Good morning, AARP Virginia supports HB1737, Del. Dawn Adams' bill to allow Nurse Practitioners to practice without a practice agreement after completion of two years of clinical practice. This is an important step in expanding the scope of practice for Nurse Practitioners. Please vote "yes" on this bill. Thank you.

The professional organizations preparing Advanced Practice Registered Nurses and Certified Midwives unwaveringly teach consultation and collaboration with MD's and other professionals as a standard of client care. NP, CNM, and CM's are all certified professionals who take an oath to do no harm. Malpractice insurance for a physician is steep and coverage of an additional provider (said professional currently required to have a written agreement with) is care-prohibitive.

Please allow Nurse Practitioners to function within the full scope of their education and licensure. They are trained to consult, collaborate and refer. This does not mean that they need a signed agreement giving "permission" to practice. Nurse Practitioners are the answer to high healthcare cost. Please let them practice without impediment. Story Jones, RN, CNM

I support these the bills and anything helping the public get care from nurse prescribers, especially certified nurse midwives. These providers offer excellent services and outcomes for less expense and should be promoted where possible. Certified nurse midwives will always work with OBs, but it's hard for them to find a competitor to sign off on their practices.

The Medical Society of Virginia ask the General Assembly to oppose HB 1737 and wait to address this issue in the 2022 session. Governor Northam reduced nurse practitioners’ required clinical experience for independent practice earlier this year via Executive Order 57. This was done in large part due to the perception from the Department of Health Professions and the Virginia Department of Health of a potential workforce shortage in the wake of COVID-19. As you are keenly aware, as EO 57 expired, Delegate Adams sponsored a budget amendment to reduce NP’s needed clinical experience and extended this change until the end of the Governor’s emergency order. As you consider HB 1737, it is also important to recall that Delegate Robinson’s 2018 legislation, HB 793, included a required report from DHP, the Board of Medicine, and the Board of Nursing to report “information related to the practice of nurse practitioners without a practice agreement that includes certain data, complaints and disciplinary actions, and recommended modifications to the provisions of this bill to the Chairmen of the House Committee on Health, Welfare and Institutions and the Senate Committee on Education and Health and the Chairman of the Joint Commission on Health Care by November 1, 2021.” Having adopted Delegate Adams’ budget amendment, the reduction of the required clinical experience for NP independent practice is already happening in Virginia. It will continue to happen as long as the COVID-19 pandemic continues in the Commonwealth. While we certainly hope the need for the emergency order ends soon, most public health experts believe COVID-19 will persist for another 9-12 months at the most optimistic projections. Given that NPs will be able to practice independently in Virginia with two years of experience for several more months, the undersigned do not see an immediate need for the code to be changed permanently in the 2021 session. Per Delegate Robinson’s HB 793, the General Assembly will receive a fuller picture of NP independent practice from the appropriate agencies next November. We humbly ask that the General Assembly wait for a complete reporting of NP independent practice in Virginia before making any permanent and lasting change.

Thank you for inviting me to testify regarding the licensure of nurse practitioners in Virginia. I am a professor of economics and director of the Knee Center for the Study of Occupational Regulation at Saint Francis University in Loretto, PA. I am also a senior affiliated scholar with the Mercatus Center at GMU. My research shows that permitting nurse practitioners to practice to the full extent of their specialized training after two years of experience improves patient access to care without increasing cost or sacrificing quality. Nurse practitioners are often restricted by state law from applying the skills that they have learned. But existing law should not tie their hands and unnecessarily delay them from practicing to the full extent of their potential. Virginia would not be going out on a limb by reducing this experience requirement. Its neighbor Maryland recognizes nurse practitioners as primary care providers with full practice autonomy after just 18 months of clinical experience. The District of Columbia grants nurse practitioners full practice autonomy immediately upon successful completion of the requirements for licensure. Research consistently shows that these restrictions on nurse practitioner scope of practice result in longer patient driving times to receive primary care and reductions in the volume of care provided by nurse practitioners. In addition, researchers consistently find that nurse practitioners are more than capable of providing quality care to patients. In my own research examining how changes to nurse practitioner scope of practice affect Medicaid patients, my colleagues and I find evidence that permitting nurse practitioners to practice autonomously is associated with patients receiving more care without increasing cost. However, our research suggests that the positive effects of granting nurse practitioners autonomy are fully realized only when they are granted full practice authority. These effects are quite large—we estimate an 8 percent increase in the amount of care that Medicaid patients receive once nurse practitioners are granted autonomy and full practice authority. Research continues to demonstrate that nurse practitioners are more than capable of providing sorely needed high-quality primary care. Allowing nurse practitioners to practice autonomously after two years of clinical experience is a commonsense reform. Virginia would not be unique; rather, the Commonwealth would be bringing policy closer in line with other states and taking steps necessary to ensure that citizens receive the care that they need. Ed Timmons 1 Donna Felber Neff et al., “The Impact of Nurse Practitioner Regulations on Population Access to Care,” Nursing Outlook 66, no. 4 (2018): 379–85. 2 Yong-Fang Kuo et al., “States with the Least Restrictive Regulations Experiences the Largest Increase in Patients Seen by Nurse Practitioners,” Health Affairs 32, no. 7 (2013): 1236–43. 3 E. Kathleen Adams and Sara Markowitz, “Improving Efficiency in the Health-Care System: Removing Anticompetitive Barriers for Advanced Practice Registered Nurses and Physician Assistants (Policy Proposal No. 2018-08, Brookings Institution, Washington, DC, June 2018), 13. 4 Lusine Poghosyan et al., “The Economic Impact of the Expansion of Nurse Practitioner Scope of Practice for Medicaid,” Journal of Nursing Regulation 10, no. 1 (2019): 1–6.

