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A
C
F
D
A
Very
good
all
right,
we
have
a
quorum,
so
we're
constituted
to
do
business.
The
first
order
of
business-
and
I
think
senator
rocky
adams
is
also
here.
If
you
want
to
get
her
on
the
roll
call.
I'm
sorry
representative,
bowling's,
president
from
the
annex
office.
Thank
you
very
much
representative.
A
Anyone
else
that
wants
to
answer
the
role
all
right.
Thank
you.
So
the
first
order
of
business
is
approval
of
the
minutes
from
our
october
20th
20
2021
meeting.
Do
I
have
a
motion.
Is
the
motion?
Is
there
a
second
and
second,
all
those
in
favor?
Please
signify
by
saying
aye
aye
any
apostles,
all
right.
The
minutes
are
approved.
The
next
thing
we're
going
to
take
up
is
going
to
be
our
regulations.
Item
number
six
on
the
agenda.
A
A
A
All
right
we've
got
a
good
agenda
for
discussion
today
on
some
topics
that
some
may
consider
to
have
some
controversy,
but
I
think
they're
important
for
us
to
have
some
discussions
on
and
to
hear
a
presentation.
The
first
item
we
have
is
scope
of
practice
in
healthcare.
We've
got
three
individuals
are
here
to
testify.
A
One
is
in
person:
one's
corey
meadows,
deputy
executive.
Vice
president,
director
of
advocacy
for
the
kentucky
medical
association.
We
have
two
remote
presenters,
dr
susan
bailey
who's,
the
immediate
past,
president
of
the
american
medical
association
and
kimberly
horvath
who's,
a
senior
legislative
attorney
with
the
american
medical
association
we'd
like
to
welcome
you
all
if
I've
done
kind
of
some
introductions.
But
if
you'd
like
to
introduce
yourselves
briefly
for
the
record
and
begin
your
testimony.
G
Well,
thank
you,
chair
alvarado
and
co-chair
mosher.
As
many
of
you
know,
my
name
is
corey
meadows.
I
am
deputy
executive
vice
president
and
director
of
advocacy
for
the
kentucky
medical
association
and,
as
always,
I
appreciate
the
opportunity
to
speak
with
you,
including
today,
I'd
like
to
reserve
a
majority
of
my
time
for
our
for
our
guests
from
the
american
medical
association,
but
before
turning
it
over
to
them.
I
would
like
to
provide
some
background
on
this
topic
known
as
scope
of
practice.
G
First,
what
does
scope
of
practice
mean
oftentimes?
The
term
is
used,
but
many
may
not
fully
understand
it
simply
stated.
Scope
of
practice
is
the
set
of
health
care,
related
activities
and
procedures
that
an
individual
is
permitted
or
authorized
to
perform
before
performing
such
activities
and
procedures.
However,
the
individual
must
demonstrate
that
he
or
she
has
the
requisite
level
of
education,
training
and
competency.
G
It's
also
worth
noting
that
a
provider's
scope
of
practice
can
also
include
express
limitations
that
may
restrict
what
an
individual
may
do
as
a
part
of
his
or
her
practice.
Determining
these
two
things,
what
a
health
care
provider
can
or
can't
do
is
meant
to
ensure
quality
of
care
and
patient
safety.
G
G
So
with
that
definition
in
mind
of
of
what
scope
of
practice
is
this
begs
the
question
who
determines
scope
of
practice?
Scope
of
practice
is
determined
state
by
state.
That
means
state
legislatures,
like
you
start
by
enacting
a
practice
act
for
each
provider
group.
Again:
physicians,
nurses,
pharmacists,
athletic
trainers,
occupational
therapists,
physical
therapists,
I
could
go
on
and
on.
They
all
have
a
practice
act.
G
Those
practice
acts
establish
what
services
can
be
performed
or
not
performed
how
they
are
to
be
performed
and
by
whom,
following
the
passage
of
the
law
by
you,
the
legislature
regulatory
bodies,
our
state
licensure
boards
then
step
in
per
your
direction
to
create
regulations
and
rules
around
that
practice.
Act
which
are
supposed
to
be
in
the
interest
of
best
serving
the
public,
not
necessarily
in
the
best
interest
of
serving
that
provider.
It's
about
public
protection
in
many
ways.
G
That,
in
a
nutshell,
is
how
a
provider
group
scope
of
practice
is
developed.
Now
I
want
a
question
that
that
comes
up
quite
frequently
is:
if
that's,
what
scope
of
practice
is?
If
that's,
who
gets
to
determine
it?
Why
is
scope
of
practice
often
a
difficult
topic
to
discuss
healthcare
practitioner
groups
approach
state
legislatures
all
over
the
country,
I'll.
E
G
You
know
that,
even
though
we
see
scope
of
practice,
legislation
each
and
every
year
in
kentucky,
that's
not
unique
to
our
state.
This
happens
in
every
state
every
year,
different
scope
of
practice,
pieces
of
legislation,
and
what
groups
do
is
they
approach
their
legislature,
making
any
number
of
requests
related
to
scope
of
practice,
oftentimes,
independent
practice,
which
means
just
so
that
we're
clear,
independent
practice
means
no
required
supervision
or
even
collaboration
with
a
physician.
G
G
These
types
of
debates
honestly
and
candidly,
they
oftentimes,
put
health
care
provider
groups
who
are
all
well
respected,
who
all
have
the
same
mission
of
providing
quality
care.
But
unfortunately,
these
debates
oftentimes
put
groups
at
odds
with
each
other
and
based
on
what
I've
experienced.
These
types
of
debates
also
put
lawmakers
in
an
either
or
a
scenario
or
proposition,
because
lawmakers
want
to
be
responsive
to
each
group's
concern.
Such
a
scenario
leaves
them
you
oftentimes
in
a
difficult
position
as
well.
G
In
short,
it's
a
delicate
balance
between
what
some
will
call
access
to
care
versus
other
groups,
serious
concerns
about
public
safety
and
quality
care,
but
I
want
to
be
very
clear
regardless
of
the
issue
or
who
is
requesting
it
or
what
group
is
requesting
it.
The
kentucky
medical
association
firmly
believes
that
first
patient
safety
should
always
be
the
overriding
objective
when
evaluating
any
request
for
a
change
in
scope
of
practice.
G
Second,
to
ensure
public
safety,
any
request
should
incorporate
what
I
will
consider
the
overarching
message
that
we
have
for
you
today
and
that
is
physician-led
team,
team-based
care,
the
team-based
care
model
notice,
I
don't
say
just
singularly
physician
care
model
or
just
np
model.
It
is
a
team-based
care.
G
G
G
Athletic
trainers,
as
many
of
you
all
know.
Recently
athletic
trainer
legislation
was
passed.
They
had
some
requests
to
be
able
to
more
clearly
define
their
practice
act,
be
able
to
do
more
things,
whether
that
be
on
a
football
field
or
a
basketball
court,
because
a
physician
and
a
nurse
practitioner
a
pa.
They
can't
always
be
at
athletic
events
that
many
of
you
all
have
in
your
districts,
and
so
they
wanted
the
ability
to
be
able
to
go
out
and
offer
their
services
again.
We
had
questions.
G
Actually,
this
would
be
a
very
good
idea.
We
have
no
issue
with
this
whatsoever.
It
will
help
with
the
continuity
of
care.
So
again,
I
just
offer
those
of
examples
of
of
how
things
can
and
should
work
on
these
difficult
issues
about
scope
of
practice,
and
so
with
all
of
that
as
background,
I
would
like
to
turn
the
presentation
over
to
dr
susan
bailey
and
kim
horvath
from
the
american
medical
association.
G
J
Yes,
I
am
here,
thank
you,
so
much
kim
horvath
is
going
to
share
and
advance
my
slides
I'd
like
to
wish
good
afternoon
chair,
alvaredo,
chair
moser
and
members
of
the
interim
joint
committee
on
health,
welfare
and
family
services.
J
J
So
I'd
like
to
share
with
you
some
information
on
three
key
areas
to
inform
your
perspective
on
scope
of
practice,
first,
education
and
training,
next,
the
cost
and
quality
of
care
and
finally,
access
to
care
next
slide.
Please!
But
first,
let
me
start
by
providing
a
national
perspective
on
scope
of
practice.
J
J
Nurse
practitioners,
physician
assistants,
nurse
anesthetists,
pharmacists
and
other
non-physicians
are
vital
members
of
the
healthcare
team.
Each
have
unique
and
complementary
skills
to
physicians,
but
they
are
not
replacements
for
physicians
and
because
of
that,
we
believe
that
physicians,
with
their
unmatched,
education
and
training,
should
serve
as
the
leader
of
the
healthcare
team.
Next
slide.
J
As
you
can
see
in
this
chart,
physicians
have
the
highest
level
of
education
and
training
compared
to
various
non-physicians.
The
top
five
lines
in
the
the
light
purple
show
this
between
medical
school
residency
and
fellowship
programs:
physicians,
complete
7
to
11
years
of
education
beyond
college
and
at
least
10
000
hours
of
clinical
training.
J
Now,
while
these
differences
are
significant,
I'd
like
to
point
out
that
there's
also
a
vast
difference
in
the
rigor
and
standardization
of
physician
training
compared
to
non-physicians
next
slide.
Please
so.
Here's
an
example
during
their
four
years
of
medical
school
on
the
left-hand
side,
medical
students
receive
a
comprehensive
education
in
the
classroom
and
in
laboratories
studying
the
biological
biochemical,
pharmacological
and
behavioral
aspects
of
the
human
condition,
and
then
we
spend
two
years
embarking
on
clinical
rotations
through
different
specialties.
J
J
J
Now
this
is
markedly
different
from
physicians
who
are
trained
in
a
specific
specialty
during
residency
and
who
often
go
on
to
obtain
board
of
certification
in
that
specialty,
physicians,
don't
switch
between
specialties
throughout
their
career
without
additional
training
simply
put
a
physician's
education
and
training,
make
them
uniquely
qualified
to
lead
the
care
team
next
slide
and
our
patients
agree.
Patients
recognize
and
value
the
education,
training
and
experience
of
physicians
as
essential
to
high
quality
care
and
support
physicians.
J
There
are
too
many
examples
of
practitioners
with
less
education
and
training
having
bad
outcomes
that
end
up
harming
patients
working
together
as
a
care
team
with
physicians
in
the
lead
is
critical
to
achieving
the
safest
outcomes.
Multiple
studies
have
also
shown
that
increasing
the
scope
of
practice
of
non-physicians
has
led
to
increased
health
care
costs.
J
This
study
found
that
6.3
percent
of
nurse
practitioners
and
8.4
of
physician
assistants
prescribed
opioids
to
more
than
half
of
their
patients
compared
to
just
1.3
percent
of
physicians
and
when
comparing
states
that
allowed
nurse
practitioners
to
independently
prescribe
compared
to
those
that
required
physician
involvement.
The
study
found
nurse
practitioners
and
physician
assistants
with
independent
prescription
authority
for
schedule.
2
opioids
were
20
times
more
likely
to
over
prescribe
opioids
than
those
states
that
had
restrictions
on
prescribing.
J
Now.
These
findings
are
supported
by
conclusions
from
other
longitudinal
studies
on
opioid
prescribing,
which
found
that
nurse
practitioners
significantly
increased
opioid
prescribing
during
the
period
of
the
study,
while
at
the
same
time,
physicians
for
almost
almost
every
medical
specialty
decreased
their
prescribing
of
opioids.
J
These
findings
should
give
you
great
pause.
In
fact,
they
highlight
the
fact
that,
like
all
areas
of
medicine,
effective
pain
control
requires
a
team-based
approach.
Opioid
analgesics
are
appropriate
for
some
patients,
like
those
with
a
severe
acute
injury,
those
who
have
cancer
or
are
in
hospice
or
with
certain
types
of
chronic
pain.
Now
these
are
all
conditions
that
require
close
physician
oversight
to
ensure
the
right
treatment
at
the
right
time.
J
Physicians
have
reduced
opioid
prescribing
nationwide
because
of
their
increased
judiciousness,
as
well
as
their
education
and
training.
The
data
aren't
clear
as
to
why
nurse
practitioners
are
prescribing
more
opioids,
but
the
bottom
line
is
that
breaking
apart,
physician-led
team-based
care
is
not
the
answer
to
more
effective
care
for
patients
with
chronic
pain
next
slide.
Please
we
often
hear
that
scope
expansions
are
necessary
to
increase
access
to
care,
particularly
in
rural
and
underserved
areas.
J
Data
show
that
this
is
a
failed
promise.
Since
2015
the
ama
has
collected
data
on
the
practice
locations
of
physicians
and
non-physicians
across
the
country
state
by
state
and
year
after
year,
the
data
clearly
demonstrate
that
non-physicians
tend
to
practice
in
the
same
areas
as
of
the
state
as
physicians.
