analysts, we need to complete a graduate training program that includes course work concentrated in applied behavior analysis. Speech and language pathologists are not required to complete any of these classes in ABA. Further, speech and language pathologists do not receive the training or experience requirements related to the provision of ABA services, nor have they passed national examination in behavior analysis.

I again would like to urge that the Public Health Committee modify and clarify the language proposed in Section 42[6] of H.B. 5537.

SENATOR GERRATANA: Thank you, ma'am. So noted.

SOLANDY FORTE: I'm sorry?

SENATOR GERRATANA: So noted.

SOLANDY FORTE: Okay.

SENATOR GERRATANA: We appreciate your testimony.

SOLANDY FORTE: Thank you.

SENATOR GERRATANA: Does anyone have any questions? No. Thank you.

SOLANDY FORTE: Thank you.

SENATOR GERRATANA: Thank you for coming this evening.

Next is Missy Olive, followed by David Brady.

DR. MELISSA OLIVE: Good evening. I appreciate you all staying here to hear what we have to say. I'm Dr. Melissa Olive, and I'm a resident in Woodbridge, Connecticut. I have served as a university professor at the University of Texas at Austin, and I'm adjunct at the University of St. Joseph. I happen to also be a co-chair for the legislative committee for CTABA. It took me a while. I'm a little slow following, and I don't really have anything addition to add. I did not submit written testimony in advance, but in preparation last night before I heard the Commissioner's testimony today, I did put together a little slide show that compares and contrasts the course work that behavior analysts take, regardless of how they get to their certification, and then I compared that to what speech and language pathologists take so that you can see our Scopes of Practice are -- are very different.

There are some people who are -- are dually certified, so they would then have the scope of practice to do both behavior analysis and speech and language pathology, but in those instances those individuals went above and beyond their one program so that they could acquire those skills in the other.

That's all I have to say.

SENATOR GERRATANA: Thank you, and your slide show. Is that going to be available to us perhaps?

DR. MELISSA OLIVE: I have copies if you'd like.

SENATOR GERRATANA: Oh, very good.

DR. MELISSA OLIVE: It's just that it's prefaced with the testimony that I had prepared yesterday that, you know --

SENATOR GERRATANA: I see; I see. So --

DR. MELISSA OLIVE: But it's okay. You can -- you can rip that part.

SENATOR GERRATANA: Well, do you think it would be helpful to us, or --

DR. MELISSA OLIVE: It might be.

SENATOR GERRATANA: It might be? Sure. Okay, thank you. Yes, Francesco maybe you could obtain that from Missy? Thank you.

Okay, yep, let's see: David Brady followed by Liz Nulty.

DR. DAVID BRADY: Hello. Thank you. I know it's been a long day for everyone, so I appreciate the opportunity. Thank you Senator Gerratana, Representative Johnson, and the committee members.

My name is Dr. David Brady and I'm a naturopathic physician. I'm licensed in Connecticut and Vermont. I live and practice in Trumbull, Connecticut, and also serve as the vice-provost for Health Sciences at UB, and have previously served as the dean of the College of Naturopathic Medicine.

And I just wanted to take a moment to ask all of the naturopathic students, physicians, patients, and educators in the room to stand up real quick. Thank you. Thank you.

SENATOR GERRATANA: They're on a field trip.

DR. DAVID BRADY: The antiquated licensing law in Connecticut for NDs, with its very limited scope of practice, continues to provide a significant impediment to healthcare consumers in this state seeking a broad range of naturopathic care, and to the university in efficiently meeting the educational mission. We are charged by the Council on Naturopathic Medical Education, which is the federally-recognized programmatic accreditor for naturopathic medical schools, with educating NDs to meet the comprehensive standards and competencies to prepare them to practice in any state including states with modern scopes of practice.

This law also greatly limits the healthcare services we can provide to our community members who visit the UB clinics on campus, and throughout our communities, where collectively we see over 25,000 patients per year, mainly folks from the needy Greater Bridgeport area with no insurance coverage, very little insurance, and no access to care otherwise.

This situation also limits the recruitment of premiere faculty and researchers, and maybe most importantly reduces the opportunities for our graduates within the state, forcing them to relocate. We seek inclusion of the previously-submitted language to H.B. 5537 regarding a modernization of the scope of practice for naturopathic physicians consistent with our education, and training, and competency, rather than to practice under a definition which is literally 90 years old.

Through the scope process with DPH, which we were directed last year to follow through, which we did, we submitted substantial amounts of data that NDs in states with modern scopes of practice deliver primary care less expensively, with better patient satisfaction, and equal or better outcomes.

I have a little bit more, can I -- can I continue?

SENATOR GERRATANA: Certainly. If you can summarize a little bit. Your testimony is extremely long.

DR. DAVID BRADY: Yeah, you got a longer version. I have a very abbreviated (inaudible).

SENATOR GERRATANA: Oh, I have the longer version?

DR. DAVID BRADY: Yes.

SENATOR GERRATANA: Okay. I'm cursoring down and going I think I'm on page seven or eight now, going to page ten.

DR. DAVID BRADY: No, I'm -- I'm almost done, a half a page.

SENATOR GERRATANA: Oh good. Okay.

DR. DAVID BRADY: The -- the licensed naturopathic physician attends a doctoral-level, four-year naturopathic medical school, and is educated in all of the same basic sciences as an MD, but also studies holistic and lifestyle medicine approaches which emphasize prevention and upstream medical intervention using all evidence-based tools to include the conservative use of prescription medications when appropriate.

We take rigorous national exams called NPLEX, and our curriculum exceeds 5000 hours over four years with 1400 of those hours in direct clinical training, with significant direct patient management responsibility.

The reality is, we're asking for something that is not new; it's not novel for naturopathic physicians. The experience in other states with prescriptive authority for NDs has shown that they use medications safely, judiciously, perhaps even more conservatively than their medical counterparts.

In the end, what we're asking for is nothing more than fairness and equity as a profession, and to be able to practice to the full extend of our contemporary education and training, and to fully participate in helping address significant challenges of our healthcare system. With the Affordable Care Act, the impending provider shortages, we sincerely hope that the days have passed when politics, self-serving economic turf battles trump logic, data, truth, and freedom of choice in healthcare policy, and I'd love to take any questions you have regarding education, safety, or any other aspects that we provided to the Department of Public Health.

SENATOR GERRATANA: Representative Sayers.

REP. SAYERS: Thank you. Dr. Brady, one of the things, and you touched on it briefly in your testimony, but one of the things that usually comes up when we're talking about scope, is what would be the difference between a naturopathic physician and an MD in terms of their education?

DR. DAVID BRADY: Well, naturopathic education is organized a bit differently than that of conventional allopathic medical training, especially in the second two years, but it's no less encompassing or rigorous in its way. MDs and DOs complete clerkships in their second, or their -- their third and fourth years, where their role is primarily observational. They don't have direct patient care responsibility. In the third and fourth year of naturopathic training, the -- our students have increasing opportunities for hands-on, direct patient management, and this helps provide them training in the ambulatory care type of environments that are used to, whereas medical students spend a lot more time, including postdoctoral residencies in -- they have to do postdoctoral residencies to gain direct patient management experience, and acquire the skills necessary to practice in more subspecialization that occurs in medicine, and in acute care inpatient facilities.

Residency opportunities, also, it should be added in medicine are funded by Medicare. There are no funded residencies for naturopathic medicine currently. Nonetheless, residency opportunities are available and the naturopathic community, the educational community, is dedicated to creating more. But since the vast majority of what we know classically as medical residency training occurs in hospital and inpatient environments, it's not necessarily appropriate training for the naturopath which is trained as a generalist in ambulatory care, and it's also true that we don't have control of those facilities, and we're not granted access to those residencies.

So it must be emphasized, we're training a little bit differently, but not insufficiently, and our goal is to not really prove that we're trained exactly the same, or even equivalents, but that we're trained, and we're competent for what we're asking. That's the important part.

It's important to note that the -- Harry Chen, which is the Department Health Commissioner, stated that he looked at the training that NDs and MDs go through, and discussed how they treated their patients in their clinics, and essentially they're following the same protocols.

It's interesting to note that the dean of the Stamford School of Medicine, one of the highest-rated medical colleges in the country, Dr. Halsted Holman, at a recent commencement ceremony with medical students, actually apologized to the graduates for not preparing them adequately for over 80 percent of their patients. These are the patients with chronic complex disease.

So in medical education, the experts agree that medical education is failing in certain realms, and that includes the management of the most prevalent, most costly diseases of our time, which are chronic disease, which require lifestyle medical intervention, dietary changes, stress management, in addition to medication. I know this because I spent the entire day today with the Associate Dean of Curriculum Development for Yale Medical School, where they are going to be rolling out an entirely new curriculum in 2015, and they're looking to us to give them the lifestyle and nutritional components in their new curriculum. They understand that there are things missing in modern medical curriculum related to chronic disease, and those things already exist in naturopathic medical curricula.

REP. SAYERS: And because we don't have the -- the language in this bill, what kind of additions to the scope of practice are you looking at? And we haven't seen the report as yet from the Department of Public Health, and are -- in that scope of practice that you're looking for, does it currently exist in other states?

DR. DAVID BRADY: It does. We've seen the draft report from the Public Health Department, and we provided commentary and any corrections of fact in the last several days. We were expecting it to be out today. It should be out imminently; we are hopeful of that. But within that process, we submitted substantial data on the safety issue, including a 2013 report conducted by the Rockefeller Center at Dartmouth College for the Vermont Office of Professional Regulations. It included multiple surveys of states that had prescriptive authority for naturopathic doctors, and they essentially found no disciplinary actions against the professional licenses of NDs in any of the states related to prescribing, and a survey of the 2010 Jury Verdicts Northwest Database, which looks at all of the Pacific Northwest states which have expansive naturopathic scopes with prescriptive authority through -- from the years 2005 to 2010, showed no cases against naturopaths for prescription negligence, and for that matter, no cases against naturopaths at all.

The NCMIC Insurance Company, the largest malpractice carrier, reported that they never opened a case involving prescription medications with a naturopath. Another large malpractice carrier, the Washington Casualty group reported that their loss experience with NDs serving in primary care roles with prescriptive authority is five times lower than that of family practice and internal medicine physicians doing the same, and finally the Wood Insurance Group reported that their assigned actuarial malpractice risk premium rate for the ND practicing primary care in these states is 50 percent that of their medical colleagues.

So there -- in the -- in the insurance industry, they go by numbers; they go by data; they -- they go by actuarial data, and the data shows that we do this, we do it well, and we do it safely.

There's also a tremendous amount of data that we supplied on cost savings from these states. Blue Shield of Washington, for instance, did a study and found utilizing NDs as primary care provider cut the cost of chronic and stress-related illness to them by 40 percent; cut the cost of specialty utilization by 30 percent; and that NDs treated seven out of the top ten most expensive medical conditions more cost effectively than their MD colleagues. And Medicaid services delivered in Oregon, in a State study, showed 57.5 percent more cost effectiveness of ND primary care services versus their conventional colleagues.

REP. SAYERS: One last question: You talked about looking for prescriptive authority, and because I know that most naturopaths do not usually treat with -- with all medicines, but more natural types of herbs and things, I'm not sure, when you're asking for prescriptive authority, what you're actually looking for.

DR. DAVID BRADY: Well, we're looking -- when -- you need to consider that naturopaths are trained to be generalists, sort of like the old family doctor, right? Not the subspecialization that we have. We have patients that rely on us as their primary care providers. We are trained to know when our lifestyle interventions, whether it's dietary intervention, stress management, counseling, physical medicine, the use of botanical medicines, and other things are appropriate, and when there is also a need, particularly in more acute situations, for a prescription.

In the vast majority of the states that have naturopathic licensing laws, this is acknowledged, and the current modern paradigm of naturopathic medicine emphasizes all of the elements that the data shows are required in chronic disease management, but it does not preclude the use of pharmaceutical agents when they're necessary. We just tend to use them more conservatively.

Through the Department scope process, we had long discussions with -- with our members, our colleague members of the medical society talking about what drugs would be appropriate, and which ones may not, and we were in agreement that there were certain agents that would not be appropriate to our types of practices. For instance, we had agreed to carve-outs of oncology medications; anti-psychotic medications, for instance; class I narcotics. There are certain agents that we just wouldn't use in our type of practice, and we're not interested in having prescriptive authority over there -- over those. We just need what we need for nuts and bolts primary care medicine. And in the other states these are being used with impeccable safety records, and we're not inconveniencing patients on having to send them to another provider. Often they can't get a visit for three weeks to a month, and by then they don't even need the prescription any more half the time, and it costs them more money, delays their care, and it's just not realistic at this point.