The National Practitioner Data Bank was established under Title IV of Public Law 99-660, the “Health Care Quality Improvement Act of 1986.” NPDB is an information clearinghouse to collect and release information related to the professional competence and conduct of physicians, dentists, nurses, and other health care practitioners. In 1996, Congress created a second data bank, the Healthcare Integrity and Protection Data Bank (HIPDB), to receive and disclose certain final adverse actions against health care practitioners, providers, and suppliers (Health Insurance Portability and Accountability Act of 1996, 1996). On May 6, 2013, the NPDB and the HIPDB merged into one database, taking the name of the NPDB. Section 6403 of The Patient Protection and Affordable Care Act (2010). The goal was to eliminate duplication between the NPDB and the HIPDB. Under Virginia law, adverse incident data is collected on all practitioners licensed to practice under Title 29. Thus, adverse action and medical malpractice information is collected on physicians, MD and DO, and advanced practice nurses regulated through title 29, which includes nurse anesthetists, nurse midwives, and nurse practitioners. Using the real-time data and the data analysis tool on the NPDB website, one can pull state-specific and provider-specific information. Using these tools, I requested information from 2015 to 2020 on Virginia health providers. Please noted that the NPDB uploads data quarterly. And, these reports reflect data transmitted to the NPDB as of September 2020. On adverse incidents, the data reported in on Virginia health providers is follows: 2015 2016 2017 2018 2019 2020 TOTAL ADVANCED PRACTICE 16 14 30 26 15 10 111 PHYSICIANS (MD) 185 173 151 123 179 132 943 PHYSICIANS (DO) 14 13 17 19 11 19 93 Adverse Action as defined by the NPDB includes (1) An action taken against a practitioner's clinical privileges or medical staff membership in a health care organization, (2) a licensure disciplinary action, (3) a Medicare/Medicaid Exclusion action, or (4) any other adjudicated action. The medical malpractice reports on Virginia health providers is as follows: 2015 2016 2017 2018 2019 2020 TOTAL ADVANCED PRACTICE 7 8 7 9 9 1 41 PHYSICIANS (MD) 104 82 103 101 104 48 542 PHYSICIANS (DO) 10 8 7 5 5 3 38 Even with the bundling of nurse practitioners with nurse anesthetists and nurse midwives, the data clearly reflects the quality and safety of nurse practitioners.

Dear Dr. Adams and Committee, I am a practicing physician of 49 years. I have been privileged to be a member of the Maryland Board of physician for 4 years. I have worked collaboratively with Nurse Practitioners for over the last ten years. I have valued them as fine team members. I have seen their many limitations, not due to lack of intellect, but due to lack of knowledge required of someone who has not had the 4 years education of medical school and a full residency. I believe 2 years “experience” with supervision that may be off site and very limited is insufficient. Their required license maintenance of 15 any type CME is substandard to that of physician required 60 very specific CME credits. Yet they want to practice the same level of medical care. This is neither fair to them nor the patients they serve. To say the poor or rural need care is true. I have worked in Southwest Virginia. These patients are entitled to the best of care. I reference an article in the Online Journal of Issues in Nursing April 2014 which discusses not just Nurse Practitioner education and training but collaboration as part of a team with physicians. Also necessary is learning from experience and one’s mistakes. I have supervised wonderful conscientious NPs. I regret to say I have seen some horrible errors in judgment. I will not sign off on any case without seeing the patient – no matter how brief. I make myself available to be interrupted at any time for consultation so as not to hold up the NP. Example: 70 year old diabetic – NP texted me – his infected leg was no better on 2 weeks of ampicillin. What antibiotic should he be changed to? She gave me no further information. It turned out he was a badly controlled diabetic, on kidney dialysis, hypertension not well controlled, and a host of other problems. The leg wound was deep about 15 inches long by 5 in wide and “ugly”. I arranged for an Emergency admission and intravenous antibiotics as well as other care. This was a fine NP who didn’t recognize the significance of all these factors. The patient would have lost his leg or life if I approved just a different antibiotic. Case # 2: Mother of baby called Nurse Practitioner stating baby lethargic and not eating. NP said to try to push fluids. Mother called several more times reporting baby getting worse. The mother was continually told try to give a bottle and watch baby. Baby died at home of undiagnosed diabetes. I was the case reviewer. I am sure you are aware there is a mandated study coming out in November on this issue which will provide more information. No matter what our field, a NP with fine credentials as Dr. Adams has, members of the legislature, consultants as some of you are, a physician as I am; when we look back we see that 2 years is just the beginning of our learning. To this day I seek contemporaneous advice, knowledge, and guidance on many issues from colleagues, others, and thru research as I have done for this hearing. I am sure you all do the same. Even one physician supervising 6 NPs and after the fact although allowed by law saddens me. Please defend the integrity of the NP profession by requiring more training before they are totally independent in their practice and oppose this bill. Thank you for your consideration. Carol L. Bender, M.D.

HB 1731 - opposed Delegate Dawn Adams, Chair 1. For past 3 years I have served as a physician supervisor of NP Faculty Clinic with Radford University Carilion. I have worked with NPs since 1987. 2. I have directly observed NP faculty training NP students. What has surprised me is the lack of knowledge/clinical experience of some of the NP faculty and students compared to physician faculty and physician trainees. 3. There appears to be a low set of standards for NP faculty compared to MD faculty required by are accreditation boards which makes me concerned on a graduates’ level of competence. 4. I have seen many NPs take additional training such as DNP since they recognized completing an NP program is inadequate to care for patients/practicing medicine. 5. There is currently a NP study that is due in November this year. I would recommend tabling this bill to next year until it is completed. To pass this bill creates mistrust of the agreement from last year. Roger Hofford, M.D. Past President, Virginia Academy of Family Physicians

I am currently enrolled in AGNP program and I can assure you my education and training will fully support me and our community with safe patient care outcomes. Once I complete my graduate degree, I would like to practice to the fullest extent of my licensure and certification. Please support this legislation. Per the Nurse Journal (2021). A nursing shortage has led to nurses working long hours with inadequate nurse-to-patient ratios, Weatherspoon says. This can lead to nurse burnout and lower-quality care. people now call for greater healthcare measures, such as the universal healthcare system proposed by the Medicare for All bill, that would provide health insurance for all Americans. “While this sounds good, it may escalate the nursing and physician shortage,” Weatherspoon warns. In the case of Medicare for All, more people would likely take advantage of preventive care, which is often the responsibility of nurses. In addition, more RNs may pursue a bachelor’s degree or an advanced degree to become an NP. This all leads to an industry that will require more nurse educators, according to Sullivan. https://nursejournal.org/resources/affordable-care-act-nursing-guide/#how-nurses-can-shape-healthcare-reforms