J
J
That's
allowed
nurse
practitioners
to
practice
outside
physician-led
teams
for
decades
now,
while
the
overall
number
of
nurse
practitioners
increased
from
about
2000
and
2013
the
slide
on
the
left
to
3
100
on
the
right,
which
is
lower
compared
to
the
overall
growth
of
nurse
practitioners
nationwide,
you
can
clearly
see
that
there's
really
no
noticeable
increase
of
nurse
practitioners
in
the
rural
areas
of
the
state
next
slide.
J
Please
we've
seen
a
nationwide
trend,
in
fact
that
there's
been
a
greater
number
in
the
growth
of
the
number
of
nurse
practitioners
in
states
that
support
physician-led
team-based
care
compared
to
states
that
allow
independent
practice
and
kentucky's.
A
good
example
of
this
here
is
your
map
from
2013.
J
primary
care.
Physicians
are
represented
by
the
dark
purple,
dots
and
nurse
practitioners
by
the
the
blue
they're
triangles,
even
though
they're
hard
to
see
they're
found
in
nearly
every
county
in
kentucky
next
slide.
This
is
2020
the
number
of
primary
care.
Physicians
and
nurse
practitioners
both
increased.
In
fact,
the
number
of
nurse
practitioners
in
kentucky
doubled
during
that
time,
but
they're
condensed
in
the
highly
populated
areas
of
the
state
and
just
like
in
2013,
there
are
physicians
and
nurse
practitioners
in
just
about
every
county.
J
There's,
not
a
significant
drift
of
nurse
practitioners
into
rural
areas.
Next
slide
please
another
example
showing
the
location
of
physician
assistance
in
kentucky
next
slide,
and
here
comparing
the
location
of
primary
care,
physicians
and
psychiatrists,
which
are
the
yellow
dots
to
psychologists,
which
are
the
blue
dots,
the
blue
triangles,
and
so
these
maps
reflect
the
reality
on
the
ground
that
physicians
and
non-physicians
prefer
working
together
in
team-based
care
models,
not
separated
into
silos
of
care,
they're
likely
other
factors
at
play.
J
Of
course,
expanding
scope
of
practice,
though
of
non-physicians,
is
not
the
answer
to
access
to
care
problems
in
rural
or
underserved
areas.
Last
slide,
please.
Now
there
are
some
real
long-term
solutions
to
increase
access
to
high-quality
care.
Like
physician
loan
forgiveness
programs,
state
funding
of
physician,
residency
programs
telehealth
now
I
know
kentucky
has
led
the
way
with
strong
telehealth
laws
kudos
to
you.
For
that,
there's,
no
doubt
that
when
the
recent
legislation
is
fully
implemented,
it
will
have
a
positive
impact
on
improving
access
to
care
for
rural
patients.
J
J
A
Thank
you
very
much,
dr
bailey.
We
appreciate
your
testimony
just
really
briefly.
I
know
that
you'd
I'll
ask
a
quick
question.
I
know
you
had
mentioned
about
some
numbers
there
regarding
aprn
prescribing
nationwide
and
that
the
numbers
were
higher
with
some
of
those.
Is
that
a
is
that
a
study
nationwide
study?
Is
it
state
specific?
Can
you
expand
a
bit
on
that.
J
That
that
study
was
localized
you,
the
the
reference,
is
in
your
in
your
materials.
I
should
be
able
to
find
that
pretty
quickly
here.
Actually,
this
was
looking
at
2015
medicare
claims
data
and
it
was
really
a
nationwide
study
and
they
they
found
that
when
almost
every
medical
susp
specialty
decreased
their
opioid
prescribing
in
the
same
time
period,
nurse
practitioners
and
pas
actually
increased
theirs.
A
So
that's
that's
nationwide.
It's
not
state-specific,
yes,
correct!
So
there's
quite
a
few
states
out
there,
where
aprns
can
prescribe
without
any
physicians
and
we've
seen
some
of
those
maps
here
as
well.
I
just
want
to
make
sure
that
was
clear
for
the
committee
now
I
mean
I
know,
there's
gonna
be
members
here.
This
is
a
a
discussion
of
some
passion
and
I
know
I'm
included
in
that
as
well.
So
I
know
people
will
have
questions
about
this.
I
will
try
to
go
through
them
quickly.
B
Thank
you,
mr
chairman
and
hello,
dr
bailey.
It's
nice
to
see
you
again.
We've
we've
known
each
other
just
for
everyone's
reference
through
the
ama.
I
I
served
as
the
ama
alliance
national
president
and
worked
closely
with
with
all
of
our
partners
at
the
ama.
So
thanks
very
much
for
your
presentation
today.
I
appreciate
your
expertise
and
and
just
some
of
the
knowledge
that
you're
you're
kind
of
bringing
and
sharing
today.
B
I
do
want
to
point
out
that
I
brought
the
scope
practice
wheels
from
the
ama
for
everyone
that
know
your
doctor
just
to
to
kind
of
outline
the
differences
in
training
and-
and
I
think
it's
a
handy
resource.
So
you
know
I
know-
we've
talked
about
standards
of
care
and
we're
we're
talking
about
prescriptive
authority.
A
lot
today,
for
consistency's
sake,
across
states
and
and
in
addressing
the
standards
of
care.
J
Some
they're
interstate
licensed
compacts
that
exist,
and
you
know,
although
the
ama,
I
don't
believe,
has
policy
on
such
compacts
for
non-physicians.
You
know.
We
believe
that
each
state
has
the
right
to
license
its
own
practitioners,
and
so
there
is
some
debate
about
that.
It
might
be
helpful
for
data
gathering,
but
you
know,
since
state
scope
of
practice,
laws
differ
widely.
You
know
uniform
licensure
might
make
things
more
complicated
instead
of
less
complicated.
B
Okay,
a
quick
follow-up
I
and-
and
I
think
I'm
I'm
really
addressing
more
about
what
goes
on
in
the
states,
not
necessarily
an
interstate
compact
agreement,
although
we
do
have
that
in
kentucky
and-
and
I
think
it's
it's-
it's
serves
its
purpose,
but
for
for
the
practitioners
who
have
a
relaxed
prescribing
authority,
so
that
would
be
anyone
that
would
be
the
pas
aprns,
even
pharmacists.
B
If
you
know,
if
that
ever
comes
about,
would
it
make
sense
to
license
those
individuals
with
it
with
relaxed
prescriptive
authority
under
one
licensure
body.
J
J
B
Yeah,
thank
you,
and
so
do
you
know
of
any
states
who
do
this
and
you
know,
is
it?
Is
it
improving
the
standards
of
care?
Are
we
seeing
a
decrease
in
the
prescribing
in
those
states?
I.
J
C
Thanks
dr
bailey
hi
everyone,
my
name
is
kim
horvath
and
I'm
a
senior
legislative
attorney
at
the
ama
who
works
on
these
issues
and
answer
your
question.
C
There
are
a
couple
states
that
have
brought
some
of
that
oversight:
authority,
shared
oversight
authority
in
in
certain
instances
and
happy
to
dive
a
little
dig,
a
little
deeper
for
you
and
provide
you
with
some
concrete
answers
on
that
representative,
mosher
and
and
and
what
I
would
say
in
terms
of
have
we
seen
have
we
seen
kind
of
improved
quality
of
care
with
that?
C
I
think
where
we
have
seen
improved
quality
of
care
is
when
there's
a
physician-led
team,
so
I
mean,
I
think,
we've
seen
that
in
in,
for
example,
with
that,
with
the
opioid
studies
that
dr
bailey
shared
in
those
states
where
there
was
just
to
keep
on
the
theme
of
prescribing
right
where
in
those
states
where
were
nurse
practitioners
and
pas,
had
independent
prescribing
authority
of
opioids,
there
was
a.
C
They
were
20
times
more
likely
to
over
prescribe
than
in
those
states
where
they
had
where
they
had
to
work
within
a
physician-led
team.
So
I
think
that
is
kind
of
testament
to
the
importance
of
ensuring
to
ensure
the
safest
care
possible
to
patients
that
they're
for
prescribing
that
they
need
to
work
as
part
of
a
physician-led
team.
A
D
Back
on,
thank
you,
dr
billy,
and
thank
you
chairman
for
telling
me
my
microphone
wasn't
on,
but
what
I
was
saying
was:
I'm
just
a
demo
kentucky
boy
from
eastern
kentucky,
so
I
don't
understand
some
things
so
I'll.
Ask
some
simple
questions:
were
we
really
talking
about
full
practice
authority
or
the
scope
of
practice
in
your
presentation
for
does
full
practice
authority
by
your
graphs?
D
D
J
Well,
I'd
be
happy
to
there's
a
lot
of
of
information
in
that
question.
Sir.
Basically,
a
scope
creep
is
a
nickname
if
you
will
for
expansions
of
scope
of
practice,
and
we
believe
that.
J
Individuals
of
individual
members
of
the
healthcare
team
all
have
very
specific
roles
to
play
very
important
roles
to
play,
and
we
believe
that
the
increased
education
and
training
of
physicians
makes
them
qualified
to
be
the
leaders
of
the
health
care
team.
Individual
members
of
the
healthcare
team
are
not
you
can't
trade
places.
We
need
each
one
to
do
their
unique
roles.
You
know
there
is
data
to
show
that
expansion
of
scope
of
practice
does
in
increase
the
cost
of
care.
J
Diagnostic
testing,
radiology
ordering
there's
a
mayo
clinic
study
that
shows
that
it
increases
the
number
of
referrals
and,
and
so
we
believe
that
physician-led
teams,
with
specific
scopes
of
practice
are
the
best
for
safe
patient
care.
D
D
D
J
I
am
not.
You
know
saying
that
at
all
that
graph
was
merely
an
example
of
the
differences
in
levels
of
education
between
you
know
some
non-physician
groups
with
physicians.
It
was
not
meant
to
be
exhaustive
and
only
deals
with
the
as
an
educational
piece
on
the
the
level
of
education.
I
Thank
you
very
much,
mr
chairman,
and
thank
you
for
the
presentation.
I
I
wonder
if
we
could
pull
up
slide
number
five
again.
I
Is
that
possible
hopefully?
So
thank
you.
This
was
the
slide
that
dr
bentley
just
referred
to
with
the
training
hours,
and
I
I
just
I
just
want
to
note
in
this
education
matters.
As
a
licensed
psychologist
myself.
I
Your
numbers
are
a
little
off
the
years
of
of
patient
care
hours.
There
would
be
at
least
a
year
of
practicum
experience.
Then
there
would
be
a
year
of
pre-doctoral
internship
and
here
in
kentucky
at
least
a
year
of
post-doctoral
intern
postdoc
prior
to
licensure,
so
that
one
year
should
actually
be
three
years.
I
I
would
also
mention
that,
there's
no
such
degree
as
a
psych
d.
We
are
either
phds
or
psyds
or
in
some
cases
eddies
and
just
you
know,
because
this
is
an
area
that
I'm
knowledgeable
about
for
me
it.
It
raises
me
to
have
doubts
about
the
other
information
in
the
presentation.
I
I
I
just
wanted
to
say
that
this
maybe
implies
and
it's
possible.
Dr
alvarado
said
emotions
run
high,
but
I
think
price
that
psychologists
are
somehow
in
competition
with
primary
care
providers.
That
is
certainly
not
the
state
here
in
kentucky.
In
fact,
the
physicians
I
know,
who
are
fortunate
enough
to
be
involved
in
care
teams
with
licensed
psychologists
are
very
very
grateful
for
the
way
the
skills
and
the
training
complement
one
another
and
things
like
management
of
of
pain
without
use
of
opioids
and
other
behavioral
implications.
I
So
I
I
just
wanted
to
emphasize
that
I
thought
that
that
slide
might
be
a
little
alarmist
and
a
little
bit
misleading
and
then.
Finally,
I
just
wanted
to
make
the
point
that
you
talk
about
access
to
care
as
if
it's
an
urban
rural
issue,
and
while
we
know
that
that
certainly
is
the
case
in
the
urban
district
that
I
represent,
we
have
huge
pockets
of
poverty
and
we
have
huge
pockets
of
provider
deserts.
I
We
have
provider
deserts
all
across
the
state
of
kentucky
in
our
urban
areas,
in
our
rural
areas
and
in
our
suburban
areas,
and
so
finally,
coming
to
the
the
question
here
with
the
access
of
care
to
care
issues
with
the
shortage
of
providers
in
this
state.
J
If
I
may
respond
first
of
all
representative
wilmer,
I
want
to
thank
you,
for
you
know
pointing
out
errors
on
one
of
our
slides.
We
will
be
sure
to
correct
that,
and
you
know,
and
the
points
that
I
was
making
with
especially
with
the
psychology
slide,
is
how
important
it
is
for
care
teams
to
work
together,
and
we,
you
know,
welcome.
You
know
all
providers
to
the
table
to
to
discuss
these
things,
and
but
you
know
I,
I
appreciate
your
input.
A
Thank
you
representative.