REP. SAYERS: Thank you.

REP. JOHNSON: Thank you. Senator Gerratana.

SENATOR GERRATANA: Thank you, Madam Chair. Actually, I wanted to start with your practice defined. It says the practice of naturopathy means the science, art, and practice of healing by natural methods as recognized by the Council of Naturopathic Medical Education, and approved by the State Board of Examiners with the consent of the Commissioner, and shall include counseling, the practice of the mechanical and material sciences of healing as follows: the mechanical sciences such as mechanotherapy, articular manipulation, corrective and orthopedic gymnatics, physiotherapy, hydrotherapy, electrotherapy and phototherapy; and the material sciences such as nutrition, dietetics, phytotherapy, and treatment by natural substances and external applications. Natural substances are then defined in Statute.

I must admit, I -- I tried to understand what this is, so I went to the University of Bridgeport's website to see what is taught. And I'm not sure, do you consider that you are a medical school?

DR. DAVID BRADY: We're a naturopathic medical school, yes.

SENATOR GERRATANA: You're a naturopathic medical school.

DR. DAVID BRADY: And I must say, what -- the language you just read is from the -- the State Statute that's 90 years old.

SENATOR GERRATANA: Yes, yes. Right.

DR. DAVID BRADY: And we don't even agree with a lot of the language.

SENATOR GERRATANA: Well, and that's was going -- that was going to be my question to you --

DR. DAVID BRADY: It's -- it's antiquated terminology.

SENATOR GERRATANA: -- do you do any of this anymore? I don't know. I don't know what it is.

DR. DAVID BRADY: I'm not sure. I'm not even sure what therapeutic gymnasia is, but I'm sure if I was around 90 years ago, I would have.

SENATOR GERRATANA: Well corrective -- I don't know.

DR. DAVID BRADY: I guess that's our point.

SENATOR GERRATANA: There you go.

DR. DAVID BRADY: It really is not descriptive of what we do, unfortunately.

SENATOR GERRATANA: You do, however, offer courses such as phytopharmacognosy. What is that?

DR. DAVID BRADY: Pharmacognosy. Yes.

SENATOR GERRATANA: Wild plants? Is that what that is.

DR. DAVID BRADY: No. Pharmacognosy --

SENATOR GERRATANA: Phyto I know is Latin for plant, but --

DR. DAVID BRADY: Pharmacognosy is the study of botanical medicines or plants medicines from the standpoint of their pharmacokinetics, pharmacodynamics --

SENATOR GERRATANA: (Inaudible.)

DR. DAVID BRADY: -- and their -- their actions in the body. I'm not sure what, you know, if you were at our Divisions of Health Sciences website, I'm not sure which curriculum you were looking into, if it was the College of Naturopathic Medicines curriculum --

SENATOR GERRATANA: Yes, it is.

DR. DAVID BRADY: -- but we have specific courses on pharmacology as well. We have 72 hours or two full courses in base pharmacology. We have any 27 hours in pharmacognosy, so that's 99 hours in pharmacokinetic as pharmacodynamics and the like.

However, it should be noted, and this is what we were doing at Yale with the medical curriculum as well, it's -- medical education has moved away by classes by name, saying okay now you're going to study microbiology; now you're going to study pharmacology; now you're going to study whatever. It just doesn't work that way. It's to silo'd and compartmentalized. So there's an integration across the curriculum with how to clinically integrate these things.

So where a large amount of the pharmacology training in naturopathic medicine school, and our curriculum included, occurs is in our systems courses. For instance, we have 504 contact hours in courses such as cardiology, gastroenterology, endocrinology. Within the context of all of those courses is the appropriate medications, their prescribing, their side effect, and -- and their drug/nutrient interactions. So you -- it's hard to look at a curriculum listed out, and just try to find how much pharmacology are these students getting by looking for classes named "pharmacology."

We have 72 hours or two courses which is fairly equivalent to, for instance, we -- we submitted correlations between various medical school curricula and naturopathic medical school curricula, and the total hours in dedicated pharmacology training is fairly equivalent. It varies a little by program, but once again the medical students are also getting significant pharmacology training within the context of their systems or organ-specific courses.

SENATOR GERRATANA: Aside from botanics and plant pharmacognosy, there is listed on your website one course in pharmacology which is two credits.

DR. DAVID BRADY: I think you were probably looking at the wrong programs curriculum potentially.

SENATOR GERRATANA: Well, I did go to the School of Naturopathic Medicine. Maybe you can provide me with something different than (excuse me) -- than what's on your website. I'm trying to understand what it is that you do, so I went to see what kind of courses that you offer.

DR. DAVID BRADY: Well, that's puzzling to me because I have the printout from --

SENATOR GERRATANA: I'm happy to give you this.

DR. DAVID BRADY: Okay. I have the printout from our website right here --

SENATOR GERRATANA: What I -- what I could download.

DR. DAVID BRADY: -- and there's Pharmacology I, which is three credits, and Pharmacology II, which is also three credits, and they add -- they total eight -- over an 18-week semester. That's 72 hours of pharmacology-specific classes.

SENATOR GERRATANA: It's only what I got off the website, so.

DR. DAVID BRADY: Okay. I'd have to look at it to be able to comment.

SENATOR GERRATANA: Maybe it needs to be updated.

DR. DAVID BRADY: No, our website is updated because our accreditors make sure it is.

SENATOR GERRATANA: Oh, well you can look at this if you like.

DR. DAVID BRADY: Okay.

SENATOR GERRATANA: I'm happy to give it to you.

DR. DAVID BRADY: We have six programs, so potentially there is something that -- that glitched when you looked at it.

SENATOR GERRATANA: It just says the College of Naturopathic Medicine Curriculum follows a sequential study of study, and I assumed it was the right one.

DR. DAVID BRADY: Yep. I'd be happy to look at that and clarify it for you.

SENATOR GERRATANA: Sure. Okay. And, yes, because I did notice that there were many courses in homeopathy, also. What is Oriental Medicine?

DR. DAVID BRADY: Naturopaths train in an integrated model of medicine where we need the naturopathic physician to understand the various disciplines that are out there, and how to counsel patients on -- how to refer patients correctly, and so forth.

Oriental Medicine is basically what is now known as traditional Chinese medicine. It accompanies -- it encompasses something, well for instance, acupuncture is in there.

SENATOR GERRATANA: Acupuncture is (inaudible.)

DR. DAVID BRADY: But it's not only acupuncture. There's traditional Chinese herbology, and -- and different ways that traditional Chinese medicine approaches various health conditions.

SENATOR GERRATANA: Right. Okay, let's see, and do you follow in your curriculum at the University of Bridgeport, do you follow evidence-based science in your studies and your curriculum work?

DR. DAVID BRADY: Of course, yeah.

SENATOR GERRATANA: Okay.

DR. DAVID BRADY: Our program is an evidence-based curriculum.

SENATOR GERRATANA: Now, evidence-based science, of course, talks about immunization. Do you -- do you proselytize, shall we say, immunization. Is that part of what you teach?

DR. DAVID BRADY: Naturopathic students and all CNME-accredited naturopathic medical schools learn immunization schedules. They learn the CDC and Public Health Policy on immunizations and practicing naturopathic physicians are committed to hold up the public health policy of whatever state they're in.

SENATOR GERRATANA: Okay, so you abide by that.

DR. DAVID BRADY: Yes.

SENATOR GERRATANA: Okay, very good. And do you have any surgical training?

DR. DAVID BRADY: I -- not -- I'm not -- me, personally? Or the naturopathic --

SENATOR GERRATANA: Well, I'm sorry. I assume you're representing the University of Bridgeport. I wanted to know if you train your students in surgery.

DR. DAVID BRADY: In minor surgery such as, you know, wound care, abrasion care, removing foreign bodies, basic suturing, things that you would deal with in a primary medical practice, particularly during rural care and things like that, but not as a surgeon per se.

SENATOR GERRATANA: I see. So minor procedures.

DR. DAVID BRADY: Right. That's what we're talking about, with exclusions of, for instance, foreign bodies in the eye and different critical areas that would be immediately referred.

SENATOR GERRATANA: Uh-huh. And if you, as a profession, do you also, for instance, have peer-reviewed journals and articles that are --

DR. DAVID BRADY: Of course, yeah.

SENATOR GERRATANA: -- (inaudible) professions?

DR. DAVID BRADY: The modern naturopathic medical profession follows the same sort of procedures as other contemporary medical professions. We have peer-reviewed journals that are indexed on Index Medicus and appear on Pub. Med., and yes, it is an evidence-based curriculum. We're not -- we're not boiling teas in a -- in a big cauldron and treating cancer.

SENATOR GERRATANA: It's a scientific evidence-based curriculum.

DR. DAVID BRADY: Yes, absolutely.

SENATOR GERRATANA: Great.

DR. DAVID BRADY: Yes, thank you.

SENATOR GERRATANA: Well, I think that differs from, I don't know, mechanotherapy. I'm not sure what that is.

DR. DAVID BRADY: Yeah, and that's -- that's soft of the point. I mean I don't think anyone in here who practices any profession would care to practice that profession under the definition as it was 90 years ago. We -- we are due for a modernization of our scope, and once again, we're not asking for anything different than is happening in many, many other states, and they're having a wonderful experience.

In fact, you know, a state as close as Vermont has a much more expansive scope, has had prescription authority, a limited prescription authority for quite a long time. The state actually came back to the naturopathic profession giving them more prescriptive authority and more scope of practice so that they can incentivize them to form accountable care organizations, group medical homes, because they've looked at the data. They did a very exhaustive study, and they realized that naturopaths, particularly in chronic, ambulatory care, deliver high-quality health care which is less expensive and more conservative, and that was very attractive to the State, particularly as they are now responsible for delivering a lot of the health care through the new system.

SENATOR GERRATANA: What prevents a naturopathic physician from participating in a patient-centered medical home? What prevents (inaudible.)

DR. DAVID BRADY: They're -- what I was referring to in Vermont is they're incentivizing --

SENATOR GERRATANA: What kind of -- you're saying -- when you say incentivize, what do you mean by that?

DR. DAVID BRADY: They're encouraging them to.

SENATOR GERRATANA: Oh, the State of Vermont "loves"; there's a bumper sticker.

DR. DAVID BRADY: I guess so.

SENATOR GERRATANA: Vermont "heart" naturopaths. I like that.

DR. DAVID BRADY: It was -- it was part of why they did the study that we're referencing, and part of why they came back to the profession and actually gave them a more expansive scope. The profession didn't ask them.

SENATOR GERRATANA: Good. I know there's about 15 states that have some regulation regarding naturopathic medicine. I did read over all the different states. I know in many of them there's either oversight regarding prescriptive authority, or there are formularies that have been established, and you're right, there are limited medicines if you will --

DR. DAVID BRADY: Right.

SENATOR GERRATANA: -- that naturopathic physicians can prescribe. It's kind of interesting.

DR. DAVID BRADY: And through the scope process, we've discussed a lot of what those might be, and we were very hopeful, and we were very collaborative; we were hopeful that we might come up with a meeting of the minds through that process, and we're still hopeful.

SENATOR GERRATANA: Good.

DR. DAVID BRADY: So we -- we would certainly be willing to engage with the Department of Public Health and even our medical colleagues in -- in trying to establish something that is workable.

SENATOR GERRATANA: Okay, all righty. Are there any other questions? Oh, yeah.

Representative Cook.

REP. COOK: Thank you, Madam Chair. Thank you for your very informative testimony, and since you've answered a lot of the questions that I had, I just have maybe a couple more.

DR. DAVID BRADY: Okay.

REP. COOK: In our northwest region -- our northeast region up here, where -- how many of our states do allow you to have some, if not all, of what you are petitioning for us to give you as far as leeway within your practice.

DR. DAVID BRADY: In the northeast states, it would include Vermont, New Hampshire, and Maine.

REP. COOK: And then I know that Washington State has embraced this for several years, correct?

DR. DAVID BRADY: Many, many years. Their law has had prescriptive authority -- Rick, you might be able to clarify this -- but for decades. Yeah, states like Washington State, Oregon, Arizona, Utah, Montana, California now, have very broad scopes of practice for naturopathic physicians, and in the Pacific Northwest, in particular, like you mentioned, Washington and Oregon, they probably have the oldest tradition of -- of prescriptive authority for naturopaths. I think in Oregon it goes back to -- Rick, do you know the year? The twenties; it's not anything new.

Connecticut was -- was really a leader in the -- in the northeast as far as licensing the naturopathic profession as a -- as a regulated licensed profession, but it just has not updated it in very, very long.