Hello, I write as a third time mother, having just experienced a wonderful home birth under the care of Kelly Siccoli, CNM and her assistant during the pandemic. My first two babies were born at Sentara Martha Jefferson Hospital under the care of two different OB/GYN practices. The first birth experience was one I remember fondly but I lost two babies after this birth and needed to be seen by a high risk OB for future pregnancies, at least during the first trimester. Unfortunately, my second birth experience was traumatic due to unprofessional treatment by the attending OB, who is no longer a practicing OB and has had a couple mal practice cases brought against her. She was not my primary OB but as many women know, most OB practices are LARGE and women rarely have any choice or say in who is there when the baby decides to come, leaving them with providers they may not feel comfortable with during one of the most vulnerable times of anyone's life. I began my fifth pregnancy (third child) under the care of the same high risk OB practice (only one that delivers at the hospital) that delivered my second child. Then COVID hit. At the time, some hospitals were not allowing fathers to be part of the birth. Several medical organizations recommended that newborn babies be separated from mothers immediately following birth until the mother had not one but two negative covid tests, and at that time, testing was limited and hard to come by. Further, the pandemic left me with no child care for my older children so I did not want to bring my baby into the world alone and at the mercy of the covid policy of the day. I began to explore the option of a home birth with a midwife during my 2nd trimester when I found Kelly but was still under concurrent care of my high risk OB. At my 20 week ultrasound, my OB saw that I had a low placenta, which would require a c-section if it did not move by 36 weeks. Kelly and my high risk OB stayed in close contact and coordinated my care seamlessly until at 30 weeks an ultrasound showed my placenta was resolved and a homebirth was recommended by the high risk OB. Thankfully, I was cleared to transfer my care over fully to Kelly because that OB ended up notifying me (in late June) that i would have to find a new provider since his practice was closing effective 7/31 (I was due on 8/4). Without Kelly, I would not have had any access to prenatal care for the last 10 weeks of my pregnancy as the only other OB practice that delivered at my hospital was 1. not accepting new patients and 2. the provider where i had lost my 2 previous babies. Kelly provided a level of care unlike anything experienced with an OB. She consulted and referred me to other providers as appropriate and needed. The US is lagging behind the rest of the world in maternal and fetal outcomes (some of the worst statistics of any developed nation) and I think allowing women more access and more choice in their prenatal care is critical in putting the US (and Virginia) closer to par with the rest of the world. Women's health is public health and should be everyone's concerns. Midwives, hand down, know women's health unlike any other provider. The midwifery model of care is one that needs expansion across our country and I would be happy to see Virginia lead the way.

To submit later

I oppose this bill on behalf of patient safety. For any medical practitioner, a "clinical apprenticeship," working under a supervisor, is instrumental for learning how to provide clinically appropriate care that is safe for patients. For M.D.s and D.O.s the minimum time for this is a three year residency plus two years of concentrated clinical time during medical school. The NP curriculum is frequently touted as being shorter, with less coursework and clinical time, than the MD/DO curriculum (and is frequently advertised as a reason to pursue an NP career). While this offers obvious benefits, it limits the ability to learn complex medical management, recognize less prevalent diseases, and, importantly, adequately practice providing clinical care in an environment that can catch mistakes. Without this experience, patient safety is at risk. At the very least, NP should be help to this same standard of five years. Additionally, the benefits of NPs are frequently touted as (1) providing more access to underserved communities and (2) providing more cost-effective care. However, the data in the state of Virginia has not yet been completed to show this benefit, while new studies are showing that independently practicing NPs can instead lead to more referrals and unnecessary testing. There is no benefit in rushing to independent practice. Doing so may not only lead to increased healthcare costs and appointment on an already strained healthcare system, but also jeopardize patient safety.

I am the current president of the Virginia Association of Clinical Nurse Specialists and am writing to support our nurse practitioner colleagues. Allowing advanced practice nurses to practice to their full extent of education and certification improves access to care for Virginia residents, improves quality outcomes, and reduces cost. I support HB1737 to decrease the amount of full-time clinical experience a nurse practitioner must have to be eligible to practice without a written or electronic practice agreement.

It is essential to address the demand for healthcare in a practical way - and these proposals are safe, evidence based, and needed. HB1987: Reimbursement for remote patient monitoring is proven to improve quality of care, lower readmissions, and lower travel and treatment costs. Remote patient monitoring is an essential benefit that allows patients to leave the hospital and get the same quality of care at home. For high risk pregnancies, it can cost as little as $26 a day to provide this service with higher convenience, better care, and keeps a hospital bed open for someone else who might need it more. Compare that to a $5,000 a day stay in the hospital with lower convenience, higher costs, and lower satisfaction. The Governor wisely removed reimbursement barriers to providers to offer this service to those suffering COVID-19 with great results. Virginians deserve access to this benefit and remote patient monitoring needs to be reimbursed immediately. HB1737: Nurse practitioners have safely served their communities with 2 years experience during the pandemic, and states across the country already allow for them to practice with the scope of practice with less restrictions that we have in Virginia. We need frontline healthcare workers practicing to their full capability and this reform achieves that safely. HB1747 / hb1817 : Enabling providers s to practice to their full capability is essential. Nurse practitioners deserve the opportunity be certified and practice according to their skills and education. This common-sense reform helps front line care providers to be more efficient and useful in serving in care deserts. In the same way, we should better leverage physician assistants in the field who could do more but are restricted by regulatory barriers. HB1769: Virginia law, unfortunately, puts walls between patients who are seeking care from licensed providers beyond our state lines. The commonwealth of Virginia does not care if a patient gets in the car and travels to another state to get treatment from an outstanding provider, but if a Virginia gets on the information highway, it can lead to criminal charges who is merely offering care to a Virginian in need of it. When the law was written, a phone was tethered to the kitchen wall. Today, our phones are supercomputers that can provide detailed healthcare information to a doctor in real-time. Our laws are still looking backwards in healthcare - not forward. Patient behavior is seeking better care with more convenience. This bill removes barriers between patients and providers across the country.

