House Health Committee, June 23, 2026
Video: https://vimeo.com/1203831946 (a timestamp t plays at https://vimeo.com/1203831946#t=<seconds>s)
Page: https://georgiacommons.org/meetings/2026-06-23/house-health

This is a machine transcript of the General Assembly's video, made by a speech-recognition model. It is not an official record and can mishear words, names, and numbers. Speakers are not identified. The video is the record: every timestamp links to the moment it plays.
[0:10:09] Now that one I, I assume is...

[0:11:40] Yeah. Good afternoon. Uh-

[0:11:46] Okay

[0:11:47] ... we're gonna go ahead and begin. Um, this meeting is gonna end at 4:00. Uh, I promised our committee members that they were getting out of here. These subjects, each subject could probably take about two days of discussion and testimony. Um, I will ask our members to keep, please keep your q- questions short. You see we have a lot of folks, we got a lot of people signed up. I wanna get to as many of these, or hopefully all of these, as I can. These are hearings only.

[0:12:19] Uh, this hearing was called because of the great interest in these subject matters. I know you've all received numerous emails, as has leadership. And, you know, sometimes, not sometimes, it is nice for us to be able to take up subjects out of session and be prepared to address those subjects in January rather than waiting till the first day of session, and then start addressing problems that we know have been there. So that's what we're doing today. Um, and we're gonna start off with the, uh, APRN issue.

[0:12:54] And I'm gonna call on Wesley Dunn to please come up and speak, with Juliana M- McCollum.

[0:13:05] Thank you, Mr. Speaker.

[0:13:06] Okay.

[0:13:07] That's on?

[0:13:08] It sound like... Oh, yeah.

[0:13:10] Oh, try it again. Hello. Uh, thank you, Mr. Chairman. Ladies and gentlemen of the committee, uh, my name is Wesley Dunn. I'm here representing U- APRNs. Um, and, um, my r- remarks today are gonna be based on things that, um, I've witnessed, I heard, I read, statements. I think there've been four statements from the Composite Medical Board issued since, um, May 7th when this began. And, um, and I, my co- my remark's gonna be based on those things I've read, uh, the board meeting on June 4th, and, um, other statements I've had personal conversations with.

[0:13:51] Anything else that comes out today are things that we've heard for the first time. Uh, we have several speakers. I'm gonna try to be brief in introducing what we think the issue is. And then we've got the, uh, executive director of the Board of Nursing, the president from the U- APRN Association, and an APRN that actually has a practice in psych, uh, medicine. As I said, this, uh, issue began with a statement issued on May 7th by the Composite Medical Board that was entitled H-, uh, IV Hydration Therapy Treatment Physician.

[0:14:27] But it went on to reference, uh, that APRN code Section 4334 25 Subsection N, which reads, "Except for practice settings identified in Paragraph 7, Subsection G of this code section, it shall be unlawful for a physician to be an employee of an advanced practice registered nurse, comma, alone or in combination with others, if the physician is required to supervise the employing, uh, advanced practice registered nurse. Such conduct shall not be subject to sanctions by the..." I- I'm sorry, "Such conduct shall be subject to sanctions by the Georgia Board of Nursing as to the advanced practice registered nurse and the board as to the physician." We do agree, a- as the Composite Board will state, that this law, this language has been in the law since its inception, I believe in early 2000, 2007, '08 or '09, in that area.

[0:15:22] Um, Ms. Taylor, the executive director for the Board of Nursing, is gonna get more into the relationship between the delegating physician and, uh, and the nurse protocol agreement. But these APRNs cannot practice without a protocol agreement signed by a delegating physician that practices in the same specialty. And, um, without that protocol agreement, APRNs cannot practice at all. I want you to keep that in mind. Code section, uh, has separate definitions for physician and a separate definition for f- delegating physician.

[0:15:57] Delegating physician is one who has entered to a no- a nurse protocol agreement. The, uh, physician is defined as a person licensed to practice medicine under this article, goes on to require the principal office to be in the state or within 50 miles of the APRN's practice. Um, delegating physicians have a number of responsibilities under the protocol agreement, um, at, that, uh, again, uh, Ms. Taylor will get into when she makes her remarks. So been trying to keep my remarks brief so these other people can talk that have more to say than I do.

[0:16:33] Um, now what's happened since May 7th meeting? There have been, I think, uh, in addition to the IV hydration statement, uh, and that claims to have something to do with med spas as well, there have been three additional communications from the Composite Board I'm aware of. Uh, and each of them have said something a little bit different. But, and generally they say this is just a guidance. They don't want any protocol agreements canceled. Uh, they wanna, um, s- renew protocol agreements as they come up with existing, uh, people or nurses.

[0:17:09] But they're gonna review additional protocol agreements more carefully. And what we found out that means is if you are a APRN trying to set up a new clinic, uh, their position seems to be that the delegating physician must own a, uh, p- the majority of the clinic. I don't know of any, uh, other profession that requires that since the inception of the APRN, uh, licensing. All over the country, we have, uh, APRNs that have s- s- standalone practices without a physician on, on the property.

[0:17:46] Uh, and that's been no different in Georgia since it started We're now hearing that the law has always been the same, but, um, they've been a- approving these protocol agreements in violation of the law since its inception. We disagree, uh, with that statement. We think there is a distinction between a delegating physician having, um, assigned a protocol agreement and a physician that's just licensed to practice in the state and the fees that are being paid from the dele- um, APRN to the delegating physician are for the professional services they are required to, uh, do and, and they're fulfilling their duties on the protocol agreement.

[0:18:27] Furthermore, if there was no compensation, you wouldn't have a contract. Basic contract law requires there to be some compensation for things of value. There are 28 states approximately that operate without the need for a protocol agreement and to s- now say that you can only have a protocol agreement if the majority of the clinic is owned by a delegating physician is just contrary to common sense and, and fairness and, um, I believe in restraint of trade and, um, I don't know what kind of country we live in if that's gonna be what the law has to be.

[0:19:05] But, uh, we've got, um, the statement that came out on May 7th said that it was for IV treatment, um, facilities and med spas. I don't know what the problem with- is with either one of those. Very little was talked about with either of those, but seems to me that the Board of Nursing and the Composite Medical Board could, uh, get together and resolve those issues and take care of any bad, um, bad, um, actors. So with that, I'm gonna turn the, my, the marks over to, uh, the executive director of the nursing board to give y'all more de- detail about how the nurses work with the delegating physicians and then I think she'll be followed by the president of the APRN and then, um, the, um, practicing nurse we have for you.

[0:19:51] Thank you.

[0:19:53] Okay, Natalia, uh, Taylor. Thank you.

[0:19:59] Good afternoon, Mr. Chairman and members of the committee. Appreciate you taking the time to hear me out today. Um, I am-- would like to speak to you on behalf of the Board of Nur- Nursing, um, regarding an issue that has created significant concern across our state following the Georgia Composite Medical Board's recently issued position statement. Um, as I said, my name's Tara Taylor. I'm the Executive Director of the Nursing Board. And to provide a little bit of background information, um, APRNs, advanced practice registered nurses, um, can serve in one of the following roles.

[0:20:37] They can serve as a nurse practitioner, a certified nurse midwife, a clinical nurse specialist, or a certified registered nurse anesthetist. And under G- Georgia law, when performing medical acts, APRNs are required to collaborate with a delegating physician and practice under a protocol agreement through which the physician delegates authority to an APRN to carry out specific medical acts. While many APRNs practice in hospitals, clinics, or physician offices where a physician is physically present, others practice in some of the same settings where a physician is not on site but continues to provide services under the protocol agreement.

[0:21:26] Delegating physicians who collaborate with APRNs through a protocol agreement must be available for consultation when needed, must review charts, um, on a quarterly basis, sometimes yearly, but, uh, many times quarterly, and assume, uh, a degree of professional liability through the protocol agreement. Because of the responsibilities and obligations associated with the delegating physician's role, many APRNs compensate their delegating physicians for the services they provide.

[0:22:01] Without this compensation, there would be little incentive for physicians to enter into a collaborative gr- agreement with an APRN. O.C.G.A. 43-34-25provides that it is unlawful for a physician to be employed by an APRN if that physician is required to supervise the employing APRN. The Board of Nursing, APRNs, and many physicians have long understood this provision to mean that an APRN may not employ a designating or delegating physician because a physician's supervisory responsibilities should not be influenced by an employment relationship with the APRN.

[0:22:49] However, the statute has not been understood to prohibit an APRN from compensating a delegating physician for professional services, nor has it been interpreted to prevent APRNs from owning their own practices. For at least the past decade, APRNs throughout Georgia have been compensating their delegating physicians for services and responsibilities associated with protocol agreements. As one APRN stated in correspondence to the board, "Financial compensation is the foundation of most collaborative agreements." So following the issuance of the Georgia Composite Medical Board's position statement, specifically the language indicating that Georgia law restricts the economic relationship between APRNs and their delegating physicians, the Board of Nursin- Board of Nursing began receiving a substantial number of inquiries from concerned APRNs In response, we, the Board of Nursing, distributed a communication to APRNs statewide requesting feedback regarding the potential impact of the potent- of the position statement.

[0:24:07] The response was overwhelming. The board received more than two hundred and fifty emails along with numerous phone calls from APRNs expressing concern that the position statement could force them to close their practices. We've also heard from several nursing organizations and received many similar reports from their members. Many APRNs have been afraid to come forward and voice their opinion due to the unknown of how it may affect their nursing license.

[0:24:38] The consistent message from the APRNs has been that delegating physicians have either terminated or are considering terminating their protocol agreements due to uncertainty surrounding the position statement. Without a protocol agreement, APRNs cannot practice legally, and this could leave a lot of their current patients without access to healthcare. I promise I'm getting there. Many of these concerns are coming from nurse practitioners who provide primary care and psychiatric services throughout Georgia.

[0:25:14] While some concerns have come from APRNs operating IV hydration or aesthetic clinics, those practices are not the board's primary concern. Their concern is for the clinics serving rural and underserved communities where physicians are already in short supply. In many of these areas, APRNs are a critical source of access to healthcare. If these practices are forced to close, patients may have nowhere else to turn for healthcare.

[0:25:46] At a time when Georgia continues to face shortages of primary care and specialty providers, enforcement of the recently issued position statement from the Composite Medical Board would create an additional barrier to healthcare across ac- across healthcare access for thousands of Georgians. I would like to close with a, um, sharing a message that we received from a psychiatric nurse practitioner. "I'm especially concerned about patient abandonment on a statewide level.

[0:26:21] If APRNs across Georgia are suddenly unable to obtain, renew, or transition protocol agreements, thousands of Georgians, Georgians..." Or excuse me, "Thou- If APRNs across Georgia are suddenly unable to obtain, renew, or transition protocol agreements, thousands of patients may lose access to care almost overnight. Psych patients are particularly vulnerable to harm when care is abruptly interrupted.

[0:26:52] Missed follow-ups, delayed refills, and sudden medication discontinuation can lead to destabilization, withdrawal symptoms, emergency room, room visits, hospitalization, et cetera." Our board has received many messages like these that you just heard. So I thank you for your time today, and thank you for considering, um, this message that the Georgia Board of Nursing would like for you to, um, understand and be informed about.

[0:27:22] Thank you.

[0:27:30] Thank you.

[0:27:30] Good afternoon, Mr. Chairman and members of the committee. Uh, my name is Dr. Nancy Hurlock. I'm an adult gerontology nurse practitioner, and I'm the President of United Advanced Practice Registered Nurses, or UAPRN, of Georgia. I come before you today as a nurse of twenty-three years, and of those twenty-three years, I've been a nurse practitioner for ten years. I'm a former home healthcare nurse, a business owner, and more importantly, an advocate for patients across Georgia. For the past eight years, I've owned and operated a house call, home-based primary care practice specifically focused on those in southeast rural Georgia, homebound elderly patients.

[0:28:07] My practice was born from a simple but urgent need: access, access to healthcare. As a nurse, I repeatedly encountered patients who could not access the care they needed due to transportation barriers, mobility limitations, provider shortages, and geographic challenges. Watching patients struggle to obtain basic healthcare became a source of frustration, but more importantly, it became a call to action. Like many APRNs across this state, I stepped forward to help meet that need.

[0:28:38] I share my story not to highlight personal achievements, but to serve as a voice for the many 20,000 APRNs practicing in Georgia today. My story is not, is not unique. As nurses, advocacy is at the core of who we are. We are trained to identify needs, solve problems, and improve access to care. Yet today, many APRNs across Georgia are facing, facing unprecedented uncertainty. On May 7th, the Georgia Composite Medical Board issued an interpretation that has created significant confusion and concern across our profession.

[0:29:16] Since that time, we have received thousands of calls, emails, messages, APRNs from South Georgia, Middle Georgia, North Georgia, literally every corner of the state. The uncertainty surrounding this issue has created not only professional challenges, but genuine fear and heartbreak from practitioners and the patients who depend on them. Many APRNs have invested their lives, their savings, their professional expertise into building practices that serve underserved communities.

[0:29:50] These practices were not created for convenience. They were created because patients needed access to care. Those APRNs saw the need and they answered the call. Georgia is benefiting every day from entrepreneurship, innovation, and high quality care delive- delivered by APRNs. We are providing primary care, behavioral health services, specialty care, home-based care in communities where healthcare resources are often limited.

[0:30:24] Today, we come before you seeking simply clarity. But more importantly, we come seeking partnership. Nurse practitioners deserve a seat at the table as these conversations move forward. We are not asking for anything that's extraordinary. Across the country, states have successfully implemented APRNs into healthcare delivery models that improve access and efficiency to healthcare. Our time today is limited, so I'll remain brief, but I wanna be clear.

[0:30:57] Georgia is facing a healthcare access crisis. That is not a matter of opinion. It is the reality experienced by patients every day. Sylvania, Georgia, Atlanta, Georgia, Sandersville, Statesboro, and it goes on. APRNs stand ready to help address that challenge. You and I can walk out of this room today, and most of us have the convenience of seeking healthcare from a MD, NP, PA, whomever we choose. The reality for most of Georgians, that reality just does not exist.

[0:31:30] APRNs stand ready to help fill that gap. I encourage each of you, when you leave here today, survey your communities. See who is providing care to your constituents. The path forward requires meaningful dialogue rooted in facts, evidence, and data, not emotions, not misinformation, and not one-sided narratives. We welcome collaboration. We welcome conversation. We welcome opportunity to work alongside policymakers, committee members, physicians, and other stakeholder holders to develop meaningful solutions.

[0:32:05] As president of UAPRN, I stand before you today committed to be part of that solution. Our members are ready. We're ready to engage in conversation. We're ready to help Georgia build a stronger healthcare system. I thank you sincerely for this consideration of your time. Um, I truly look forward to future opportunities for dialogue, and I want to defer the rest of my time to Holly Hart. She is a psychiatric mental health nurse practitioner.

[0:32:29] Yeah. We've got 40 minutes for this time slot, and we've only got 10 minutes left, and we haven't heard from the other groups. So I apologize. You know, we, we had, we had these folks on the list, but now we've gotta give some time to the other side, and I, I apologize, okay? So let's go ahead and hear from Brent Walker, General Counsel from the Medical Association of Georgia.

[0:32:58] Thank you, Mr. Chairman and members of the committee for, uh, taking the time to hear us out on this very important issue today. Really appreciate you being here and listening in on what's going on. Um, I will endeavor to be brief, although I am a lawyer, being General Counsel and Director of Government Relations for MAG. Uh, so it is sometimes a challenge for me. But not to rehash what you've just heard, I think we've gotten some good context about the statements issued by the Composite Medical Board and others. And I think what we're hearing is, is one of the key issues is uncertainty.

[0:33:28] There's uncertainty around how the laws that this general assembly have passed to recommend and protect the patients in this state when it comes to the delivery of healthcare are being implemented by the Composite Medical Board as the regulatory authority overseeing physicians in the practice of medicine and under protocol agreements, nurse practitioners, because they are responsible for approving those protocols, even though the Board of Nursing is responsible for the licensing of APRNs. And that's a key, key issue that we have to deliberate, and we are open to that. The Medical Association of Georgia, again, like UAPRN, is ready to collaborate.