I
do
want
to
comment
that
one
of
the
reasons
why
we're
having
this
group
present
here
today
this
has
been
a
topic
that
has
been
presented
in
multiple
committee
hearings
in
other
committees,
licensing
and
occupation,
in
particular.
Where
there's
this
topic,
the
other
side
has
been
presented
multiple
times
with
this
side,
not
having
an
opportunity
to
present
its
case,
so
they
may
have
been
allotted
two
minutes.
Perhaps
so
that's
why
I
thought
it
was
important
for
us
to
hear
this
side
of
the
story
in
this
committee
in
some
detail.
A
If
you
want
to
hear
the
other
side,
I
would
invite
you
to
log
in
and
find
where
licensing
and
occupation
has
covered
this
in
multiple
years
in
the
past
repeatedly
and
one
side
has
been
heard-
another
has
not
so
I
would
encourage
you
to
go
back
and
watch
those
if
you
want
to
hear
the
other
the
side
of
the
case
on
the
other
side
of
it.
Next,
I.
E
Thank
you,
chairman
alvarado,
and
it's
like
here
we
go
again.
I
think
your
points
are
well
taken
about
this
has
been
heard
numerous
times
and
licensed
occupation
should
be
what's
the
focus
of
this
committee.
What
should
it
be?
It's
improved
the
health
of
our
population.
I
think
we
lose
sight
of
that.
E
You
know
whenever
there's
a
avoid
in
the
vacuum,
it's
going
to
be
filled
by
something,
and
I
think
we've
got
to
ask
ourselves
well.
How
did
we
get
here?
Well,
obviously,
there
was
a
void
and
back
when
I
started
in
the
business,
you
principally
had
physicians
and
nurses.
That
was
pretty
much
a
healthcare
delivery
team
and
it's
expanded
since
then
to
try
to
address
that
void,
and
I
think
this
has
been
a
natural
progression
of
that.
That's
the
way
capitalist
system
works.
E
And
why
don't?
We
ask
a
fundamental
question
of
why
won't
physicians,
nurse
practitioners,
any
health
care
professional
choose
to
practice
in
a
rural
community
and
I've,
given
this
speech
before,
because
it's
not
an
equitable
system.
When
I
talk
to
our
insurance
partners,
they
say
we
pay
everybody
the
same.
Equally,
no,
you
don't
it's
an
equitable
system.
It
builds
on
itself,
and
even
all
these
things
we're
doing,
it
still
hasn't
changed
the
outcome,
particularly
for
rural
kentucky,
or
is
noted
in
some
of
our
urban
areas.
E
It's
not
going
to
happen
until
we
recognize
that,
and
this
should
be
an
economic
model
as
well
that
if
you
can't
get
people
to
go
to
an
area,
what
do
you
have
to
do
you
have
to
entice
them
by
giving
more
pay?
I
asked
a
question
in
our
managed
care
organization
or
our
medicaid
oversight
meeting
the
other
day,
the
mcos.
Why
won't
physicians
go
to
rural
communities
when
they
know
they're
going
to
be
making
25
to
30
percent
less
than
their
urban
counterparts,
they're
going
to
have
a
more
critically
ill
population,
a
less
compliant
population?
E
Why
would
anybody
go
there
and
quite
sure
they
didn't
have
an
answer
for
me
other
than
well.
He
some
people
kind
of
feel
it's
a
mission
to
to
do
this
sort
of
work.
I
appreciate
that
and
embrace
it,
but
it
doesn't
address
the
fundamental
issue
that
if
you
want
people
to
go
to
rural
communities-
and
we
want
to
improve
the
health
population,
we
should
be
paying
those
people
more,
not
less.
E
It
doesn't
cost
any
more
because
we're
going
to
save
tremendous
amounts
of
money
by
improving
the
health
of
our
population,
but
here
we
are
again
talking
about
scope
of
practice
was
not
going
to
improve
the
access
to
care
whatsoever.
This
must
come
on
my
sixth
session
here
in
the
general
assembly
in
every
session.
We
have
talked
about
this
and
you
you
noted
that
states
deal
with
this
as
well.
That's
the
wrong
thing
to
focus
upon,
and
I
assume
that
this
session
we're
going
to
have
more
bills
about
scope
of
practice.
E
My
fundamental
question
is:
what's
the
end
game
of
this?
What
are
we
trying
to
accomplish
other
than
self-protectionism
from
everybody
which
just
doesn't
advance
our
cause
whatsoever?
There's
got
to
be
a
different
way
to
do
this,
a
better
way
to
do
this,
we're
not
hitting
on
that.
I
think
we
got
to
focus
on
access
to
care,
true
access
to
care
for
everyone
and
be
fair
about
it
and
we're
not
at
all.
E
E
So
what's
the
end
game
here,
how
much
longer
are
we
going
to
continue
to
do
this,
and
quite
truthfully,
I
I
like
this
team
based
care
concept-
that's
great
in
theory,
but
if
you
don't
have
a
physician
in
your
community,
it
falls
apart
and
I
think
that's
part
of
this
natural
progression
is,
if
you
don't
have
a
physician
there,
who
steps
up
to
fill
that
role,
and
I
think
the
nurse
practitioners
have
had
to
do
that
in
rural
communities.
So
as
a
when
they've
had
that
experience,
then
they
start
to
ask
themselves
well.
E
Why
shouldn't
I
be
able
to
do
these
other
things
as
well?
I
think
it's
a
fair
question,
but
quite
candidly
I
don't
mean
this
critical
evidence.
It's
every
profession,
they
don't
know
what
they
don't
know,
so
they
can't
determine
their
limitations.
I
guess
that
falls
back
to
us,
but
again
I
want
to
know,
what's
the
end
game
of
this
thing,
how
are
we
going
to
address
this
and
what
does
scope
of
practice
truly
mean
if
it's
not
directed
upon
improving
access
to
care,
I
don't
care
about
people
protecting
their
turfis.
G
G
The
the
strategy
is
again,
we
use
the
phrase
access
to
care
and
if
I
had
a
nickel
for
every
time,
I've
heard
it
sometimes
legitimately
sometimes
as
a
marketing
tool,
but
I
would
be
on
a
beach,
not
here,
enjoying
myself
in
retirement.
If
I
had
a
nickel
for
every
time,
I've
heard
it,
and
so
I
think
the
biggest
point
out
of
what
senator
meredith
is
saying-
and
I
I
think
I
have
full
confidence
that
the
kentucky
medical
association
stands
behind.
The
statement
of
access
to
care
will
be
accomplished.
G
Legitimate
access
to
care
will
be
accomplished
when
we
have
all
providers
in
all
areas
of
the
state.
And
again
I
told
you
in
my
opening
comments.
If
you
took
nothing
else
away
from
what
we
said,
we
want
a
team-based
care
model
because
it
is
happening.
It
happens
to
the
providers
that
you
go
see.
Oftentimes
many
of
you
have
said.
Well,
you
know
I
love
my
pa.
I
love
my
aprn.
G
I
love
my
doc,
but
it's
crowded
in
there,
and
so
it
looks
like
they're
really
working
hard
together
to
accomplish
to
take
care
of
their
patients,
and
that
is
absolutely
positively
correct
and
that's
the
workable
model,
that's
the
right
model,
and
so,
if
we
have
nurse
practitioners
out
in
the
rural
areas
and
not
physicians,
it
won't
work.
If
we
have
pas
out
in
rural
areas
and
not
positions,
it
won't
work.
Quite
frankly,
if
we
have
physicians
out
there
without
help
from
nurse
practitioners
and
pas,
it
won't
work.
G
So
the
the
answer
is
true
access
to
care
where
they
have
those
providers
all
available.
Our
point
here
is
not
to
oftentimes.
We
hear
hear
that.
Don't
talk
about
education
and
training,
because
that
diminishes
other
groups,
and
so
for
many
years
we
have
stayed
away
from
that
talking
point,
I'm
going
to
be
honest
with
you,
because
physicians
don't
want
at
least
my
members
that
I
talk
to.
They
don't
want
to
have
that
reputation.
G
They
want
us
to
say
how
much
nurse
practitioners
and
pas
are
valued,
but
when
it
comes
to
facts
and
why
we
need
to
build
the
team
and
in
our
opinion,
who
needs
to
lead
that
team,
we
have
to
draw
some
distinctions
so
that
we
know
who
is
leading
the
team
and
who
should
lead
the
team
based
on
education,
training
experience.
G
But
that
doesn't
mean
doctors
know
how
to
be
nurses
or
nurse
practitioners
or
pas.
They
all
are
uniquely
educated
and
trained
to
accomplish
a
purpose
and
when
we
put
them
together
and
hopefully
when
we
put
them
together,
meaning
with
assistance
from
the
general
assembly,
we
will
then
see
better
health
outcomes.
G
That's
that's
what
we
mean
and
I
think
that's
what's
going
to
do
it
and
if
that
means
incentives
to
get
not
just
physicians
out
in
in
underserved
areas,
let's
call
it
underserved
areas
that
encompasses
both
urban
and
rural
areas
that
have
needs
to
get
not
just
physicians
there,
but
all
providers
there.
I
think
that's
when
we're
going
to
see
a
true
turnaround,
but
that's
difficult
right
oftentimes.
When
we
talk
about
incentives,
we
talk
about
money
and
and
certainly
in
a
cash-strapped
state.
G
That's
tough
to
come
up
with
at
times
so
oftentimes,
it's
easier
to
say:
hey
we're
going
to
work
on
the
access
by
removing
this
restriction
from
this
group
or
that
group,
but
but
to
doc.
Senator
meredith's
point
by
this
point:
he
probably
could
be
a
doctor,
but
to
his
point
you
know
it
hasn't
worked
for
25
years.
G
There's
been
various
groups
that
looking
at
changing
the
scope
laws
and
we
come
back
every
single
year
and
say:
oh
well,
just
give
me
this
one
more
give
us
this
one
more
thing
and
that'll
solve
the
problem
and
then
we're
back
the
next
year
kma
having
to
come
up
and
express
concerns.
Other
groups
saying
well,
let
us
do
this
or
let
us
do
that.
It's
it's
well
intended!
Maybe,
but
it's
a
model
that
just
simply
is
not
working.
E
First
down
to
the
point,
I
wish
we
would
just
put
a
stay
on
this
whole
discussion
and
really
focus
on
the
core
problem,
which
is
access
to
care,
true
access
to
care,
and
I
think
it
goes
back
to
the
payment
methodology
and
the
delivery
model
that
we
use.
You
know
hand
in
hand
with
this.
We
know
that
60
70
percent
of
health
care
problems
are
based
on
social
determinants,
but
yet
we
never
address
our
social
tournaments
because
we
say:
there's
not
enough
money,
there's
enough
money
in
the
system
to
solve
these
problems.
E
If
we
spend
it
the
right
way,
but
we
don't
we
don't
ever
so.
How
much
longer
we're
going
to
continue
this
financial
death
spiral,
which
is
going
to
be
because
now
we're
getting
20
of
our
gross
national
product
is
on
health
care
if
it
hits
25,
this
economy
is
going
to
collapse,
not
only
that,
but
the
health
of
the
population
is
going
to
get
worse
and
worse.
We
haven't
accomplished
anything
it's
time
to
have
a
reset
on
this
whole
process
or
we're
going
to
fail.
Everybody
is
we
won't
be
worried
about
scope
of
practice?
A
You
senator
so
I've
got
about
seven
or
eight
people,
who've
just
started,
raising
their
fingers
and
want
to
talk
and
we've
got
about
an
hour
left
in
the
committee,
and
we've
got
two
other
groups
of
presenters.
So
I'm
going
to
try
to
go
about
five
more
minutes
on
this
topic.
The
next
person
I've
got
is
senator
adams.
B
K
H
J
Thank
you.
There
was
a
car
horn
going
off
the
parking
lot.
I
I
think
kentucky
has
has
done
a
good
job.
You
know
many
states,
including
kentucky,
have
you
know,
seen
the
the
importance
of
of
patient
safety
in
terms
of
having
physician-led
care,
physician-led
teams.
B
B
J
B
Okay,
but
I
will
remind
you
that
a
nurse
practitioner
cannot
write
a
prescription
without
a
physician's
authorization.
B
Okay,
but
again
we're
talking
specifically
kentucky,
and
so,
if
you're
extrapolating
data
and
giving
us,
I
guess
a
snapshot
of
what
you
portray
kentucky
to
be.
Your
data
is
not
accurate
portrayal
of
what
is
happening
in
our
state,
and
so
so
I
just
want
to
be
clear
that
I
think
some
of
the
assumptions
that
are
made
are
not
kentucky
specific.
A
Thank
you.
Senator
I
remind
everybody
that
we've
suspended
the
kappa
cs
rules
for
physician
supervision
for
the
last
two
years,
so
we'll
have
an
opportunity
to
look
at
that
data
in
the
upcoming
year,
because
those
that
rule
has
been
suspended
by
the
general
assembly
in
light
of
covid.