As a member of Virginia's physician community, I write in opposition to Delegate Adams's bill. I have held several leadership roles within the Medical Society of Virginia, and am currently the chair of the MSVPAC. There are several issues which arise with this legislation: 1) Required experience will be cut by more than half: Under current law, 5 years of full time collaborative practice is required for independent NP practice. For the average person, full time is 40 hours per week, translating to approximately 10,000 hours in a 5 year period. Physicians perform 12,000-15,000 hours of supervised patient care before autonomous practice. After 4 years of medical school, physicians receive specialty training in a required residency, which lasts between 3-8 years. NPs must first achieve their RN and enter a graduate-level program which can last between 2-4 years, with anywhere between 500-750 hours of patient care time during their required training. This is 1/16 of the required training of a physician. (See https://www.tafp.org/Media/Default/Downloads/advocacy/scope-education.pdf) 2) Existing data shows that increased independence does not increase patient access to care. More data is forthcoming, which can guide us on this issue: A study by the Department of Health Professions (DHP) is pending release in November 2021. The study was mandated after the passage of 2018’s HB 793, which required the Boards of Medicine and Nursing to report on: the number of NPs who have been authorized to practice without a practice agreement; the geographic and specialty areas in which NPs are practicing without a practice agreement; and any complaints or disciplinary actions taken against these NPs, along with recommended modifications to the act which would include recommendations on clinical experience. Regardless, NPs have not vastly moved to underserved areas, despite the fact that NPs may practice in underserved areas, even if their collaborating physician is not local. National data shows that the geographic distribution of NPs is not significantly different from that of physicians (see https://www.ahrq.gov/research/findings/factsheets/primary/pcwork3/index.html). In fact, underserved areas (whether they are rural or urban) should not need to settle for less comprehensive care. We should be doing more to help recruit and retain physician led care teams in these areas! 3) Governor Northam's Executive Order #57, which was put into effect in the spring of 2020, has temporarily suspended physician supervision requirements for NPs who already have at least 2 years of practice experience due to the pandemic state of emergency. A budget amendment by Delegate Adams in the Special Session extended this until the end of the state of emergency. In order to best use the commonwealth’s resources already put towards this issue, codifying this change in requirements for practice experience into the Virginia’s regulations should only be considered once we have the information which is forthcoming in the aforementioned DHP study. Thank you for your consideration.

I am for nurse practitioner to be able to practice without a doctor being there

Nurse practitioners are more qualified and more caring than most of the medical practitioners you deal with. They have the skills, the education and take time to hear their patients .

I support these bills that will give nurse midwives, certified midwives and nurse practitioners autonomy and authority in their respective practice.

Tying the NP/midwife to a doctor unfairly restricts access to providers who are credentialed and licensed to practice in the Commonwealth. The physicians are positioned to unreasonably limit or control access to more affordable health care options in low-risk scenarios because they may arbitrarily want to maintain economic superiority. Thank you for doing what is best for the patient.

Addressing topics for perspective is a form of growth.

Support the Bill

I used a CNM for my 3rd pregnancy and delivery. She was so professional and compassionate. She did everything my prior OB would have done for my care but provided an extra level of passion. I was very pleased with my experience using a CNM

My name is Akilah White I am a doula and home birth midwife assistant in Virginia Beach, VA. I serve birthing families in all of the Hampton Roads area. Currently there are very few home birth CNM’s in the area I serve. As a doula I welcome the collaborative works of midwives and doulas. In the community, birth doulas and midwives working together only enhances quality of care and is greatly beneficial to birthing families reducing health disparities. I believe CNM’s are competent and needed. I support VA HB 1817.

I fully support!

I am in full SUPPORT of HB1817. As a family nurse practitioner myself and also a patient of a certified nurse midwife, it is crucial that we pass HB1817 in order to not lose access to these exceptional providers. I had a home birth with my second child this past July and Kelly Sicoli was the CNM who provided my pre and postnatal care and attended the birth of my baby boy. She was extremely well-trained, highly educated and discerning. She appropriately collaborated with my previous providers (I switched to her care at 30 weeks) in addition to consulting other providers when needed. She swiftly referred me to pelvic floor PT post birth. Her bedside manner was incredible. She respects women was whole people, taking time and and energy to be thoughtful, caring and look beyond the surface. I am certain it was her confident, calm and gentle presence that played a huge role in how smoothly my birth went. We need providers like Kelly in order to care for women in a safe & evidence based way.

Will be available if technical questions . No position on bill

Dear Friends: I write in support of HB 1817 as a Certified Nurse-Midwife with over 35 years of clinical experience who has practiced in many states. As a native Virginian, I originally left the state to practice in Maryland and Pennsylvania due to restrictive issues with practice in my home state. Currently, I live and work in Virginia Beach for Sentara Health Care. The greatest and sometimes unspoken issue with CNMs' requirement for a contractual type agreement with a physician is the barrier it creates to independent practice. You may ask: "why do these Nurse-Midwives want independent practice? Do they think they are as competent as physicians?" Indeed, it has nothing to do with this reasoning. It has more to do with our ability to work in settings that are conducive to patient care. We do not want independent practice for financial reasons. We do not need independent practice for a kind of power or recognition. Certified Nurse-Midwives understand we will ALWAYS need physician colleagues for consultation, collaboration, and surgical intervention. This change will have no negative effect on safety and CNMs will not suddenly become renegades delivering babies in the wilderness without proper supplies! The bigger issue is the legal requirement of a signed agreement often means that physicians can control our practice from a fiscal and employment perspective. Our choice and ability to serve patients well, including those who may lack access to care, is determined by our employer. Many OB-Gyn practices limit the number of patients with Medical Assistance for fiscal reasons. Most OB practices will not see patients until insurance is active. These delays decrease access to OB care, especially for the most vulnerable patients. Unless we can practice independently and make these decisions ourselves, we are not able to make exceptions for patients who need care. Another important issue is that the necessity for a contract means that CNMs are evaluated, hired, and fired by physicians who control our ability to practice. I have been fired from jobs for disagreeing with the care a physician rendered in the event of a serious postpartum hemorrhage. Because she was my employer, I was tempted not to confront her about substandard care because I knew full well that if I did, I would lose my job and my ability to support my family. I did lose my job, by the way, because I confronted her. We are better providers if we function in a team with physicians, but necessarily as their employees. I am blessed to work for Sentara now where I feel free to care for patients with the best evidence-based care possible and to have a team of excellent physicians who support my role. Not all CNMs are as fortunate! I am also aware that the lobby against this bill advertise that this will make maternity care unsafe and before you know it those crazy midwives will be delivering everybody at home where babies are in danger." The majority of CNMs in Virginia (> 99%) function within hospitals and established offices. Very few do home birth I hope you will see through the hype of this argument. They are grasping at straws and using scare tactics. Thank you for your consideration and I urge you to pass this bill, HB1817, for the benefit of women and infants in our great state! Beth Uzzle, CNM, MSN, RN Virginia Beach, VA

My name is Rebekah Antoine. I am a Doula and Masters in Public Health student. I also work with the Southern Birth Justice Network and National Black Midwives Alliance. Above all I am a black mom and black pregnant woman living in Norfolk, Va. I am currently seeking Midwifery care and facing difficulties finding Midwives that look like myself. As a black woman who has to face many disparities and inequities, it is important to have a birth team that looks like me that includes my Doula and my Midwife. Both are essential to my birth team and work together. The reason why I am seeking Midwifery care is because their model of care focuses on community, holistic and women-centered/individualistic care which will help myself and my baby have better pregnancy and birth outcomes. The HB1817 bill will increase my birthing options and reduce the barriers to access to care for women that look like me.