REP. COOK: And so understanding that we obviously educate and graduate hundreds of students from the University of Bridgeport, how many students actually stay here, and how many are leaving because we have limited their ability to practice?

DR. DAVID BRADY: Basically the students who are attached here, either family reasons, a spouse, or they just are extremely dedicated to going back to their home communities and servicing them, stay. But a very large number of them get on the first plane to one of these other states we're talking about, because it's just not, you know, they didn't spend all of that time training to then really have handcuffs put on them, and not be able to train to their modern competency. So we -- we have a brain drain in this profession in the state of Connecticut. They're training here, but they're leaving, which is not great for the -- for the healthcare consumer. It's also, quite frankly, not great for the University's program. The same state that licenses and accredits this naturopathic medical program has a scope of practice and a licensing act which makes it very difficult for us to be as competitive as we should be with our peer institutions.

REP. COOK: Thank you for that, and I think that that's a significant component to this conversation. And we're always looking to figure out a way where we can get our young people to stay in the state of which they are educated, and I think that this is a clear indicator of how we're pushing them out. And so I -- I'm looking forward to moving the change. Thank you, doctor.

DR. DAVID BRADY: Thank you.

SENATOR GERRATANA: Thank you. Thank you so much. Any additional questions?

Representative Srinivasan.

REP. SRINIVASAN: Thank you, Madam Chair. Good evening now, and thank you for your testimony.

DR. DAVID BRADY: Good evening, doctor.

REP. SRINIVASAN: Good to see you again. Just a couple of questions. I know we've talked about this in the past. Give me your real-life scenarios where a patient walks in into one of your offices.

DR. DAVID BRADY: Okay.

REP. SRINIVASAN: And the clinical diagnosis that you have made or a primary physician would make, or a family practitioner would make is, let's say urinary tract infection.

DR. DAVID BRADY: Sure.

REP. SRINIVASAN: It's very clear cut; it's obvious that's what it is. In that case, as a naturopath, would you go to what your MD colleagues would do, and treat the urinary tract infection with an antibiotic, or whatever is needed, or since you said you're conservative, and you don't use medications as much, would you still be using alternatives first, and then go to the antibiotic if needed?

DR. DAVID BRADY: That's a -- that's a great question. It's a difficult one, as you know, to answer because it really depends on the clinical scenario, and the specific patient in front of us, and how acute they may be.

Your example of a urinary tract infection is a very good one, because it's a very common condition, particularly in women that come into a primary care provider. If -- if I have a patient who is having, you know, has a low-grade urinary tract infection, that has a history of them chronically, which is often the case, particularly if there is any anatomical issue going on, we might treat that conservatively. Many -- many people in the room may know that plants that have certain sugars like D-mannose block the adhesions of certain of these bacterial organisms from binding to the bladder wall and ureter, and they can -- and they can diurese them out essentially.

So we would use things like D-mannose or cranberry, or other types of things; high-dose vitamin C with a lot of water to basically flush out the urinary tract; but there are clearly times when the person has a much more acute or fulminate UTI that needs to be treated, because we don't want it to go to a kidney infection, and we don't want complications. And naturopaths are trained on when to pick those battles, so to speak. Many times they would treat the acute infection using an antibiotic, but then follow up with probiotics, use other things to sort of prevent the next infection, particularly if its chronicity is involved.

But in that scenario, the naturopath would be trained on the signs and symptoms, the correct laboratory analysis. They will do the urinalysis, have a culture; the patient has urinary urgency and frequency, and pain on urination; and they would love to be able to just prescribe them the antibiotic that they know is appropriate, but now they have to get them -- tell them you need to go back to your primary care provider. There's a delay in getting there. Many times they can't get in very quickly, and when they do, what's particularly ironic, is often when they go to their primary care doctor's office, they see a physician assistant who prescribes the medication. In my division, which I run at the University of Bridgeport, I also have a physician's assistant program. I know exactly how they're trained. I helped form the program and got it accredited. They train for 28 months. They have good training. I'm -- I'm a proponent of physicians' assistants, but I'm here in front of you to tell you, as a person who oversees a University division with both of those programs, that the naturopathic physician is trained to a much higher level than the physician assistant. They're training four full years post-graduate at the doctoral level, and a resident clinical program in addition to that.

So, NDs are really trained, once again, as general, primary care practitioners, with an emphasis on upstream lifestyle interventions, but we are independent providers. We are not trained to be dependent providers; a PA is, so it makes for shorter training. But it's kind of ironic; we have to send them back to a provider. Often times they see a provider with less training than us to get the -- the therapeutic agent that they could have gotten right in our office. It's really an inconvenience, and it adds a lot of costs to the system. It's very inefficient.

REP. SRINIVASAN: Thank you very much for the very eloquent answer. Just two quick followup questions. One is, s far as I understand at this point in time, without any change at all, a naturopath can order any lab tests, x-rays, whatever he or she feels is appropriate. Just correct me, to make sure that I'm right on that, that he or she feels, and there is no restriction there.

DR. DAVID BRADY: With -- there are some restrictions. For instance, if we wanted to do a diagnostic imaging procedure which required a prescriptive dye or some sort of contrast, we would have to have the medical physician order that, or the radiologist with the radiology center we were using. But generally, yes, we can order the diagnostic tests; we just can't always use the therapeutic agent that's appropriate once we get the answers.

REP. SRINIVASAN: Thank you, and that's what I thought. I just wanted to be sure I was clear on that.

DR. DAVID BRADY: Yes.

REP. SRINIVASAN: And my final question is a takeoff from Representative Sayers as far as the prescriptive authority is concerned.

DR. DAVID BRADY: Yes.

REP. SRINIVASAN: Now, in your request to us as to move forward so you are no longer in the Dark Ages, and you're in 2014 moving forward, your prescriptive authority, what I heard you testify earlier was, that certain drugs, like cancer drugs, and all of that, you're not going to ask for that --

DR. DAVID BRADY: Correct.

REP. SRINIVASAN: -- because (inaudible).

DR. DAVID BRADY: Correct.

REP. SRINIVASAN: But all others, let's say. Are there any other limitations other than that in terms of narcotics being (inaudible)?

DR. DAVID BRADY: Yes. I -- I will let Dr. Liva speak to that, also, because he was also a member of the committee with -- with myself and Dr. Malik with the Public Health Department, and -- and Rick's also a pharmacist, so he -- he can even add more light on this. But we -- we had agreed right away to many -- many carve-outs actually: oncotherapy drugs, anti-psychotic drugs; Class I narcotic agents; abortifacients. Help me, Rick; I'm thinking here: glaucoma drugs, for instance; yeah, general anesthetics. You know, we need nuts and bolts primary care prescriptive authority. We need basic antibiotics; we need anti-inflammatories; we need basic analgesics. You know -- you know, sort of basic stuff; not drugs that are really in the realm of the specialist, but -- but in the realm of the family practice or the generalist.

REP. SRINIVASAN: Thank you very much. Thank you, Madam Chair.

SENATOR GERRATANA: Thank you, and just to follow up on some of the work that you're doing, and trying to catch up on where you are today with respect to your practice, just -- just going back very quickly, so at one point in time perhaps, medical doctors and naturopaths were just about the same thing. Is that -- is that -- I kind of gleaned that from your testimony, like you know --

DR. DAVID BRADY: I -- I think when you go back about -- you go back to the turn of the 20th century, it was a very different landscape. You had a lot of competitive paradigms in health care or medicine. You know, you had the homeopaths; you had the naturopaths; you had the chiropractors, the osteopaths, the allopaths; and they were all soft of competing for -- for landscape, and then with the advent of what was known at the Flexner Report, and then sort of the maturing of -- of the pharmaceutical industry, things drove in a certain direction, and there were a lot of different pressures that drove it that way: political pressures, economic pressures, but really, it's interesting. It's soft of coming back where I think health care is -- and this is not being driven by the provider; this is being driven by the patient. The patient is demanding collaborative care. They're demanding their providers to actually talk to one another, collaborate, and use best practices from various different perspectives and disciplines, particularly when it comes to chronic ambulatory conditions. And we see that in this term, you know, "integrative medicine." That's what it is, to integrate a lot of these histories and -- and approaches, and I travel all over the country and indeed all over the world speaking at conferences and symposias, and mainly who I'm speaking to is roomfuls -- rooms full, hundreds and thousands of medical doctors -- I'm training them how to do the approaches we use, because they're starving for this. Their political organizations aren't always starving for it, but they, as practitioners are, because they're on the front lines facing the frustration of these patients with very complex, chronic disorders that the answer is not just to give them a pill in a six-minute office visit.

Naturopaths spend a lot more time with patients. They get to know them. They know their stresses; they know their social situations; they know how much they exercise; they know what they eat. They know a lot of things about them, and it's sort of a throwback in a way, but, you know, the data doesn't lie. The American public -- this is a study, federal study of about five years ago. The American public spends then about 40 billion, with a b, dollars a year in out-of-pocket medical expenses to complementary and alternative medicines providers. That's more than they spend out of pocket to ambulatory care conventional providers. That's staggering. That is the market speaking. They want this kind of care. They want the freedom to access this kind of care, and the -- the modern-trained naturopathic profession brings that type of care to them with the most organized, evidence-based approach that is most akin to what you would see in an allopathic, Western medical approach, just sort of using the best of all -- all worlds. And we're very proud of that tradition.

SENATOR GERRATANA: Thank you so much, and then finally, continuing education. Are your requirements for continuing education that you follow through on, do they --

DR. DAVID BRADY: We do have requirements for continuing medical education in Connecticut, and we are willing to up them. Some of the states that have prescriptive authority, for instance for naturopathic physicians, require CMEs or continuing medical education, but a certain carve-out of those CMEs annually or biannually have to be in pharmacology, and that's the model we would see happening here in Connecticut as well.

SENATOR GERRATANA: Okay. Any additional questions? Thank you so much for your testimony --

DR. DAVID BRADY: Thank you very much.

SENATOR GERRATANA: -- and your great answers to your questions.

DR. DAVID BRADY: Appreciate it.

SENATOR GERRATANA: The next person on the list is Mary Boudreau. No? No?

A VOICE: (Inaudible.)

SENATOR GERRATANA: Okay. Liz Nulty, and then Rick Liva.

Sorry about that.

ELIZABETH NULTY: Hi, my name is Elizabeth Nulty, and I am a board-certified behavior analyst. I'm also the past president of the Connecticut Association for Behavior Analysis, and I am a behavior analysis consultant to special education programs within the state of Connecticut. And as the four behavior analysts who came before me stated that the language was unclear in H.B. 5537, Section 42[6], and I just wanted to reiterate what my colleagues before said, that it's important to not blur the lines between the two scopes of practice between the behavior analysts, and the speech and language pathologists, and that I would urge the committee to change the language to the bill.

SENATOR GERRATANA: Very good. So you have some proposed language.

ELIZABETH NULTY: Absolutely.

SENATOR GERRATANA: Okay. And are there any questions? Okay make sure that -- we'd like to work with you on that. Make sure that we have access to that, and we'll take a look at it.

ELIZABETH NULTY: Absolutely, we can definitely send in something.

SENATOR GERRATANA: Okay. Great. Thank you.

Now Rick Liva, and then Mary Boudreau.

DR. RICK LIVA: Hi.

REP. JOHNSON: Hi, just tell us what your name is for the record.

DR. RICK LIVA: Sure. My name is Rick Liva. I'm a naturopathic physician practicing in Middletown. I'm also the chairperson of the legislative committee for the Connecticut Naturopathic Physician Association.

Senator Gerratana, Representative Johnson, and the rest of the Public Health Committee members, I come to you today to ask that you support the attachment of bill language for the modernization of the naturopathic scope of practice, and attach it to House Bill 5537.

As you may remember, I testified before this committee approximately one year ago seeking the same thing, which is support for the modernization of the 90-year-old naturopathic practice set. As you know, we went through the scope process and the report is supposed to come out. I understand it is supposed to be available on Monday.

In essence, the outcome from my perspective of the report will detail the strong opposition of the medical doctors. Their position is this group, us, of providers is not adequately educated or trained to have the level of prescriptive authority that they seek. If granted, it may be a detriment to public safety. I ask that you be open minded and pragmatic. Historically medical doctors have opposed all their competition.

During the committee process we presented evidence that naturopathic doctors have an exceptional safety record using prescriptive authority in other states. The MDs refuted that evidence, saying that it isn't sufficient to demonstrate a strong safety record, or that patients are not at risk, and that this information should not be the sole source for drawing any conclusions regarding health and safety benefits associated with the request for expanded scope.