So
there
has
been
no
physician
supervision
in
that
regard,
and
I
might
be
a
good
point
for
us
to
talk
about
independent
nurse.
Practitioners
are
independent
practitioners
in
the
state.
A
Perhaps,
mr
meadows,
you
could
expand
on
that
a
little
bit
because
I
think
people
think
that
they're
somehow
fully
dependent
on
physicians.
It
only
comes
down
to
the
kappa
cs
model
we've
talked
about
with
prescribing
of
narcotics.
Maybe
you
can
talk
about
the
ability
for
a
nurse
practitioner
to
practice
independently
in
the
state
refer
independently
in
the
state.
See
patients
independently
in
the
state
prescribe
other
medications
independently
in
this
state.
Maybe
you
can
go
into
that
in
some
detail.
G
Well,
other
than
echo
what
you
just
said,
which
I
think
is
absolutely
accurate
in
kentucky-
and
I
do
think,
there's
a
disconnect
often
times
and
I'll,
hear
this
from
physicians
too.
When
I
speak
to
them
it's
oftentimes.
The
assumption
is
that
nurse
practitioners
are
must
work
for
a
physician
are
directly
supervised
by
a
physician.
G
There
is
a
difference
between
the
definition
of
supervision
and
there's
even
varying
degrees
of
what
supervision
means.
Sometimes
it's
direct
like
right
over
the
shoulder.
G
Sometimes
it's
supervision
where
you
are
responsible
for
that
that
practitioner,
but
you
can
be
located
down
the
street,
but
as
long
as
they
can
get
a
hold
of
you
by
the
phone
or
some
communication
method,
then
that's
still
supervision,
but
it's
a
little
more
relaxed,
but
there's
a
big
difference
between
supervision
and
even
collaboration,
and
then
there's
certainly
a
big
difference
between
supervision,
collaboration
and
full
independence
and
in
kentucky
what
we
have
is
physician.
Assistants
are
directly
they're,
supervised
by
physicians,
they're,
actually
regulated
by
the
kentucky
board
of
medical
licensure.
G
Just
like
physicians,
athletic
trainers
are
supervised
by
physicians.
They
are
regulated
by
the
kentucky
board
of
medical
licensure.
Nurse
practitioners
are
different
in
that
they
are
regulated
by
the
kentucky
board
of
nursing
and,
and
so
even
though,
you've
got
practitioner
groups
doing
virtually
the
same
thing.
You
have
different
regulatory
boards
and
so
in
kentucky
by
by
law.
G
G
They
are
required
by
state
law
to
have
a
collaborative
agreement
notice,
I
didn't
say
supervisory
agreement
collaborative
agreement
with
a
physician
when
it
comes
to
prescribing
both
non-scheduled
and
scheduled
drugs
and
and
the
more
recent
conversation
has
been
about
scheduled
drugs.
We're
talking
about
controlled
substances
there
we're
not
talking
about
z,
packs
and
high
high
blood
pressure,
medications,
cholesterol,
we're
talking
about
xanax,
oxycontin,
hydrocodone,
those
types
of
things,
and
so
by
law.
G
They
have
to
enter
into
a
written
agreement
with
a
physician
when,
when
doing
prescribing,
does
that
mean
that
they
have
to
be
somewhere
close
to
a
physician?
G
No
not
at
all
right
now-
and
this
is
the
other
thing
that
we
oftentimes
get
into
is
we
talk
about
unmet
needs,
whether
it's
in
underserved
areas
in
the
city
or
in
the
rural
parts,
there's
nothing
that
prohibits
a
nurse
practitioner
currently
from
going
out
in
hindman
kentucky
to
use
not
county
as
an
example
to
set
up
a
practice
again:
they're
they're,
independent
they're,
regulated
by
the
board
of
nursing.
G
It's
just
that
if
they're
going
to
prescribe
controlled
substances
again
those
drugs
that
I
mentioned,
they
they
enter
into
a
collaborative
agreement
with
a
physician,
and
what
is
that
meant
to
do
just
just
briefly.
I
know
we're
running
out
of
time,
mr
chair,
but
what
it
is
meant
to
do
is
not
for
the
necessarily
the
doctor
to
tell
a
nurse
practitioner.
You
must
do
this
or
you
must
not
do
that.
It
really
is
meant
to
be
an
agreement
to
where
they
work
together.
That's
collaboration!
That's
why
it's
collaboration
and
not
supervision.
G
If
it's
a
supervision
agreement,
the
physician
would
probably
have
more
say,
but
it's
supposed
to
be
a
two-way
dialogue
to
where
they
enter
into
it.
On
some
of
the
most
habit-forming,
let's
face
it
dangerous
drugs
to
where
it's
supposed
to
be
a
mutual
benefit
for
both
to
be
quite
honest
because
physicians
are
not
perfect
in
prescribing,
and
so
it
really
is
meant
to
be
a
two-way
communication
where
they
collaborate,
they
meet,
they
talk
throughout
the
year
and
they
assist
each
other
when
it
comes
to
prescribing
those
types
of
drugs.
A
C
C
Your
opinion.
Does
our
current
collaborative
agreement
requirements
in
kentucky
meet
the
definition
of
a
physician-led
team,
and
let
me
let
me
clarify
that
a
little
bit
my
understanding
of
these
collaborative
agreements
which
I've
worked.
You
know
I've
looked
into
them
a
bit.
Is
you
know
the
nurse
practitioner
is
required
to
pay
a
physician
to
into
a
collaborative
agreement,
but
what
I
can't
find
on
the
other
side
is
any
responsibility
of
that
position.
C
There's
no.
I
can't
find
where
it
says
you
have
to
do
a
monthly
review,
but
you
have
to
be
available
on
call
that
you
have
to
do
a
semi-annual
review,
an
annual
review
that
you
have
to
do
anything
in
writing.
I
can't
find
what
the
responsibility
of
this
physician
is.
So
for
me
as
a
practicing
physician
who
works
in
physician-led
teams
in
the
hospital
I
mean
you
have
to
have
a
responsibility.
C
J
Thank
you
for
that
question.
You
know
I
envision
a
physician-led
team,
even
though
they
may
not
all
be.
In
the
same,
you
know
physical
location,
to
be
where
the
physician
holds
the
ultimate
responsibility
for
that
patient's
care,
and
I
you
know
with
the
definition
my
understanding
of
how
things
work
in
kentucky,
and
I
confess
that
I'm
not
an
expert
on
that
it.
It
is.
It
does
sound
like
a
physician-led
care
team
model.
J
Although
you
know
no
model
is
perfect,
every
model
can
improve
and
I'm
not
an
expert
on
the
roles
of
the
supervision
for
physicians
in
kentucky.
So
I
can't
really
answer
that
part.
A
I'll
be
happy
to
jump
in
here,
there's
not
a
requirement
for
a
doctor
to
be
paid.
I
supervise
nurse
practitioners
that
I'm
not
required
to
be
paid
to
supervise
them.
There
is
a
regulation
that
deals
with
this.
A
Our
staff
is
getting
that
for
you,
dr
berg,
we're
going
to
afford
you
the
regulation
that
provides
what
physicians
are
required
to
do,
but
it
sounds
like
you
might
be
open
to
the
idea
of
perhaps
passing
some
kind
of
legislation
to
tighten
those
requirements
for
physicians
who
supervise
nurse
practitioners,
and
if
you
have
that
I've
I've
filed
that
bill
before,
and
I
would
welcome
that
all
right.
Well,
we've
got
we've
got
to
move
on.
I
appreciate
all
the
presenters.
I
know
there's
others
that
have
questions.
I've
got
several
people
that
want
to
ask
them.
A
This
could
probably
go
on
for
another
hour
and
a
half.
We
do
have
other
presenters
here
and
in
light
of
their
time,
I
want
to
go
ahead
and
get
to
the
next
presentation
of
others.
Hopefully,
dr
bailey,
if
you'd
be
available
or
others
might
be
willing
to.
After
all,
the
presentations
are
done.
Some
of
the
folks
who
have
questions
could
ask
that
of
mr
meadows
and
yourself
if
you're
willing
to
hang
out
and
listen
to
our
other
presentation.
I
thank
you
all
for
coming
today
and
for
the
information.
A
This
is
always
a
hot
topic,
with
a
lot
of
passion
on
all
sides.
So
and
again
I
share
in
that-
and
I
appreciate
you
all
presenting
information
on
on
this
side
of
it.
The
next
item
on
the
agenda
is
liability.
Reform.
We've
got
today
several
presenters
here.
It's
we
have
a
partnership
for
common
sense
justice.
We
have
jim
musser
the
vice
president
for
policy
and
government
relations,
the
kentucky
hospital
association
and
also
the
chairman
for
partnership
for
or
pcj
as
we
know
it.
I
believe
we
have
also
kate
shanks.
A
I
know
ashley
wasn't
able
to
join
us
today,
so
kate
shanks
is
representing
the
chamber
of
commerce.
We
have
nathan
morris
vice
president
of
legislative
affairs,
the
united
states
chamber
institute
for
legal
reform,
and
I
believe
mr
meadows
is
going
to
be
hanging
out
also
to
talk
about
as
again
director
of
advocacy
for
the
kentucky
medical
association.
A
L
Thank
you,
dr
alvarado,
for
for
having
us
thank
you,
chairwoman,
moser
and,
as
this
is
thanksgiving
week,
I
would
like
to
say
just
a
couple
of
other
thank
yous.
I
would
like
to
thank
dr
bentley
for
all
the
work
that
he
did
in
the
last
session
and
the
session
before
for
our
rural
hospitals
on
the
rural
loan
program
and
I'd
like
to
say
a
very
sincere
thanks
to
representative
frazier
for
the
work
that
she
did
on
telehealth.
L
Both
of
those
have
been
so
important
for
our
patients
to
receive
the
kind
of
care,
and
thank
you
to
all
of
you
for
being
so
good
at
being
stewards
of
the
health
care
of
our
people.
As
I
often
say
to
you,
your
constituents
and
our
patients
are
the
same
people
and
we
want
the
same
good
outcomes
for
them.
L
L
L
What
you
should
know
when
we
talk
about
liability
reform,
it's
not
a
code
for
radical
change.
It's
not
put
plaintiff's
attorneys
out
of
business
40.
Other
states
have
already
enacted
liability
reforms
and
there's
access
to
the
courts,
and
we
support
access
to
the
courts.
Everybody
should
have
access
to
the
criminal
justice
system
and
to
the
civil
justice
system,
and
we
are.
L
We
are
not
at
all
opposed
to
that,
but
problems
have
have
arisen
over
the
term
of
a
number
of
years,
and
the
current
system
really
does
drive
health
care
costs
and
it's
not
just
health
care
costs.
It's
cost
for
every
business
in
our
commonwealth,
but
the
health
care
costs
from
our
from
my
kha
hat,
we're
seeing
increasing
insurance
in
premiums
insurance
premiums
every
year
providers
are
concerned
more
and
more
about
paying
insurance
premiums
and
protecting
themselves
from
lawsuits,
and
it
becomes
very
easy
for
a
provider
to
say.
L
Do
I
settle
in
louisville,
or
do
I
put
my
new
practice
in
indiana
where
there's
liability
reform
and
the
insurance
is
so
much
less
and
it's
an
easy
choice
for
so
many
of
them?
Unfortunately,
it's
an
important
choice
that
too
many
of
them
make
and
say
I'll,
go
to
indiana
or
I'll
go
to
tennessee
or
I'll
go
to
some
other
state
that
doesn't
have
the
unpredictability
that's
been
built
into
our
system
and
again
this
isn't
because
of
plaintiff's
attorneys.
L
Plaintiff's
attorneys
follow
the
rules
that
have
been
put
into
place
over
the
years
and
we've
we've
kind
of
developed
this
sort
of
wheel
of
justice
system
that
too
many
people
look
at
and
they
think
oh.
This
is
the
way
to
become
a
millionaire
and
they
they
think
that
this
is
the
thing
to
do
because
they
see
advertisements
on
tv.
L
L
So
how
did
we
get
where?
Where
we
are?
How
is
it
that
we
got
to
this
system,
that's
so
unpredictable
and
that
so
pushes
the
costs?
You
know
dr
alvarado,
and
I
know
dr
berg,
you
know
this
you're
you're
pushed
into
practicing
defensive
medicine,
and
that
raises
the
cost
for
your
patients,
the
patients,
your
constituents,
they're
facing
that
increasing
cost
so
where
we've
come
from
and
how
we
got
here
is
because
the
courts
over
time
have
irrigated
powers
to
themselves.
L
That
rightly,
do
belong
to
the
legislative
branch
and
we
think
that
the
right
step
to
take
is
rebalancing
that
the
founders
made
it
quite
clear.
The
founders
wanted
three
co-equal
branches
of
government,
but
if
you
look
at
the
constitution,
the
first
among
the
equals
is
the
legislative
branch.