My name is Rebekah Antoine. I am a Doula, Masters in Public Health student. I also work with the Southern Birth Justice Network and National Black Midwives Alliance. Above all I am a black mom and black pregnant woman living in Norfolk, Va. I am currently seeking Midwifery care and facing difficulties finding Midwives that look like myself. As a black woman who has to face many disparities and inequities, it is important to have a birth team that looks like me that includes my Doula and my Midwife. Both are essential to my birth team and work together. The reason why I am seeking Midwifery care is because their model of care focuses on community, holistic and women-centered/individualistic care which will help me have better pregnancy and birth outcomes for myself and my baby. The HB1817 bill will increase my birthing options and reduce the barriers to access to care for women that look like me. 

Dear delegate Adams, My name is Halima Barqadle and I am a certified Nurse Midwife currently practicing in Virginia. I started my midwifery career in Washington DC where midwives have independent practice. I cared for my patients throughout their pregnancy during labor and delivery and for any women’s health issues they had. I consulted and collaborated with my Obstetrician Gynecologist colleagues as needed. This was not due to any written agreement but because that is what my patients needed to get the best care possible and what is required of me within my scope of practice and the standards of practice set by the American College of Nurse Midwives. Many of my patients traveled from various areas in Virginia because they were seeking midwifery care. Women and birthing people may not always have a choice in where or how they birth due to their geographical locations. Approximately 50% of counties in Virginia do not have a maternal child health provider and families living in these areas need to travel to get care. This forces them to endure long wait times or failure to receive adequate care before, during, and after pregnancy. I remember a patient of mine who delivered en route to the hospital because she lived about an hour away and was coming from Virginia to deliver in DC. It is imperative that certified nurse midwives are able to practice within their full scope, this will improve outcomes and increase access to maternity care providers. I have chosen to work and care for women and families in this great state of Virginia which has always been my home and hope bill H.B. 1817 will pass.

Allowing CNMs broader access has been shown to improve maternal perinatal outcomes. Please support CNMs!

In the COVID era especially, I think it is essential for healthy women to have the ability to opt for midwifery care/home birth. I was very blessed to deliver my baby at home this year and avoid possibly contracting the virus in a highly traffic hospital. Requiring midwife's to have the written signature from an OB, who is 'okay' with adding to their competition seems a bit like an oxymoron. Let's equip midwifes to give the best care, and then let's let women have the final say over their care providers

I come from a family of physicians, and I am proud to call myself a nurse, belonging to the most trusted of professions. I started my training as a maternal and infant care provider as a doula, I then apprenticed for a year as a homebirth midwife while seeking to become a Certified Professional Midwife. Recognizing the difficulty in finding willing physicians to consult while operating outside the medical institution, I intentionally went to nursing school, became a registered nurse and finally a Certified Nurse Midwife because I believed so strongly that I needed to become part of the medical institution, so I could build relationships in order to consult, collaborate, and refer when necessary with my physician colleagues. I could have chosen to be a homebirth midwife at many different points along the way, but I chose to work within the medical institution because it helped me to create those valued professional relationships. Many midwives choose to remain in the institution setting because of the resources available to them, there. The idea that once we would be released from a requirement to maintain a formal consultation agreement we would leave the institutional setting and open a homebirth practice is highly unlikely because there is little incentive to do so. Practicing homebirth offers neither financial reward nor job security. It absolutely ensures poor work/life balance, as a midwife is almost always on call and has few if any other practitioners to share the patient load, unlike in larger, institution based practices. While I am operating outside the institution and have a private practice, I sought work/life balance through regular office hours and seeing patients throughout Virginia via telehealth. My practice is built to create more collaboration between midwives and physicians, not less. My practice is built to address gaps in care for maternal mental health as well as access to a higher level of care in a timely manner via telehealth. As a Certified Nurse Midwife and autonomous practitioner, I am in the business of creating safety through collaboration, working to the full extent of my scope of practice, and addressing gaps in care for the welfare of women and families in Virginia. I urge you to support better access to qualified healthcare practitioners by removing redundant requirements of written consultation agreements for Certified Nurse Midwives.

As someone who documents and researches the implication of pregnancy care, birth, and postpartum for a living, I cannot stress enough how midwives are the future of maternal care in the US and beyond. Their focus on low-risk pregnancies and in-depth knowledge of the history and science of unmedicated birth is absolutely fundamental in increasing the quality of care as well as lowering the mortality rate, which is at an all-time high in this country. CNMs will always work in consultation/collaboration with OBs. It is a clear aspect of our training and scope of practice. The way things are set now does not reflect the collaborative reality of their complementary sets of care. Requiring OBs to sign an agreement for their "competition" has obvious flaws. CNM will never replace OBs, but OBs cannot, in all honestly, perform and offer the same quality and level of care CNM offer. Please consider, in the interest of all birthing people from various demographics, passing this bill that will be lifesaving.