However, it's extremely important to note that the medical doctors presented no evidence or data whatsoever to refute the safety information that NDs provide -- or provided to validate that patients are at risk or care has deteriorated in other states where naturopathic doctors have prescriptive authority.

David mentioned this thing that happened in Vermont. I ask that you please review the February 2013 Vermont report entitled "Presciptive Authority for Naturopathic Physicians." I submitted this as a part of my testimony so that you have the document. The report is from the Director of the Office of Professional Regulation. The report was to determine if naturopathic physicians receive sufficient academic training in pharmacology and clinical training in using all prescriptive drugs safely. Skip forward to present day. The Governor of Vermont signed the legislation that does allow naturopathic doctors in Vermont to use all prescriptive items. They have to pass a pharmacology review exam, and they have to have some medical doctor oversight for a period of time.

So why do the officials in Vermont trust naturopathic physicians to give them such authority? Because they are convinced that after a thorough examination of the facts, that NDs are sufficiently educated and trained, and they provide desired services to the residents in Vermont in a safe manner.

REP. JOHNSON: Could you please summarize, because the bell rang.

DR. RICK LIVA: Oh, it did. Okay. Well essentially, at the end of the day, I understand that your concern, as the Department of Public Health is concerned, with the safety of the residents of Connecticut. This Act needs to be updated. If not now, when? If not this year, we'll be back next year, and the year after that. And to sort of finish up, we're very much open to compromise and welcome a dialogue between DPH and legislators so that we can settle on a fair and reasonable and safe plan that sufficiently modernizes the law.

REP. JOHNSON: Well thank you so much for that excellent summary, and excellent presentation --

DR. RICK LIVA: Thank you.

REP. JOHNSON: -- and I want to open it up to the committee.

Senator Gerratana.

DR. RICK LIVA: And I read that without my glasses.

SENATOR GERRATANA: Thank you so much for coming today and giving your testimony. And I did read it, and you did attach many of the, well, pieces of information, if you will.

DR. RICK LIVA: I also gave to your administrative person the exact language.

SENATOR GERRATANA: Yes. Yes. Well, you know it's one thing to negotiate with us, and also, you know, of course the Department of Public Health or whatever input, but of course, unfortunately this evening we don't have testimony of those who may -- others that may be involved such as medical doctors --

DR. RICK LIVA: Right.

SENATOR GERRATANA: -- and so forth, so that is missing. I hope that they will submit testimony.

DR. RICK LIVA: It will be in the report, I promise you.

SENATOR GERRATANA: I'm sure it will. And I have one final thing. I did read the Scope of Practice of Naturopathic Physicians, but nowhere in there do I see treat or diagnose. That's not in your scope of practice.

DR. RICK LIVA: If you look at the language I submitted and --

SENATOR GERRATANA: No, no; I'm talking currently in your practice.

DR. RICK LIVA: Yes, I understand that.

SENATOR GERRATANA: Okay.

DR. RICK LIVA: And that's a missing. It should be there, obviously, and the language that we submitted does have that in there.

SENATOR GERRATANA: Okay. Thank you.

REP. JOHNSON: Thank you. Any additional questions?

Yes, Representative Miller.

REP. MILLER: Thank you, Madam Chair, and thank you for your testimony. Last year you gave us a couple of very simple examples of how this would allow you to be better -- give better assistance to your patients, and could you give us one or two examples. I thought they were very helpful last year.

DR. RICK LIVA: Sure. One of the things that I think extremely important to note, that when people come to us, and they have been to medical doctors and they say, "So I would like to get off of some of my medication; is that possible?" Well, without the prescriptive authority to actually prescribe the medication, from my understanding of law, we're not legally allowed to take them off of it. So we have to do certain double-speaks and semantics to be able to work with someone, and also say it's important that you let your medical doctor know that this is your wish so that they are informed that you would like to do this.

So I wanted to put that out there because that's one of the things that we find most disturbing. People come; they want to pare down, if possible, depending upon their clinical situation, their medications, and we can't directly do that with ease, okay? So that's one thing that prescriptive authority would afford us.

Other examples, I mean David Brady used the urinary tract infection example. I could give several others, and I will. Over the course of the past three years I've been concerned with many of the men that come in with a certain constellation of symptoms, and I check their testosterone. Their testosterone inevitably ends up being extremely low, below the lab limit, or very close to the lab limit, and they would like a trial of therapy. Well again, I can't treat them. I know how to do it; I know the indications; I know the contraindications, the adverse reactions, and so on. I have to send them back to their medical doctor, either their primary care doctor, or they have to get a referral, or directly go to an endocrinologist. That's not always easy. So just use the same example with someone who comes in with low thyroid symptoms. You do the blood test; you find that the blood test is abnormal. I can't prescribe thyroid for them. They have to do the same thing, go back to their medical doctor, have a dialogue with them, or go see an endocrinologist, and so on.

I could give you a dozen examples of that very thing: women who want to have sort of more dialed-in, low-dose hormone therapy, estrogen progesterone combos; we can't do that. So do you want more?

Okay, the antibiotic thing is particularly frustrating. I've had Lyme disease ten times in my life; horrible to say, but I have. Fortunately I've recovered each and every time. I have people come in and Lyme disease is not necessarily a diagnosis from a laboratory test. The laboratory tests are generally 50 percent false negatives. So a medical doctor will typically order a cursory Lyme disease test, and if it's negative, all bets are off, you don't have Lyme disease, unless there's a big bullseye rash. But most of the people, or a large number of people don't get a bullseye rash, or don't get a rash at all. I never had a rash. So a trial of treatment would be appropriate. Even before I considered a trial of treatment, I might do other testing that's more robust and may get at the situation in regard to saying there's definitely Lyme disease here, or it's probable that there's Lyme disease here. So that -- and I see that with some regularity.

Again if you're on the cusp of a negative test that a medical doctor has done, and something that I've done that shows the possibility of Lyme disease, if it's not screamingly abnormal, medical doctors don't tend to treat it. I would tend to treat it because frankly I'm afraid of Lyme disease. If it goes chronic it ruins people's lives. So that is something that I often see.

Again in regard to, let's just say blood pressure medication. It's a standard of care that medical doctors can give up to four drugs to basically control someone's blood pressure in the normal range. I frequently get people on two or three, rare four, but after a while, because of the side effects, or they just want to see if they can pare them down, I would like to be able to help the person do that. So it's not just taking someone off the medication. I have to wean them off slowly so I can see over a period of time how are they doing; is their blood pressure staying in the range that I think is safe, with medications that are dropped at a very slow level. So those are more examples.

REP. MILLER: Thank you. I appreciate it. It really helps us --

DR. RICK LIVA: Certainly. Thank you.

REP. MILLER: -- helps us understand it. Thank you. Thank you, Madam Chair.

SENATOR GERRATANA: Thank you. Any additional questions? Thank you for your well-delivered testimony.

Okay, the next person on the list is Mary Boudreau followed by Cane Fercodine.

A VOICE: Neither one is here.

SENATOR GERRATANA: No? Okay, Marsha, and then it's Marsha --

A VOICE: Prengruber.

SENATOR GERRATANA: Yeah, very good. That'll -- I'll -- there's --

A VOICE: Back for a long time.

SENATOR GERRATANA: You -- it's kind of all scrunched in there together, so. Thank you so much. Please state your name for the record.

MARSHA PRENGUBER: My name is Marsha Prenguber, and I won't ask you to repeat that, even when it's heard and seen.

I'm a naturopathic physician, and I've recently returned to the state of Connecticut to live and work here as a newly-appointed dean of the College of Naturopathic Medicine at the University of Bridgeport. I have held that office now for nine days.

My training includes a Bachelor of Arts Degree in Education from St. Joseph College here in Connecticut. Oh come on, I just got started. A Master's Degree in Education from Johns Hopkins University, a Master's Degree in Education Administration from California State University, and I received my Naturopathic Medicine degree from the College of Naturopathic Medicine in Oregon. I also completed a residency in naturopathic oncology.

I'm the past president of the Council on Naturopathic Medical Education which Dr. Brady referred to earlier. It's the US Department of Education-recognized programmatic accrediting body for naturopathic schools. That experience provided me with the skills to evaluate the academic and clinical aspects of the naturopathic schools, and evaluate each program against the rigorous standards of the accrediting body. This includes evaluating the academic and clinical training of the use of pharmaceutical, botanical, and nutritional agents, as well as the use of specific medical devices and minor procedures with a focus on patient safety throughout.

My most recent role prior to my appointment at the University was as the Director of Integrative Care at Indiana University Health Goshen Center for Cancer Care, an integrative cancer treatment center. In that role I worked collaboratively with surgical, medical, and radiation oncologists to address the needs of patients diagnosed with cancer. As is common for patients undergoing treatment for cancer, a significant volume of medications including toxic pharmaceuticals are employed to eradicate the cancer. Safety concerns are ongoing regarding the potential for interactions through the use of many pharmaceuticals, botanical medicines and nutritional supplements. The oncologists rely on the expertise of the naturopathic physicians to assess each of the botanical and nutritional supplements in conjunction with those pharmaceuticals, and make recommendations appropriate to the regimen to support chemotherapy and other medications or radiation.

It's the comprehensive training of naturopathic physicians that provide us with the skills to do that. I'll skip of my other testimony that you -- I don't know if you have before you yet. It was provided earlier today. It's a bit redundant to some of the presentation earlier.

The needs of the population have changed, as has the practice of medicine since the Practice Act for Naturopathic Physicians was developed and implemented in Connecticut so very long ago. Efficacies of treatments and safety concerns regarding polypharmacy -- do I get a little extra time now since it's a re-do?

SENATOR GERRATANA: Certainly, summarize because this is certainly a question of mine. I -- it was answered, but certainly another perspective on --

MARSHA PRENGUBER: Okay.

SENATOR GERRATANA: -- the historical aspects --

MARSHA PRENGUBER: Sure.

SENATOR GERRATANA: -- will certainly help us understand how there was a parting of the ways between the medical doctors and the naturopathic doctors.

MARSHA PRENGUBER: Well, and hopefully a reuniting of some of that work regarding the polypharmacy developed since then. And so our capacity to address those issues requires a variety of skills, therapies, and providers, types of healthcare providers. Naturopathic doctors have the training in the use of botanical, nutritional, and pharmaceutical medications that can provide safe healthcare approaches to support their patients, to restore and maintain health. We're constantly looking at those issues regarding chronic health. Because we have the training in each of those areas, it enables us to do the evaluation necessary.

I think that some of the parting left behind for medical doctors some of those lifestyle, and nutritional and botanical approaches that we are have -- are able -- we are trained and able to use, as well as the pharmaceuticals, so I think a joining of all of those pieces makes us uniquely qualified.

SENATOR GERRATANA: So with respect to the resources you're using in certain types of homeopathy in your practices, the materials for that aspect of your practice -- where are you getting those materials from? The homeopathy materials?

MARSHA PRENGUBER: Well it's actually a pretty long history with the use of homeopathy. There have been more research trials that have been done in recent years to evaluate them. For example, there's a relatively well-known trial that was done in Nicaragua with the use of homeopathy, with standards of care versus just standard of care, in children with diarrhea, ongoing diarrhea. And they found that, in fact, the homeopathy was what made the difference. And so we use those bases of information, trials that are done around, to help in the teaching of the use of that. Does that answer your question?

SENATOR GERRATANA: It's -- it's a start certainly. Thank you. Any questions?

Okay, well thank you so much --

MARSHA PRENGUBER: Thank you.

SENATOR GERRATANA: -- for your testimony. We very much appreciate it.

Rhonda Boisvert and then Peter MacKay.

RHONDA BOISVERT: Is this on?

SENATOR GERRATANA: Welcome, and please state your name for the record.

RHONDA BOISVERT: Hi there. Okay. Yes, Senator Gerratana, Representative Johnson, and members of the Public Health Committee, my name is Rhonda Boisvert. I own Pleasant View Manor and Shailerville Manor, and I'm the president of the Connecticut Association of Residential Care Homes.

I am here today to testify against Section 15 of House Bill 5537. This section of the bill would require residential care homes to take burdensome and unnecessary steps in writing a resident discharge plan, and perform tasks that homes are not equipped to provide or have ever done.

To let you know, our homes are comfortable and homelike. They do not look sterile, and they do not resemble nursing homes or medical facilities. We are community based. Our staff is small. We are family. The staff works hard by cooking, cleaning, and arranging medical appointments for our residents. They provide emotional support if needed. An employee must be kind and understanding to our residents, and they need to act quickly in an emergency.