[0:34:02] We're ready to hear from them. I've spoken to several of them since the, uh, medical board meeting earlier this month. Still waiting on a few calls and emails, but we're here. We've been here for 177 years, and we're still here to work together to solve this problem and really to provide clarity on what the issue is. And what we really wanna focus on, first, is the Composite Medical Board for the past several years has been under tremendous amount of scrutiny and criticism for regulatory and enforcement failures, whether fairly or not.

[0:34:33] And Jason Jones and the staff over there and the current appointed members of the board have been working very hard to improve regulation. And one of the things that they did was issue this guidance statement on IV hydration clinics, and it implicated the concept of APRN supervision. In the State of Georgia, as you've heard, the statute is an APRN may not employ the physician that is supervising them, and the concept is not about compensation. No one's here saying that a physician cannot be compensated for the oversight that they are providing.

[0:35:04] The key issue here is the longstanding law that's been on our books since 2006 about the employment prohibition, and employment as a concept is very nuanced within the law. The courts have litigated extensively the meaning of employment when it comes to physicians. There are at least 11 factors that a court applies when they look at r- Whether or not the physician is employed, it's not just a W-2 or a 1099. It's what the substance is of the relationship over the form. And the concern of the board is, is the substance being met, and is patient safety being enforced?

[0:35:40] Is there compliance? Is there chart review? Is it meaningful? Because in the past several years, with the improvements to the system, we've seen a startling rise in the number of these clinics where we have these rubber stamp relationships. We've seen a rise in websites where you can go on and match with a physician to provide oversight that may not even live in your community, that may live in a completely other state, different state, and that creates issues with patient safety. What the board wants and the clarifications that they are continuing to issue regarding this advisory opinion that they've laid out and how they're going to enforce this is it needs to be more meaningful than just a rubber stamp relationship where your physician lives in South Florida and you operate in rural Georgia.

[0:36:20] The physician has to be involved. They have to provide delegation oversight, patient review. You know, they have to look at and meet and do these things, and that's what we've been finding. And what I understand, and, and Director Jones, who will testify after me, is gonna give you some more of the details of what they've been finding. What I find really interesting is they have been approving at a very rapid rate an increased number of nurse protocol agreements within the State of Georgia. There are 25,000 active nurse protocol agreements in the State of Georgia. They've approved 7,000 this year.

[0:36:51] We're putting APRNs to work in the State of Georgia at a rate that we haven't seen in the past, and it hasn't been a problem except in a few select circumstances. And the board has said, "We aren't telling you to shut down. We're not telling you to quit. We're not telling you to abandon your patients. We just wanna make sure that you're focused on patient safety and that the collaborating and supervising relationships are meaningful and not just this sham that you bought online for $500 or $1,000 a month, that you really are engaged in keeping the patients first when it comes to practice and the expansion of access to care." And we really appreciate your time hearing this.

[0:37:29] If there are any questions, I'd be happy to entertain them, but I believe we're short on time. Thank you, Mr. Chairman.

[0:37:36] Yeah. Well, sorry.

[0:37:38] Yeah. I, uh... From lawyer to lawyer, I would certainly appre- So first, the 11-factor analysis, are you just talking about the IRS's guidance on employee-

[0:37:47] No, this is actually very specifically related to physician employment.

[0:37:50] I think it would be, uh, in reading the position statement, I, I understand the need for a, quote, "genuine clinical oversight." I very much understand the need to comply with the law. With the fact that there are 11 factors, I can also understand the uncertainty felt by others. A- And, uh, it would really, really helpful to see, and maybe this is not appropriate for MAG, to see the composite boards or Department of Labor, I know we've dealt with employee misclassification here generally, or, uh, the AG, some- something more than a paragraph that defines what an employee is for...

[0:38:23] A- And I understand that's important for APRNs, PAs to get that, but the legislature would l- uh, and speaking up for us, we would love to see that.

[0:38:31] Yeah. And I have, and I can share later when there's more time, I can provide it to the committee, uh, an analysis of the case law. I've actually got a couple of cases in my binder that, that address this. Um, but it is. It's very unique. It's-

[0:38:43] Are they able to, uh, the, are the providers themselves able to apply it? Do they get sufficient guidance so that not retroactively when there's already enforcement, that they understand how they might be classified?

[0:38:54] Well, and that's the goal that we're working towards, is to provide the clarity when we are faced with such uncertainty. So we have been in discussions with the Composite Medical Board. Our physician members, uh, would love to talk to the APRN community, to the Board of Nursing. Uh, we've done this as an organization in the past. Uh, we can issue, uh, documents for our members that help advise them on what the physician relationship and the supervisory relationship looks like. And we're ready and willing to go as far as even creating CMEs, uh, f- that are accredited for nurses and physicians about what is involved in the physician relationship.

[0:39:27] We did that as recently as the death certificate issue, uh, that passed last year.

[0:39:31] Well-

[0:39:32] So we're happy to provide more information.

[0:39:34] Yeah.

[0:39:34] Thank you, Chairman. Um, could you tell me how many APRN-owned businesses there are and how many patients they service?

[0:39:43] It's really difficult to have that data. I think the nursing board may have better access. I looked just as a general proposition, like Bureau of Labor Statistics and Georgia's Board of Healthcare Workforce. Closest we can figure, there's around 12,000 to 13,000 APRNs licensed in the State of Georgia right now, in addition to the 25,000 active protocols. Uh, but it's really unclear, and, and I've talked to Jason Jones about this, what the practice settings are. I think there are a lot of multiple practice settings where they're working clinically, say, inside an emergency department and also have, uh, a wellness spa or IV hydration as, as a side job sometimes.

[0:40:18] You know, you have a lot of availability, especially in emergency medicine. Very entrepreneurial bunch, um, and they work on this, so there's multiple protocols. So it's a little unclear about how many are owned, and I think that's something that we could collaborate on to start getting an idea of how many numbers there are.

[0:40:32] Follow-up right quick.

[0:40:34] Margaret.

[0:40:34] Um, when you say owned, I as a nurse owned a beauty salon. That didn't make me where I was violating their-

[0:40:43] No

[0:40:43] ... laws, right?

[0:40:44] No.

[0:40:44] So when we saying AP- O- APRN-owned businesses, are we talking about the corporation that they may own or be- have some type of shares in, or how are we defining that?

[0:40:56] It's, it's a clinical practice where they're engaged in the delivery of care. So not just rental units or whatever. And again, to, to narrow that down, there's a lot of confusion in Georgia, too, because we don't have a very specific corporate practice of medicine doctrine. They pull it from case law and the way that the rules are set up, so anybody can own a, a medical practice. The, the real key here comes down to supervision, right? And that supervision relationship. In the past, I've set up these agreements, uh, for medical day spas and others where the APRN owned it but wasn't clinically supervised.

[0:41:27] They participated in management, and the physician they employed supervised other APRN employees. We've seen partnerships. There's a lot of different ways to work around this issue. We need to work with the board and the Board of Nursing to find out what works so we can appropriately advise everyone and clean, and clear the uncertainty.

[0:41:43] Chairman Hatchett

[0:41:49] I think it's might, might be me.

[0:41:50] Who's seven?

[0:41:51] That's me.

[0:41:51] Oh, you.

[0:41:52] Number eight is you. I'm seven, by the way.

[0:41:55] Oh, seven.

[0:41:58] I've, I've got Janice next down here. Go ahead and get her.

[0:42:03] Okay. Are you seven?

[0:42:04] Yes.

[0:42:05] Representative Clark.

[0:42:06] Thank you, Mr. Chairman. Um, really quickly, um, I'm hearing, um, a lot of back and forth, and I guess the question I have is, what does the board contemplate is a solution for this? And is there any legislation that is being proposed in the following session that is going to, um, in your mind, fix what you perceive the issue to be?

[0:42:28] From our position, we don't think that this necessitates legislation, but I think we need to continue working on the clarification of enforcement of the rules. And I think Director Jones can speak to that, uh, a little bit more robustly, and I don't want to take up too much more of his time. But I think that we can come together over the next couple of months and help issue clarifications and potentially even rule changes if we need to, so that people have a better understanding and more certainty.

[0:42:50] Thank you.

[0:42:51] Representative Maniar.

[0:42:53] Thank you, Mr. Chairman. Okay, what I first heard you say was there has not... Thank you for being here.

[0:42:59] Thank you.

[0:43:00] Let me start all over. Thank you for being here. Have you- I heard you say that you have not had conversations with the APRNs. Is that-

[0:43:07] I have not yet.

[0:43:08] Okay.

[0:43:08] We had a couple of discussions after the June Composite Medical Board hearing.

[0:43:12] Okay.

[0:43:12] But, uh, we haven't had any engagement since then.

[0:43:14] Okay.

[0:43:15] I know that they have been in robust conversations with the Composite Medical Board. And of course, these things are a process.

[0:43:20] Gotcha.

[0:43:20] It's hard to get everybody together, so.

[0:43:21] Gotcha. Kind of trickle down. So to... L- let me ask you something else, too. It's my understanding that the medical doctors can have 14 APRNs that they supervise. Is that-

[0:43:36] Eight

[0:43:36] ... true?

[0:43:37] It's, it's up to eight. So, and, and this is actually a very important point. A, a lot of these websites that, that are providing information and claiming to be, you know, their compliance solution for the businesses they're starting, really don't have current information. I know that the board has seen some of the contracts, and they're extremely lacking. I just went on Google and looked at a few of these websites. There's about a dozen of them that match these relationships. And like, they didn't n- have the appropriate answer to that question because, see, the last year, 2024, we changed the ratio from four nurse practitioners-

[0:44:09] Yeah

[0:44:09] ... to, and four PAs, up to any combination, up to eight, a physician can supervise up to eight advanced practice professionals under their license. And, and you know, those, those websites still were listing four, and that's kind of problematic. If, if you're missing that, h- how can you claim to be the regulatory authority that's gonna keep people apprised and updated, you know? And I think that's really one of the problems we're seeing is it looks like an easy fix, and it's really not. It, it really requires taking a close look at what the con- contract is and, and how the relationship works, and if you can do the reviews, right?

[0:44:44] If you are involved in the practice and the patient evaluation and the immediate consultation, uh, provisions. So that's really, I think, one of the problems that we're seeing as well.

[0:44:53] Thank you, Mr.-

[0:44:53] I have one more. Can I have just one more?

[0:44:54] I, I've still got the director to get up. So thank you-

[0:44:58] It's really fast?

[0:45:00] Really fast.

[0:45:01] Um, is today's conversation specific to IV hydration and med spas? Is that what we're talking about today?

[0:45:08] I think that's where it started, but I think we're more generally looking at the nature of APRN supervision-

[0:45:13] The whole thing

[0:45:13] ... in the state of Georgia now.

[0:45:14] Thank you. That was it.

[0:45:15] Okay.

[0:45:15] Thank you.

[0:45:15] Thank you.

[0:45:15] Easy peasy.

[0:45:16] They get it. All right. I'd like to-

[0:45:17] Thank you

[0:45:17] ... hear from, uh, the director, Jason Jones, of the Composite Medical Board.

[0:45:23] All right. Thank y'all so much for-

[0:45:24] Thank you

[0:45:25] ... for having us. I'll try to be quick. You know I can talk fast, Chairman, so I'm gonna try to do that. Um, but the mission of Georgia Composite Medical Board is to protect the health, uh, of Georgians through proper licensing of physicians and other healthcare practitioners and the objective enforcement of the Medical Practice Act. That's what we're doing here, is that objective enforcement of the Medical Practice Act, uh, when it came to problems we were seeing. Um, since the implementation of the board's online licensing system in around July, August 2025, uh, the GCMB has approved approximately 7,300 advanced practice registered nurse protocols and denied 519.

[0:46:00] So that's 6.6% of denials, uh, which is a low percentage of, of protocols being denied, um, uh, for failure to meet legal or rule-based standards governing employment supervision, practice location, or comparable specialty requirements. Uh, more than 25,000 active APRN protocols currently remain in effect across the state, including within, uh, Georgia's 120 rural counties. So on average, the board now approves approximately 900 APRN protocols per month, uh, compared to the average of 250 per month prior to the launch of our new system, um, an increase of more than 260%.

[0:46:35] So we're putting more APRNs to work than we ever have before. Um, the growth reflects substantially higher rate of APRNs being credentialed, uh, to practice today, uh, than one year ago, where all required documentation and signatures are properly submitted and some protocols are approved the same day. That didn't happen in the past. So, uh, I think we're doing better with these, um, as we move forward, so I think, uh, y- you'll see that cons- that continued, um, improvement. So for context for the IV hydration therapy position statement, uh, the GCMB's position statement on IV hydration therapy, uh, and advanced practice providers, uh, physician supervision does not represent a new policy or reinterpretation of existing standards.

[0:47:19] Rather, it reflects the board's response to a steady, uh, prolif- proliferation of IV hydration therapy clinics, medical spas, and other alternative medical practices throughout Georgia, uh, a number of which have prioritized business and profit models over proper medical supervision, patient examination, and patient safety. Uh, in fulfilling its statutory mission, the GCMB is required to enforce the rules and laws established by the Georgia General Assembly Uh, the IV hydration position statement reflects this responsibility directly.

[0:47:50] Uh, the underlying issue stems in part from instances in which APRNs have begun practicing outside appropriate regulatory parameters, uh, often without first researching applicable rules and laws, and have entered into business arrangements with physicians who execute, um, supervisory protocols without providing the oversight those protocols require. Uh, this is not a one-sided issue, but a shared responsibility with direct implifica- implications, uh, for patient care and safety. So it's a two-sided ordeal we're trying to get, get a grasp on.

[0:48:21] Uh, the board's review has further found that APRNs have in, in some instances, received misinformed legal advice from private legal counsel. Uh, in addition, private collaboration matching companies that pair delegating physicians with APRNs or vice versa, uh, have in certain cases omitted key information regarding Georgia law and board rules from the resulting contracts, inadvertently leading these professionals into a non-compliant agreement. So sometimes they were given bad advice on these, uh, contracts with these collaborating companies.

[0:48:52] We've, we've reviewed the contracts, and we've seen that they've omitted, uh, quite a few things. So, uh, since July 2025, the board has operated under a fully online system, ThoughtSpan. This transition has revealed, uh, several compliance issues related to supervision, location requirements, specialty alignment, and the misrepresentation of information within APRN protocols, so issues that were less, uh, far less visible under the former paper-based process. These findings include the following.

[0:49:23] So out-of-state oversight. Um, physicians licensed in Georgia but practicing out of state have applied for protocols despite not practicing within Georgia. It's one of the requirements in the law is you have to practice within Georgia or fifty miles of the location where the protocol is being utilized. These arrangements have in some cases been facilitated by matchmaking services that provided inaccurate information or omitted board law and rule requirements from the governing contracts. A review of the contracts revealed that the following board requirements were consistently absent, incomplete, or stated only in generic terms.

[0:49:57] So the contracts will leave out restricted license prohibition, uh, comparable specialty requirements, uh, maximum APRN cap, as, uh, Brent was saying, employment prohibition, they left that out, uh, controlled substance, family self-prohibition. Um, record review obligations are frequently stated in generic, non-specific terms. Substitute coverage and referenced, uh, referenced in agreements, but those agreements do not clearly implement the board's concept of a designated backup physician. They were leaving out key aspects of our rules and laws in these, uh, contracts, which were misleading, uh, to these, uh, APRNs and physicians who were entering these, into these, uh, agreements.

[0:50:36] So misrepresent- misrepresentation of practice locations. In multiple instances, physicians and APRNs have submitted inaccurate practice locations to obscure either the physician's out-of-state location or the APN's ac- APRN's actual practice location and services rendered. A recurring pattern involves the use of a month-to-month leased office, uh, where no genuine medical practice occurs to mask a non-compliant arrangement. So what they were-- What we found is, um, the month-- They, they would rent an office space with a desk and a chair, say that's where they're seeing patients, but they weren't.

[0:51:13] So then there would be another location, um, where the APRN was practicing, and the physician would be out of sight, out of mind. So, um, that's one of those five hundred and so that was probably denied. Uh, specialty misalignment. In some cases, ph-physicians and APRNs have listed mismatched or inaccurate specialties, misrepresenting the nature of supervisory relationship within the protocol, which is in violation of our rules and laws. Uh, incorrect use of institutional protocols for independent practice. So in several cases, a physician APRN have entered into a valid protocol agreement within a hospital or clinic setting.