I support HB1817. I am a CNM in a group CNM practice in NoVA/DC/MD providing well woman exams, birth control, STI screening, and care for healthy pregnancies. Our birth center/home birth practice, BirthCare & Women’s Health, has a much lower neonatal mortality rate (1.8 per 1000 live births) compared with the national rate for all provider types and settings (3.8 per 1000 live births). Our rate of cesarean births for normal, full term pregnancies is a fraction of the national rate (5.5% BirthCare over 30 years versus 25.6% in US in 2019). We achieve excellent outcomes with attentive, holistic care. The requirement for a written consultation agreement does not improve upon the CNM model of care, it just limits where and with whose permission CNM businesses can open. There is an unsubstantiated fear that CNMs would forego physician consultation if the law did not mandate it. This has already been proven false in the 28 states that allow unobstructed practice. CNMs are well aware of the extent of our expertise. Our certifying body, AMCB, defines our scope, and to practice outside of it would jeopardize one’s license and certification. There are opponents who would argue that the current law does not truly limit access to care for Virginians. Consider the following hypothetical scenarios contrasting the adoption of HB1817 (A) versus the status quo (B). Scenario A: I move to a new area and establish a midwifery practice. New client Jane comes to me for a well woman visit, and I find a thyroid disorder. I refer her to Dr. E. It’s simple to refer and doesn't require any prior written agreement. I call and introduce myself to Dr. E and set up an appointment for Jane. Later she becomes pregnant and wants to see me for prenatal care. I collaborate with Dr. E as the pregnancy progresses, to ensure Jane maintains optimal thyroid levels. Now that Dr. E and I have a professional relationship, we continue to consult each other as needed. Scenario B: I move to a new area. I am not allowed to do the job I am qualified to do, unless a physician signs onto a written agreement to consult with me. Since Dr. E is not an OB/gyn, she doesn’t sign on. There is no local OB/gyn physician. Jane doesn’t have an annual well woman exam. Her thyroid disorder remains undiagnosed and worsens prior to conception, putting her at risk for pregnancy complications. There are 59 counties in VA with no OB/gyn, and more still with no CNM. This includes Amelia County, where my extended family lives. Health conditions don’t simply disappear when there is no one in the vicinity with the expertise to screen for them. None of my grandma’s physicians knew that the “sore” she had beneath her breast that just wouldn’t go away was actually breast cancer. I knew the moment I saw it, while I was visiting her in the hospital when she had back surgery in November 2019. She was discharged into assisted living from that hospital without receiving the breast imaging I had urged her hospital physician to order. It took two months more for her physician-led outpatient care team to get her the imaging that finally confirmed the diagnosis. We lost her in May, after months without being able to see her due to COVID-19 restrictions. HB1817 won’t undo the missed and delayed diagnoses that have resulted from maternity and gynecology provider shortages, but it will open the possibility for CNMs to start practices where they are needed most. Tana McCoull, CNM, FNP, Arlington VA

The professional organizations preparing Advanced Practice Registered Nurses and Certified Midwives unwaveringly teach consultation and collaboration with MD's and other professionals as a standard of client care. NP, CNM, and CM's are all certified professionals who take an oath to do no harm. Malpractice insurance for a physician is steep and coverage of an additional provider (said professional currently required to have a written agreement with) is care-prohibitive.

I am in favor of HB1817. Current laws require CNMs to practice with a signed practice agreement with a doctor. this is a hurdle to practice for MANY midwives (leading to a shortage of CNM-owned practices both in and out of the hospital). CNMs will ALWAYS work in consultation/collaboration with OBs. It is a clear aspect of training and scope of practice. However, requiring OBs to sign an agreement for their "competition" has obvious flaws.

I would support CNMs being able to practice without the written consent of an OB as it seems clear that they consult with OBs as necessary. I support HB 1817.

Certified nurse midwives provide much-needed care in many areas, especially rural areas. They bring safe and affordable care to those who may not have it. They are specially trained birth professionals that work in collaboration with obstetricians as a normal scope of practice. They are fully qualified to practice independently and should not need a collaborative agreement with a physician. This should be seen as a conflict of interest, as midwives serve the same community as the obstetrician. Certified nurse midwives need to be utilized to their fullest extent to allow for safe and cost-effective care. Not only do they provide birth services, they provide primary care for the woman across nearly her entire life span. The certified nurse midwife Please any central role in the healthcare of our population. It is said that the health of a mother and her children can directly measure the health of the next generation. Certified nurse midwives need the autonomy to practice independently without physician collaboration agreement.

There are 70 counties in VA that have no OB providers at all. This is a huge barrier for women to obtain prenatal care, which means they either may not establish care at all or late and/or may have to travel far distances to see a provider. Having qualified and certified midwives in these instances will help decrease neonatal morbidity and improve maternal care

Please support HB1817 so our wonderful and capable certified nurse midwives can practice without the need for partnering OBs to declare them competition and so midwives may continue to meet the needs of women and babies. Thank you.

I work with 3 OBGYNs and therefore this bill does not directly affect my current ability to provide care to women. Nor does it affect my employment. However, my OBGYNs do provide back-up services to several of the area CNMs, CMs, and CPMs. None of these area midwives have paid my OBGYNs a fee to maintain a practice agreement. Why is that? Because it is unnecessary. Because any professional refers a patient who is out of their comfort zone to another professional - one who has more expertise. This is no different than an OBGYN referring to a Maternal Fetal Medicine specialist to manage a fetal disorder, or a hematologist to manage a patient with an inherited clotting disorder. Patients are referred to specialists out of clinical need for another level of care. Not because of a signature on a piece of paper (which for some reason usually involves money - otherwise known as a bribe). Even though we do not have practice agreements with several of the area midwives (who must have practice agreements with other OBGYNs), they still bring patients to us. We provide the quality care that they expect for their beloved clientele. We earn the trust of the patients and the midwives. No one is beholden to some piece of paper. I would go as far as saying that OBGYNs should refer normal pregnant and laboring women to midwives! Wouldn't it be something if every OBGYN was required to maintain an agreement with a midwife? Someone to send patients to who were NORMAL. So they could get pregnancy and birth care that would not set them up for surgical birth, or complications from lying on their backs in labor for 20 hours. (Both of which set a woman up for a dangerous blood clot). Someone who would keep them from getting an infection in their amniotic fluid if their water broke too early. An infection is a big deal: often meaning a baby is admitted to a NICU and a mom is at risk for complications in the early weeks postpartum. The best way to take care of all the women in Virginia is to let the patients choose who they want to see for well-woman, pregnancy, birth, and post part care. Let the free market dictate the results - everyone should have a choice of family doctor, midwife, or OBGYN. Let the safety statistics and outcomes speak for themselves. Let the professional organizations continue to oversee the quality metrics. Midwives will continue to send women with any complications to the OBGYNs who are skilled in managing those complications. In the meantime, remove the barriers to this excellent midwifery care for normal families.