Section 15 of House Bill 5537 would require residential care homes to take additional steps in writing a resident's discharge plan to an already burdensome Statute that is inappropriate and not realistic. There is no reason for a home to evict or discharge a resident unless the resident has broken house rules, has become psychiatrically or medically unstable, or doesn't pay their rent.

Of course, if a resident is requesting a discharge, the situation is changed, and finding placement elsewhere is usually not difficult. When the discharge becomes an eviction to the resident, the facility hires representation and this can take several months along with increased costs to the facility. At the same time the house has to deal with someone who is causing disruption to residents and staff. Often we have to utilize the police, ambulance services, and emergency rooms.

I just want to give you a little scenario of what we went through over the holidays in out Shailerville Home in Haddam, Connecticut. What would you think of a resident who is on oxygen, drunk, and smoking in his room? The resident refuses all medical care that is offered. The police come the first two times that they are called, but on the third call we are told "We are not your babysitters."

Other residents called their local ombudsman to complain of the house being unsafe. The ombudsman only speaks to the residents and once to the administrator by phone, but never comes to visit to see for themselves what the state of the house is. Mobile Crisis is called as another one of our resources. We are told that the resident has a behavior problem, and there is nothing that they can do to help us. We called the oxygen company to inform them that the oxygen is not being used properly and is endangering everyone in the home. They don't come out to assess the situation.

We have made doctor appointments for the resident, but he refuses to go. The Resident State Trooper is not happy that he has to use valuable community resources to sent to Shailerville Manor. He visits with the Town Selectwoman to voice his concern. We call DPH and make an appointment to complain of our experience and lack of resources.

I urge you to remove Section 15 from House Bill 5537. This section would only create new costs and burden to our industry and require an already inappropriate amount of work in a discharge plan that doesn't work for residents, staff, and administrators of residential care homes.

And I do want to let you know that this is just not a once, you know once in a while problem, it's a problem that occurs pretty much on a regular basis. I think you can talk to any homeowner, and that one time or another that they've had a situation like this.

REP. JOHNSON: Thank you for coming out, and I really appreciate your testimony.

And Representative Sayers has a question.

REP. SAYERS: Hi, how are you. Who would write those discharge plans in your home?

RHONDA BOISVERT: The discharge plans are -- would be, I mean in the new Statutes, I guess they want all this information from doctors and psychiatrists, but now we write them. And we have kind of like a form letter that we go by, and the -- the resident is given ten days to appeal, and a letter gets sent to DPH, and then the resident gets ten days to appeal, and then it starts from there.

REP. SAYERS: One of my concerns is they're talking about discharge planning, and yet the only requirement for staffing is that they be 18 years of age, and it doesn't require them to have any training, so I'm wondering who would have that ability to plan the discharge and write that type of a discharge plan.

RHONDA BOISVERT: That's what we're asking; that's why we're saying that this is not realistic. I mean the plan that's in place now is -- it's inappropriate. We don't have resources to help us, and so they're adding more, and it's going to be very cumbersome to the residential care home.

REP. SAYERS: Right, and I know when I worked at the Department, I received many calls from homes with those type of problems that you read in your testimony here tonight, asking for help and what they were going to do moving forward because it was difficult. And yet the other side of the coin is I've seen the Department go in and tell them that they need to discharge someone because they no longer are appropriate for that level of care, but they don't have the means to discharge them, so. Thank you for your testimony. I know this is really difficult, and I think that we need to provide more help with these homes and discharging residents when they're no longer appropriate for the level of care, so. Thank you for your testimony.

RHONDA BOISVERT: Thank you. I really appreciate hearing that and thank you very much.

REP. JOHNSON: Are there any other questions? I have a couple of questions, just in terms of your -- your certification for your level of care. I presume this is a rest home level of care?

RHONDA BOISVERT: I'm sorry. I didn't hear.

REP. JOHNSON: What is the level of care that you -- that you're -- at your facility?

RHONDA BOISVERT: For the people that --

REP. JOHNSON: It's a rest home, correct?

RHONDA BOISVERT: Okay, yes. It's a rest home/licensed boarding home.

REP. JOHNSON: Correct.

RHONDA BOISVERT: I do -- I do have to say that more and more. We are getting --

REP. SAYERS: It's a residential care home, not rest home, because there's a rest home with nursing supervision which is a different level of care.

REP. JOHNSON: Ok, so you're a residential care facility? Thank you.

REP. SAYERS: Residential care home or homes for the aged.

REP. JOHNSON: Thank you. Thank you, Representative Sayers. Thank you.

RHONDA BOISVERT: Yes. We do not have licensed help in the home.

REP. JOHNSON: Okay.

RHONDA BOISVERT: Well actually, I mean we, ourselves, don't hire licensed help, but there are visiting nurses that come to the home.

REP. JOHNSON: I understand. I was -- I was just trying to place exactly what type of a certification you had there. It's a residential care facility, so I understand that you have visiting nurses coming to your home.

RHONDA BOISVERT: And they are instrumental in helping us, but you know, it's just -- it's a whole long, long process. This situation here took place over Thanksgiving and Christmas, and just was a very horrible situation for the residents and staff.

REP. JOHNSON: You're a private residential care facility, or are you a publicly-run one?

RHONDA BOISVERT: Well we're all affiliated with the State of Connecticut, but we're private, yes.

REP. JOHNSON: And -- and in terms of the ownership of the residential home that you have, is that owned by you?

RHONDA BOISVERT: Yes.

REP. JOHNSON: Yes. And so when you went to create the certification and become a residential home, were you -- did you have backup help that you could seek assistance from if you ran into difficulty with your residents?

RHONDA BOISVERT: Well I -- I mean just knowing the community, I know, you know, what -- what's available to us, but it just seems like more and more, you know, that it's -- we're getting less and less help from -- from people that we were able to turn to in the community before, other agencies, and it's becoming, you know, less help. A little trip to the emergency room might be, you know, sending someone who is very disruptive, and they go to the emergency room and they're back in two hours because when they went down there they were okay, and they were appropriate, so they sent them back. We run into that quite often. We run into the calling for the Crisis Center to come out, and many times they will talk to just the resident over the phone, and not come to visit. We have to get very persistent with them to come down and see the residents if we're having a hard time.

REP. JOHNSON: So in terms of a discharge plan, or somehow an eviction, what do you -- do you evict the people who are not appropriate for the setting?

RHONDA BOISVERT: Yeah.

REP. JOHNSON: Or do you -- how do they get -- and where do they go from there? How do you make -- figure out a placement for them when they move from a residential home to a residential care facility to some other -- other place?

RHONDA BOISVERT: In this -- in this case here with this gentleman who came to us with a year of not having any problems with alcohol, the day he walked into our facility it went downhill, you know. He started drinking right away, and -- and he was disruptive. He wouldn't let us help him, and so I -- I have to say, and this doesn't make me feel good, but he got discharged on the whim of a State Trooper who came and had a talk with him and just told him, you now need to leave, you know, this community; you need to go, and so I'm going to come back in two days at 8 o'clock in the morning, and I'm going to meet you to make sure that you're leaving, and I want to hear of the place were you're going.

So that did happen. He did say that he was going to his mother's house. I don't know if that happened or not, but he was escorted off the grounds.

REP. JOHNSON: So in terms of your -- where did you get the placement from? Does an agency place --

RHONDA BOISVERT: The placement actually came from a rehab center where he was rehab'ing for breathing problems, and actually came from a nurse who came to our facility every week as -- as one of the visiting nurses, and she had gone to work for this agency where they were placing people, and just told us that he would really be a good fit for our place.

REP. JOHNSON: How many people in your place?

RHONDA BOISVERT: Fifteen in that home.

REP. JOHNSON: Fifteen? Okay. And in terms of the patient mix, do you try to balance certain -- certain issues a patient might have against maybe other -- other situations that patients might find themselves in? Is there a way that you're trying to -- trying to have a particular type of residential care facility? Or how do you deal with your patient mixes so that they're compatible?

RHONDA BOISVERT: We have a tool that we use that we -- that we use to get information, and -- and talk to the people that are -- are trying to send them to us and -- and basically what we want to know is we strive to get the truth of what -- what the resident's situation is, so that we -- not so that we can say no, you can't come here, but so that we can say we want to be able to know if we can deal with this person when things are not going right, okay? And -- and that's -- that's basically how we do it, and we thought that we had this covered with this guy, and we didn't.

REP. JOHNSON: So what is so difficult about the discharge plan?

RHONDA BOISVERT: It's find a place for him to go, and -- and no one wants him. I mean quite honestly, if I call another rest home and say I have this guy that I want, you know, to know -- I want to know if you have a bed available to him, so, their antennas go up like this, you know, like really, okay, what's the problem? Why would you be sending us someone?

So -- so right there that's not a good option. I think this guy did need more help. He needed help with going to an alcohol rehab, but he absolutely refused. He refused everything that we tried to do for him, and doctors' appointments, you know, and to the point where the doctor said don't call and make any more appointments because, you know, he just won't show up.

REP. JOHNSON: Very good. Well thank you so much for your testimony.

Yeah, Representative Tercyak, yes, thank you.

REP. TERCYAK: Hi.

RHONDA BOISVERT: Oh, hi there. I didn't recognize you. Hi.

REP. TERCYAK: I look different and older now than when we worked together. You look just the same.

Part of this has requirements for discharge planning, name of doctors, and things. Do you do use a W10 when someone transfers from your place to someplace else?

RHONDA BOISVERT: We do use one when we transfer to the emergency department. Yeah.

REP. TERCYAK: Uh-huh. Okay.

RHONDA BOISVERT: And we don't sign under the doctor's signature, we find --

REP. TERCYAK: Right, but that would be a place where you are already listing all the patient's meds, and who their doctors are.

RHONDA BOISVERT: Yes. Yes.

REP. TERCYAK: It's not like there's not a form that exists. This would just require a new form.

RHONDA BOISVERT: Right. If somebody's going to the emergency room we actually just make a -- a copy of their Kardex with the medications on it.

REP. TERCYAK: Back when we used to work together (some of us call it the good old days), you used to be on an assertive team, and would go out to places --

RHONDA BOISVERT: Right.

REP. TERCYAK: -- like this and pick up troublesome residents and bring them back to a respite unit. Does the State no longer provide services like that?

RHONDA BOISVERT: They no longer provide enough respite unit beds. I mean in Middletown at River Valley Services that would serve as that home, has seven respite beds. And -- and seven respite beds, and how -- I think you're supposed to stay there for like a week or something, they have residents that have been there for a year because they don't have placement for them.

REP. TERCYAK: Thank you very much. Thanks for all the good work you do.

RHONDA BOISVERT: Thank you.

REP. JOHNSON: Yes, Representative Sayers.

REP. SAYERS: Actually I don't have a question, but if I might ad, the residential care home is a licensure level of care. The staffing requirements for this level of care is one staff member per 25 residents. Obviously, if I care for even 15 residents, that's impossible and you can't do that. It is -- most of our homes either have elderly or they have chronically mentally ill patients, and a good many of them have chronically mentally ill, and so most of them are -- are receiving their health from Medicaid. They're on Medicaid. The payment source is through the State, but it's from Aging, and so, you know, it's not -- it's not like they're all private pay. And I -- you know, just because most people aren't familiar with this level of care, I like to say it's somewhat like assisted living, except at assisted living everything is ala carte, and in our residential care homes, your room and board pays for everything, all your -- all your services. I know Representative Srinivasan you have Gilead House in your district, and they have -- they have all chronically mentally ill there. Thank you.

REP. JOHNSON: Well thank you for that, Representative Sayers and Representative Tercyak. I much appreciate it. I have a place in my district called the Card Home, but most of the people are not mentally ill; they're seniors who are needing help of their activities of daily living. So it seems to me that we should maybe look at the -- if people have that designation as needing behavioral health services that perhaps we need to take a look at --

REP. SAYERS: Yeah.

REP. JOHNSON: -- making sure additional services are there for them. But it sounds like this -- this client -- patient that -- that Ms. Bonnabavet had is -- is something that he must have had kind of a psychiatric condition that warranted more care than just having a place to live.

REP. SAYERS: Also probably -- I don't if it's your District or the next one over, but Lyons Manor is.

REP. JOHNSON: Yes. Yes, that's not my District.

REP. SAYERS: And that's -- they have psychiatric there, more than elderly, but Card Home, I've been there. They're all elderly.

REP. JOHNSON: It's in Wilmington.

REP. JOHNSON: But thank you so much for your testimony and enlightening us about this situation, and pointing out the difficulties, and we will like to work with you on this, and try to move forward so that we can reconcile what the Department of Public Health is trying to do with what you need to do, and make sure that we provide appropriate care for people who are in these circumstances. So thank you very much for your time and testimony.