[0:51:48] So let's say they work at Emory, um, Piedmont, one of the, one of the hospitals, enabling the APRN to obtain a DEA registration under that protocol. The APRN has subsequently leveraged that same protocol and its associated prescribing authority to operate an independent side business despite the approved protocol being limited in scope to the original hospital or clinic setting. Uh, a number of these cases have involved IV therapy clinics or medical spas.

[0:52:15] So then the excessive protocol agreements, they can enter into up to eight. Some get with APRNs, um, and they may have fourteen applications. APRNs payin' that physician to, uh, enter into a protocol, but they can't because they already have eight. So now they're paying this physician, uh, thinking they're gonna have a protocol, but they don't. So we're trying to stop that as well, not just, uh, any practice with APRNs. We're trying to stop the practice of physicians from doing, uh, some of this stuff.

[0:52:45] So, uh, protocols involving restricted licenses. We've had some that own restricted licenses that try to apply for protocols, um, and so we denied those. That's part of those denials too. Uh, and importantly, these findings represent only approximately seven percent of all protocols, demonstrating that the supervisory system and processes the board has implemented are functioning as a, functioning as intended. Um, so we do have a path forward. Uh, GM- GCMB is committed to ensuring that all licensees are compliant with the rules and laws of the state in order to protect both patients and integrity of the practitioners who serve the citizens of Georgia.

[0:53:21] To advance this goal, the GCMB will work with its licensees, APRNs, and stakeholders, which we have been doing, uh, ever since I've been there two years ago. Uh, we've been talking with the APRN association, with the nursing board, and other boards, trying to figure out how we can, uh, collaborate better. So, uh, what we wanna do is develop and administer educational programming, including continued medical education, that reinforces the standards governing the practice of medicine. in Georgia for all practitioners. We've learned that the laws and rules sometimes are not looked at, uh, so they do what, uh, people do and follow what somebody else is doing.

[0:53:57] So maybe they're doing wrong, we gotta make sure we educate and make sure they're doing right instead of following the wrong way. Uh, maintain a sustained effort to keep practitioners compliant with current rules and laws through consistent education and compliance activities, which we're doing with these statements. Uh, direct GCMB legal counsel to review and update all rules and laws pertaining to the Medical Practice Act and the professions the boards regulate, uh, ensuring alignment with current best practices. So we're trying to figure out what the current environment is so that we can either adapt or, uh, figure out how we can better, better serve, um, the patients, uh, of Georgia, uh, as well as the practitioners.

[0:54:34] Establish a more consistent and collaborative working relationship with the Georgia Board of Nursing and relevant stakeholders, which we do. Um, me and Atara email probably every week on something. Uh, so we're, we're building that relationship, um, and trying to, uh, make sure we're, we're engaging in the proper way. Engage the GCMB board in defining clear compliance standards for the current practice of medicine and APRN protocols. So we're gonna review, uh, what we have here. We're gonna go back and, and see what we can do, uh, with legislators to make sure that we're, um, addressing the needs.

[0:55:05] But, um, as you can see, I mean, we, uh, we wanna continue to approve, uh, on a daily basis legally compliant protocols that meet supervision, location, and specialty req- requirements as outlined above. Um, the board has enabled 260% more APRNs to enter practice over the past year through the consistent approval of approximately 900 protocols per month. So we're continually doing better, getting better. Uh, there's not a shortage of, of APRNs.

[0:55:36] Um, we're putting them to work, and we're, we're gonna work to make sure we keep doing that. Um, the board's primary concern, as always, is the health and safety of patients of Georgia. Uh, GCMB looks forward to continued collaboration with both parties, uh, including physicians assistants, 'cause they're in here too, uh, who provide invaluable services to the citizens of Georgia. Um, I also wanna make one comment that, uh, the board's never said that we want clinics owned, uh, 50% by physicians, that I'm, that I'm aware of.

[0:56:05] Thank you.

[0:56:06] Yes, sir.

[0:56:06] Thank you very much. Uh, we have some questions. I'm gonna apologize to the committee, but these microphone cords are all messed up. I can't figure out who's got what mic. They're not lined up in the correct order. So I'm gonna identify the mic, and then please identify yourself for the camera, okay? And for the recording. Uh, mic number 10.

[0:56:31] Right here. Representative Stinson, representing rural Georgia.

[0:56:34] Yeah.

[0:56:34] Mr. Director, um, one of the presenters made a statement about Georgia's facing a access to healthcare crisis. H- how do you, how would you respond to that?

[0:56:44] So from my research on studies, it's not the access to care, it's the cost, uh, and the insurance, uh, affordability in rural areas. So, um, it's the cost of that medical care, no matter who's providing it, is why there's a, um, a limit, I gu- or a problem from the studies that I've seen. Uh, there is a need for, um, medical professionals in, uh, all 120 of those, those rural counties.

[0:57:13] Mm-hmm.

[0:57:13] Uh, but how are you gonna get them there if they can't get paid, um, for their services if, if there's, uh, if the cost is so much and there's no patients? So that's just my, um, preliminary study. I haven't looked into that 'cause that's not our, our role. Uh, there's other state agencies that do this, but I am looking into this to see how we can, we can help. 'Cause we can, we can give you the medical professionals. We're licensing them quicker than we ever have.

[0:57:39] Mm-hmm.

[0:57:39] It's just, is there a place for them to be, and is there patients for them, uh, to see because of the cost and the lack of insurance, I think.

[0:57:47] Well, I would like to talk more offline.

[0:57:48] Yes, ma'am.

[0:57:49] Thank you.

[0:57:50] Yes, ma'am.

[0:57:50] Thank you, Mr. Chairman.

[0:57:51] Mic number six.

[0:57:53] I don't know if that's me or not. There's not a number.

[0:57:57] Who... Is that you?

[0:57:57] Thank you, Mr. Chairman. I don't know.

[0:57:58] Yeah.

[0:57:59] Can you hear me?

[0:57:59] I don't know. I'm just saying numbers. I don't know what mic you got.

[0:58:02] All right. Anybody else number six?

[0:58:04] No. No.

[0:58:05] All right.

[0:58:05] You're it.

[0:58:06] Thank you, Mr. Chairman.

[0:58:07] Yes, sir.

[0:58:07] Jason, I just wanna thank you for the work you've done over the last two years because you have taken the bull by the horns and corrected some, some problems that were definitely there. Um, your legal counsel, I think, said that there had not been any coordination about this ruling or announcement. You have said y'all coordinate all the time, so I just would like to say that I hope that from here out that you and the other boards will work together-

[0:58:37] Yes, sir

[0:58:38] ... and come to us with a solution, 'cause you don't want us to fix it.

[0:58:42] Yes, sir. No, we will. We, we were working today on a solution, uh, that we're gonna present to the, the, the, the nursing board and, and a few others. So, um, if I can guarantee you something, we're gonna work. So.

[0:58:55] Wisely said. Thank you. I got this side sort of figured out. Representative Lim.

[0:59:02] Yep, yep. Uh, so two premises. One, you said that roughly 95% of the protocol agreements most recently are getting approved, and that, uh, from the previous testimony, that there are 11 factors on determining who's an employee. It seems to me from your statement that those 11 factors aside, if you are getting compensation of any kind, direct or indirect, um, non-monetary or monetary, you cannot, uh, y- you cannot be the del- the, the physician, the supervising physician if it's even a partially APR- O- APRN-owned entity.

[0:59:38] So my question is, does that mean that you can give us reassurance that that roughly 95% of those protocol agreements, that none of those physicians are getting any sort of compensation from any even partially owned-

[0:59:51] I cannot guarantee that because, uh, sometimes it's not disclosed. So we, we review the information that's provided, so if they meet the, uh, supervision, they meet the location, and they meet the, uh, specialty, we don't ask that. Now we were asking it for, for a period just because we knew we were having issues, but we stopped asking that after this so that we can go back to, uh, reviewing those, um, other criteria to make sure they match. And if they match, we're, we're not asking are you paying or anything else.

[1:00:21] We just wanna make sure that physician is supervising the APRN appropriately by our rules and laws, uh, to make sure that... Uh, because they're, they're giving them the prescribing authority to be able to prescribe medications, so we wanna make sure that that supervision's there and they're reviewing the records and they're making sure that practice is legit. Um, so, a- and it's hard to see that on a application or a piece of paper. Uh, so if we get a complaint, we're gonna look into it further. If not, unless we have something else, that protocol's gonna be approved, which, which they have been. Um, we just don't know which ones may or may fit that category.

[1:00:54] So I'm-

[1:00:54] I-

[1:00:54] ... not advocating one way or the other for it, but from what I heard you say is you don't always ask if there is compensation unless X, Y, Z are checked. It- given that's such a critical part of the analysis, uh, why?

[1:01:07] Um, because it's, it's, the employment piece is, is, um, in question. So, uh, as long as the supervision specialty is aligned, um, why should we ask that right now? Because that, that will just muddy the waters more, I believe, um, instead of fixing and getting people to work, making people comfortable that it's actually gonna do a good thing. Um, so we're not, we're not-

[1:01:34] Okay. Thank you

[1:01:34] ... looking at it at, in that, that way. Yes, sir.

[1:01:37] Representative Davis.

[1:01:39] Thank you, Chairman. Uh, my question is this. You...

[1:01:44] My question is this. You made these changes in the regulations and, or the law, or however you govern the APRN-owned businesses, right? Uh-

[1:01:57] No, there was no changes, ma'am. That, these, these have been in effect since 2006. We just, we just put out a statement reiterating that that law was in effect because we were having so many issues with, uh, uncom- uh, not compliant protocols, um, that were coming in, and we had to make sure nobody else made that mistake. So this has always been, uh... The board has always took action on this law and rule. It's just only when a complaint came in and we were able to investigate it.

[1:02:25] Okay. Well, I guess I'm a little confused 'cause I'm looking at this from the point of view that we have long tried to attack the issue of healthcare deserts.

[1:02:34] Mm-hmm.

[1:02:35] Uh, mental health deserts. And a way to attack that is using APRNs as a source of accessing care. I guess I'm trying to figure out who was doing the oversight 'cause this seems to be-

[1:02:49] So, yes, ma'am

[1:02:50] ... at a crisis level.

[1:02:51] So 2006, the whole intention of this legislation was to put APRNs in rural areas. Uh, I don't know who was in charge of that at the time, um, but it appeared that 20 years later we're still trying to work on that issue. So, um, this is why we're trying to, to step forward as a medical board to, to implement some of these things 'cause it, your question is just my question. Why in 20 years, uh, is, is this still going on? So that's why we're doing more APRN protocols to put people in, in work in these areas, and that's why, um, you know, we're tripling the numbers of protocols we approve.

[1:03:29] So we're, we're doing our, our part to try to get more practitioners out there, but they have to be compliant with the current rules and laws.

[1:03:36] Well, I'm, I'm, y- your testimony seems to conflict quite a bit.

[1:03:40] Yes, ma'am.

[1:03:40] So if you could provide us some type of data as to how many APRN-owned businesses we're talking about, how many patients-

[1:03:50] So nobody keeps that data

[1:03:51] ... could possibly be-

[1:03:52] So we don't have a, we don't have a registration for who's owning what practice. We just, we just have the, uh... What we regulate is the physician supervising in that protocol with APRN. We don't regulate APRNs. That's the nursing board's, uh, job, and we don't regulate the, the practices. Uh, so we don't have any registration, um, mechanism, uh, within the state. So we're looking at that as far as the protocol maybe to, uh, edit that a little bit to, to add that because we don't have that and, and it hasn't been in effect for a number of years.

[1:04:29] So I think we're looking at that though because I, I see what you're, uh, what you're getting at and it's, we need that information too.

[1:04:34] Thank you. Mic number seven.

[1:04:37] Thank you, Mr. Chair. Very quickly, um, the, um...

[1:04:44] You made a statement, or a statement was made on May 7th, and since then, have you heard from any physicians that are now worried that they need to, uh, basically cancel the pro- nurse protocol agreements they have with the, uh, APRNs? And if so, what do you think the impact m- of that might be if that happens while we're trying to figure this out when it comes to access to care in certain parts of the state that do have a healthcare access issue?

[1:05:22] Yes, ma'am. Uh, so, uh, I got with staff to see if they received any correspondence through our next request customer service, or any emails, or any phone calls. Uh, we haven't received any specifically to that. Uh, we've also asked have we had any nurses, uh, APRNs contact us saying that this is happening. No. We hear that, uh, the nursing board and the APRN, um, uh, you APRN are getting those. Uh, we're asking them to forward that to us so that we can look at it on a case-by-case basis, but we don't see a crisis because of this.

[1:05:53] Uh, physicians have canceled APRN protocols, uh, since 2006. I mean, it, it happens every week. They're gonna cancel a protocol because of whatever. If the supervision isn't there and a, and a physician decides to cancel that protocol because of that, um, I mean, I think that should be done because they're not given the proper supervision. But we haven't seen an increased number of those according to our current stat, uh, that we pulled today. Um, but we're, but we're monitoring that to make sure that there's not an issue. But we wanna hear from those that, uh, may have that issue.

[1:06:26] But, uh, again, we're not getting that information sent to us. Um, the nursing board did send us some of those emails, and the ones we were able to look up have active protocols. Um, some had denied protocols because of certain criteria wasn't met, but we don't see it from the, the medical board standpoint as a crisis, um, happening in the state.

[1:06:49] Okay. Thank you.

[1:06:49] Okay. Yes, ma'am. Thank you. Yeah. Um, we are now at 3:00, and we have a couple other large issues to, to handle. I know you have some... And thank you very much. Thanks, y'all. Appreciate y'all. Jason, I appreciate it. Uh, I know you have some more APRNs to speak. Hopefully, we can do that after we get through some of these others, but we got a lot of folks here to talk about the, uh, 20% reductions, and so we need to get to that. Let me just also say this. This is the beginning of a conversation and not the end. Hopefully, the groups here speaking today can come to an agreement and fru- fruition of a pathway to settle this issue between now and session.

[1:07:32] If they do not, and if they're not in litigation, because obviously we can't address subjects, uh, completely in litigation, if those things are, are not accomplished or do not happen, then we will again pick this up in January when we go back into session. If, if, if both groups feel like that or anybody on this committee feels like that, then we'll revisit this situation. Again, if we have some time, we'll come back to some of the APRNs. I, I think you've got a couple more, Mr.

[1:08:02] Dunn. Yeah. And well, I've got one on the list, too, that I don't think is, that you're, you're aware of. Okay. Now, let's move to the care management organizations, which is a 20% rate reduction to the therapy codes. First one up is ABA, Neil Jacob- Jacobitz, Jacobitz. Is Neil here?

[1:08:21] Yes.

[1:08:21] Yeah. Okay.

[1:08:26] And each one of these speakers are gonna have two minutes.

[1:08:29] Two minutes. Okay.

[1:08:29] Two minutes.

[1:08:30] We'll try. We'll, we'll try to, we'll try to do it in two, two minutes. Um, good afternoon, Mr. Chairman and members of the committee. We're, uh, here today representing Autism Family Alliance. It's a coalition of ABA providers providing therapy for children with autism across Georgia. We represent children, well over 1,000 children across these providers in well over 100 counties. Some of these are including in very rural counties. I obviously prepa- prepared, you know, quite a few, uh, talking points, but we're limited on time, so I'll just try to be brief.

[1:09:02] And, uh, also we have another group here today as well that's gonna talk about some of these points as well that we collaborate with and work together with. But to make a long story short is, um, we've been providing care and service to these children, well-needed care, for many years. And in middle of, uh, a contract, uh, CareSource, which is a CMO, a coordinated managed, uh, organization, um, decided to cut rates 20% across the board, and did that without warning, um, without any actual commentary, and when trying to engage was of very little help, and actually, you know, threatened that if you don't wanna join, if you, if you don't accept, you actually will be, uh, thrown out of the network.

[1:09:46] And, you know, what this does obviously is in already a, uh, constricted labor environment where it make it very challenging to, to have labor and provide, you know, care for these children, it, this only makes it more difficult. Um, we're talking about this as losing access to many children across, you know, many counties, um, particularly in rural areas where there is an inadequate amount of providers to begin with. So that means if there's, it's not a matter of, okay, these, these children can, you know, go to some other provider that may accept these rates.