My name is Martha Weaver. I am a certified nurse-midwife practicing since 1985 in Northern Virginia, Washington, DC and Maryland and I am writing in support of HB 1817. I work at BirthCare and Women’s Health, a private free standing birth center, home birth and well-woman service that provides obstetrical and gynecological care to healthy women through their childbearing years and beyond. It is located at 1501 King Street, Alexandria, Virginia 22314. BirthCare is a business that opened in 1987 and has been providing prenatal and postpartum care, delivering babies, and practicing well-woman gynecology for the last 33 years. Our owner, Marsha Jackson, is a black nurse-midwife with 40 years of experience leading midwifery practice and establishing excellent standards for out-of-hospital obstetrical care and birth in the Washington, DC Metro area. As a Black-owned business, BirthCare has assisted over 5700 families during their births and served thousands more with well-woman gynecological care. Approximately 25-30% of our clients are black families who benefit greatly from an individualized midwifery model of care which encourages client self-advocacy and provides close one-to-one monitoring and support during the prenatal, Intrapartum and postpartum periods. However, our practice has been restricted unduly by the Virginia Law that requires a signed consultation agreement with local obstetricians in the area. The current requirement for medical oversight in the form of a signed consultant agreement is unnecessary since our business already complies with the national practice requirements and standards set by the American Midwifery Certification Board (AMBC), the American College of Certified Nurse Midwives, and the Commission for the Accreditation of Birth Centers (CABC). Further, this requirement has placed an undue burden on our company when our medical consultants have faced personal health challenges or retirement that forced them to withdraw their services to BirthCare. Locating other consultants to fulfill this legal requirement has at times been a challenge and a barrier to practice which in turn, threatened to restrict access to care for mothers and babies in Virginia.

I support these the bills and anything helping the public get care from nurse prescribers, especially certified nurse midwives. These providers offer excellent services and outcomes for less expense and should be promoted where possible. Certified nurse midwives will always work with OBs, but it's hard for them to find a competitor to sign off on their practices.

I am a board certified OBGYN, in practice for more than 30 years. I have worked with Certified Nurse Midwives my entire career. My experience has been in multiple practice models. I have been privileged to work as an employer of CNMs as part of an integrated practice, as a Residency Faculty Women’s Health Director with CNMs providing the majority of the educational and clinical experience for Family Medicine Residents and as an independent OBGYN providing consultative services for CNM managed patients. I have worked with both new grads and 20 plus year veteran CNMs. My interactions have been overwhelmingly positive. CNMs and CMs are well trained consummate professionals. They provide the necessary care to our most vulnerable citizens. CNMs, all of the evidence supports, have proven to be able to bridge the health disparity chasm that exists in this country. To force these caring, compassionate and exceedingly competent women’s health care providers to form legal alliances which might prevent their ability to take care of these at -risk women makes no sense. In my community, our CNM run midwifery practice is legally and financially bound to a local MD – OBGYN practice. They cannot continue to provide care to the hundreds of women whom they currently serve without this arrangement. The passage of H.B. 1817 would allow these skilled and highly motivated professionals to provide much needed care to more of this severely underserved population here in Central Virginia. They would be able to care for patients from Farmville to Danville - an area sorely lacking in medical providers in general, and OBGYN care more specifically. Collaborative care and appropriate consultation is a fundamental part of what CNMs are taught. It does not require legislative mandate for this to occur. I fully endorse and support without reservation, the passage of H.B. 1817.

HB1817 will increase access to CNMs and offer women more options for birth care. It is not fair for CNMs to be required to have support from their “competition.”

Requiring OBs to sign off on work of someone who takes away business from them limits the public’s access to safe CMNs.

Please support HB 1817. Thank you

Thank you

My name is Karen Kelly, I am a graduate prepared, board-Certified Midwife. I live in Virginia and maintain my license in New York where Certified Midwives(CMs) and Certified Nurse-Midwives(CNMs) have Full Practice Authority, and no need for an unnecessary written practice agreement. Midwifery and medicine have overlapping but distinct education and training that reflects our different scopes of practice. The recognition of doctors and midwives as equal and complementary partners in reproductive health care requires respect for our relative fields of expertise and it makes no sense to tie the ability of the individual midwife to function within the health system to the inclination or availability of any one physician. Our education and competency standards follow rigorous national accreditation and validation. We must prove ourselves able to diagnose, manage, treat, consult and refer independently, prior to graduation and sitting for our boards. Passing HB1817 means CNMs will continue to practice identically to how they already do and as they were trained to do, according to our nationally recognized Standards of Practice and state regulations. Required written collaborative agreements limit the ability of midwives to serve areas already suffering from a shortage of obstetric care providers, while increasing costs that get passed along to patients and tax payers. States with full practice authority have approximately twice the workforce of midwives per 1,000 births than do states where CNM practice is more restricted. Given that over 50% of counties in Virgina do not have any maternity care, it is our responsibility to be doing everything we can to increase midwifery access. As recently published in the Lancet, “A substantial increase in midwifery coverage could avert 41% of maternal deaths, 39% of neonatal deaths, and 26% of stillbirths, whereas a modest increase in coverage could still avert 22% of maternal deaths, 23% of neonatal deaths, and 14% of stillbirths. The Department of Health and Human Services’ Action Plan to Improve Maternal Health in America encourages states to eliminate scope-of-practice barriers that prevent care being delivered by midwives. Full licensure increases the supply of women’s health care providers and improves Virginians’ access to high-quality maternal, gynecologic, and primary care especially in rural and underserved areas. Collaborative agreements affect, among other things, hospital privileges, third-party reimbursement, the ability to contract with telehealth providers and midwives’ desire for to move to Virginia in the first place, when better work environments exist in bordering states. As you know, Virginia has an increasing maternal and infant mortality crisis, with marked racial and ethnic disparities. One contributing factor to this crisis is the fragmentation of preconception, prenatal and postpartum care. Full Practice Authority for Certified Nurse-Midwives is a known, recommended solution to this fragmentation, by strengthening access to quality women’s health care, especially in those communities with least access. Thank you for your consideration on this important matter.

Hello, Forcing an OB to have an agreement with their "competition" has obvious dangers. Vote NO!

I believe we need to empower Certified Nurse Midwives to practice safely, and remove as many legislative hurdles as possible. By making it difficult for CNMs to practice, we are encouraging women to seek out the care of less-trained midwives. As a NICU nurse, I have seen more than my share of failed home births, and I would love to see more trained CNMs in practice and fewer lay midwives.