RHONDA BOISVERT: Thank you. Thank you for hearing me.

REP. JOHNSON: The next person on the list is Peter MacKay followed by Kimberly Sanders.

Welcome, and please state your name for the record.

PETER MACKAY: My name is Peter MacKay. I'm from the Roseland in Brooklyn, Connecticut. We're a residential care home. Senator Gerratana, Representative Johnson, members of the Public Health Committee, my name again is Peter C. MacKay. I'm the owner/administrator of the Roseland. It's a residential care home in Brooklyn, Connecticut. I'm also the treasurer of CARCH which is the Connecticut Association of Residential Care Homes.

I'm here to testify in opposition of Section 15 of House Bill 5537. This bill would require us to write a discharge plan explaining the resident's social or emotional requirements, and makes decisions as to what type of facility a resident is appropriate for. These duties are the responsibility of the resident's case worker, doctor, counselor, or therapist, all of which are trained professionals, and none of which have a job description that are within the realm of our abilities. We do not have any of these professionals on our staff, and the State is very clear about us not being able to do so to help keep the cost associated with our facilities down.

Our responsibility is to provide a clean, safe environment of room and board with general housekeeping and meals included. We do not have the training or expertise in psychological analysis. It would be totally inappropriate for a resident's landlord or housekeeper to make -- to be making decisions on his or her mental or psychological status. This, in essence, is what Section 15 of House Bill 5537 is asking us to do.

We currently do, however, provide a list of area housing and assist the residents in filling our applications when needed. We also make the residents' medications lists and other pertinent medical information available upon the resident signing the appropriate release. We already are assisting the resident when they wish to move to a different facility or geological area. This additional discharge plan is not appropriate for facilities at our level of care. We are not medical facilities.

REP. JOHNSON: Thank you so much for that. So you're not medical facilities, but nevertheless you're -- you are facilities that -- you do have from time to time people who do have psychiatric disabilities --

PETER MACKAY: Yes.

REP. JOHNSON: -- or some type of behavioral issue.

PETER MACKAY: The majority of people at the Roseland are either -- well I have a couple that are traumatic brain injury; two -- two are bipolar; and the rest are schizophrenic. We have 16 residents.

REP. JOHNSON: And in terms of -- not -- when these conditions are all controlled and people are getting the kind of treatment that they need, I'm sure that there's not a problem, but --

PETER MACKAY: Correct.

REP. JOHNSON: -- when there -- when there are some issues or changes in circumstances that might create a difficulty, how do you -- how do you address that?

PETER MACKAY: Well the people -- our clientele for the most part, as you -- as you said, are usually pretty stable, and the medications keep them that way. The problem is is over a period of time, six months to a year, everybody's different, their bodies adjust to the medications that they're on, and they don't -- they don't respond as well as they were. Being the fact that we give them supervision, and we're there -- we're with them 24/7. We're staffed 24 hours per day, seven days a week; there's always somebody available. We start to see these people degrade. We start to see them having trouble, throwing away their belongings, acting inappropriately, saying inappropriate things. If -- if caught soon enough, you can suggest a person, for the most part, to go -- it's time to go on a vacation, you know, and we -- we don't like -- they don't like to go to the psych ward. The psych ward is a bad place. So they don't go to the psych ward; they go on vacation. You know, it's time for you to take a break, you know, and maybe you just go take a break for a couple of weeks, see what they can do, maybe get things adjusted, then come back and we go again.

And -- and by having that constant supervision that -- that usually works. When they're out in the community there's no one to see that supervision. There's no one to make sure they take their meds. They feel fine so they feel no reason to take their meds, and then they start to degrade and then they get to a point where they can't take their meds because they can't make the conscious decision to do that, and that's where we end up with emergency room visits, police visits, the whole nine yards.

REP. JOHNSON: Do you also have conservators for some of your clients?

PETER MACKAY: I have conservators for a handful. I have pays for -- for quite a few. I've pushed for the longest time. Anybody who's living in our facility, there's a reason why they're living in our facility, and if they are, I think they all should be conserved, because they're there because they cannot take care of themselves.

REP. JOHNSON: And what about -- do -- is there any time you need an order from a Probate Judge to have a person have the vacation?

PETER MACKAY: Oh, yeah, yeah. And also, the first time they don't pay their rent and they spend their money on other things, I give them -- they get a break that one time, and you know, now next month you're going to pay your rent, and you're going to pay a little bit toward your back rent. You miss your payment plan, I file a petition with the Probate Judge for a Pay. You know, we're running a business and -- and I understand that the person has rights, a person has rights to make their own decisions; a person has the rights to do their own -- but they also have a responsibility that comes with those rights. They have to be responsible. They have to not -- their individual rights -- I draw a line when their individual rights start impeding other people the ability to enjoy their rights. So when they're violent, or they're -- showering was a big thing. You know, we're told by the Department of Health we cannot make them shower. Well when you get a person who's 45 years old, who soils himself and refuses to shower, and "you can't make me shower," there's an issue, okay? And now it's time that it has to go to a different level, okay?

The same thing with the Department of Health. They're asking us to write a discharge plan, and in this discharge plan they want us to do -- tell in the plan what this person's psychological level is; what they're capable is; what their social skills are. That's not my job. I don't have those expertise. I'm not a psychiatrist or counselor or any of that. I'm a landlord, you know.

REP. JOHNSON: Exactly. So, so can you -- so with a visiting nurses association coming in perhaps in those circumstances -- do they come in for patients who have these behavioral issues? Would they be able to do the W10 like Representative Tercyak had suggested?

PETER MACKAY: The W10 would go -- would have to be filled out by a doctor, and usually the only time we do that is if we're -- if someone is moving from our facility to a nursing home, we get an order from a doctor with a W10 to -- to -- for the nursing home to take that person in. Or if we're sending the person to a hospital, we'll send their med list with them.

As far as visiting nurses come in, we are med certified. Visiting nurses come in only for residents who need injections. So if they're diabetic, and they need insulin or whatever, then that's fine. But as far as a regular medical disbursement, their regular meds every day, twice per day, we do that at the facility.

REP. JOHNSON: Yep. Okay. So that's very interesting. Did you -- I guess that's all the questions I have. Does anybody else have any questions?

PETER MACKAY: As -- as far as admissions we do, is in my application, they're required to list their medications and I go to the visiting nurse with a list of medications, and I say look, this is what this guy's taking every day; what's going on with him? Because they can look at the meds, and they can say, you know, this guy's got some serious problems or whatever. And that's pretty much the screening that we can do, and that's all we can do. You know, and other than that, like Rhonda said, you take the word of whoever the person is that's giving them to you.

REP. JOHNSON: I guess my concern is -- is that without some kind of plan, or trying to evict somebody that's going to end up in a homeless shelter when they're already fairly behaviorally dysfunctional, and that's -- that's I guess a concern of mine without having more of a connection with other -- other agencies like Visiting Nurses Association, without doing the work with the emergency room, and the -- and perhaps the Probate Judge.

PETER MACKAY: I can appreciate that, but the reality is is that we're -- we're a small community of 16 people, and in that you have your private room, and you have your private bathroom, but you share the living room; you share -- you share the dining room; you share the -- the front porch, all these, you know, you're living in a community. And in part of that community, you have a responsibility to your other people in your community. If you're going to be totally disruptive, you're going to be abusive, you're going to be using -- smoking cigarettes in your room. I've had a -- I had a woman come in continually smoking her room. She caught -- she put her coat in her closet and caught the closet on fire.

I have a responsibility to the other 15 people.

REP. JOHNSON: I understand that completely, and I really appreciate the detail that you gave me in your testimony; it's very much appreciated. Are there any other questions? Thank you so much.

PETER MACKAY: Thank you.

REP. JOHNSON: The next person is Kimberly Sanders followed by Rachel Vincent.

Welcome, and state your name for the record, please.

KIMBERLY SANDERS: My name is Kimberly Sanders, and I am a naturopathic physician. I am a naturopathic resident physician at the University of Bridgeport College of Naturopathic Medicine, and I am here tonight to read the testimony of Dr. David Katz, who is a medical doctor and Master of Public Health.

Dr. Katz founded the Integrative Medicine Center at Griffin Hospital in Derby, Connecticut in 2000, and directs the center to this day working side by side with naturopathic physicians in direct patient care. In that context, he has participated in the postgraduate training of naturopathic physicians in evidence-based, integrative care for over a decade. This is his testimony.

Dear Legislators: I have worked extensively and closely with naturopathic physicians in every context relevant to the advancement of medicine, direct patient care, teaching, and research.

Naturopathic physicians are rigorously trained, completing a four-year program of postgraduate education just like their allopathic counterparts. The basic science curricula are identical, and training then diverges. Allopathic trainees are more intensively trained in hospital-based and acute care settings with a predominant emphasis on drugs and surgery, whereas naturopathic training is focused more particularly on ambulatory care and a range of treatment modalities encompassing pharmacotherapy, neutriceuticals, mind/body medicine and hands-on treatment methods.

These approaches to training are overlapping and complementary. Because of the similarities, allopathic and naturopathic can and should interact as efficiently and constructively as all physicians do in the collaborative process of patient care.

Because of the differences, naturopathic physicians can often meet the needs of patients when allopathic physicians cannot. They are particularly adept at meeting the needs of complex patients, providing holistic care plans, finding alternatives to pharmacotherapy when such approaches are poorly tolerated and addressing chronic symptoms when diagnostic clarity is elusive.

Of course the acumen and proficiency of naturopathic physicians varies as widely as that of the allopath. No level of training is a substitute for personal attitude and aptitude. In general, naturopathic training produces professionals ideally suited to meet the primary care needs of Connecticut residents. The overall quality of medical practice in our state, and the satisfaction of patients here will be advanced by offering naturopathy as a primary care choice. This should occur in a context of collaboration so that professionals in both disciplines can and do call on one another for assistance whenever warranted, just as generalists routinely call on their specialized colleagues now.

In my firsthand experience, naturopaths are devoted, knowledgeable clinicians; they are well versed both in what they know and in what they don't, perhaps the cardinal requirement in all clinicians. They have a good working knowledge of pharmacotherapy and suitable alternatives, offer a wide array of safe and effective treatments, and understand when and why to call for consultation. Working with naturopaths for the past 15 years, I have been impressed by their professionalism, inspired by their dedication, and enlightened by their important insights.

In summary, there is a need for more primary care providers in Connecticut, and in my opinion, based on years of firsthand knowledge, I submit that naturopathic physicians are ideally suited to play this role and offer this service.

With my respect and sincere thanks, David Katz, MD, MPH.

REP. JOHNSON: Very good. Thank you so much for that.

Senator Gerratana has a question.

SENATOR GERRATANA: Thank you. Kimberly, welcome. Where did you do your undergraduate work?

KIMBERLY SANDERS: So I went to undergraduate at Fordham University in the Bronx.

SENATOR GERRATANA: In the Bronx?

KIMBERLY SANDERS: I'm from Long Island.

SENATOR GERRATANA: And what did you major in there?

KIMBERLY SANDERS: I was pre-med. I majored in biology.

SENATOR GERRATANA: And you did, yeah, that's great. And I have a question: Do you do like a clinical rotation in hospital settings? Do you do an internship or residency, or something along that line?

KIMBERLY SANDERS: Do you mean as a resident, or in my doctorate training?

SENATOR GERRATANA: What -- what do you do in the hospital setting?

KIMBERLY SANDERS: Well right -- when I did my doctorate at the University of Bridgeport, we don't do any hospital rotations. It's just not conducive to our training as a generalist, and now at the residency level, I am required to do rotations with medical doctors as part of my residency training.

SENATOR GERRATANA: So you're a resident?

KIMBERLY SANDERS: I am currently a resident at the University of Bridgeport. So I did graduate last year.

SENATOR GERRATANA: Oh, you graduated. So you're doing post -- postgraduate?

KIMBERLY SANDERS: Correct.

SENATOR GERRATANA: Okay. Would you say that the four years that you do -- well, no, I answered that question. Okay. Thank you very much.

KIMBERLY SANDERS: Okay.

REP. JOHNSON: Thank you. Any additional questions? Thank you so much for your patience in being here all this time. I really appreciate your testimony.

Rachel Vincent, and then Anton Alder.

Welcome, and please state your name for the record.

RACHEL VINCENT: My name is Rachel Vincent and I reside in Hamden, Connecticut. I thought I was the last, so I'm glad not to be the last.

Freedom of choice is an important element of American life. This freedom is especially important when it pertains to the health of our society. Connecticut has lagged behind other progressive states by limiting that choice in health care, and I feel it is time for a change.