You
are
the
voice
of
the
people
and,
unfortunately,
the
voice
of
the
people
has
been
repeatedly
thwarted
by
a
court
system
that,
down
through
the
years,
has
taken
more
and
more
power
onto
itself
and
whether
it
was
democrats
in
charge
or
whether
it
was
republicans
in
charge.
L
So
the
time
really
is
ripe
for
us
to
rebalance
that
for
the
legislature
to
reassert
its
role
in
determining
what
the
liability
system
is
supposed
to
look
like
in
this
state
and
we're
looking
forward
to
working
with
you
on
that,
because,
as
senator
meredith
points
out,
the
way
to
address
the
social
determinants
of
health
is
to
have
a
wealthier
society.
Health
and
wealth
are
inextricably
intertwined,
there
is
there's
no
separating
them,
and
the
only
way
to
have
a
wealthier
society
is
to
make
sure
that
businesses
find
the
liability
system
here
attractive.
L
It's
part
of
a
business
climate
that
needs
to
be
welcoming
it's
part
of
a
business
climate
that
says
everyone
deserves
access
to
the
courts.
All
litigants
should
be
treated
the
same
way.
Everybody
should
have
their
fair
day
in
court,
but
we're
not
doing
this
to
make
people
rich
we're
doing
this
to
make
things
just
so
we're
looking
forward
to
you
working
with
us,
and
you
can
see
the
list
of
groups
that
are
involved
with
the
partnership
and
it
really
does
represent
every
walk
of
life
in
our
society.
L
We
think
that
the
time
is
right
and
we're
looking
forward
to
working
with
all
of
you
on
legislation
to
make
sure
that
we're
rebalancing
things
the
way
that
they
need
to
be
rebalanced.
We
think
that
there
are
plenty
of
steps
that
you
can
take
to
reclaim
your
power
and
again.
Thank
you.
Thank
you
for
having
us
today
and
thank
you
for
all
the
work
that
you
do
on
behalf
of
our
patients
and
your
constituents
trying
to
to
make
us
a
healthier
state.
M
And
I'm
kate
shanks,
I'm
senior
vice
president
of
public
affairs
for
the
kentucky
chamber
and
we're
happy
to
join
our
colleagues
at
the
hospital
association,
the
medical
association
talking
about
this
topic,
and
I
think,
when
you
think
about
liability
reform
issues,
you
you
automatically
think
medical,
but
we
look
at
this
from
a
broad-based
business
perspective
and
I
know
chair
alvarado.
We've
worked
with
you
on
legislation
involving
caps
on
non-economic
damages.
We've
worked
chair,
moser
with
you
on
the
attorney
advertising
legislation
and
with
you
as
well
senator
alvarado
on
that
legislation.
M
So
this
is
something
we've
worked
on
for
quite
some
time,
but
when
coveted
19
hit,
it
really
shined
a
bright
light
on
the
underlying
concerns
of
business
leaders.
When
it
comes
to
liability,
we
saw
it
firsthand.
We
would
hold
webinars
with
some
of
our
attorneys
just
to
help
answer
questions
that
business
leaders
might
have.
They
were
always
incredibly
well
attended.
M
We
answered
questions
from
so
many
business
leaders
just
wanting
to
understand
the
new
regulations
that
were
placed
on
them
to
control
covid
wanted
to
do
everything
they
could
to
protect
their
employees,
dealing
with
an
uncertain
virus
that
they
had.
Never
dealt
with
before,
along
with
new
rules
that
they
had
never
dealt
with
before.
M
And
my
colleague
nate
is
going
to
tell
you
a
little
bit
about
why
that
matters
that
you
know
you
were
absolutely
going
to
to
protect
and
defend
these
business
leaders
and
these
these
places
where
people
worked
and
visited
because
they
had
done
so
much
to
to
stop
the
spread
of
the
virus.
So
I
do
want
to
thank
you
for
that.
We
come
at
this
issue
through
the
lens
of
competitiveness,
and
so
I've
asked
my
colleague
nate
morris
to
join
us
with
the
u.s
chamber
and
I'll.
M
Let
him
introduce
himself
for
the
record
as
well,
because
they
have
a
really
great
perspective
on
those
issues
across
the
states
and
he
can
kind
of
help
us
understand
where
we
are
and
where
we
can
go,
and
I'd
like
to
chair
turn
it
over
to
him
to
give
just
a
few
comments
as
well.
N
Okay,
chairman
of
members,
thank
you
for
the
opportunity
to
be
with
you
to
discuss
the
importance
of
kentucky's
legal
climate.
As
kate
mentioned,
I'm
nate
morris,
I'm
the
vice
president
of
legislative
affairs
for
the
u.s
chambers
institute
for
legal
reform
for
and
if
you'll
indulge
me
since
we
don't
testify
here.
Very
often,
the
u.s
chamber
of
commerce
directly
represents
over
300
000
members,
including
many
many
businesses
from
kentucky.
We
also
represent
through
partnerships
with
great
organizations
like
the
kentucky
chamber.
N
Millions
of
members
across
the
country,
ilr,
is
division
of
the
u.s
chamber
of
commerce,
and
our
mission
is
to
advocate
for
a
fair
legal
system
that
promotes
economic
growth
and
opportunity.
As
part
of
that
mission,
ilr
raises
public
awareness
of
legal
issues
and
we
urge
policymakers
to
affect
positive
change
to
improve
your
state's
legal
climates.
N
We
also
have
a
research
team
that
publishes
white
papers
on
legal
issues
and
explores
the
economic
and
other
impacts
of
litigation.
One
of
our
recurring
research
products
is
a
ranking
of
states,
legal
climates
and
those
rankings
are
based
on
senior
in-house
attorneys
perceptions
of
states.
Legal
climates,
experienced
attorneys
are
asked
to
evaluate
different
features
of
legal
systems
such
as
how
states
handle
scientific
and
technical
evidence,
for
example,
kentucky
ranked
40th
in
our
most
recent
survey.
N
N
In
our
last
survey,
a
record
number
of
respondents
89
reported
that
important
decisions
are
impacted
by
a
state's
legal
climate,
but
your
legal
climate
doesn't
just
influence
decisions
about
the
future.
It
has
a
very
real
and
very
current
effect
on
businesses
and
kentucky
families
in
2018.
Can
we
skip
ahead?
Thank
you.
I
should
know
how
to
work.
This
myself
in
2018
ilr
released
an
economic
study
that
quantified
the
total
cost
of
the
tort
system,
the
united
states.
N
We
were
able
to
break
that
number
down
state
by
state,
as
this
slide
shows
tort
costs
and
compensation
are
equal
to
about
2.3
percent
each
year
of
kentucky's
gross
domestic
product.
That's
higher
than
many
of
your
neighbors.
We
have
several
listed
here.
North
carolina,
virginia
ohio
indiana
are
all
lower
they're,
all
under
two
percent,
and
that
may
seem
like
a
small
difference.
2.3
1.8,
it's
only
half
a
percentage,
but
that
adds
up
to
tens
of
millions
of
dollars
a
year
in
additional
costs
in
kentucky
and
what
those
higher
costs
translate
to
for
kentucky.
N
Families
is
about
2
600
per
year
in
torque
costs.
If
you
can
average
those
costs
across
all
the
family
units
and
households
in
kentucky
put
another
way.
That's
a
bit
more
than
six
percent
of
a
median
household
in
kentucky's
annual
income,
which
means
that
your
tort
system
costs
the
median
family
in
kentucky
more
than
your
state
income
tax.
N
N
That's
2.5
times
their
revenue
share
as
they
bring
about
19
of
business
revenue
nationally
for
the
smallest
businesses,
those
that
bring
in
under
1
million
annually
in
revenue,
tort
costs
are
10
times
higher
than
they
are
for
large
businesses
as
a
fraction
of
revenue.
That's
a
lot
of
numbers,
but
the
point
I'm
trying
to
make
is
a
really
simple
one.
As
I
travel
the
country,
I'm
sometimes
told
that
legal
climate
issues
are
a
big
business
problem.
N
That's
just
not
true.
It's
an
all
business
problem
and
it's
an
especially
pronounced
small
business
problem.
We've
heard
about
medical
providers
quintessential
small
businesses,
kate
mentioned
sb5
and
the
broad
coalition
there,
and
I
think
what
the
interest
in
code
liability
shows
is
that
it's
not
a
business
problem
exclusively.
It's
a
healthcare
problem,
an
education
system
problem
and
even
a
problem
for
charities
and
religious
institutions.
N
I
don't
have
a
slide
for
this,
but
I
do
want
to
take
and
talk
about
how
acting
to
improve
your
legal
system
worked
in
your
recent
history
and
touching
a
few
things
that
could
be
done
to
strengthen
it
in
the
future.
On
the
impact
of
reforms,
kentucky
was
an
early
mover
on
code
liability
issues.
You
were
among
the
first
states
in
the
country
to
address
health
care
provider,
liability
and
liability
for
products
used
as
covered
counter
measures.
N
Then
you
circled
back
and
passed
sb5
to
address
exposure
issues
over,
and
so
I
had
the
research
team
go
back
and
pull
some
numbers
on
this
before
I
came
down
and
over
the
course
of
the
pandemic,
kentucky's
year-over-year
gdp
growth,
which
was
slightly
below
the
national
average
pre-pandemic,
dropped
less
and
bounced
back
faster
than
the
national
norm.
Looking
at
unemployment
data,
you
see
the
exact
same
story:
pre-pandemic
unemployment
in
kentucky
was
higher
than
the
national
average
during
the
pandemic,
especially
after
sp5.
N
More
folks
in
kentucky
kept
their
jobs
and
workers
who
lost
their
jobs
were
back
to
work
faster
than
average
across
the
country.
Small
businesses
in
kentucky
saw
less
revenue
drop
off
than
their
national
peers
and,
as
a
result,
more
will
stay
open
over
the
course
of
the
pandemic.
So
correlation
is
not
causation.
N
I
don't
want
to
make
a
specific
claim
as
to
cause,
but
I
think
it's
reasonable
to
say
that
kentucky's,
prompt
action
on
covid
liability
helped
the
state
fair
better
than
many
of
your
peers
over
the
last
18
months,
and
that's
a
success
story
that
you
can
build
on.
We
produce
a
comprehensive
guidebook
on
how
to
improve
legal
climates,
101
ways
to
improve
state
legal
systems.
N
I'd
be
happy
to
provide
every
member
with
a
copy
that
covers
more
issues
than
would
be
possible
to
talk
about
here
today,
but
forum,
shopping,
jury,
diversity,
evidence,
rules,
calculation
of
medical
damages
guardrails
for
class
and
mass
actions,
controls
for
punitive
and
non-economic
damages
and
lots
more
in
addition
to
the
things
that
are
laid
out
in
the
101
ways.
Primer
and
the
issues
that
have
been
discussed
here
today
about
medical
liability,
specifically
I'd
suggest
the
legislature
take
a
close
look
at
legal
services.
Advertising
lawyers
can
advertise
their
services,
that's
a
given.
N
Second,
large-scale
investors
are
putting
a
lot
of
money
into
lawsuits.
A
bloomberg
article
from
earlier
this
month
reported
that
the
so-called
litigation
finance
industry
has
grown
to
about
39
billion
dollars,
parties
and
juries
and
judges,
especially
judges.
We
think
should
know
if
a
new
york-based
hedge
fund
is
staking
a
kentucky
lawsuit.
N
We
also
believe
that
they
should
be
liable
for
fees,
costs
and
sanctions
that
are
assessed
if
they
stake
a
bad
case.
Finally,
I'd
echo
other
suggestions.
I
think
kate
suggested
this
explicitly,
but
if
she
didn't
die
well,
that
sp5
should
be
extended.
Businesses
are
confronting
a
lot
of
challenges
today.
N
Covid
supply
chain
issues,
inflation,
worker
shortages-
if
fb5
sb5
expires
as
it's
set
to
in
january.
That's
another
serious
challenge.
They'll
have
to
confront
that
they
probably
don't
need
right
now.
So
thank
you
for
the
opportunity
to
speak
with
you
today.
I'd
be
pleased
to
answer
any
questions
you
have
to
the
best
of
my
ability.
G
And
then,
finally,
for
the
record,
my
name
is
corey
meadows,
deputy
executive
vice
president
and
director
of
advocacy
for
the
kma.
I
appreciate
the
opportunity
to
speak
to
you
further
today
on
this
particular
topic,
and
I
would
also
like
to
echo
the
the
general
sentiments
of
of
everyone
who
has
spoken
thus
far,
but
in
the
interest
of
time
I'm
not
necessarily
going
to
repeat
everything
that
they
have
said.
However,
I
do
think
one.
G
One
item
is
certainly
worth
repeating,
and
that
is
the
profound
appreciation
for
the
passage
and
the
reauthorization
of
senate
bill
5
and
its
provisions,
and
we
also
strongly
urge
the
general
assembly
to
pass
those
provisions
again.
Your
actions
protected
physicians
and
nurse
practitioners
and
pas.