[1:10:18] It's effectively meaning these children will no longer have care. Um, and this is, this is life-changing care for these children. Um, you know, unfortunately, these, these children, um, you know, need, need day-to-day treatment, and it's provided in a variety of settings from schools to clinics into their homes, and the, the care that we're delivering is actually getting them to a place where they can, you know, be part of a school program or any other, you know, part of society, and it's actually geared towards enabling them to graduate.

[1:10:49] And we also are, you know, provide, you know, care and guidance to the parents, um, and are compensated for that. There are codes for that to be able to empower the parents to continue the care that, that we're delivering when we're not there or when these children graduate the program. Um, this is a very, very critical issue today, um, because of it's so many families that it's obviously affecting. Um, but I wanna, you know, be mindful of time and obviously hopefully this will start the conversation and we'll be able to engage further, um, beyond this point.

[1:11:22] Thank you.

[1:11:22] Thank you very much. Appreciate it. Kim Dane.

[1:11:28] ABA Apollo Behavioral.

[1:11:33] Hey, good afternoon. Um, I'm Kim Dane. I re- represent Autism Providers of Georgia. Uh, we, similar to Neil, we represent, uh, ABA therapy providers throughout the state. We have about, um, well over 1,000 kids represented from our provider group, well over 1,000 employees. And, uh, to give a little bit of background on this issue, uh, Georgia started to cover ABA therapy through the Medicaid program starting in 2018. Since then, there's been a 3% rate increase which happened in 2025.

[1:12:05] Uh, with a 20% rate cre- that rate cut, that would be effectively an 18% cut since the inception of the program. Uh, meanwhile, as I'm sure everyone here knows, costs have gone up tremendously in that timeframe. Um, further, many in this room probably also know that Georgia is only one of two states in the country that pays a different rate based on place of service. So Georgia compensates in-clinic care at a higher rate than, excuse me, uh, in-home care at a higher rate than in-clinic.

[1:12:36] The legislator addressed that in the last legis- legislative session. We appreciate that very much. Um, the timing of this cut is very curious. Uh, as you all know, um, this, these announcements came out, uh, right as the rate increase that you all approved was becoming public, and it also came, uh, in an environment where CareSource is the only incumbent managed care provider. So very notable there.

[1:13:02] Um, if these cuts stand, not only would it be very disruptive, but it would put Georgia, uh, Medicaid rates well below, uh, pr- North Carolina, TRICARE in Georgia, and, uh, for clinic-based care, even below South Carolina. And you all may have received the handout which has a chart showing the rates.

[1:13:22] Um, what this cut means for providers is they face a very difficult choice of either discharging the children that they serve, or, uh, in almost all cases, with this being a very thin margin business, uh, operating at loss in order to serve CareSource's members. Um, I think the reality is that most providers simply won't be able to abs- absorb this type of rate cut, and even if they do, they're very likely to limit the number of CareSource members they serve in the future. So, uh, it becomes a compounding network adequacy issue. Um, and what this means f- for families is many of them will lose access to care, and it will happen in rural areas, it'll happen in urban areas, and, um, that is in, in many ways very catastrophic because if children's- are going through these programs, their opportunity to make permanent lifelong progress is greatest when they're youngest.

[1:14:11] So disruption could make them permanently worse off, and also make the taxpayers permanently worse off because their cost of care will be higher over their lifetime. Um, w- so we conducted a member survey. Uh, we had... Yes.

[1:14:25] Can we wrap up?

[1:14:26] Yeah, absolutely. Um, uh, my final question to the committee is, um, whether or not it's appropriate for, uh, providers in the state to have to come out of pocket to serve the CareSource members. Um, thank you.

[1:14:37] Thank you. And I apologize, but we, we, we do have a few people here that want to speak to this. Um, Margaret Ann Parker, OT, occupational therapist.

[1:14:55] Thank you, Mr. Chairman. Mr. Chairman and the members of the committee, thank you for this opportunity. My name is Margaret Ann Parker, and I'm a licensed speech language pathologist, um, founder of Speech Therapy Services PC, established in 1986. For 40 years, our practice has served rural southwest Georgia bordering Florida and Alabama. The region we serve clearly meets the definition of a therapy desert with five counties north and east of us that we have provided services to because they have no providers, therapy providers at all.

[1:15:32] I am here to ask you for your support of a current crisis and for great, uh, for better protection in the future. Pediatric therapy providers have struggled for a long time. They're at a breaking point due to this recent notification of, uh, rate reductions that was mentioned earlier from both CareSource and Peach State in the same week. If these cuts move forward, clinics will close, and we are already seeing this happen.

[1:16:04] These new cuts are especially devastating because of the, um, General Assembly's increased rate to help struggling providers in 2024, and this increase was a l- uh, lifeline for some. These recent cuts wipe out that increase and more, and now physical and occupational therapy rates predate 2017 levels and speech therapy rates to pre-2007 levels.

[1:16:34] For the current crisis, we ask you to help us intervene and start the conversation to try to help contract changes and stop these reductions. For future proder- provider protection, please insist that DCH strengthen their contracts in the next round of contracts to ensure that their contracts include provisions for directed payments and Medicaid managed care. Please do not allow carve-out therapy subcontractors that have already failed in Georgia and do not approve unfair provider contracts.

[1:17:14] We ask because every missed therapy session, every clinic closure represents a child losing developmental time that can never be recovered. CMOs have justified this rate reduction as claiming that Georgia has an oversupply of therapy providers, yet DCH's provider directory shows substantial gaps: 42 to 60 counties with zero therapy CIS providers. I also recognize there are legitimate budget concerns, however, traditional therapies, I do not believe, are the primary drivers of this cost overruns.

[1:17:55] I encourage you to, uh, look at the, at the manuals and compare the traditional therapies to the other therapies, and I just wanted to say it's not simply a provider issue, it's a statewide access issue affecting every Georgia family. These reductions will affect a- access to Medicaid and non-Medicaid children because clinics will close. I thank you for your leadership and partnering with us to continue this conversation to preserve and strengthen Georgia's pediatric therapy workforce before the shortages become irreversible.

[1:18:36] Thank you for your time.

[1:18:37] Thank you very much. Thank you. Cynthia Burroway with the physical therapist.

[1:18:49] Good afternoon, Mr. Chairman and committee members. I thank you for the opportunity to speak to you today. My name is Cynthia Burroway. I'm a licensed physical therapist and founder of Atlanta Children's Therapy Associates. We provide environmental pediatric, occupational, physical, and speech therapy to homes, schools, and daycares. Our team of 30 therapists serve children across a vast geographic footprint. From as far north at this time from Jones B- from Gainesville down to Jonesborough and b- everywhere in between.

[1:19:23] We bring skilled physical, a f- skilled pediatric therapy directly to families who face health, financial, and travel barriers to going to traditional clinics. Um, I hate it to count the years, but with over 41 years of clinical experience and three decades operating in Georgia, I see firsthand on-the-ground realities facing these Georgia families. This is about the children. This is not about the practices. This is about the children of Georgia. The truth is that pediatric therapy is in severe crisis that will only be intensified by the recent reimbursement cuts that have been announced by Peach State and CareSource.

[1:20:03] Pediatric therapy services serves children diagnosed with developmental delays, such, or disabilities from conditions such as cerebral palsy, prematurity of birth, Down syndrome, or other specific genetic disorders. Pediatric centers, therapy centers on habilitation, and what that means to learn is that they help these children master vital skills such as walking, feeding, speech for the very first time. We partner with families to make this happen. Today, the system is broken, and provider networks are completely inadequate.

[1:20:36] Before all this, they're completely inadequate, may I tell you, to the meeting a massive growing demand of the children in need in Georgia. Beyond this general s- shortage, there's a severe natural environment blind spot in the state's provider assessment framework. The federal law mandates that therapy for infant and toddlers, that's the zero to three children, under the program of Babies Can't Wait, occur in the natural environment. While our practice serves these Babies Can't Wait children, we also, we serve all the children in that natural environment because that's where therapy has been shown to be most effective.

[1:21:11] This model is essential for children of all ages who suffer from severe medical conditions, making travel highly difficult. It is also a vital lifeline for these low-income families who simply lack transportation or resources to drive to a clinic, not once, but every single week or on a regular basis to obtain that care for that child. And it prevents excessive time when you come to them for having these c- c- the caregivers or parents so they can be in their home doing the things they do or be able to work and take care of their family.

[1:21:47] Um-

[1:21:47] Could you wrap up?

[1:21:49] Sure. This crisis will only escon- escalate, and if reimbursement allow- allows re, if Georgia allows reimbursement rates to decrease or stagnate, our pediatric force will continue to disappear. I'm asking three things today. We cannot solve a problem we refuse to measure. We cannot sustain a workforce we refuse to pay fairly. And I'm asking if there is a way to halt all the CMO rate reductions. They should not be allowed to buff their profits at the expense of the provider networks while they are failing to meet the medical needs of the, the members.

[1:22:21] To please overhaul the network analysis system to drastically reform how it now analyzes provider adequacy to account for the real-world wait lists and protect reimbursement rates. The su- the new CMOs that are coming in must e- explicitly state that pediatric therapy reimbursements cannot fall below Georgia Medicaid rates. Thank you for your time and commitment to these most vulnerable children.

[1:22:43] Thank you.

[1:22:46] Thank you.

[1:22:46] Jack Kronenberger, Autism Speaks.

[1:22:52] Good afternoon, Chairman and members of the committee. My name is Jack Kronenberger, and I am reading the testimony of JJ Hurley, who is a longtime Georgia resident, a member of the Autism Speaks Autism Response Team, and most importantly, the mother of Jackson, a non-verbal young adult with, with level three autism and significant support needs. Thank you for the opportunity to have my testimony read today. I have asked this testimony to be shared on behalf of many Georgia families whose loved ones have complex developmental needs and rely on Medicaid for their care. For adults with intellectual and developmental disabilities, finding dental specialists equipped to serve them is already an extreme challenge.

[1:23:28] This is the reality we are facing with my son Jackson. This past May, he aged out of the dentistry program at Children's Healthcare of Atlanta. Now we face the daunting task of finding an adult provider who can safely care for him. For many of these individuals like him, routine office cleanings are fine, but complex procedures like extractions, specialized X-rays require sedation. For safety, sedation must take place in a hospital operating room. For over 30 years, adults with complex developmental disabilities across Georgia have relied on these specialty dentists in the Atlanta area.

[1:23:59] WellStar Kennestone Hospital has historically been the critical partner providing these dentists with operating room access necessary to treat Medicaid and high-needs patients. However, we recently re- learned that WellStar Kennestone has notified these specialty dentists that their hospital's operating rooms that they've had access to for almost 30 years will be coming to an end on July 15th. While I do not know all the administrative reasons behind this decision, I know the impact could be devastating for thousands of vulnerable Georgians who may be left with nowhere to go for medically necessary dental care. My ask to the committee today is this: Please use your voice, oversight role, and convening authority to bring the right stakeholders together and identify a path forward.

[1:24:37] We understand this committee may not be able to directly reverse a hospital decision, but you can elevate this urgent issue, ask important questions, and help ensure these families are not left behind. Autism Speaks is fully ready to partner with members of this committee, state agencies, providers, hospitals, and families to find a solution. Thank you for your time and your service to Georgians with developmental disabilities and complex care needs.

[1:24:59] Thank you.

[1:24:59] Thank you.

[1:25:00] Actually, this subject is gonna come up next. I just saw autism, so

[1:25:03] I was a little bit...

[1:25:04] I, uh, I-

[1:25:04] I, I was caught off guard at first, yeah.

[1:25:06] Yeah, yeah. No, that's okay. That's okay. Okay. Uh, let's call on Jesse Wethington, the Georgia Association of State Healthcare Plans to speak now.

[1:25:16] Uh, good afternoon, Mr. Chairman, members of the committee. Uh, thank you for the invitation to be here. Again, I am Jesse Wethington. I'm here as the president of the Georgia Association of Health Plans, which is a trade group which represents both the commercial, uh, and the Medicaid managed care industry in the state. Um, so, um, appreciate the opportunity to be here and speak to the committee. Um, you know, our association is here to provide some additional context or information to you all around this. Um, we do have a position that if we take a public position that's unanimous, um, as you've heard, there are three incumbent CMOs, two of which have kind of taken the steps that you've heard from the provider community here.

[1:25:52] So I'm not gonna address any kind of specific carrier to business type question, but can address any issues that y'all have in general around concerns with access. Um, obviously it's a difficult situation, uh, and we do not wanna be in the situation of having to pass rate cuts on to providers. I think many of you may have been here back in the Great Recession. The last time we had to do that, it was a painful experience. Um, unfortunately, the situation that, uh, two of these, uh, CMOs have found themselves in is having to, uh, make some reductions based off of pressure, um, on the growth of therapy services, particularly autism and ABA therapy, but as well, you know, s- as ST, PT, OT as well.

[1:26:31] And, um, again, you know, we are funded at a level funded capitated rate per Medicaid member. That fixed dollar amount has to go toward that whole person's care, uh, for everything that that member may need. And so, uh, those two carriers have had to make some difficult decisions around what do we do to make sure we're able to sustain the whole benefit model for the whole person while still making sure that those members can get in and see services. Um, as you've heard, there's two CMOs who have kind of taken steps, uh, around rate reductions. Um, that's not to say that the third is not doing anything.

[1:27:04] Um, they are also looking at, um, high cost claims, outliers, um, if folks are billing more than 40 hours a week per services, if they're billing an RBT at a psychiatric level. And so there's pressure here. Really, I think the, the big story is that this is a benefit that has really grown faster than anybody anticipated in terms of both the footprint, workforce, and labor force that's devoted to it, as well as the expense. And so that has not quite kept up with the growth, uh, in the expense that we have to address as an at-risk plan.

[1:27:37] And so unfortunately, we've had to make some difficult decisions. Now, there are remedies in the current contract that can address that. You may hear a little bit about that later from the department. But I believe the current geo-access requirements, tell me if I'm wrong, is 30, 30, 30 and 45, 45 rural, urban. So that member needs to be able to get and access their medically necessary care within 30 minutes or 30 miles, uh, in an urban area, 45 minutes and 45 miles for a non-urban area. So if there are instances where a provider does not wanna take, you know, the new rates that are on offer, um, that Medicaid member can be seen potentially by another provider that does elect to stay in the network.

[1:28:14] They have the option to potentially change carriers and get to a different CMO that does have their preferred provider in network. Or if there is an access gap that is identified, then the department is not at all shy about making us go back to the market, contracting with a provider at a rate that is acceptable, um, so that that member is able to access the service in a timely fashion according to the contractual, uh, service level agreements that are laid out in all the contracts with the state. Um, I've heard that some of those discussions have been happening, like even in the hallway here.

[1:28:48] Um, so there are individual cases where if we identify a gap, the carriers are working to make sure that those gaps are filled, help to make sure that that member gets service. Um, at the same time, you know, yous- all of you that are deeply involved in Medicaid budgeting, this is conversation we've had with y'all, uh, you know, over the last several months. I know personally I've had it with at least three of you, kind of alerting you to this funding pressure issue and that some of these things may be coming down the pike. Unfortunate, but that is where the situation we find ourselves today. So thank you, Mr.

[1:29:18] Chairman.

[1:29:19] You have a few questions.

[1:29:20] I suspected I might.

[1:29:21] Mr. Jones. Thank you, Mr. Chairman. Um, uh, first I want to address the providers i- in the room here. I, I have a 17-year-old son with Down syndrome who is now a health, hath, healthy, healthy, happy young man, uh, because of you and the way you've changed his life through Babies Can't Wait and other programs. I'll tell you, it's difficult to access when we were going through it. It's gotten even worse. Um, Mr. Wethington, is, is there a member, is there someone from CareSource here in the room today?

[1:29:49] Uh, there was a representative from CareSource here earlier today. He waited as long as he could. Unfortunately, he had to go to an OB appointment with his wife. Uh, he did have to exit. There are representatives from CareSource here.

[1:29:59] And, uh, well, do they plan to get up to the mic and speak?

[1:30:05] If you want, uh, now would be the time. I mean, I'd love to address them directly. Right.

[1:30:11] I mean, because...

[1:30:15] Yeah. Josh Mackey, uh, I represent CareSource here in Georgia.

[1:30:19] But there's no one from the organization itself here.

[1:30:21] As Jesse stated, there previously was. He waited. He had to go to another event. I've worked with CareSource for 13 years here in Georgia. So I would tell you I can... I, I, I would say I represent them, I hope well.