As a long-time patient of a naturopathic physician, I would value the opportunity to integrate a broader approach and additional treatments into my overall healing. Although I consider my naturopath to be my primary care physician, there are still basic elements of care for which I have to source treatment elsewhere. This not only leads to inconvenience and additional expense, but challenges to a comprehensive treatment plan. These challenges include integrating treatments from different providers, additional monetary outlay, and added time constraints for multiple provider visits which is worsened by the frustration and finding integrative and collaborative partners.

Along with freedom of choice, it's also important to me that I visit with a healthcare professional who provides a comprehensive and wellness model of health care. As opposed to merely receiving acute care, my experience with my naturopath over the years has been to combine treatments for diet, stress, exercise, and overall wellness. This has led to a substantial decrease in acute illness and symptoms, and an increase in my quality of life.

My wish is that other patients have opportunity to experience such positive treatment outcomes with the challenge -- without the challenges associated with it. Personally I would appreciate being able to receive a much broader scope of treatment directly from my naturopathic doctor. This would include the ability to receive necessary prescription medications, medical devices, nutrients by injection, in-office procedures, and other similar treatment options. These treatments all lie within the scope and education of today's naturopath, but for which I currently have to visit another physician.

My hope as a patient would be to exercise freedom of choice, and choose the healthcare provider with which I am most comfortable.

I appreciate your consideration.

REP. JOHNSON: Thank you so much for your well-delivered testimony. It's very much appreciated. Are there any questions? Thank you so much for waiting so long.

RACHEL VINCENT: Thank you for your time.

REP. JOHNSON: I apologize for skipping over Gene Ferodine, and is Gene still here? I know, and don't worry, Anton, I'll get to you. I'm so sorry, Anton Alder, I know; he's on the edge of his seat.

Thank you, and welcome, and I'm sorry; I thought I might have -- maybe you were out of the room. I thought I read your name, but maybe I didn't. I'm sorry.

GENE FERCODINI: My name is Gene Fercodini. Good evening, Senator Gerratana and Representative Johnson. I am the past president of the Connecticut Association of Realtors. The Connecticut Association of Realtors would like to submit testimony in opposition of H.B. 5537, AN ACT CONCERNING THE DEPARTMENT OF PUBLIC HEALTH'S RECOMMENDATIONS REGARDING VARIOUS REVISIONS TO THE PUBLIC HEALTH STATUTES.

The Act is designed to implement the Department of Public Health's recommendations concerning various revisions to the Public Health Statutes. The Connecticut Realtors has an objection to Section 30 of the Act. This section requires reporting on a monthly basis all air and radon in water reports to the Commissioner of Public Health by companies that provide for radon testing. The Connecticut Realtors are in favor of safe homes for the citizens of Connecticut, but we do not understand the rationale for this section.

The proposal requests a collection of data to be deposited with the Department of Public Health, but it does not specify the use of this data. The Connecticut Realtors believe this bill would stigmatize properties as having high radon counts when radon mitigation can easily be provided for. This action could result in a property not being as marketable due to its inclusion on said report.

The Connecticut Realtors also believes this proposal would add a large burden of administrative costs onto both testing companies and the regulatory body. These costs would in turn be passed on to the home-buying consumer and Connecticut tax payers.

To conclude, the Connecticut Realtors oppose this Section as we believe it to be an excessive reporting requirement, does not add to the protection of the home buyer as it will unnecessarily increase the cost of all involved.

Connecticut Realtors represent over 15,000 members involved in all aspects of real estate in Connecticut. For this reason, the Connecticut Realtors ask that you oppose this Section of the proposal. Thank you for your attention to this important matter.

REP. JOHNSON: Thank you so much for taking the time and spending all day with us today. I really appreciate it. I -- I'm just wondering, is there a way to disclose knowledge of radon that's already known? Would you recommend something of that nature, because if you know about -- isn't there a disclosure form on the -- when you go to sell a property, you have to disclose what you know, so how would this be more onerous than that?

GENE FERCODINI: Well what's going to happen is radon is not found -- there's a level of radon in every house in Connecticut to some extent. What's going to happen is if this is reported to the -- to the Department of Health, it may stigmatize a neighborhood where one house maybe has radon, but when someone's going to go look at that property, and they call the Department of Health, they're going to say well there's a house in that neighborhood that does have excessive radon. Is that going to prevent somebody from possibly wanting to look at property in that area? It's the same with well water. I mean you could have a well on one street that doesn't get any water, and the next street over gets plenty of water. Same thing with radon. You can have a house right next door to each other. One would have an acceptable level; the other one would not.

REP. JOHNSON: Well the fact is that many people who don't smoke find themselves getting lung cancer because of the exposure to radon, so I think it's an important thing to disclose if you have knowledge.

GENE FERCODINI: Oh, definitely, and our disclosure -- in our contracts there is a property condition disclosure that the people who own the property have to disclose if they have any reports or knowledge or radon. There is also a stipulation in the contract where we request people to do due diligence and do those types of tests, whether it be radon, whether it be pest control, whether it be water. That's part of what we do. That's part of what we try to get our buyers to do.

REP. JOHNSON: So, so we are -- so you're disclosing already, when you have knowledge of the radon, so what is your objection to this, reporting it to DPH?

GENE FERCODINI: Well I think what they're asking for is continued tests, you know, to be done on property. Once it's mitigated, it's pretty much done. And what they're saying here, in what's here, that they want reports sent at least on a monthly basis, houses that did have a report of radon in them.

What happens, too, is what's really is recommended is that one company do the mitigation, and a separate company come in to do the test, so that there's no confusion as to -- as to whether the work was done correctly.

REP. JOHNSON: Very good. So would you make a recommendation for a change, because I think it's important to have -- have somewhere that the information be reported, that the Department can track this, but I agree that probably every month is a bit excessive. And also once it's mitigated, there should be no problem. You're going to make sure that people do find out that they have the radon, and that they're able to mitigate the radon, because once -- once you have the venting and the proper thing done, you know, there shouldn't be a problem at all.

GENE FERCODINI: Well I think -- I think what we're concerned about is there is no testimony, or no -- nothing in there that says what they're going to do with the information, nor is there any consideration for what the extra costs would be to it, especially to a first-time home buyer who has to do these -- these types of tests, if, in fact, they have a record that it's not considered high radon, so.

REP. JOHNSON: Any questions? Thank you so much for your patience. Sorry I skipped over you my mistake.

GENE FERCODINI: Thank you. Thank you.

REP. JOHNSON: Thank you.

The next person is Anton Alder, followed by Robert Murphy, and Elizabeth Kontomerk.

Welcome, and please state your name for the record.

ANTON ALDER: My name is Anton Alder, and as you can tell I'm excited to testify. It's also exciting to hear from Dr. Kim Sanders who spoke of Dr. Katz from -- from Yale. It's nice to hear a gleaming review from our allopathics colleagues.

I -- I live in the south end of Bridgeport with my wife and baby son who are with me today. You may have seen them coming in and out. I am currently a student of naturopathics medicine at the University of Bridgeport College of Naturopathic Medicine. I take great pride in saying that I am a student of the only naturopathic medical school on the east coast. I am actively involved in generating interest in our program as an ambassador, and I am happy to testify that for the first time ever, the University of Bridgeport has been honored with hosting the student-directed naturopathic gathering later this year. We will host students, faculty, and professionals from the United States and Canada.

I believe in this school so much that I uprooted my family from Oregon and moved here. This is important to note, because Oregon also has a naturopathic medical school. However, I feel that the University of Bridgeport provides an academically superior curriculum, and that is why I'm here today.

Having lived in Oregon, I have seen naturopathic doctors practice in that state. I have worked with one as his assistant for two years. Oregon's scope of practice is up to date, and the students who graduate there can employ all their training in practice. That is not the case in Connecticut. The scope of practice for naturopathic doctors has not been updated in Connecticut in decades. I am here to testify that this is harming the community and the public health. The citizens of Connecticut are unable to access the full range of naturopathic primary care. This situation is also making my training at the University of Bridgeport more difficult and expensive. When graduating students are faced with staying in a state where they can't implement everything that they have learned, many are opting to leave.

As the only naturopathic medical school on the east coast, we should be attracting more students to the area, and the future of healthcare providers to Connecticut, not chasing them away. This is a concern among prospective students I have had the opportunity to speak with as a student ambassador. In fact today I met with more. One of my fellow classmates, Ryan, is a disabled veteran. He is a medically-retired US Army Captain, and a combat veteran from Bristol, Connecticut that was diagnosed with an auto-immune disease that began while he was serving in Iraq. His family now lives in Berlin, and naturopathic medicine, which is well suited to treat his disease doesn't really allow him, as a naturopathic provider in this state, to actually treat veterans and citizens of the same state that he has practiced learned to practice in.

I submit that the current scope of practice is harming the economy and the healthcare system in Connecticut. Naturopathic doctors can help to cut the costs and fill the gaps in our stressed healthcare system. We must take advantage of the resources we already have. As I have stated already, we have an accredited naturopathic medical school right here in Connecticut, so why not use those who are already been trained, and continue to be trained right here in our state, to help address the rising needs in health care. Please give these trained professionals a reason to stay and build a better Connecticut by expanding their scope of practice to match their training.

REP. JOHNSON: Great. Thank you so much for your testimony. Are there any questions?

Yes, Representative Cook.

REP. COOK: Thank you. I'm so glad you finally made it to the chair.

ANTON ALDER: Me, too.

REP. COOK: I just have a really quick question, and I know we had talked outside, and it was -- it was really nice to spend some time with the students and to hear what you all have to say.

You're a young professional with a growing family. If we change this, will you stay in the state of Connecticut, and if we don't change it, what are the odds of you leaving the state of Connecticut?

ANTON ALDER: Well, as stated before, I am from the state of Oregon, so my family is back there, and my wife's family is from California, so yes, there is pull in that direction. But, that being said, we love it here in Connecticut and I would love to stay. I have many people that I know already are begging me to complete my degree early so that I can start to treat them.

REP. COOK: So we have a little bit of pull, too?

ANTON ALDER: Yeah.

REP. COOK: Yeah, great.

ANTON ALDER: Quite a bit.

A VOICE: That's not going to happen.

REP. COOK: We're starting a dispute; we will stop here. Thank you, Madam Chair.

REP. JOHNSON: Thank you so much. Thank you. So the state of Oregon and California give more latitude to naturopathic doctors?

ANTON ALDER: Yes, they do.

REP. JOHNSON: I think I saw that, but you ---

ANTON ALDER: They have an extensive scope.

REP. JOHNSON: What's that?

ANTON ALDER: I said their scope of practice is much more extensive than here.

REP. JOHNSON: Great. Okay, well thank you very, very much.

And now we have Elizabeth Kontomerik? I hope I didn't brutalize your name.

ELIZABETH KONTOMERKOS: Elizabeth Kontomerkos.

REP. JOHNSON: Oh, I didn't see the "os" at the end.

ELIZABETH KONTOMERKOS: Thank you. I would like to thank all the members of the Public Health Committee for the opportunity to speak with you today. My name is Elizabeth Kontomerkos and I'm in support of adding the naturopathic scope expansion language to Bill No. 5537.

I'm a full-time working mother of two from Fairfield. My family and I have been patients of naturopathic doctors for almost ten years, and have truly come to appreciate and rely on our ND's proactive, holistic approach to our health. Our first doctor visit is always to our ND, as I find the overall approach, exam, and diagnostic testing to be more comprehensive. In essence, our ND has become our primary care doctor, and it has been truly beneficial and life changing for our family.

NDs in general have become a more integral part of our healthcare system, and therefore many patients like me are demanding to receive a more comprehensive spectrum of qualified care from the ND of our choice.

In addition to providing excellent preventive and wellness care, my ND has successfully addressed and corrected chronic issues such as thyroid imbalance, allergies, and high cholesterol. She has opened our eyes to the effect of certain foods and environmental stressors. NDs have provided -- NDs have provided friends of ours solutions to fertility issues, post-cancer wellness care, digestive issues, immune system disease, and detection of an unidentifiable Lyme disease. How could such an astute and educated healthcare professional not then be able to write me a simple prescription? Until now my ND has had to ask me to take a second appointment with an MD or go to a walk-in clinic. This is not only inefficient, more expensive to me, and adds additional work to our already burdened insurance system, but also delays my access to health care which, in today's world, is unacceptable.

NDs are highly educated doctors that follow a rigorous four-year postgraduate education largely comparable to that of MDs. They take professional state board exams, and are trained to serve as primary care general practice physicians. As a result, NDs graduate fully prepared to diagnose and treat patients, and prescribe medications when needed.