This
is
an
issue
of
common
interest
and
it
really
did
protect
those
health
care
providers
who
rose
to
the
challenge
and
hardships
caused
by
the
coca-19
pandemic.
G
With
that
said,
the
passage
of
senate
bill
5
should
not
necessarily
distract
us
from
the
fact
that
kentucky's
liability
system
is
fundamentally
broken
and
it
needs
to
be
fixed
to
ensure
greater
fairness
and
predictability
within
our
legal
system.
The
medical
liability
system
remains
one
of
the
most
vexing
issues
for
kentucky
physicians
and
health
care
providers.
Today
it
actually
places
a
wedge
often
times
between
physicians
and
health
care
providers
and
their
patients.
It
forces
physicians
to
unfortunately
practice
defensive
medicine,
which
is
very
hard
to
quantify.
G
Many
studies
have
been
done
on
that
and
the
numbers
are
large,
even
at
the
most
conservative
estimates,
but
that's
the
wedge
that
places
between
providers
and
their
patients
and
it
costs
our
health
care
system
an
untold
amount
of
money.
Every
year
it
puts
physicians
at
emotional,
reputational
and
financial
risk
as
well.
I
can
offer
you
an
example.
I
know
we're
pressed
for
time
a
little
bit
but
anytime
you're
interested.
G
I
can
offer
you
some
national
statistics
about
how
often
and
the
frequency
in
which
physicians
are
sued
during
their
career
and
it
it's
it's
mind-blowing.
How
often
they
face
at
least
one
lawsuit
and
some
of
our
more
high
risk
providers,
like
general
surgeons
and
ob
gyns,
actually
face
that
at
an
even
greater
rate.
G
We
know
the
reason
that
it
affects
supplies
is
because
we
know
that
the
liability
system
affects
not
only
how
physicians
and
healthcare
providers
practice,
but
where
they
practice
as
well,
and
so,
if
you
go
to
a
climate
or
where
liability
concerns
are
high,
you're
less
likely
to
find
people
who
actually
want
to
locate
and
live
there.
It's
an
economic
development
issue
as
well,
which
I
think
has
obviously
been
covered,
but
it
is
worth
saying
that
every
area
of
the
country
is
in
competition
for
providers
and
infrastructure
needed
to
support
a
healthy
workforce.
G
How
many
times
have
we
heard
that
we
need
a
healthy
workforce
in
order
to
prosper?
Economically
jobs
follow
good
medical
care,
as
any
employer
looks
to
where,
where
to
locate
their
company.
It
looks
at
many
factors,
but
clearly
at
the
top
of
the
list,
is
a
strong
health
care
community
to
support
its
workforce,
and
that's
clearly
one
of
the
reasons
why
we
sit
alongside
the
chamber
of
commerce
in
supporting
my
medical
liability
reforms.
G
A
A
Radiation
of
a
year's
worth
of
sun
exposure
is
equivalent
in
one
cat
scan.
Imagine
having
62
years
worth
in
one
year.
Why,
for
fear
of,
I
might
miss
something
I
better
go
ahead
and
repeat
it
just
in
case
and
that's
what
we've
been
training
our
physicians
residents,
lots
of
people
in
healthcare
to
do,
and
it's
really
feared
out
of
lawsuit
driven
and
you
get
trained
on
that
very
early
on
and
that's
kind
of
how
the
mentality
is.
It
isn't
necessarily
an
academic
approach.
A
A
I've
had
patients,
who've
stopped
anticoagulants
who
have
suffered
strokes
and
death
because
of
advertisements
on
television
thinking.
We
thought
that
the
fda
said
something
so
they
were
fearful
and
stopped
it
and
really
it
was.
It
was
a
legal
advertisement
by
a
law
firm
looking
for
lawsuits,
a
couple
of
questions
for
our
presenters,
I'm
not
sure
who
might
be
able
to
answer
that.
How
do
we
rank
in
terms
of
lawsuits
per
capita?
I
know
that
we
our
rankings
from
what
I
understood
one
time
we
were
top
five,
I
think
in
lawsuits
per
capita.
N
And
I
became
a
lawyer,
so
I
didn't
have
to
do
math.
I
don't
have
that
number
in
front
of
me:
we'd
be
happy
to
get
it
for
you.
A
That'd
be
great,
I
mean:
do
we
have
any
idea
how
we
rank
on
contingency
fees
in
particular.
I
know
when
I
filed
bills
before
to
limit
that
in
this
state.
I've
had
colleagues
of
mine
in
the
legislature
who
are
lawyers
who
didn't
believe
the
amount
of
contingencies
that
are
being
used
by
some
attorneys
and
when
they
went
to
their
bar
association,
confirmed
that
it
was
between
40
to
45
percent.
On
some
cases,
do
you
have
any
idea
of
where
we
rank
in
this
state.
N
So
because
the
fees
are
an
agreement
between
the
plaintiff
and
the
client,
that's
not
something
that's
disclosed
in
the
normal
course
of
business.
We
have
a
sense
of
what
that
is
nationally.
50
would
be
quite
high.
Different
firms
will
handle
this
different
ways.
Normal
is
between
30
and
35
percent,
and
then
there's
a
question
as
to
whether
it's
inclusive
or
exclusive
of
fees
and
expensive
filing
fees,
copying
fees,
etc.
N
I've
seen
cases
where
folks
end
up
getting
almost
nothing
with
small
dollar
claims
because
they
paid
so
much
in
filing
and
copying
fees,
for
example,
so
how
the
fee
is
structured
is
important
too.
I
would
say
I
raised
the
issue
of
litigation
finance.
One
of
the
reasons
contingency
fees
exist
is
because,
in
theory,
attorneys
are
taking
a
risk
onto
themselves
by
taking
those
cases
if
they've
got
outside
investors
financing
the
case,
they've
de-risked
the
case,
that's
the
entire
business
proposition
for
the
funders.
A
A
This
doesn't
really
exist
and
I
always
struggle
to
get
insurance
data
from
the
insurance
companies
who
defend
these
most
people
that
have
these
don't
want
to
disclose
it
for
fear
of
their
reputation
being
tarnished
about
how
many
lawsuits
we
know
that,
maybe
someone
can
describe
the
process
of
how
this
goes
and
often
it's
demand
letters
and
when
I
talk
to
providers
and
I've
reviewed
cases
that
have
no
merit
only
to
find
them
have
settled
the
case.
I
go
why
there
was
no
merit.
A
G
Typically,
what
most
people
don't
see
is
that
pre-litigation
process
oftentimes,
we
think
about
well
lawsuit-
is
immediately
filed.
They
head
straight
to
court,
it's
over
in
a
matter
of
months.
Quite
the
contrary,
the
pre-litigation
phase
goes
on
for
quite
a
long
time
and
that's
whether
or
not
the
case
ultimately
reaches
a
trial
verdict
or
not.
G
In
fact,
most
of
the
time,
a
trial
by
jury
and
a
verdict
is
is
never
given,
because
it's
settled
long
before
that,
but
it
will
typically
and
I'll
I'll
defer
to
our
attorneys
on
the
committee
as
well,
but
it
it
normally
one
of
the
most
initia.
The
first
processes
that
you'll
see
is
that
demand
letter.
Ultimately,
it's
an
attorney
sending
an
individual
or
a
liability
carrier
or
someone
a
letter
basically
saying.
G
We
believe
that
malpractice
has
been
committed
and
therefore
we
are
thereby
wanting
to
settle
this
very
quickly
up
front
for
this,
for
this
requested
amount,
oftentimes
those
are
rejected
and
that
enters
into
a
negotiation
period
where
the
parties
come
together
and
ultimately,
if
they
can't
reach
some
sort
of
an
early
settlement,
then
they
go
into
that
more
involved.
Pre-Litigation
process
to
where
records
are
gathered.
Depositions
are
given
a
lot
of
interrogatory.
What
they
call
interrogatories
are
submitted
and
answered.
G
It
is
a
very
time-consuming
process
and-
and
I
point
that
out-
because
it
can
be
very,
very
expensive,
and
so
when
I,
in
my
comments
when
I
reference
the
emotional
toll
or
the
financial
toll
that
it
can
take
on
in
in
kma's
purview,
a
physician
that
is
extremely
a
heavy
burden
on
physicians
that
can
last
anywhere
from
well
can
last
years,
but
it
doesn't
usually
get
resolved
very
quickly.
G
It
drags
out
for
for
many
many
years.
I
know
one
particular
physician
who's
actually
actively
involved
in
kma,
who
had
a
civil
case
go
on
for
10
years,
10
years
that
hung
over
that
provider's
head
going
to
various
depositions
going
through
the
various
processes.
Ultimately,
he
did
not
settle
and
he
went
to
trial.
It's
one
of
the
rare
few
that
actually
went
to
trial
and
he
won.
G
But
what
kind
of
congratulations
do
you
get
when
you've
been
in
it
10
years
and
that
kind
of
money,
and
that
kind
of
time
that
dark
cloud
is
hanging
over
your
head?
How
does
that
even
affect
your
patient
care?
So
it
is
a
real
issue
that
is
a
more
long
and
drawn
out
process.
Now
I
want
to
be
clear
that
we're
not
saying
that
people
who
have
legitimate
claims
due
to
medical
malpractice
or
what
what
have
you
done
don't
deserve
their
day
in
court.
G
A
Of
people
that
have
been
wronged,
who
have
to
wait
10
years
also
to
toll
on
that
person
and
that
plaintiff
as
well,
I
mean
to
argue
the
other
side
of
it
as
well.
I
mean
it
it's
a
toll
on
everybody.
It's
a
system,
that's
broken
in
this
state
that
it's
very
it
takes
a
long
time
to
get
things
done,
and
it's
very
expensive.
Okay,
I've
taken
up
enough
time.
I've
got
five
members
who
have
questions
representative,
birch.
E
G
There's
various
proposals
that
have
been
offered
there
have
been
constitutional
amendments
offered.
There's
been
smaller
initiatives
offered
like
medical
review
panels
a
few
years
ago
that
we
were
successful.
G
You
know
in
getting
helping
the
general
simply
enact
ultimately
with
the
supreme
court,
but
because
of
the
way
our
courts
interpret
our
current
state
constitution,
they
struck
down
that
law,
and
so
there
have
been
smaller
initiatives.
There's
been
larger
initiatives,
but
it
it
seems
pretty
clear
that
if
our
court
is
going
to
continue
to
strike
down
the
smaller
initiatives
that
are
meant
to
help
that
there's
going
to
have
to
be
a
fundamental
change
in
the
language
of
the
constitution.
E
E
G
I
I
think
that
there
was
I
what
comes
to
mind
is
a
cbo
study
that
was
done.
It's
been
several
years.
I
don't
know
that
the
cbo
has
done
a
study
recently,
but
when
the
cbo
last
looked
at
this
and
they
looked
at
largely
the
data
that
they
had
available,
which
is
a
lot
of
medicare
claims,
what
they
found
was
yes,
health
care
costs
would
be
lowered
quite
significantly.
G
B
Thank
you,
mr
chairman.
If
I
might
add
to
what
mr
meadows
said,
sometimes
you
can
go
to
trial
and
if
the
looks
like
the
jury's
going
to
award
in
the
other,
favor
they'll
make
a
deal
too.
So
I've
been
there.
My
question
is
in
kind
of
light
of
the
previous
conversation
and
shortage
of
physicians
and
needing
a
physician-led
team.
B
How
many?
What's
the
data
on
or
do
you
have
data
on?
How
many
physicians
have
left
kentucky
because
of
tort
reform
issues,
liability
issues,
because
I
know
I've
known
obs
that
have
left
or
left
the
field
completely
or
gone
to
other
states
and-
and
I
know
family
practice-
physicians
have
stopped
doing
ob
for
those
reasons
and
many
other
examples.
But
do
you
have
any
data
on
how
many
have
actually
left
kentucky
because
of
it.
G
No
studies
immediately
or
data
comes
to
mind
immediately,
but
we
can.
We
can
give
that
some
look
and
and
see
what
we
can
find
that's
out
there.
I'm
sure
there's
been
some,
probably
national
studies
that
have
been
done.
That
goes
back
really
to
a
point
that
I
think
senator
alvarado
made
is
data
collection
in
this
particular
area
is
is
extremely
difficult.
G
We
all
love
the
data
as
long
as
we
can
quantify
it,
but
oftentimes
getting
those
thoughts
and
impressions
about
why
someone
stays
here
leaves
here
can
be
difficult,
especially
if
they're,
if
they're
already
gone,
but
we
do
know
through
studies
that
that
is
a
factor
when
a
physician
determines
where
to
practice.
So
naturally,
it
backs
up
the
anecdotal
evidence
that
we
hear,
which
is,
can
lead
to
why
somebody
would
also
leave,
and
so
we
know,
that's
a
real
thing
and
appreciate
the
question,
but
we
can
we
can
look
into
that
further.
B
Thank
you.