[1:30:35] Well, I'm disappointed they weren't able to be in the room. I, 'cause I, frankly, I've got no tolerance, no tolerance for anyone who is hurting some of our state's most vulnerable kids. Uh, and so I, I've got several questions. I'm gonna keep it short. Please. Thank you. Um- A lot of lights ... were the rates changed in the midst of a contract?

[1:30:55] Um, yes. And-

[1:30:58] What good is a contract then if we can, we can move the goalpost?

[1:31:00] That is permissible under some contracts.

[1:31:03] Okay. So-

[1:31:04] That is not something that's exclusive to CareSource or Medicaid contracts. That's pretty much exists across insurance, commercial, and non-commercial.

[1:31:13] How does a network stay viable if costs are going up 18%, but reimbursement's going down 20?

[1:31:20] Um, I don't necessarily think it's going to be unviable or viable based upon that. I think that's part of the process that we're going through.

[1:31:28] Did CareSource make its decision based on us increasing our budget?

[1:31:32] No.

[1:31:33] Okay. Thank you, Mr. Chair.

[1:31:35] Thank you. Uh, Representative Schofield?

[1:31:40] No, I yield.

[1:31:41] Oh, you yield? Okay. Now we're back to this side. Uh, mic 10.

[1:31:46] That is me.

[1:31:47] Okay.

[1:31:48] Representative Stinson from rural Georgia.

[1:31:50] Thank you.

[1:31:51] I just wanna know, I don't know who can answer this, but all of these cuts and all this discussion, how does, how would this impact a single mom down in rural Georgia? That's what I wanna know.

[1:32:02] So they would either... What we've heard is that a lot of providers are accepting the new proposed reduction and staying in network. That may not be representative for everybody in this room- ... but I, I assure you that that is happening. Um, so-

[1:32:17] But they're saying it's not true, so what is it? What is true?

[1:32:20] Well, ma'am, I, I think we don't have a whole sample-

[1:32:22] I mean, they did that

[1:32:22] ... size here, but, um-

[1:32:23] Okay

[1:32:24] ... they would either be able to potentially be seen by the same-

[1:32:27] Yeah. I, I would need to know that, but I don't know if this is the time or the place. But I do want the answer to that at some point. So thank you. Thank you, Mr. Chairman, you can continue on.

[1:32:33] Okay. Mic number eight. Thank you.

[1:32:36] Thank you, Mr. Chairman. And, uh, Jesse, my friend, um, I'm glad you're here, but I have a lot of questions for you. First of all, to your point about, uh, the services increasing far more than was anticipated, well, uh, isn't that one of the things you, uh, accept when you take on a capitated program?

[1:32:55] Absolutely.

[1:32:55] Isn't that part of what you're doing?

[1:32:56] Yes. We are, we are-

[1:32:57] So anyway, so listen. So, so as you know, I'm a longtime provider of, uh, the, the frail, the elderly, the disabled. You name it, I've served them. Um, we've taken a, a, the, the right position in Georgia to not expand Medicaid to able-bodied working people who choose to, who choose not to work. And we did that for one reason. Because every effort we make should be focused on taking care and improving services, not decreasing them.

[1:33:30] To improving services for the frailest of the frail and the most vulnerable in society. That is the reason I've taken that position from the day I've been here, because our efforts must be to making things better for the disabled before we think about doing anything else. I don't understand how when the legislature makes it very clear that we want to improve a particular service because we know the benefit of that service to improving the lives of children so that we spend less caring for them in the future.

[1:34:08] So when the body sends a strong message that that's what we're doing, as we did last year with the, with the monies that we put in, thanks to the chairman here and his great work, the monies that we put in for the exact same thing we're talking about today, and then no sooner have we hit the door and we've got, we, we, you know, we're starting getting calls about rate cuts. Listen, my people, uh, multitudes of my people have children that need adequate care, and I hope that all of us can agree that the most vulnerable population among us is children with a multitude of, of needs, autism, and you name it, uh, physical or intellectually.

[1:34:48] But, um, I, I, I think it's, I just wanna emphasize that this is a capitated program. You alluded to that. Again, my friend, you alluded to that. And so when the excuse is, "Well, we didn't anticipate this growth," well, that's your job, to anticipate the demand and the need for services. And I'm gonna leave it with this, for the chairman's gonna get mad at me.

[1:35:10] Already.

[1:35:10] What ex- So nothing new.

[1:35:13] Yeah.

[1:35:13] Every day.

[1:35:14] Yeah.

[1:35:15] Uh, uh, one, one question for you. What is driving that increase in demand? Thank you. Thank you, Chairman.

[1:35:24] In terms of the increase in utilization?

[1:35:26] Yes, sir.

[1:35:26] I mean, we've seen that. You've, you've seen behavioral health services, I think utilization's increased about 62% over the period from 2018 to 2025. Um, a lot of these areas, especially in, like, the autism services community subset of it, you know, again, that's not the whole picture, it's a big piece of the picture, that has been more like 300%. And so we are at risk. We are capitated. That is part of the thing that we signed up for as CMOs. Uh, but we have a rating conver- we have a conversation with the state every year when, when they, uh, develop our rates.

[1:35:59] That's always a back and forth. There's a little bit of give and a take there. But this is something, and, you know, Georgia's not the only state that's in this position. Several states have recently done, uh, actions to retrench expenditure, uh, particularly in light of the growth in this program. So I mean, the growth is driven by, I think, demand and diagnosis, and now there's a lot more, I think, awareness of this, uh, in the wider body, in public. But, you know, we still have a commitment. We have to make sure that that member gets seen. They have to be able to get into that appointment within 30, 30 minutes 30 miles, 45 minutes 45 miles if you're in a rural area.

[1:36:34] And if they're not, then we have to go back to the market and contract.

[1:36:38] 2018, it doesn't-

[1:36:39] Uh, excuse me.

[1:36:41] Way to go.

[1:36:41] Excuse me. Uh, mic number eight. Mic eight? Who, I don't know who that is.

[1:36:47] That was, that was-

[1:36:48] Oh, that was se- oh, mic seven then.

[1:36:50] Seven. You cut me off.

[1:36:50] Okay, who's seven?

[1:36:52] That's me.

[1:36:52] They're all crossed up, so thank you.

[1:36:54] It's, it's fine. Thank you, Mr. Chairman. Um, very briefly, I wanna talk a little bit about impact because, uh, we got a packet of papers, and one of those, um, included a survey, um, from, I'm not sure, um, what this organization is. Uh, but, um, it said that, um, of the people that responded to their survey, about 60% of them were considering terminating their CareSource agreement if they, if this, um, rate cut- Um, prevails.

[1:37:29] And so I just wanna talk a little bit about what the impact of that would be on the children in our state. I don't- I'm not even talking about the providers. What is the impact on the children in our state if 60% of the people that prov- that are providing this care say, "I can't afford this," and they pack up and leave?

[1:37:56] So, uh, my hope would be that those children would be seen either by another provider of a similar service that did chose to stay in network, or that member, h- that Medicaid beneficiary does have the option to change it to a different plan that may have a network that is more in line to meet their particular needs based on where they live and what their, you know, child's, in this instance, medical needs are.

[1:38:17] So, um, uh, just a quick follow-up to that. So, um, I am just going to make the assumption that, um, CareSource is providing, um, or is the, uh, organization that's providing a lot of the contracts with these providers. Sorry, I'm not using the right words at the moment. But even if they try to go somewhere else, again, impact-wise, and I...

[1:38:47] You probably can't give me a number, but I just, I'm thinking about the children at this moment. What does that actually truly mean in practice? 'Cause I think it's really important that we don't just look at these things as numbers on a sheet of paper, but these, we're talking about babies.

[1:39:04] Right.

[1:39:04] We're talking about children, and I'm a mom, so this is important to me. I, I really wanna understand what you all contemplate would be the impact beyond numbers on a sheet of paper.

[1:39:16] Sure. So I, I think the initial impact is that you probably are going to have some providers drop out of the network, whether or not that results in geo access gaps for Medicaid members will kind of be determined on a member by member basis where they live. Um, and, you know, as we've previously stated, there are three CMOs currently providing services. They all three have statewide networks, and so there are other options. I mean, that's one of the reasons why the state has always had multiple MCOs, was so that members and providers had somebody else to go to if they felt like they weren't being treated the way they wanted to or it didn't meet their needs.

[1:39:47] And so I think we'll see some of the networks shake out. I think there'll be some disruption, unfortunately, and we wanna make sure that those kids are getting seen by therapists. We're committed to do that, and we're contractually obligated to ensure that happens.

[1:40:01] Okay, last question. Representative Davis.

[1:40:03] Thank you, Chairman. My quest- my question is, um, how did you determine which providers to do the 20% cut?

[1:40:12] I didn't make that determination, ma'am. That was done by the two carriers that did that. I'm here to speak from the whole industry perspective.

[1:40:18] Well, I, I, I guess-

[1:40:19] I can't... I'm sorry. I d- I can't answer your question directly. I'm sorry.

[1:40:21] I, I guess if, if... I know that a lot of times people put out a contract for, to compete. But if you put out a contract to compete to be the provider, I mean, be the one who dishes out the money, and you always know that at any time in between those contracts, you can cut it yourself, wouldn't that be a problem for all of us? Uh, because we're the ones who's gonna get the calls for the people who are gonna lack the service when people decide, "I'm not gonna work here in Georgia because I can't depend on the contract that you give me." Um, was it in your contract that you can do these cuts without the approval of, like, those of us that, the state that's p- paying you?

[1:41:12] Is that in your contract?

[1:41:14] Yes. The DCH contracts have service level agreements that are, in this case, really described as a geo access requirement, and so that is, does that Medicaid member have the ability to get this service within that circle that they drew?

[1:41:28] Is that a federal or state?

[1:41:29] It's state, but that's a feature of the Medicaid program probably in any state, I would think. But the, the managed care function is the state has hired the CMO to manage the network and negotiate the rates. And so, yes, that is, that is a feature, that is a design of the system that we have implemented in the state since 2006.

[1:41:45] Representative Davis, I'm gonna go ahead and call DCH up. I think they may be able to address your question. And so if, uh, thank you, Jesse. If, if-

[1:41:53] Yeah. Sure

[1:41:53] ... DCH would come up, um, either Emily or, or-

[1:41:58] Lynette

[1:41:58] ... Lynette. Okay. Lynette Rhodes.

[1:42:02] Hi. Good afternoon. Thank you, Chairman and members of the committee. Um, so, uh, I think your question is, does the contract allow for, uh, changes in reimbursement rates? The answer is yes. Those contracts contain specific terms that not only allow them to adjust rates, but they also allow them to terminate a provider, um, with or without cause. And that typically is seen in, in many contracts between the CMOs and their providers. It's not specific to Georgia. This is nationwide.

[1:42:32] You see these exact same types of, of contract provisions. So the providers, um, are aware of this when they sign those contracts, um, that these are the terms that they are agreeing to.

[1:42:48] Would you like to make a general statement before you leave- ... about what you've heard today?

[1:42:53] Sure. So, um, uh, I think just a couple of quick things. I wanna first start with, um, provider revalidation and talk about what's gonna happen in July. Then I'm gonna circle back and just address the specific issue at hand. So one of the things that we do need to work on in Georgia, um, that we are working to resolve now is to actually correct our provider directories, to update them so that they accurately reflect who in fact is in the network.

[1:43:24] And the way that we do that is through a process called provider revalidation. So that's gonna kick off in July, and the reason why that is important is because that will clear up, uh- who's actually in the network, where they're actually operating, what their office hours are, what their, uh, days of operation are. It will give real clarity in terms of which providers are actually operating and where. It's been quite some time since we have completed that process in Georgia, but it is mandatory and needed in order to be sure that our provider directories clearly reflect which providers are enrolled and available in the network.

[1:44:07] So I did want to mention that, because that's going to, um, ensure that our provider directories and the CMOs, because we send them the data, this will ensure that the provider directories are not overstated or that they are not understated, that they are in fact accurate. Um, so that's the first thing I want to mention. The second thing is, um, we are aware of the concerns around this rate reduction. We take network adequacy very seriously, uh, at the state of Georgia. We are receiving weekly updates from CareSource, uh, on the network, how many providers, uh, have accepted the rate reduction, how many have rejected and opted to, uh, leave and terminate their contracts with CareSource, and we will continue to do that on an ongoing basis weekly for the next several months to ensure that we have a very good grasp on what is happening with the network.

[1:45:04] Um, we are, uh, in constant communications. We have requested heat maps so that we can get clear visibility in terms of where providers are located across the state of Georgia. Uh, that's for individual practitioners and group practices. Uh, and we're also just making sure that we have clear understanding of the members that are going to be impacted, which particular members are going to lose their providers. We want to ensure that those members are getting redirected to new providers.

[1:45:36] Uh, we have also explained to CareSource, and I think this has been stated, uh, by both Mr. Wethington, uh, and the other CareSource representatives, that if they are unable to identify an in-network provider that can serve this member, they must go out of network. Uh, the same thing happens in a commercial plan. If there is no in-network provider available, then they're gonna have to go out of network, and the way that they will do that are through single case agreements. They will have to negotiate those rates, um, or they will have to redirect that member to a different provider that is in network.

[1:46:15] And within distance. And within-

[1:46:16] And distance and time.

[1:46:17] That's correct.

[1:46:18] Right. Okay. Got a question, Representative Lim?

[1:46:23] Uh, Lynette, thank you for, for being here. I know you've, I've asked you many questions offline. One I'll make for the record, I do think it's important, and I know you've already heard this, um, f- to ensure that whatever process, both for network adequacy evaluation-

[1:46:38] Mm-hmm

[1:46:38] ... as well as for the RFP coming up-

[1:46:41] Right

[1:46:41] ... um, that the consumer and what they're reporting in whatever form that is, whether it's a formal grievance or not, whether they are as, as you've stated to me, calling in just to switch, the 60% that Representative Clark has stated, that that is part of the consideration and it's not just the, the audits that you all do as well as the self-reporting.

[1:46:59] Yes.

[1:46:59] So I do wanna make that public record. The second question I had for you is I know that in a different capacity, um, that with the Mental Health Parity Act that, uh, Commissioner King has issued a lot of fines around network adequacy in a different context.

[1:47:14] Yes.

[1:47:14] Could you provide us data on the fines that you all provided in order for, for us to be able to assess whether you have sufficient authority, essentially, that it's not just, quote, the cost of doing business, but that in fact those who are violating network adequacy despite repeated admonitions that they are doing so are in fact re- remediating?

[1:47:36] Right. So each year the department does an analysis on mental health parity. Uh, and in doing so we look at claims data, uh, we look at prior authorization data, and we compare that to, um, services in the physical realm, right? To say, you know, are prior authorizations being denied more often than not on the behavioral or the phys- physical health side? Are claims being denied more often than not? To do a true comparison to determine, you know, if there is parity. We also look at utilization, we look at the providers, and we look at the network.

[1:48:10] Based upon the most recent, uh, annual reports that were completed, and those are available publicly on our website, I do wanna mention that for anybody that wants to look at those, there were no findings, uh, with respect to violations of the Mental Health Parity Act.

[1:48:26] And I want to be clear, I'm, I'm not specifically speaking about mental health at Baldwin, but I understand-

[1:48:30] We can move on.

[1:48:31] Yes. Thank you, Chair.

[1:48:33] Representative Clark.

[1:48:34] Yeah. Thank you, Mr. Chairman. I think, um, this is a very important conversation, and I would actually love to hear, um, and maybe this was already in the plans, DCH's position on what's happening behind this.

[1:48:46] You're hearing that. That's where we met.

[1:48:48] Oh, this is, that's where, okay.

[1:48:49] Rhodes is DCH.

[1:48:50] So-

[1:48:51] Yeah.

[1:48:53] I, I guess then my question... Well, never mind. I'll, I'll leave it at that.

[1:48:59] Well, Emily, you wanna address something?

[1:49:00] Yeah. And I, I think I'll just make a, a note on the point, and I'm-

[1:49:03] Okay

[1:49:03] ... and Lynette answered this in a question, and the only thing, I mean, Lynette is by far the expert here, so I'm gonna let her answer any specific subject matter questions. But I think the, the reality is here, I think one thing about our, our current, our current contract with the CMOs, it does not control the rates, and that needs to be understood in managed care. It is up, those, those contracts between the CMO and the provider is what controls the rates that they receive. Our duty is that network adequacy, you've heard all of that, and I just wanna put a fine point on that because I know we answered the question, but just to say it more specifically, you know, our department is, I, I don't know that we would take a position, and I'm gonna be very honest about that.