We, like many people in Connecticut, have come to depend on NDs for high quality primary care services including prevention, diagnosis, and treatment of illness. We should allow our NDs to practice consistent with their education and training, especially since 17 other states already have legislated this. In the states that allow NDs to prescribe medications, the track record for safety is exceptional. What worries me the most is that Connecticut's outdated law will limit the number of NDs that choose to stay in Connecticut, and as said, move to states that have updated scope of practice laws to begin their practices.

In summary, I am such a firm believer in the naturopathic approach and philosophy that for the sake of my children, and the future of all our family, I urge you to please support this important legislation. It will allow these highly-trained physicians to further benefit Connecticut patients with a more comprehensive and efficient care, while keeping our naturopathic doctors local and available.

Thank you for you time.

REP. JOHNSON: Thank you so much for your testimony and waiting so long.

ELIZABETH KONTOMERKOS: Sure, my pleasure.

REP. JOHNSON: Much appreciated. Are there any questions?

Yes, Representative Srinivasan.

REP. SRINIVASAN: Thank you, Madam Chair. Thank you very much for your testimony and waiting so patiently.

ELIZABETH KONTOMERKOS: My pleasure.

REP. SRINIVASAN: We appreciate that very much.

When you go to -- and I've heard this before from previous people who came in for testimony, and I'm not clear in my mind -- I was hoping you'd be able to help me with that. When you go to a naturopath for an office visit, a sick visit, obviously something like that, and they say that they spend a lot of time, take an intense history. What time frame are we talking about, you know, I mean not the first visit, I'm just, you know, not the very first visit which is always a long one --

ELIZABETH KONTOMERKOS: Right.

REP. SRINIVASAN: -- because there's a full history, so on and so forth.

ELIZABETH KONTOMERKOS: Right.

REP. SRINIVASAN: But when you go for an acute visit, that is a bronchospasm, that is urinary tract infection, whatever it is --

ELIZABETH KONTOMERKOS: Right.

REP. SRINIVASAN: Are you still spending a lot of time with them, or is it like an MDs office where you're in and out in 15 minutes?

ELIZABETH KONTOMERKOS: No, absolutely not. You definitely spend a lot more time. I think a lot of it is primarily because they have such a history of you that they're able to use that as -- as the infrastructure and the background that generates a lot more questions. They have a fully -- a much more fully comprehensive view and scope into you as a person holistically, so it does open up a lot more dialogue about what could be going on. And the diagnostic testing, when you do go say not for a well visit, but for a -- you know, you're sick, I just find that the testing -- the type of testing that they do is just a lot more thorough. And I know this recently because I had been going to my naturopathic physician for many years, and that person was no longer available, and I had an issue, and I hadn't found a new naturopathic doctor. So until then I went to my kind of back-up MD, and I was really just disappointed in, you know, the type of -- the lack of real questions about, you know, my situation, any outside background, you know, key features that could be going on in my life, and the testing that was done was just really quick. I just didn't feel I got the -- I guess I was spoiled. Let's just put it that way. I didn't feel like I got the service that I really deserved.

REP. SRINIVASAN: Thank you. Thank you very much.

ELIZABETH KONTOMERKOS: You're welcome.

REP. SRINIVASAN: Thank you, Madam Chair.

REP. JOHNSON: Thank you. Any additional questions? Thank you so much for being with us today.

ELIZABETH KONTOMERKOS: Thank you.

REP. JOHNSON: The last person I have on the list is Robert Murphy.

Welcome, and thank you for waiting so long, and welcome to the public hearing in Public Health.

DR. ROBERT MURPHY: Good evening, co-chairs Senator Gerratana, Representative Johnson, and the esteemed members of the Public Health Committee.

My name is Dr. Robert Murphy, and I am a naturopathic physician. I have a practice - a full-time practice in Tarrington, and I happen to live out in the sticks in that far, far town of Cornwall. We're out there!

I'm here today to testify and ask that you do everything possible to move forward language to attach to House Bill 5537 to modernize the Naturopathic Medical Practice Act. The current Naturopathic Practice Act, as you have heard, is 90 years old, and has not kept pace with the advances that have been made over the decades. Expanding prescriptive authority, and defining certain office procedures for naturopathic physicians will greatly improve our ability to delivery primary care service to our patients.

This is in turn -- this in turn will reduce redundancy in care, and reduce cost to patients and insurance companies alike, including the Connecticut CMA Programs, Husky, and Medicaid, which we are now being allowed to go back into. I have made my application last week. It would also allow the University of Bridgeport Naturopathic Medicine Program, as Dr. Brady so eloquently described, to teach students without doing walkarounds, and to teach them to the full extent that other naturopathic colleges do, to the full extent that other jurisdictions are licensed.

I've been licensed as an ND in Connecticut for the past 30 years, and also licensed as an RN in Connecticut since 1972, with a background in critical care nursing. I also served 15 years as the chair of the Connecticut State Board of Naturopathic Examiners. I was appointed by then Governor William O' Neill.

It would really be in the best interest of patients to be able to say for me to give someone antibiotics as well as the naturopathic remedies for acute Lyme disease. I practice in Litchfield County. We have the highest rate of Lyme disease of any place in the world; what a distinction. I do fill out the forms to send to the Department of Health, but I'd also like to be able to suture up a minor wound that came into my office. And I'll summarize shortly.

So I think in states which have expanded prescriptive authority to naturopaths, for example New Hampshire and Vermont, they demonstrate exceedingly safe, good safety records on close scrutiny.

Thank you in advance for your efforts in promoting the modernization of the naturopathic practice act, and I would love to take any questions.

REP. JOHNSON: Thank you so much for your time here and your good testimony, and I wonder if there's any questions?

Representative Cook.

REP. COOK: Thank you, Madam Chair. Well that's a strange thing to do for a Friday night date. But thank you for hanging out with us, and I wanted to thank you for your hospitality and showing me around your facility last week. I learned much.

DR. ROBERT MURPHY: Thank you.

REP. COOK: And -- and I think more -- I was on board before, but I was on board more after I left, just understanding the -- the connection between it all. And I think there were so many misconceptions out there, that listening today to hear what people had to say and again seeing our students and realizing that we can, you know, start working on keeping people actually in the state instead of, you know, having them leave us so quickly is extremely important. But I did, I wanted to thank you for your service, your time, your information and knowledge, and your testimony and spending date night with us. Thank you.

DR. ROBERT MURPHY: Thank you, Representative Cook.

SENATOR GERRATANA: Thank you. Are there any more questions? If not, thank you very much for coming and testifying today, and also I'll ask, is there anyone else here who would like to testify?

Richard Malik. Is that Richard? Come forward Richard.

RICHARD MALIK: Thank you. I'm sorry for my error. I was supposed to sign up.

SENATOR GERRATANA: You were supposed to sign up. I'm sorry. That just makes you the last person. Thank you.

RICHARD MALIK: So thank you for the opportunity to testify. I am Richard Malik, a naturopathic physician with a full-time practice in Salisbury, Connecticut in the northwest corner of the state, and a part-time practice in Manchester Center, Vermont.

I started my Connecticut practice in 2006 and my Vermont practice in 2010. The scope of practice for naturopathic physicians in Vermont is broader than our scope of practice in Connecticut. The broader scope of practice in Vermont allows me to serve the community better and help fill the gaps where the current healthcare system is deficient. With a similar scope of practice in Connecticut, I could further improve the healthcare delivered to our state's residents.

Currently all Vermont naturopathic physicians can prescribe from a limited formulary that includes many classes of legend drugs. Antibiotics that all Vermont naturopathic physicians can prescribe include amoxicillin, used to treat upper respiratory tract infections, other penicillins, tetracyclines, including doxycycline, commonly used for treating Lyme disease, macrolides including azithromycin, commonly used for pneumonia, and Bactrim which is commonly used for urinary tract infections.

The current Vermont scope of practice also includes drugs for treating gastrointestinal parasitic infections, hydrochlorothiazide for treating elevated blood pressure, statin medications for treating elevated cholesterol, thyroid hormones for treating hypothyroidism, antiviral agents for treating shingles, short-acting and long-acting agents for treating asthma, prednisone for treating acute allergic reactions, oral contraceptive pills, and vaccinations.

I regularly prescribe these medications for my patients in my Vermont practice, and if allowed I could do so safely in Connecticut as well. Vermont naturopathic physicians have been able to prescribe prescription medications since 1996 and due to our excellent safety record, the formulary has been expanded in 1998, 2008, 2011, and once again in 2014. The most recent expansion of the formulary is a C-change in the approach Vermont uses to regulate naturopathic physicians. It will take effect later this year. Instead of listing medications Vermont naturopaths can prescribe, the Vermont Office of Professional Regulation and Dr. Harry Chen, the Director of the Vermont Department of Public Health have decided that naturopaths should be regulated like other healthcare providers and be able to prescribe from the complete formulary of prescription medications to the extent of a physician's training and experience.

In order to qualify for this vastly expanded prescriptive authority, Vermont naturopaths must do two things: pass a pharmacology examination accepted by the Office of Professional Regulation, and their prescriptions are to be supervised for one year.

SENATOR GERRATANA: Thank you, Mr. Malik. Could you summarize for us, please? Thank you.

RICHARD MALIK: Yes. The reason why the Vermont Office of Professional Regulation changed the scope of practice for naturopathic physicians is not due to naturopathic physicians lobbying for this. It's because they saw a real need and a real benefit for the -- for the residents of Vermont.

I ask that you attach bill language to update, modernize, and expand the naturopathic scope of practice in Connecticut to House Bill 5537 please.

Thank you for your time.

SENATOR GERRATANA: Thank you, Dr. Malik. I corrected myself. Sorry, I'm trying to do two things at one time. Does anyone have -- ?

Yes, Representative Johnson.

REP. JOHNSON: Thank you, Madam Chair. Just quickly, would you mind providing us with a copy of what Vermont has done so we can see where they -- what they are doing, and compare it against -- ?

RICHARD MALIK: That has been submitted with my testimony. The law is approximately 20 pages long, and there's a short section that discusses exactly what it entails in regard to the expanded prescription authority.

REP. JOHNSON: And do they have -- this is just recently implemented? How long has this been in -- ?

RICHARD MALIK: This was passed by Peter Shumlin, the Governor, on July 1, 2013, and they're currently working on logistics of the qualification for the naturopathic physicians.

REP. JOHNSON: And did they have a legislative hearing and the whole procedure like we're doing now?

RICHARD MALIK: Exactly. And the bill was proposed to the Legislature. It passed both Legislatures and was signed by the Governor.

REP. JOHNSON: Thank you so much for that. We really appreciate it. Are there any additional questions?

Yes, Representative Srinivasan.

REP. SRINIVASAN: Thank you, Madam Chair. Good evening and thank you for your testimony this evening. This -- the pharmacological/pharmacology exam, whatever you need to take, as you said, in Vermont, that's -- I can understand. There's a course you take; you pass the test and so on and so forth. Could you just expand on that one year of physician supervision? What does that involve and, you know, in that one year that you have to be under the supervision?

RICHARD MALIK: Yes, I want to just clarify. The pharmacology exam does not require attendance in the course. It just requires passing of the -- of the examination, and prescriptions are to be supervised for at least one year by an objective independent, supervising Vermont-licensed physician with at least five years' experience with full prescriptive authority. And that does include naturopathic physicians. So five years from now, when I have had five years of experience of prescriptive authority, I will qualify to supervise another naturopath in their supervised period.

Does that answer your question?

REP. SRINIVASAN: It does, it does. But just if you would just expand on it for a minute or two as what is the supervisory role? I mean do you present it to the MD, and the MD says yes you're right in choosing the antibiotic; I'm glad you withheld the antibiotic. Is that the kind of a role?

RICHARD MALIK: It would be supervision for prescriptions that are written that are reviewed on a regular basis, not prior to the dispensing of the prescription, so there's just a regular supervision by a medical doctor, at this time, and I think that that's part of the logistics that the Vermont Office of Professional Regulation are ironing out at this time.

REP. SRINIVASAN: Thank you. Thank you. Thank you, Madam Chair.

REP. JOHNSON: Thank you so much.

RICHARD MALIK: This greatly expanded prescriptive scope. Our current scope we can do without any kind of supervision.

REP. JOHNSON: Okay, very good. Any other questions?

Okay, anybody else?

Thank you so much for your testimony today.

RICHARD MALIK: Thank you for your time.

REP. JOHNSON: We really appreciate it, and thank you for waiting to speak. Are there any other people who didn't sign up who would like to speak?

I guess then we have the hearing closed. Thank you so much.