I
just
comment
that
I
feel
like
it's
a
very
important
issue
for
businesses,
for
hospitals
for
medical,
and
I
think
it
definitely
refers
back
to
the
previous
conversation.
I
think
we
need
public
assistance,
reform
to
get
people
engaged
in
the
process
and
and
educated
and
taking
better
care
of
their
health.
I
think
we
need
the
tort,
reform
and
and
other
changes,
so
thank
you
for
your
presentation.
Thank
you,
mr
chairman.
Thank.
H
H
I
don't
support
amending
the
constitution.
I
you
know
the
the
kentucky
constitution
has
26
sections
to
its
bill
of
rights,
and
I
want
to
read
section
7.
The
ancient
mode
of
trial
by
jury
shall
be
held
sacred
and
the
right
there
thereof,
remain
inviolate,
subject
to
such
modifications
as
may
be
authorized
by
this
constitution,
and,
as
you
know,
if
we
do
pass
a
constitutional
amendment,
the
people
of
kentucky
would
have
the
ultimate
decision
on
that
and
I'll
be
honest
with
you.
H
I
think
the
people
of
kentucky
in
the
form
of
a
jury
have
much
better
judgment
than
138
politicians
here
in
frankfort.
So
that's
that's
going
to
be
my
argument
on
that.
If
it
does
in
fact
pass
you
know,
abraham
lincoln
had
a
great
quote
on
the
jury
system.
H
I
think
it
applies
here
as
well,
so
I
won't
go
into
that
detail,
but
if
it's
good
good
tort
reform
legislation
I'll
support
it,
if
it's
not,
I
won't,
but
I
don't.
Obviously
I
don't
support
amending
the
constitution,
but
ultimately,
if
we
do
pass
it,
the
people
of
kentucky
would
make
that
decision
and
I
think
they
would
decide
to
leave
that
power
in
their
hands
instead
of
the
general
assembly.
So
thank
you.
H
H
B
G
Combination
of
all
of
them
is
I'm
not
speaking
on
behalf
of
pcj
or
the
chamber
or
the
kentucky
hospital
association.
But,
given
that
we've
spoken
on
both
topics,
we
would
say
it's
multifactorial.
C
Sorry,
it
took
me
a
minute
to
unmute.
This
is
an
honest-to-god
question.
I
do
not
know
the
answer
and
I
would
really
like
somebody
to
try
to
explain
it
to
me.
I
have
practiced
medicine,
I'm
licensed
and
I
practice
medicine
in
multiple
states
and
for
many
years
I
worked
at
a
small
community
hospital
in
southern
indiana
and
in
indiana
you
don't
buy
your
own
malpractice,
insurance
there's
a
statewide
program,
every
physician
contributes
to
it
and
the
and
the
cost
is
significantly
less
than
what
I
had
to
pay
to
be
covered
in
kentucky.
C
G
The
short
answer
is
they
have
liability,
reform
and,
and
we
don't
have
meaningful
liability
reform,
and
specifically,
I
don't
want
to
speak
too,
too
detailed,
but
it's
my
understanding.
They
have
things
like
medical
review
panels.
G
They
also
have
a
concept
called
a
an
injury
compensation
fund
that
providers
and
maybe
other
entities,
actually
pay
into
and
it's
my
understanding
they
willingly
pay
into
so
they
can
address
not
having
to
deal
with
it
individually.
They
pay
into
a
common
system,
and
so
when
there's
an
injured
patient,
it's
largely
redressed
through
that
injury,
comp
that
patient
compensation.
I
think
I
said
injury
com,
it's
patient
compensation
fund.
So
that's
the
short
and
a
little
bit
more
of
a
longer
answer.
C
If
I,
if
I
can
yes,
I
do
believe
that
every
provider
pays
into
this
patient
compensation
fund.
I
do
not
believe
that
they
have
medical
review
panels.
I
you
know,
as
chief
of
staff,
I
went
through
a
lot
of
legal.
You
know
medical
legal
litigation
potentialities
in
indiana.
C
I
never
dealt
with
the
medical
review
now,
but
I
did
we
did
have
a
patient
compensation
fund
and
what
each
and
every
individual
physician
contributed
both
to
the
state
fund
for
your
malpractice
coverage
and
to
the
combat
the
patient
compensation
fund
in
aggregate
was
so
much
less
than
what
I
was
saying
in
kentucky.
It
was
really
interesting
that
the
systems
were
so
different
to
me.
A
Thank
you,
dr
berg.
Indiana
does
in
fact
have
a
medical
review
panel
system.
It's
been
up
and
running
used
it
as
an
example
when
we
got
our
our
bill
here
passed.
Thank
you
all
for
your
presentation.
We
appreciate
bringing
light
to
this
topic.
We
have
one
more
presenter
and,
as
always,
I
always
I
think
it's
like
I.
My
eyes
are
bigger
than
my
stomach.
I
think
we
can
cover
these
things
in
a
short
period
of
time,
but
we
have
another
important
topic.
A
All
payers
claims
database
and
we
have
today
ben
chandler
who's
the
president,
the
ceo
foundation
for
healthy
kentucky,
and
I
believe
we
have
a
couple
of
presenters
also
from
the
kentucky
primary
care,
association,
chase,
coffee
and
teresa
cooper.
This
is
a
topic
that
many
other
states
have
implemented.
We
were
hoping
they
could
come
and
educate
us
today
on
what
an
all
payers
claims
database
is
the
importance
of
it
and
why
it
would
be
a
good
idea
here
in
kentucky.
I
know,
there's
been,
I
think
one
bill
already
proposed.
A
F
F
We
are
a
foundation
that
is
interested
in
improving
the
health
of
our
people
and
senator
meredith.
I
was
very
interested
in
in
hearing
what
he's
he
said
earlier,
and
that
is
that,
among
other
things,
we're
not
getting
a
whole
lot
of
of
that
done.
We
are
not
really
improving
the
health
of
our
people
a
whole
lot,
and
I
could
say
that
it
goes
back
many
many
years.
Many
many
legislative
sessions,
everybody
to
some
extent,
has
a
blame
for
that.
F
It's
an
endemic
problem
in
the
commonwealth
and
and
we
as
a
foundation,
are
looking
for
as
many
solutions
as
we
can
to
these
problems
and-
and
they
really
are
very,
very
difficult.
F
One
of
the
things
that
I
think
actually
can
move
us
down.
That
road
is
an
all-payer
claims
database.
Now
I'm
happy
to
tell
you
today
this
subject:
we
we're
coming
after
the
subjects
of
tort,
reform
and
and
scope
of
practice.
So
hopefully
this
will
be
a
whole
lot
less
controversial
than
the
things
that
you
all
have
been
talking
about.
I'm
I'm
hopeful
that
that's
the
case
because
we're
what
we're
talking
about
here
and
we've
had
some
discussion
earlier
about
the
lack
of
data
and
other
places
where
you
get
data.
F
Well,
that's
what
this
is
about.
It's
a
boring
subject,
but
data
is
crucial
if
you
guys,
if,
if
our
elected
members
of
the
general
assembly
are
going
to
make
decisions-
and
obviously
you
have
to
make
decisions-
you're
you're
sent
here
by
the
people
that
you
represent
to
make
decisions
on
their
behalf.
F
You
can't
make
those
decisions
unless
you've
got
good
data.
You
just
can't
do
it.
You
can't
base
it
on
anecdote.
It
just
ultimately
is
a
poor
way
to
make
decisions.
You've
got
to
have
the
facts
now
now.
I
will
admit
that
we
to
some
extent,
are
living
in
a
a
a
society.
Now
that
doesn't
necessarily
follow
the
facts.
F
These
days
I
mean
we,
we
wonder,
and
we
we
see
all
sorts
of
claims
on
the
internet
and
on
cable
news
on
both
sides
talking
about
things
that
may
or
may
not
be
true,
but
this
is
an
effort
here
in
the
commonwealth
of
kentucky
to
actually
get
data
that
can
be
relied
upon
for
decision
makers.
This
is
about
transparency.
F
It's
about
cost
containment,
it's
about
seeing
trends,
seeing
trends
in
the
medical
data
that
payors
pay
for
medical
procedures
that
they
pay
for.
Those
trends
can
give
us
some
idea
about
where
the
problems
lie
and,
frankly,
what
the
solutions
may
be
to
those
problems
and
that's
why
we
think
it's
so
important.
19
other
states
have
already
set
up
all
claim.
All
payer
claims
databases
19
other
states
are
ahead
of
us.
We
will
not
be
recreating
anything.
F
I
mean
we'll
not
be
creating
anything
new,
we'll
be
creating
something
that
that
we've
got
lots
of
of
evidence
showing
that
that
it's
useful
in
other
states.
Really
it's
it's
about
insurers
and
other
payers,
private
insurers
and
government
payers.
I
mean
you,
know
huge
percentage.
Almost
all
of
medical
payments
are
made
either
by
the
government
or
by
private
insurers
of
one
sort
or
another.
All
of
those
people
would
be
required.
F
Hopefully,
if
you
all
were
to
pass
this
legislation,
they
would
be
required
to
submit
their
data
of
payments,
and
all
of
it
would
be
protected
the
the
individuals
it
would
be
hipaa
compliant.
The
individuals
who
whose
data
is
being
sent
in
would
would
obviously
not
be
discoverable
by
anybody,
but
you
get
trends
and
you
provide
that
data
to
the
public.
It
informs
that
they
have
the
opportunity
to
ask
for
it.
Now.
There
are
lots
of
different
ways
to
do
this
again.
F
We
are
very
much
in
favor
of
this
at
the
foundation.
We
believe
that
it
gives
us
one
of
the
best
tools.
It
would
give
us
one
of
the
best
tools
again
to
make
the
right
decisions
that
need
to
be
made
to
get
ourselves
moving
in
the
direction
of
actually
improving
the
health
of
our
people,
and
we
spend
enormous
amounts
of
time,
and
I
understand
why
we
do
it,
but
we
spend
enormous
amounts
of
time
talking
about
health
care.
Health
care
is
important.
F
F
We
want
to
see
our
people
be
healthier.
We
want
to
see
them
be
healthier
on
the
front
end
when
they
present
to
their
physician
we'd
like
them
to
be
presenting
long
before
they
have
chronic
or
acute
problems,
and
if
they
can
do
that,
if
we
can
get
to
that
point
in
our
society
we
will
have.
We
will
save
a
whole
lot
of
money.
First
of
all,
minor
detail
and
we'll
have
a
much
happier.
F
I
think
society
people
I
mean
there,
isn't
anything
more
important
than
your
health.
Nothing,
if
doesn't
matter
how
much
money
you've
got.
If
you
don't
have
your
health
doesn't
matter.
So
what
we're
talking
about
here
is
is
more
important
than
anything
and
it
wouldn't
it
be
better.
If
we
could
see
these
trends
put
policies
in
place
that
ultimately
moved
us
toward
better
health,
and
I
will
stop
there.
I
know
you
all
already
had
a
long
session
and
turn
it
over
to
you.
K
A
F
M
F
Didn't
introduce
her,
but
you
all,
I
think,
know
her
very
well
and
she's
here
with
me.
K
K
K
All
payer
claims
databases
create
equitable
metrics
by
having
data
submitted
through
a
common
data
layout,
which
harmonizes
collection
efforts
and
reduces
the
administrative
burden
of
the
data.
The
equitable
metrics
allow
the
stewards
of
the
program
to
compare
performance,
cost
and
quality
leading
to
better
information
on
which
to
base
future
accountability.
Measures
on
utility
utility
is
also
an
important
part
of
how
all
payer
claims
databases
can
be
beneficial
to
the
commonwealth
as
a
whole.
These
data
systems
allow
users
to
access
and
analyze
data
to
to
inform
decisions
regarding
cost
utilization
and
quality.
K
The
types
of
users
vary
based
on
the
parameters
outlined
by
each
state,
but
typically
public
health,
administrators
employers
providers
and
payers
all
have
huge
benefits
to
gain
by
having
access
to
this
data.
Research
of
unidentifiable,
data
by
organizations
such
as
universities
can
assist
in
driving
innovation
and
quality
improvement.
K
K
Ultimately,
all
payer
claims
databases
are
mission,
driven
data
systems
which
embody
putting
health
before
health
care,
they're,
a
tool
for
policy
makers,
payers
providers,
health
care
organizations,
academia
and
the
general
public,
which
provides
ready
access
to
comprehensive
longitudinal
data,
sorry
on
health
care
services
and
their
cost
and
their
cost.
This
comparable
data
can
be
used
to
inform
decisions
on
all
levels
in
regard
to
population
health,
individual
health
and
the
quality
of
health
care
in
kentucky.
K
I
would
like
to
add
one
final
point:
if
I
may,
I've
heard
this
committee
many
times
over
the
past
few
years,
discuss
how
the
value
of
a
dollar
changes
based
on
the
impact
that
it
has
a
well-implemented
all-payer
claims
database
has
the
ability
to
vastly
increase
the
value
of
that
dollar,
especially
when
it
comes
to
employers
and
their
health
benefit
costs
all
payer
claims.