[1:49:42] But I mean, we're not, you know, supportive of this. We're not saying it's bad. But I would say that it is something that the department currently doesn't have the authority over to control the rates that happen between the CMO and the provider.

[1:49:55] Thank you. Uh, and thank you very much for both of you. Okay, we're gonna now move on to our next subject, which is patient access to hospital dental procedures, um, requiring anesthesia. Uh, is Dr. Schatz here, President GDA? Would you come up and speak, please?

[1:50:17] Do you want me to let the room clear real quick?

[1:50:19] Do you think I would-

[1:50:21] I'm just gonna, I'm gonna introduce him. I'm just gonna introduce him and the things.

[1:50:25] Okay.

[1:50:26] I just didn't know if you wanted me to-

[1:50:27] Janelle Adams, if you would like to go ahead and introduce Dr. Schatz.

[1:50:30] Um, good morning, afternoon. I'm Janelle Adams with the Georgia Dental Association. Um, I'm gonna turn over my time for just a bit, I will wrap up after then, um, to Dr. Peter Schatz. He is the current GDA president and a practicing periodontist in Marietta, as well as a community VA provider. Um, and we will also have Dr. Jordan Blankenship, who is a practicing dentist out of Roswell, who is also a hospital dentist. So Dr. Schatz, the floor is yours.

[1:50:54] Yep.

[1:50:55] Thank you, everybody, Mr. Chairman, Dr. Chairman, uh, ladies and gentlemen of the board, thank you for your time. The Georgia Dental Association has joined the American Academy of Pediatric Dentistry, the American Association of Hospital Dentists, and others to raise concerns about limited operating room access for dentists in the state of Georgia. There will always be a subset of our population who need access to hospital operating rooms for those that cannot tolerate dentistry in the traditional dental clinic or in special needs clinics, or certain medical conditions and, uh, events that force you to go under general anesthesia under close supervision in a hospital setting.

[1:51:37] These include medically complex patients close and tied to major medical surgical events, children with, uh, developmental disabilities who cannot tolerate anything other than that with complex medical events, and our veterans who served our country with both complex physical and psychosocial issues that cannot be handled in a typical outpatient setting or even an ASC. National data specific to the needs of special needs patients, but show growing evidence of limitations on oral, sorry, OR access and hospital dentistry.

[1:52:14] In a survey of the AAPD, the American Academy of Pe- uh, Pediatric Dentistry, there's about a 67% cited OR access as key concerns for their providers, and a recent analysis presented at the 2025 annual meeting of the Medicaid State Dental Association suggested that as many as one million pediatric patients nationwide, however, indicate that, are indicated for general anesthesia, and that most of those did not receive general anesthesia care in the last 12 to 24 months.

[1:52:46] Bottom line is that even in our own backyard, there's an existing gap in access for dental care that appears to be growing. Providers throughout metro Atlanta report, report increased OR waiting lists and culling of operating block times that have been given to them in the past several years. The causes of this gap include limited OR time and space in operating rooms inside of Georgia and other procedures that need priority, the financial complexities of caring for intellectually and developmentally disabled individuals and other patients where reimbursements are relatively low compared to general surgical reimbursements, and high costs of setting up the room relative to the Medicaid reimbursement levels in the state of Georgia.

[1:53:30] Thus, the hospitals, being businesses as they are, look at that time and reallocate as needed. However, that is culling out time for a special population of veterans and children and adults that cannot otherwise tolerate care in a traditional dental setting. With that, I yield the microphone to Dr. Blankenship.

[1:53:51] Dr. Blankenship?

[1:53:52] Yep.

[1:53:55] Jordan Blankenship, go ahead.

[1:53:58] Good afternoon, Mr. Chair and members of the House Health Committee. Thank you all for staying here. I know we're getting close to time. Um, again, my name is Dr. Jordan Blankenship-Snycker. I'm a practicing dentist in Roswell, Georgia, and for the past 10 years, I've focused on treating adults with severe medical complexities and adults with developmental disabilities in a hospital operating room. Um, because I know that we are concerned about the children, but all of these children become adults tomorrow, and they need the care just as much as those children do.

[1:54:30] Um, so I'm here today to ask you to make access to hospital-based dental care for these patients an urgent priority. This is not just a dental issue, it is a healthcare issue. It is a disabilities right issue, and it's an access issue. Oral health is deeply connected to the whole body. Dental disease can affect digestion, cardiovascular health, cognitive ability, the immune system, and overall quality of life. The mouth is not separate from the rest of your body. For patients with developmental disabilities, this connection is especially important.

[1:55:04] Many cannot rely, reliably communicate pain. Dental infection may show up as a refusal to eat, poor sleep, self-injury, or a sudden change in personality. Dental diseases can cause chronic conditions to worsen and health to deteriorate. Unfortunately, for many of these patients, treatment in a traditional dental office is simply not safe, realistic, or successful. A dental office can be overwhelming, even terrifying for medically fragile patients.

[1:55:35] Despite compassion, patience, and every sensory accommodation possible, some patients simply cannot tolerate care in a traditional setting. For them, dental treatment is not just difficult, it can become medically dangerous. Seizures, airway obstruction, aspiration, cardiovascular instability, allergic reactions, bleeding complications, and uncontrolled movement can turn routine care into emergencies fast For these patients, hospital-based dental care with an anesthesia team is not convenience.

[1:56:11] It's safety, it's dignity, it's medically necessary, and the only humane way to provide the care that they desperately need. Right now, access is disappearing. When hospitals close their ORs to dental care, these pa- these patients do not suddenly become treatable in a regular practice. They simply lose access. The result is delayed care, untreated pain, worsening infection, emergency room visits, hospitalizations, and caregiver crisis.

[1:56:45] Delay means greater pain and higher costs, both per- personally and monetarily, and that should concern everyone. This issue is also growing, as I stated earlier. The prevalence of developmental disabilities is increasing. The children who need these services today become adults with even greater medical complexities tomorrow. Their caregivers age, but yet their dental problems remain. If we do not protect hospital-based dental care now, Georgia will face a much larger access crisis in the future.

[1:57:18] We can provide dental care safely in a hospital, and families exhale. Pain's treated, infection is removed, behavior stabilizes, a patient wakes up healthier, and a caregiver feels seen. That's what access means. These patients deserve more than just sympathy. They deserve systems that work. They deserve hospitals that make room for them. They deserve a collaborative network of providers dedicated to treating patient-based, ch- patients based on their individual circumstances, and they deserve advocates willing to say clearly, "Oral health is part of your health.

[1:57:56] Disability access includes dental access, and hospital-based dental care for adults with disabilities is protected." When dentists, anesthesia teams, major health institutes, and policymakers work together, I know we can make the difference that these patients need. Thank you for your time.

[1:58:14] Thank you. Thank you. Okay. Next, I would like to call Anna Adams up with the Georgia Hospital Association.

[1:58:25] Thank you, Mr. Chairman, members of the committee. I am Anna Adams with Georgia Hospital Association. Let me adjust this microphone. I'm a lot taller than you. Sorry.

[1:58:35] That's okay.

[1:58:36] Um, thank you for hearing from us today. We did some extensive research, just to give you some background today, on what is happening in our hospitals and their ORs with relation to dental services. And I want to first start by clarifying, these dental services are considered elective because they are scheduled ahead of time. That doesn't mean that we are not available for emergency dental services. That is, of course, covered under EMTALA. When looking at the data, what we have in Georgia is more hospitals at this point who are allowing these elective dental procedures than we have hospitals that are delivering babies.

[1:59:09] And the vast majority of the hospitals that are not doing elective procedures, there are not a lot of dentists in their areas. Most of them are rural. One of the things that I do want to touch on today that I think is really important to point out is that our population is aging. It is changing, and hospitals are having to be dynamic in how they're responding to those needs. And so that means we have to do more surgeries. We have to do more emergency care, et cetera. So keeping those ORs open and available for those patients that have an acute need is of vital importance.

[1:59:39] I think that there have been some hospitals that have made some decisions recently to reduce that number, and for those facility to, facilities, excuse me, it is my understanding that they have made some alternative suggestions. But in looking at the map and where these are located, there's not a specific area of the state where it looks like there's a hole for these services. So while you may have to drive 10 minutes further, there is an available option. GHA, um, is always proud to help with sponsorships and, um, introductions for these facilities should they need help getting into a hospital if they don't know who to contact.

[2:00:13] We're happy to be a resource for that. But for now, I think we've got hospitals making the decisions that they're making with their patients' best interest at heart, but also still wanting to be a really important part of the community.

[2:00:25] Okay. We, you do have a question. It's Mike 8. I wonder who that is?

[2:00:29] I got it right here, Chairman.

[2:00:30] Hi.

[2:00:31] Uh, thank you, Chairman. Yeah, uh, so this issue is a really important issue, and I don't know today how we fix it, but I, I, I know you wanna f- I know everybody wants to fix it. Um, uh, folks, uh, in Savannah, uh, travel 80 to 100 miles to Savannah from all around.

[2:00:48] Mm-hmm.

[2:00:49] If they have someone that needs, uh, uh, i- int- intellectual disabilities, needs to be anesthetized for-

[2:00:57] Mm-hmm

[2:00:57] ... treatment, I mean, y- you just can't find it. And so my understanding is we've lost that one place we had to do that now. So this is a real issue that we need to address, and I'd love to have, uh, the Hospital Association, uh, weigh in and let us know what we might and can do to help, because it is a real, uh, it is a real problem.

[2:01:21] Absolutely.

[2:01:21] It's a real legitimate problem.

[2:01:22] Thank you for your question, and I appreciate you bringing that up. So Savannah, St. Joe/Candler in Savannah, does the second-most elective dental procedures of any facility in the state.

[2:01:31] They did.

[2:01:32] They still do. I have their data up until even through 2026.

[2:01:35] They were stopping it last year, and if they changed their mind, that's great.

[2:01:39] Yeah. They've got a pretty substantial number in there, so excited about that. One of the facilities I know has m- recently made a decision to offload some of those surgeries to a different one of their operated and owned facilities, um, was doing a much smaller number of those. I think it was, like, 2% of the total elective dental procedures. So while that is a loss, I'm sure, for that community and for those providers, they did provide a backup option for those dentists to be able to have access.

[2:02:06] Representative Lim.

[2:02:09] But thank you. And I, I would, I would love to see the map. I- it goes back to the network advocacy conversation.

[2:02:16] Mm-hmm.

[2:02:16] 'Cause, um, my- my understanding from speaking with, um, Mr. Skipper at WellStar is that you had conducted a poll and that it was verbal. And but, you know, even with the WellStar thing, technically they could say, you know, the Windy Hill location-

[2:02:28] Yeah

[2:02:28] ... appears to be the one that's going to stay open, but there are questions-

[2:02:32] Right

[2:02:32] ... about scheduling, et cetera. So I think it's d- digging down deeper into what access actually means-

[2:02:38] Mm-hmm

[2:02:38] ... is important, particularly we're doing it on a statewide basis. And personally, I would love to see. I, I don't know how much we can do particularly about the WellStar issue. It seems to me from communications with both parties, I think I see Dr. Kurtzman over there, that there's been a lot of miscommunication. So anything that can be done, especially in the lead up to-

[2:02:55] Right

[2:02:55] ... I believe the July 15th-

[2:02:57] Right

[2:02:57] ... for all of the parties to get in the room would be great. But more broadly speaking, mapping that out and truly seeing-

[2:03:04] Right

[2:03:04] ... what access looks like.

[2:03:06] Thank you.

[2:03:06] Well-

[2:03:06] It's fine

[2:03:07] ... um, Jason Skipper, who represents WellStar, has assured me that they're working through ancillary-

[2:03:13] Yeah

[2:03:13] ... clinics of theirs, you know, to get this conversation.

[2:03:16] Yeah, and I would appreciate it if they're doing that.

[2:03:17] And they're still working. Yeah, they're still working on that. Mike number nine, whoever that is.

[2:03:23] I don't have a number on the mic, but I guess that's me 'cause the lighting mic.

[2:03:26] Oh.

[2:03:26] Thank you, Mr. Chairman. Um, I, I just wanna echo the, the, the request from my colleagues for that map. I think that's a great idea.

[2:03:33] Yeah.

[2:03:33] Um, I was contacted by a woman who lives in Jackson County, uh, who has a 37-year-old autistic son, um, who needs these services. Um, they, they've been trying to find someone to take him to. Uh, they, they... apparently there's a provider in the Athens area who is so full, he can't accept any more patients. Um, they had an appointment at WellStar, but they were told, uh, I think towards the end of May that that was canceled-

[2:04:00] Mm

[2:04:00] ... because they were wi- withdrawing that service. So-

[2:04:02] Mm

[2:04:03] ... um, when you say there are no holes in the state, I'm hearing differently. I, I-

[2:04:08] Yeah

[2:04:08] ... would very much like to see that map.

[2:04:09] So I think you just raised a really important point, which is that this patient doesn't have access to a dentist, and you as a general assembly have recognized that we have a dental shortage in Georgia, and so therefore have funded the dental program down in South Georgia. Um, I think having enough dentists to be able to perform these types of procedures in the hospital setting is also a really important key to this.

[2:04:31] I agree with that, but it seems like there's a facility issue, too, right? Is it a shortage? Is it a profitability issue? Like, what-

[2:04:38] Uh, well, I think if they couldn't get an appointment with the dentist, that's kind of the first step, and once they get in to see the dentist, then they would move forward with what facility can we perform your services at?

[2:04:49] Okay. Fair enough.

[2:04:50] Okay. Thank you. Uh, we have wanting to speak Dr. Baloh from Emory.

[2:04:58] Yeah.

[2:05:02] Uh, thank you, uh, Chairman Hawkins and, uh, board. I represent Emory Healthcare. I just wanted to bring you a little up to speed as the chair and professor of oral maxillofacial surgery. I'm sort of responsible for the majority of care for Children's Healthcare of Atlanta, Grady Memorial Hospital, or Emory Healthcare systems. Right now, there is, uh, uh, issues in terms of access to be able to get in to see us. Most of us have waits that extend for months and months before you can get in because the capacity outstrips our ability.

[2:05:34] There is 200 oral maxillofacial surgeons in Georgia, and there's five of us at Emory, and we've just increased that to seven starting in a couple of months, and we're looking to expand our services with build-outs at Emory Healthcare, uh, institutions, particularly Emory University Hospital Midtown. It's, that should provide some access, uh, and an improvement. But right now, there are simply more patients than we can physically take care of, and we're one of the few institutions that take care of everything. So the dental services are really important, but we deal with the trauma, the cancer, the reconstruction, the jaw joint replacements.

[2:06:10] We're number one in the United States for many of those things, and our referral pattern is from all of southeast, uh, um, uh, the United States. So we're sort of at capacity as best we can, um, and that provides some, some challenges. I was on call for a week, uh, for, and I have a full three-day operating room schedule plus two days in clinic like my partners. Um, as I said, we cover Grady and all the other hospitals, so we're everywhere, and we have 25 residents in training. On the particular six days that I was on call, I took 38 calls from the Emory transfer service for other entities and institutions looking to transfer patients for me to take care of, and I have to manage that on top of my full schedule as it is.

[2:06:53] So you can sort of imagine, we have a lot of access issues, and we really can't, we can't manage all of Georgia alone. We really need some support in terms of reimbursement, in terms of encouraging others in the private sector to, to help make this manageable. We'll continue to do what we can for the, for the, for the patients of Georgia and for you all, uh, to the best of our ability, but w- we're sort of at capacity.

[2:07:16] Right. Right. And thank you for your, for your comments. I would suggest that maybe you and Ms. Adams get together with her association, the hospital, Georgia Hospital Association, and see if, uh, they can, uh, provide some help in this, because it sounds impossible what you're doing, but I really appreciate everything you do.

[2:07:34] Yes, sir. Thank you.

[2:07:36] Um, okay. We've got another subject to move to, and that is, um, the diabetes-related amputations. Andy Lord, would you like to get up and speak? Up there. Yeah.

[2:07:50] I'm sorry. I, I can't hear you. You, you need to get to a mic. I just asked for you to speak, so go ahead.

[2:07:58] I'm so sorry, Mr. Chairman.

[2:07:59] Yeah.

[2:07:59] We had, uh, uh, sent in slides, uh, from Dr. Olaleye from-

[2:08:05] I'm sorry. W- w- where are we at? I know the time is late. Um- Yes. Yes. Yeah ... I think you all have them printed in front of you. So I'm happy to- Right ... um, let you know leks, next slide when we get to it. Um, but there are only eight slides. Um, I will be brief in each of them, uh, except the last one. We have- So good afternoon, um, everyone, Chairman Hawkins and the members of the, um, uh, committee. My name's Dr. Olamide Alabi. I'm a vascular surgeon and associate professor of surgery at the Emory University School of Medicine. Um, but today I am res- representing the American Diabetes Association as a volunteer, and I'm representing the thousands of Georgia residents battling the compounding crises of diabetes and peripheral artery disease.

[2:08:39] As a physician, I see my patients, their caregivers and loved ones, our friends and neighbors plagued by the negative consequences of this disease literally every day. Um, if you look at the second, uh, page, every three minutes and 30 seconds in the United States, a limb is amputated due to diabetes. This is not car accidents, this is not wartime. This is literally secondary to diabetes and poor blood flow. What should alarm every leader in this room is that the vast majority of these amputations are entirely preventable. Um, so yes, that's, uh, by the time I finish talking through this slide and perhaps the next one, another limb will have been amputated in the United States.

[2:09:15] I apologize about that. I apologize. That was about the slides. I was not aware. No, no. It's okay. And go ahead. It's okay. Go ahead. You guys have them in front of you. So, um, you know, uh, what's really important, you know, you, you're saying I'm talking about the United States in general. What's happening in the state of Georgia? Georgia ranks among the top five states in the nation for lower extremity amputation, leg amputations, and that's a staggering 473 lower extremity amputations per 100,000 Medicare fee-for-service beneficiaries. So we're facing a severe cataclysmic, yet entirely preventable public health crisis right here in our own backyards, and today I want to discuss how we can rewrite that narrative.

[2:09:49] Uh, this is for the next slide. This shows you a progression of how diabetes can, um, can lead to limb loss. And as you can see, just kind of in short, it's a progression. There's a process, right? It doesn't just start from one to the end. So, um, uh, along, uh, several steps along that way, we, there are a lot of, uh, junction points where we could prevent things, this, uh, amputation from happening. Um, but right now we're, you know, we're not able to do that effectively. Uh, one thing I will mention specifically is that between 2016 and 2019, 19% of all diabetic foot ulcer cases in Georgia resulted in amputation.

[2:10:24] That's one in five diabetic foot ulcers in our state progressed to leg amputations. Next slide. Beyond the terrible toll that a leg amputation places on human life and longevity, workforce losses, uh, household wealth and earnings, quality of life, mental health, et cetera, uh, there is a massive fiscal burden that Georgia's healthcare infrastructure is bearing directly. Uh, so as you can see on the left side of the screen, uh, the slide, uh, diabetic foot complications account for nearly one-third of the 245 billion spent on diabetes care in the United States annually.

[2:10:57] That's 13 in our state, 13 billion in our state. Managing a single diabetic foot ulcer costs $33,000 per patient per year. Um, every s- uh, severe acute episode of this diabetic foot ulcer is at least 17,000 or above for each episode. And once an amputation occurs, costs jump to over 52,000 per patient per year. And go ahead and make that 100,000 per amputation per year, factoring in surgery and acute recovery and prosthetics and, uh, long-term rehabilitation.

[2:11:27] So now compare this to the alternative. What's the ideal state? We deploy evidence-based early multidisciplinary care that has been proven to reduce leg amputation rates by at least 50% and achieve a 95% limb salvage rate. We provide proactive, consistent outpatient follow-up and preventive podiatric care that slashes total treatment costs by 50%. And, um, this also can cut hospital stays in the unfortunate situation where someone does need to be hospitalized for this, cut them, uh, in half, from 13.4 days down to just 7.1 days.

[2:11:59] The next slide, and I, I think these are the numbers that are a bit sobering here. I want to direct the committee's attention to the American Heart Association's Peripheral Artery Disease Collaborative's heat map that is included in your briefing, uh, materials. This interactive online tracking tool analyzes claims down to the county and congressional district levels. In the pictured map, what you're looking at right there, uh, the one with the two maps and an arrow, uh, so this is by congressional district, as you can tell. And, um, the average rate of amputation secondary to poor blood flow, uh, throughout the entire country is about nine per 1,000 Medicare patients.

[2:12:33] In our state of Georgia, our average rate of amputation secondary to poor, poor blood flow is now up to 13 per 1,000 Medicare patients. We're winning in all the wrong ways. Next slide. When you look more closely at this heat map, this one delineated by county here, you can easily see that where a patient lives dictates where, whether they keep their legs or whether they lose their legs. Across all 159 Georgia counties, 45% are dual desert counties, so that means that there are no podiatric surgeons who have primary practice locations in those counties, and there are no vascular surgeons who have primary practice locations in those specific counties.

[2:13:09] 45%. Among counties with available amputation data, amputation rates demonstrated substantial variability, with the variability largely driven by high, uh, burden rural counties. For example, Taylor County alone has jumped from an amputation rate of 1,000 Medicare be- uh, per 1,000 Medicare beneficiaries from a rate of 22 in 2019 to a rate of 50.98, five zero point nine eight. It's more than doubled in 2023, compared to approximately 14 per 1,000 in Fulton County.

[2:13:41] Dual deser- desert counties are overrepresented in the highest quartile of amputation rates. The deep shading in our rural counties and underserved urban pockets illustrates exactly where diabetes prevalence, severe lack of screening, and specialist shortages intersect. And it's absolutely unacceptable that a Georgian's geographic location determines their physical wholeness, quite literally. This data provu- uh, proves that our current model is reactive and not proactive. And if nothing else, this right in front of you, that's our call, call to action. So we urge that the, uh, committee, uh, we urge the committee to support policy measures that strengthen preventive care in our communities.

[2:14:18] The good news is that this crisis is not insurmountable. We know who's at risk. We have some data that shows us, in a Medicare population at least, where many of the amputation hotspots are, and we know what works. First, I recommend that we create a state, statewide Georgia Diabetes Amputation Prevention Initiative and build a Georgia Amputation Surveillance Dashboard, because if we can measure it, we can manage it. We can't effectively address a problem that we do not track, identify, report out, or understand. Second, we must invest in community awareness, education, navigation, and screening programs.

[2:14:51] Everyone knows what a heart attack is. Everyone knows what a stroke is. But people don't know that their risk for limb loss is almost just as high as those entities in our state. Um, so we need preventive podiatric care as well as aggressive podiatric surgical care to be easily accessible throughout the state. We need better access to diabetic footwear. Uh, remember, a diabetic, uh, foot footwear costs about $200. An amputation, over 100,000. Um, so we need better foot, foot surveillance, outreach in the communities that need it most, and after all, the most expensive diabetic foot ulcer is the one that we never saw coming.

[2:15:25] Uh, third, we must ensure that high-risk patients with diabetes have access to evidence-based limb preservation care. This includes annual foot exams, A1C monitoring, access to advanced therapies such as topic- uh, topical oxygen therapy, and emerging technologies that help identify problems before they become emergencies. That's the key. And in the situation where a limb-threatening issue presents itself, we need better access to excellent multidisciplinary care teams, vascular specialists, podiatrists, wound care clinicians, primary care physicians, endocrinologists, cardiologists, the list goes on.

[2:15:56] Mental health professionals, et cetera. No one specialist, uh, no one specialist can prevent amputations. Teams prevent amputations. And fourth, we must, uh, direct resources tow- towards rural and high-need communities where the burden is greatest and access to care is often the most limited. Guideline-based therapies can save limbs and save lives, but only if patients can actually reach them. Uh, and finally, we must create a reimbursement pathway that supports prevention. Evidence-based screening for risk, uh, high-risk di- patients with diabetes, annual foot exams, and coordinated limb preservation programs should be viewed as investments, not expenses.

[2:16:32] We should fund limb preservation centers that bring together multidisciplinary teams and, um, coordinated care pathways. Um, members of the committee, limb preservation is within our reach. We have the knowledge, we have the tools, we have the passion, and we have the opportunity to change the tra- trajectory of this disease in our state. Georgia already pays for diabetes-related amputations every single day and, as I mentioned before, almost every, uh, several, several minutes. The question before us is whether we want to continue paying for amputations or start investing in prevention of amputations.

[2:17:04] Because when we invest in prevention, we don't simply save money, we save limbs, we save lives, and we give thousands of Georgians the chance to keep walking into their futures. Thank you.

[2:17:18] Thank you. I want to apologize to you and Andy. Thank you. I want to apologize to you and Andy. I did not realize that you were, you weren't on my presenter sheet.

[2:17:24] Mm.

[2:17:24] But I did see this, so ap- apology. I just didn't know. And I appreciate you hurrying up through that. Yeah. Oh, no, I'm going to get to you. Oh, okay.

[2:17:33] I'm just... No, I didn't forget. I just don't know who seven is. I guess seven's you .

[2:17:37] Is that seven?

[2:17:38] No, I'm seven.

[2:17:39] We didn't see those slides 'cause I imagine they were in color and this was black and white.

[2:17:42] Yeah, they were. Oh. They, and they're very pretty in color.

[2:17:46] Oh. Oh, oh, okay. Were you seven then? No, that was Okay.

[2:17:50] This is Karen.

[2:17:51] Oh.

[2:17:52] And-

[2:17:53] Okay.

[2:17:53] All right.

[2:17:53] I'm sorry.

[2:17:54] Um, uh, uh, uh, three questions really quick. Um, do we have an average age of amputees in the State of Georgia and also, um, in the country? Uh, that's my first question. Um, my second question is if you compare the age, um, are most of these people Medicare age that are, um, having, uh, to have amputations? And then the last thing I will say is, um, are screenings for this, so for example, the ankle brachial index-

[2:18:27] Mm-hmm

[2:18:28] ... and other screenings, are these covered-

[2:18:31] Mm

[2:18:31] ... by most insurance policies? Um, and if they are, if they are covered, is there an age at which they are covered versus you would have to pay to get this screening?

[2:18:45] Yeah, these are excellent questions. It's almost as though I planted you there. So, um, you know- ... i- in terms of the average age of a lower extremity amputation in the nation, that average age, uh, you know, kinda depends where you are, but can range anywhere between 60 to 75. The thing is, the, um, fastest growing, uh, population, subpopulation of individuals getting lower extremity amputations actually have premature peripheral artery disease, meaning less than age 50. So this is not a problem of the aged. This is not the problem of the older adults. This is a problem that we're seeing in our neighbors and our friends and our church members and our, you know, at our schools, et cetera.

[2:19:19] Mm-hmm.

[2:19:20] Um, in terms of, uh, sorry, what was your second question?

[2:19:22] Um, uh, well, that, those two kind of-

[2:19:24] Okay

[2:19:24] ... went hand-in-hand. I was just trying to get the idea of-

[2:19:25] And the third one was about the ankle

[2:19:26] ... how many people are eligible for Medicare-

[2:19:30] Mm-hmm

[2:19:30] ... that are getting these versus not eligible yet.

[2:19:32] Correct. Yeah.

[2:19:33] And then after that.

[2:19:33] Mm-hmm.

[2:19:34] Okay.

[2:19:34] Um, and so the, for the third question about screening, um, so screening right now with the ankle brachial index is not covered. The ankle brachial index is a non-invasive study. It is the non-invasive diagnostic gold standard for peripheral artery disease in particular, and it is not currently covered. Um, but certainly, I would say low-hanging fruit.

[2:19:55] Thank you so much.

[2:19:56] Mm-hmm.

[2:19:57] And just, uh, really quickly, if it were to be covered, is there a specific age that you feel like it should be, like this is standard and it should be covered as a part of preventative care? 'Cause a lot of times preventative care is covered. Um, would that be 50 or do you think it should be 60?

[2:20:13] I, I think it should be 40.

[2:20:14] 40.

[2:20:15] Mm-hmm.

[2:20:15] Thank you. Thank you very much.

[2:20:17] Mm-hmm.

[2:20:19] Prevention.

[2:20:20] Right.

[2:20:20] Yes, absolutely.

[2:20:22] Thank you, Congresslady.

[2:20:26] Okay. Schofield, Representative Schofield.

[2:20:28] Yes. Thank you, Mr. S- Chair. I just have one quick question. How many of their, the s- limb preservation centers are currently in Georgia?

[2:20:35] That's a great question. Um, the first one started last year at Emory

[2:20:42] Oh, okay. Ah, Representative Lim. Mm-hmm. Yeah, could... So I understand that the ankle-brachial index isn't covered. Is the annual foot exam covered under insurance? And if so, are, are, is it... I understand probably all of these are problems.

[2:20:58] Mm-hmm.

[2:20:58] But what's the severity, or let me use a different word. Are there a lot of high-risk patients with diabetes, I would know, that they're not getting diagnosed, but if they're guy- getting diagnosed, what is the reason that they're not getting the annual foot exams, the A1C moni- monitoring, the-

[2:21:14] Mm-hmm

[2:21:14] ... I'll call it the more basic therapies.

[2:21:17] Yeah. I think that probably, uh, in terms of the things that could be done for each patient and very low-cost things that could be done for each patient, um, the A1C monitoring is probably the one that has the highest penetrance, I would say. Um, the-

[2:21:30] Yeah

[2:21:30] ... in terms of an annual foot exam, uh, I think the burden on the provider has been who is supposed to do it.

[2:21:36] Oh.

[2:21:37] Right? Um, should it be the vascular surgeon? That's too late. When you're meeting me, that's too late, right? Um, if you ask, is it the podiatrist, do you have enough, uh, po- podiatrists in your location if you're in a rural location, whatever the case may be. Um, if it's a primary care physician, there's so... You're inundated with so many things, is that really appropriate to be, uh, placed on the block of that person? So, um, uh, right now, uh, there's no one who is really owning the, the podiatric foot exam exactly.

[2:22:02] It, I just quick- Is it... I understand we put a lot on PCPs.

[2:22:07] Mm-hmm.

[2:22:07] Is it your opinion that, that it- they would be capable of administering, uh, a foot exam?

[2:22:15] Oh, absolutely.

[2:22:16] Okay.

[2:22:16] Yes. Absolutely.

[2:22:18] Repre-

[2:22:18] Uh, not an ankle-brachial index, but a, but a foot exam.

[2:22:21] Sure. Yeah. Foot exam.

[2:22:21] Yes. Mm-hmm.

[2:22:21] Representative Davis.

[2:22:23] Um, I'm thinking of the fact that you said we're in the top five.

[2:22:27] Mm-hmm.

[2:22:28] Considering prevention and having the test, is the test expensive, so expensive that it, it wouldn't, uh, be worth us, you know, moving forward to have it covered? I mean, what could we save if we did the prevention as opposed to how we're doing it now?

[2:22:47] Mm-hmm. The test is not expensive. The test takes, uh, less than 15 minutes to perform as well. Um, mm-hmm. It is a, you know, a formal ankle-brachial index in a vascular lab. Uh, uh, you know, not every setting has a vascular lab. But a poor man's test ankle-brachial index is a manual blood pressure cuff and a Doppler machine.

[2:23:07] Wow. Yeah.

[2:23:08] Thank you.

[2:23:08] Mm-hmm.

[2:23:09] I want to thank you for being here today, and thank you for your testimony. And thank you, Andy, for providing this. This is very important. You know, we, we dealt with some legislation on peripheral arterial disease from Representative Douglas last year. I thought hopefully we can come back and look at that again, maybe get, get something done on this. Thank you very much.

[2:23:27] Mm-hmm. Thank you.

[2:23:28] I want to thank the committee for your time. I told you it'd be 4:00, and we're after 4:00 now. But we have some people out there that came that want to speak. So if y'all need to leave, I appreciate your commitment, but I'm gonna listen to some of these folks. So it's, it's up to y'all. Okay? APRN, I think you've been sitting there so patiently, and I appreciate that.

[2:23:51] Thank you.

[2:23:51] So would you introduce yourself? I don't think I have your name up here.

[2:23:54] Yes, yes. Um, good afternoon, Dr. Chairman and representatives. Thank you for staying. I appreciate you giving me the opportunity-

[2:24:03] Sure

[2:24:03] ... to speak.