Databases
can
be
used
to
establish
broadband,
broad-based
measures
and
benchmarks
to
identify
high-value
services,
providers
and
health
benefits.
K
I'm
sorry,
this
information
can
be
helpful.
K
This
information
can
be
helpful
in
designing
a
health
benefit
product
that
max's
my
maximizes,
the
dollar,
by
reallocating
resources
towards
high
value
care,
which
provides
greater
quality
of
services
care
and
improves
health
and
improves
employee
health,
allowing
the
employer,
both
public
and
private,
to
get
greater
value
per
dollar
on
benefit
cost,
while
improving
employee
health
and,
ultimately,
population
health.
It
also
addresses
social
determinants
of
health
and
thank
you
for
the
opportunity
to
present
on
this
subject.
Are
there
any
questions.
A
Covered
it
all,
okay,
very
good.
We
appreciate
that
I'll.
Tell
you
a
couple
of
things.
Whenever
we've
had
this
topic
before,
I
know
several
states
have
this.
I
know
I'm
kind
of
working
off
of
a
west
virginia
model.
They
recently
passed.
Something,
and
some
of
these
databases
can
be
very,
very
detailed
and
provide
a
lot
of
info.
The
question
always
comes
down
to
who
controls
the
information
and
who
controls
the
data.
A
Who
can
access
that
data?
That's
always
a
concern,
and
then
what
is
done
with
that
data?
Ultimately,
and
obviously
the
driving
interest
for
me,
as
well
as
to
drive
health
care
policy,
better
outcomes
and
how
we
can
do
that.
I've
had
some
folks
who
have
been
concerned
about
in
some
states.
What's
happened,
is
you'll.
Have
insurance
companies
request
the
data
just
to
look
at
who's,
getting
paid
what
and
so
that
it
uncovers
it
for
them
to
say?
A
So
I
want
to
make
it
clear
that
when
we
try
to
put
this
together
and
draft
that
we
want
to
create
something,
that's
going
to
help
us,
collect
data,
drive
better
quality
measures,
be
able
to
we've,
had
discussions
and
hear
about
our
managed
care
organizations
who
don't
seem
to
know
how
to
drive
better
quality
outcomes.
We've
had
10
years,
we
haven't
seen
good
quality
outcomes.
This
can
help
us
as
a
legislative
body
to
be
able
to
say.
A
Okay,
these
are
the
things
we
want
to
work
on
or
what
we
need
to
work
on
and
to
start
pushing
the
direction
for
where
the
mcos
need
to
go,
where
the
cabinet
needs
to
go
perhaps
and
have
that.
But
the
one
thing
I
want
to
be
careful
of
is
that
we're
not
creating
an
opportunity
from
a
business
angle
for
people
to
say:
hey,
I'm
going
to
get
a
business
advantage
to
collect
that
data
and
undercut
providers,
because
that's
that
would
be
harmful
to
the
situation.
You
wouldn't
get
a
lot
of
support.
A
We've
got
the
primary
care
association.
So
clearly
we
know-
and
I
think
a
lot
of
providers
are
interested
in
this-
it
just
depends
on
how
it's
used.
We
want
to
make
sure
that
we
don't
hurt
providers
and
I'm
going
to
be
very
careful
to
work
on
that
to
make
sure
that
if
we
can
shield
that
some
of
that
information,
perhaps
and
just
to
sort
driving
towards
diagnosis
outcomes,
that
sort
of
thing
and
that
we
can
get
that
better.
So
I
just
want
to
make
that
commitment
go
ahead.
K
Yeah,
if
I
could
address
that,
we
believe
that
those
concerns
could
be
addressed
in
the
contract
agreements
once
the
legislation
is
implemented.
A
D
F
F
If
it
is
a
central
problem,
I
think,
with
the
health
care
system
in
general
is
the
lack
of
transparency.
So
that's
something
that
that
I
think
most
everybody
ultimately
is
in
favor
of
certainly
the
general
public
is
in
favor
of
it.
I
would
also
say
in
response
to
what
senator
alvarado
and
his
concerns
you
all
have
the
ability,
when
you're
fashioning
this
legislation,
to
make
sure
that
you
put
things
in
place
that
protect
providers,
and
I
think
providers
can
be
protected
in
in
this
regard.
F
F
D
F
I
was
just
talking
about
thinking
about
on
the
way
over
here
I
was
attorney
general
here
really,
I
seems
like
yesterday,
but
it
was
18
years
ago,
which
is
hard
for
me
to
believe.
That's
when
I
actually
left
office
and
susan
westrom
who's
getting
up
right
now,
I
think,
is
the
only
person
on
this
panel
who's.
Actually
in
the
legislature
when
I
was
attorney
general
now
I
don't
mean
to
age
you,
susan,
but
I'm
certainly
aging
myself,.
A
Well
into
the
topic
we
were
talking
about
earlier,
I
mean
that
is
representative
bentley,
a
concern
I've
got,
and
so
again
this
might
be
like
the
telemedicine
bill.
With
the
first
time
we
passed
the
original
build,
it
was
more
of
a
skeleton
base.
Let's
get
this
thing
started
and
then
we
were
able
to
add
to
it
as
we
went
along
representative
fleming,
you
have
a
question.
C
Thank
you,
mr
chairman.
I
appreciate
the
the
question
the
opportunity
to
ask
and
appreciate
the
folks
come
in
and
talking
to
us
about
data
and,
of
course
I
like
data
and
so
forth.
I
want
to
say
thank
you
very
much
for
for
the
question
in
regards
for
control,
but
I
want
to
ask
the
congressman
secretary
of
state
attorney
general
and
whatever
else
you
want
to
call
him,
as
he
describes
himself,
because.
C
Everybody
you're
a
politician
everywhere,
so
now
we've
got
a
long
time.
I
do
want
to
ask
two
service
questions,
one
when
you
talked
about
best
practices,
what
are
the
data
sources
that
are
used
to
apply
or
go
into
the
best
practice?
And
second,
how
is
the
data
scrubbed
to
ensure
the
data
integrity.
F
Well
again,
I
mean
that's
that
when
you're
putting
the
legislation
together,
I
think
you're
going
to
have
to
to
look
at
at
how
best
to
do
that,
and-
and
I
don't
have
an
immediate
answer-
because
there
are
a
lot
of
different
ways
that
states
handle
this.
We've
got
19
states
that
do
it,
but
there
are
certainly
there
are
examples
before
you
which
work
very,
very
well.
F
That
will
handle
any
of
the
scrubbing
of
information,
and
I
don't
think
it
will
be
difficult
at
all
for
the
staff,
and
I
understand
that
that
some
folks
are
going
to
be
sitting
down
together
to
be
looking
at
some
of
these
practices
to
come
up
with
the
the
best
overall
plan.
But
I
I
think
that
we'll
come
up
with
a
very
good
one
and
I
think
that
they
will
take
into
consideration
the
protections
that
are
necessary
for
people.
C
Okay,
well,
I
I
I
appreciate
that
and
I'm
sure
there's
quite
a
few
folks
will
be
putting
in
some
criteria
and
language
into
the
in
the
bill
and
I'm
sure
the
the
chairman
is
going
to
do
a
good
job
in
terms
of
coming
up
with
that
he's
always
very
thorough
with
all
that
stuff.
But
I
appreciate
it
and
thank
you,
mr
chairman,.
A
Thank
you,
representative,
again,
representative
bentley
and
representative
fleming.
I
welcome
input.
I've
got
a
very
early
draft
I'll,
be
happy
to
share
with
anybody
who
wants
to
review
it
and
and
have
some
input
on
it,
because
we're
still
again
early
phases
of
putting
this
together
again,
even
at
the
very
least,
I'd
like
to
get
a
skeleton
base
for
this
that
we
could
build
off
of
if
we
need
to
in
the
future.
But
we
want
to
make
sure
that
we
we
do
something
that's
going
to
allow
us
to
collect
data.
A
F
That
one
senator
is
a
new
one.
You
know,
I
think,
I'm
not
sure
whether
that's
positive
or
negative,
either.
E
F
E
F
D
F
E
Constituents
well,
my
contention
is
you
know
we
have
delegated
that
responsibility
and
what
becomes
if
everyone's
responsible,
no
one's
responsible.
I
think
it's
part
of
the
issue
well
and.
E
They
do
somebody's
got
to
drive
and
maybe
goes
back
to
being
king
and
that's
one
of
the
things
that
I
pushed
for
is
somebody
needs
to
be
responsible.
Why
shouldn't
it
be
the
department
of
public
health
in
kentucky?
Somebody
needs
to
be
held
accountable.
There
is
none.
You
know
we
delegated
this
to
the
mcos
a
decade
ago.
They've
not
improved
the
health
of
population,
so
you're
right
about.
F
That,
but
at
the
end
of
the
day,
I
think
the
buck
stops
with
the
people
that
we
elect
quite
frankly
having
been
in
that
chair
myself
before.
I
think
the
people
that
we
elect
both
on
in
the
general
assembly
and
as
governor
and
other
other
offices,
the
federal
offices,
those
people
have
to
make
decisions
on
behalf
of
the
people
that
they
represent,
and
you
know
it's
a
heck
of
a
messy
process.
F
We
all
know
that
having
been
in
the
middle
of
it
is
a
very
messy
process
and
when
you've
got
138
people,
each
of
whom
are
elected
by
a
similar
number
of
of
citizens,
they
can
disagree
about
a
thing
or
two.
You
know
as
you've
heard
people
say
it.
Good
luck
if
you
can
agree
with
your
own
spouse
on
most
things,
but
to
to
get
full
agreement
with
138
people
is
not
easy,
and
I
think
that's
why
we
have
the
problem
that
we
have
well.
F
You
and
then
you
demand
it.
You
know
what
we've
done.
We
have
essentially
created
an
economic
system
in
this
country
and
and
this
no
people
don't
want
to
hear
this,
but
we
have
we.
We
have
a
lot
of
jobs
in
this
country
that
are
tied
to
making
people
sick
and
producing
such
things
as
tobacco
and
certain
foods
that
are
have
very
little
nutrition
and
high
level
of
calories
and
so
forth,
and
on
and
on,
and
then
we've
created
on
the
back
end,
a
rescue
system
to
rescue
those
people
who
we've
made
sick
to
begin
with.
F
Now,
when
I
it's
a
societal
problem,
nobody
is
is
responsible
for
it,
and
that
is
part
of
the
problem.
Nobody
is
responsible
for
it,
but
it's
been
institutionalized
in
our
society.
Part
of
it
frankly,
is
due
to
freedom.
I
think
you
know
we
have
the
freedom
to
eat,
what
we
want
and
then
not
exercise
if
we
want
the
result
of
that
is
that
a
whole
lot
of
the
rest
of
us
have
to
pay
to
rescue
those
of
us
who
don't
behave
in
the
right
way,
and
you
all
know
that's
true.
Well,.
E
F
A
Thank
you,
gentlemen.
That's
always
an!
I
had
this
discussion
with
my
brother
last
night.
It
was
his
birthday
and
it
was
the
discussion
of
you
know.
Other
countries
do
not
require
treatment
of
hot
from
hospitals.
They
just
say:
do
you
know
you
come
in
and
you're,
sick
and
you're
dying?
Do
you
have
money?
A
If
not,
I
got
a
paying
customer
if,
when
I'm
done
with
them
and
if
I
feel
like
it
I'll
provide
you
care,
america
hasn't
done
that
with
america
we
take
response,
we
have
a
moral
obligation,
we
think
to
our
fellow
citizens.
We've
done
that.
That's
part
of
what
limits
us
and
makes
it
difficult
so
that
people
can
make
decisions
about
their
own
health
care.
They
may
have
an
out
a
negative
outcome
towards
those
decisions
as
a
society.
A
We've
agreed
to
help
with
that,
and
that's
it's
a
moral
dilemma
for
americans,
but
that's
it's
a
pr
one
that
I'm
proud
that
we
take
on
other
countries,
don't
seem
to
have
as
much
of
that
issue.
So
thank
you
all
for
coming
and
presenting
today
we'll
be
working
on
this
and,
like
I
said
anybody
who
has
any
information.
I
welcome
their
input
on
that
I'll,
be
happy
to
share
it
with
anybody
who
wants
to
see
the
language
of
it.
That
concludes
our
business.
For
today.
A
Our
next
meeting
is
scheduled
for
wednesday
december
the
15th
at
1
pm.
I
think
the
chairwoman
and
I
have
discussed
some
potential
bills
you
might
be
hearing
in
the
in
the
session
coming
up,
so
we'll
be
having
an
opportunity
to
talk
about
some
of
those,
even
if
it
is
briefly
just
to
have
the
committee
aware,
as
we
start
entering
january
into
regular
session
unless
there's
any
other
business
before
the
committee,
we
stand
adjourned.
Thank
you.