[2:24:04] Sure.

[2:24:04] Uh, my name is Holly Hart. I'm a board-certified psychiatric nurse practitioner, small business owner, staff nurse practitioner in a pediatric emergency setting, an expectant mother hoping to raise my daughter in a state that welcomes healthcare professionals, encourages entrepreneurship, and expands access to care. I am deeply concerned that the proposed ownership restrictions would significantly worsen access to mental healthcare in Georgia.

[2:24:40] We all know it's already a problem. 90 Georgia counties do not have a psychiatrist. People wait months for care, and some never receive it, resulting in 30 to 40,000 suicide attempts annually with over 1,600 deaths in Georgia. That gap is where NP-owned practices step in. I started my career working in a physician-owned practice where nurse practitioners had to see two to three patients an hour.

[2:25:13] That practice has since been sold to private equity for millions. And I personally know three other Atlanta-based psychiatrists who sold their practices as well, fully staffed with nurse practitioners, to private equity. Each of those four physicians remain employed. They remain employees of the private equity firms that purchased those practices. This makes me question whether ownership status alone is truly what determines quality or patient safety.

[2:25:48] Today, I own my own practice where my patients receive three-hour evaluations and one-hour follow-ups. It grants me the time to collaborate with therapists, primary care providers, families, and my delegating psychiatrist. Many of my families, many of my patients have autism, trauma, chronic pain, and medical comorbidities. Many come to me after years of struggling to find care that gives them enough time to be fully understood.

[2:26:20] The medical board's executive director today said, Jason Jones, uh, that there are no talks of physicians being required to own our clinics. However, if physicians cannot be compensated for their services to collaborate with us, then they effectively must own our clinics

[2:26:45] Practice ownership allows me to prioritize quality over volume, in part because I am not influenced by the profits, by the profit motives of a third party. By imposing new physician ownership requirements instead of relying on customized collaborative agreements which the state has allowed for over 15 years, we're simply replacing one incentive structure with a worse incentive structure. I respectfully ask this committee to consider three simple questions.

[2:27:19] First, if the goal is to improve quality and protect patients in Georgia, what evidence suggests that requiring physician, physicians to be unpaid will achieve that outcome? Secondly, if I am legally licensed in Georgia by the law to diagnose a patient and prescribe them medication, as well as having the personal and professional legal liabilities associated with those actions, why am I not trusted to own the very practice in which that care is delivered?

[2:27:57] Does that distinction truly serve our patients? And finally, how is it fair and consistent if anyone in this state, even non-physicians in private equity, can own my clinic in entirety ex- and compensate physicians, except for me as the clinician? There may be sham agreements, yes, but those should be dealt with on a case-by-case basis.

[2:28:30] Sham ownership structures can occur just like sham ownership, uh, just like sham agreements. Georgia should not default to assuming that all compensated collaborative agreements are shams. And I do wanna mention they talked about third-party, uh, companies. Uh, prior to my current collaborative agreement, I worked with two physicians using a third-party agency, and they were not sham agreements, and I personally was able to get ahold of them anytime I needed to in order to collaborate.

[2:29:07] I also know many people who, um, who work with them currently with good collaboration. These restrictions will not expand access to care. They will reduce it and replace the current perceived problems with different problems. I'm asking you today to carefully consider the consequences of these policies. Our patients need more options, not fewer. Thank you.

[2:29:31] You have a question. And Representative Davis?

[2:29:39] I'm with you on this ownership. It, it's throwing me off because I'm thinking of an engineering company. A private individual can own an engineering company as long as a engineer holds a specific position in that company. And then I look at what you do.

[2:30:00] Mm-hmm.

[2:30:01] APRNs, on the other hand, even though they're actually-

[2:30:05] Mm-hmm

[2:30:05] ... within the profession, understand you're mi- you have a board that oversees how you operate.

[2:30:15] Yes.

[2:30:15] If you do something wrong, they could punish you or-

[2:30:18] Mm-hmm

[2:30:18] ... take your license on both sides-

[2:30:21] Mm-hmm

[2:30:21] ... right? The doctor and the nurses. So I'm, I'm trying to make sense of the argument on the ownership.

[2:30:30] Yeah.

[2:30:30] Is that the real thing that we're dealing with or is it something that we're not being told that is causing this crisis?

[2:30:39] So I, I have heard, I... Number one, the question was asked today if nurse practitioners are leaving Georgia, and I can answer that. They are. I personally know of nurse practitioners whose collaborative physicians do not want to continue working with them, and mine personally is very uncomfortable with the situation, and I have an established practice. And so she is willing to work with me now, but we have to resolve this because the physicians are not comfortable with it.

[2:31:15] To answer more of your question, physicians take the Hippocratic Oath, and shouldn't we trust them to make the right decisions in these situations? Because $750 a month or $1,000 a month seems like a small amount for them to be making decisions that would harm patients in supervising us.

[2:31:42] Does that answer your question?

[2:31:47] There, there-

[2:31:47] There's, I do think there's stuff not being said because I, that's why I clarified the ownership. There was something that we learned last week that-

[2:31:55] Mm-hmm

[2:31:55] ... you know, they said there's no talks of it going to a place where physicians have to have ownership, but they're also, they've also said that we cannot compensate a physician.

[2:32:07] Well, just a, a quick statement. I'm just uncomfortable with a rule possibly putting a large percentage of the businesses out of business when I don't know how many there are and how many patients they're ac- uh, a- are servicing.

[2:32:26] Yeah.

[2:32:26] So we, we really do need that data.

[2:32:29] And I can probably add some-

[2:32:30] Well, it, it's, uh, it is in... Excuse me. It is in code, and the code says it, it should be unlawful for a physician to be an employee of an advanced practice nurse alone or in combination with others. Um- I'm trying to stay out of this argument. I'm, I'm trying to be the, you know- ... balance everything. So, but I'm just saying it, it is in code right now. The question is how is that gonna be interpreted-

[2:32:57] Yeah

[2:32:58] ... by others, and that's gonna be something that we're gonna see in the future. That's the reason we're doing this today. And as we get into session, if this is not in the court, we're gon- we're gonna hear this again. Hopefully between now and then it can be worked out. But that, that is the point, and, and it has happened in other states, and I'm not even gonna get into the depth of that. But thank you, and I've still got some more people that have signed up.

[2:33:21] Thank you.

[2:33:21] Appreciate it. Um, is Tim Davis still here? Nope. Um, Robb? Is it R-O-B-B?

[2:33:34] Is that the last name?

[2:33:35] Yes, last name.

[2:33:37] Okay.

[2:33:37] Sorry. I, I can't quite read your handwriting on the, on the first name. Sorry.

[2:33:42] That's too bad. I should tell you I'm a doctor because the handwriting, but-

[2:33:45] Oh, okay. Thank you.

[2:33:48] Hi, everyone. Um, thank you all for staying. I'm Darcy Robb. I'm the executive director of the Georgia Council on Developmental Disabilities. We put together a bit of research and policy information, my staff and I did, so I wanna share that with you, and then I'll be very brief.

[2:34:26] Okay. So again, thank y'all for this opportunity. Georgia Council on Developmental Disabilities is an independent state agency. We are governed by a council of Georgians with intellectual and developmental disabilities, their family members, and select state agency representatives. And our mission is to make the kind of social and policy changes that will let Georgians with IDD and their families live li- live, lead, learn, work, play, and worship in their Georgia communities. The reason that I'm here today is because my members have been quite concerned about some of the conversations y'all have heard today, namely about the potential rate cuts, uh, as well as about the dental services.

[2:35:06] On the front page, you can see some data about the value of early intervention services. I'm not gonna go into that because you've heard a lot from some pediatric therapy providers today. Um, but I do wanna go into on the second page, which has some information about dental services with IDD. I think it's well known to all of us that oral health is a huge component of overall health. What's not as well known and what the research indicates is people with IDD experience disproportionately high unmet dental care needs, and that statistic that really caught my eye down there is midway down the page.

[2:35:38] Less than half of Georgians in the most recent year of data we could find, less than half of them had had a dental visit at all in the past year. Now, that's especially something to pay attention to because when preventive dental health goes untreated, that can lead to much bigger concerns further on down the line, and that also leads to a bigger cost investment on behalf of the state of Georgia. So I share this with you just because, uh, of a knowledge base, and we at our members were always concerned when folks may lose access to services.

[2:36:10] The last piece that I've attached there, since y'all clearly don't have enough to think about today, um, is we just wanna be mindful of working with you and with DCH as states need to make hard decisions in the coming year and the following years with implementation of the federal H.R.1 and of states needing to make difficult decisions about Medicaid cuts. We all know that the intent of these Medicaid cuts is not to hurt people with intellectual and developmental disabilities, but there's also a lot of hard decisions yet to be made. So I thank you for your time. I hope this information is helpful to you, and I encourage you to please use my team and I as resources in these policy discussions.

[2:36:46] Thank you.

[2:36:46] Thank you.

[2:36:47] Very good presentation. Appreciate that.

[2:36:48] Thank you.

[2:36:49] Yeah.

[2:36:49] Appreciate it.

[2:36:50] Okay. Let me see. I've got Tyler Adams. What?

[2:36:55] He's back

[2:37:03] there.

[2:37:03] Oh, okay. Is Tyler Adams here? Nope. How about Tim Davis?

[2:37:11] No.

[2:37:19] Sorry, you're out of time.

[2:37:22] I appreciate y'all. I'll certainly be brief. Uh, my name is Tim Davis. I'm the senior director of government affairs at the Georgia Nurses Association. Um, I appreciate the questions from the committee during the presentation. Um, you know, uh, another presenter alluded to the fact that we have, you know, 90 counties, 90 of our 159 that don't have a practicing psychiatrist. Um, I know y'all are aware of the stats that, you know, we have 18 that don't have a family medicine physician, 40 that don't have a physician practicing internal medicine, 65 that don't have a pediatrician, uh, over half, 82, that don't have a practicing OBGYN, and then 90 that don't have a, a psychiatrist.

[2:38:04] And I think as you all think through how to respond to what the Composite Medical Board is approaching from a regulatory standpoint, um, that if Georgia is married to the existence of the necessity for a protocol agreement, and I could talk until I'm blue in the, blue in the face about w- w- whether that needs to be or not, um, we should really be looking at things, uh, aimed at streamlining the process to obtaining one, um, incentivizing physicians to want to enter into one.

[2:38:37] Um, because ultimately when, um, regulatory barriers are, are put in place, the people who ultimately, um, suffer from that are Georgia patients, are the citizens of Georgia in these places that we would consider healthcare deserts. And so we want to empower our APRNs to practice to the extent of their education, their training, their certification nationally, and if a protocol agreement is a way that they can do that- For a person who needs a prescriber in a county with no physician, it's not a question of is the psych mental health NP on the bypass better than the psychiatrist that's in town, it's a question of is the psych mental health NP that's in my county better than no prescriber at all?

[2:39:25] And I think to the extent that we can empower nurses to be able to do that, um, it would behoove us to do so. And we've got some great ideas about how we can maybe streamline that process for nurses. Um, so I'd love to continue to collaborate with not only this committee, but the members of the general assembly and anybody who's interested in hearing a little bit more about it, and certainly grateful for your time today. Well, thank you. You know, I have looked into this a little bit and, and I am concerned that, uh, states that do have the APRN extensions and all and, and autonomy like Florida, uh, national average is 18% to 20% are practicing in rural areas.

[2:40:03] So I'd, I'd be interested in seeing those numbers go up- Mm-hmm ... and especially in our state b- before we, we, um, start down a new path. But anyway, I'm, I'm, like I said, I'm trying to stay out of this. Who was number five? Is that- Yeah ... Representative Levin. I have no problem not staying out of it. I would love to see, uh, w- I, I j- I'm still blown away by the, the comment by the composite board regarding, um, uh, again, having read the May 7 statement- Mm-hmm ...

[2:40:33] their definition of employee. Which I c- I, I can understand what they're going for, but then- Mm-hmm ... that seems a little bit inconsistent with the information they're collecting. And again, I don't wanna advocate for that 'cause I would assume that you don't necessarily want to report that. But I, i- my request would be, I would love to see what informatio- from like the user experience, what information and process you submit/go through in both, um, entering into an agreement and also in, in respect to making sure... I don't know what the enforcement is and the renewal is.

[2:41:04] Mm-hmm. But I would love to see what you actually provide and what the process is like because if the question is genuine clinical oversight, which I can certainly support, I think it's incumbent on us to ask, "Well, how are they determining that?" Mm-hmm. 'Cause obviously they're, you know, they might do a site visit here, there, I don't know, but it seems like most of it is from collecting that information upfront before approving an agreement. And so I think we would lo- I would love to see what the information is actually collected. We can certainly- Yeah ... you know, work with you and collaborate with you so that you have a full understanding of what it looks like.

[2:41:36] You know, we've been inundated at the Georgia Nurses Association, I know you, APRN, and also the Board of Nursing, from nurses who either can't get a protocol for whatever reason, already have one but are worried that their physician is now going to pull out because their licensing board is saying that they can't be compensated in any way, shape, or form. Um, but then also, you know, there's a number of APRNs who have pending protocol agreements who, um, feel like the rules and regulations that are being applied to say who gets approved and who doesn't, aren't standard across the board, and that's how it feels at least.

[2:42:15] So I'd ha- be happy to help you, help inform you of that process and some of the people and where they lie within it, for sure. And I think... Oh, Mr. Chair, for the record, uh, I wish Chairman Hatchett were still here. I think it would be weird if we didn't acknowledge what's been recently coming about, about the Georgia Composite Medical Board, and I'd, you know, I don't wanna get into that, but it seems to me that it would be incumbent upon us to maybe fund them more. Well, you know, we've been trying to do that. I know. We put it in the budget. I know on the House side. Yeah. We, we, it's been going in the budget, and Chair Lady Darlene Taylor has been excellent about working on that.

[2:42:49] I know on the House side we've been- I've got a chart of what we asked for and what we got. Yeah. When I c- like I said, we're not getting everything. That's why I want it on the record. Yeah. We can, we can be here till tomorrow. I think all of our regulatory- Yeah ... boards would benefit from some more resources- I think if Representative- ... for sure, certainly nursing. Yeah, thank you. Representative Davis? Uh, quick. Mm-hmm. Can you provide the information that the other people could not, like how many APRN-owned businesses they're speaking about? We can certainly try. I would've thought that the first place for you to get that information would be the people who are approving the protocols to give it to you.

[2:43:25] Um, we do know, uh, from a nursing perspective, how many nurses there are. Um, via re-licensure now, we have a survey that nurses have to submit in order to re-license, and in that survey we're collecting data about where they're practicing in the state and in what capacity. And so that information certainly will inform, um, some of those questions. Um, but, you know, it'll, it'll... Yeah, I, I, I can't speak for the Board of Nursing, but I think the boar- I don't, I don't believe the Board of Nursing has, you know, a list per se.

[2:43:59] Mm-hmm. But I can certainly endeavor to try to find one for you for sure. Well, you know, I, I noticed that the law continues by saying such conduct should be subject to the sanctions of the Georgia Board of Nurses as to advanced practice. Yeah. So it's in code. There are a lot of things in code that, um, we would like to highlight. For sure. Boy, now that is a long list of things. Right. That for sure. Thank you. Thank y'all so much. Listen, thank you for what you do. Ab- absolutely. I'm, I'm not being critical. I mean, I know this is a... Healthcare is evolving at such a rapid rate, and the healthcare that, that we can provide in rural counties where we're having problems getting healthcare people there is, is different than in, in, in the, in the, in the metropolitan areas, and even within the large cities.

[2:44:44] Mm-hmm. We still have some deserts, you know, where, where people are having a hard time getting healthcare. Yeah. I had a good story about a guy at my barbershop that can't get surgery 'cause the anesthesiologist wasn't there, but I just omitted that for- ... y'all's, uh- All right ... the sake of y'all's time. I appreciate y'all sticking by and paying attention. Yeah. And thank you so much for your work. Thank you. I got one more signed up. Roland, um, can't read the B-E-H-M, is that right? Is Roland still here? Nope. All right. Committee, thank you so much for hanging in here.

[2:45:15] You know, I've sort of broken my own rule about two hours, but there was so much here that I failed you. But thank you again, and thank you for b- sticking with us and all. Thank y'all very much. This committee is c-