I would like to strongly urge you to support HB1817 to allow CNMs to practice without a written collaboration agreement with an OB. This severely restricts practice and further aggravates access to medical care for pregnant women. The reality is that CNMs will already consult with an OB for medical problems outside of their scope of practice (this is what they are trained to do). Requiring midwives to have a written agreement from the OB counterparts (who are also often their “competition”) often proves to be problematic.

Homebirths would save the U.S. millions of dollars each year. With CNMs, homebirths are usually the healthiest, best options for low-risk pregnancies. Make it more accessible to more women!

In favor of House Bill HB 1817. Current laws require CNMs to practice with a signed practice agreement with a doctor. This is a hurdle to practice for MANY midwives (leading to a shortage of CNM-owned practices both in and out of the hospital). CNMs will ALWAYS work in consultation/collaboration with OBs. It is a clear aspect of their training and scope of practice. However, requiring OBs to sign an agreement for their "competition" has obvious flaws.

The current requirement for Certified Nurse Midwives to have a signed physician agreement results in 1) Decreased safety for women2) Restriction of trade3) Higher cost for maternity care for all women including uninsured. HB1817 would reverse these problems. Increased safety: Certified Nurse Midwives are an essential part of maternity care for many low risk women.  Women who are not sick are best served by these providers, resulting in better outcomes (breastfeeding rates, vaginal birth rates, higher satisfaction with care).  Many other developed countries with maternal and neonatal outcomes far exceeding ours use midwives for all of their low-risk care and OBs for high risk care.  When fewer CNMs are available, more women are subject to choosing between high intervention (expensive and potentially dangerous) care or unattended births. CNMs able to practice within the full scope of our license: Requiring "permission" to practice from competitors is not something that would be acceptable within any other field.  It would be considered a restriction of trade.  For example: We know that primary care doctors are not experts in every field and that if the need arises they will need to consult with specialists (cardiologists, psychiatrists, etc).  However, we would never expect the specialists to give permission to the PCP to practice.  Similarly, all CNMs acknowledge the need for OBs in their capacities as surgeons and as specialists in maternal disease.  We have become CNMs because we want to maintain our specialty in low-risk, normal pregnancy and birth and are happy to refer as appropriate for any of the many problems we are skilled at identifying.  We have bachelors degrees in Nursing and masters degrees in Midwifery.  Our educational and license requirements mirror those of Nurse Practitioners. Physicians are happy to receive referrals from midwives, but requiring them to sign a "practice agreement" gives them the false sense of liability and the opportunity to eliminate competition. Lower Cost: The type of low-intervention care that midwives offer both in and out of the hospital provide the lowest-cost care with the best outcomes.  Obstetrics is known to be a field in which increasing cost does not lead to improved outcomes in the low-risk population, however overuse of diagnostics, induction, and surgical deliveries at the expense of lower face-to-face care, listening and education account for much of the contradictory outcomes.   Please support HB 1817 to allow CNMs to serve all low-risk women who wish to have this kind of care.  Eliminating the signed practice agreement requirement in no way changes the need or ability to consult, refer, or transfer clients as appropriate.  This is how we have been trained.  Our clients' safety is our job.  Our pride and job satisfaction come from our ability to deliver cost effective care with excellent outcomes.  We will always need OBs to be a part of our care plan for those cases that warrant it, but asking for a signed practice agreement eliminates midwives thereby decreasing safety and increasing cost for women and their families. Story Jones, CNM 703-534-0373

My name is Yanna Spellman, a Full Spectrum Doula and Certified Lactation Counselor. I am in favor of HB1817. I believe this should pass because it will give more options to the families I serve. One hundred percent of my clients are Black families. They need options to birth where they feel safe and with CNMs who give more intimate care.

Support HB1817. I am a retired Certified Nurse Midwife (CNM). Please vote for this bill; for the removal of a huge barrier to CNM practice; that of the requirement for a signed consultation with an MD. The Certified Nurse Midwife is a fully licensed and certified provider of care who is able to practice independently by virtue of training and certification. There is an immediate and critical need for CNM services in the Commonwealth and the CNM has been shown repeatedly to be a safe, affordable and satisfying provider of obstetric and gynecological services. Consultation with an OB/GYN MD is a routine part of providing safe and effective care; however, requesting a signed agreement creates an unnecessary burden on both maternal health care providers. I urge the House to vote in favor of removing the signed agreement requirement to increase access to safe and effective maternity care in the Commonwealth. Thank you. Sincerely, Deborah Meslar-Little, NP, CNM

My name is Patti Mojzak, CNM, WHNP. I am writing in support of HB 1817; I believe we can achieve improved outcomes for women and babies in Virginia if CNMs are given the freedom to practice independently. The notion that without the agreement we midwives would practice outside of our scope and not consult or collaborate appropriately is absurd. I consult and collaborate with physicians not because a written agreement somewhere says I should, but because in some cases it is appropriate and necessary to deliver excellent care to my patients. My top priority is always my patients’ safety. Independent practice for CNMs is not a brand new idea. It has been implemented in many states and there is no evidence that outcomes have suffered. Please pass HB 1817, and make it easier for the women of Virginia to access evidence based ObGyn care.

Madam chair and members of the sub-committee, I have been a midwife client 4 times, a midwife‘s assistant, a doula for home and hospital births, and recently was involved in hiring a midwife for my first grandchild. We chose a Certified Nurse Midwife because of her excellent education, training, and safety record. We were highly satisfied with the professional and personalized care our family received from the CNM. Her care was thorough, attentive to detail, and safe. I have since been surprised to learn that CNMs in Virginia are required to have a signed agreement with a physician in order to practice, even though they don't need this in 28 other states. I am concerned that other families may not have access to a CNM because of the barrier, which is a restraint of trade, and does not improve safety.  Please support HB 1817 and remove this barrier to CNM practice, so they may continue to serve mothers and babies in the Commonwealth. Respectfully, Bunny Patterson

Madam Chairman and the members of the subcommittee my name is Nichole Wardlaw and I am a Certified Nurse Midwife speaking in favor of HB1817 which will grant Certified Nurse Midwives full practice authority in the commonwealth of Virginia. As a midwife with 15 years of experience and trained at the Medical University of SC I have chosen to work in communities of color where my presence has been more effective. While doing this work I realized that I had to be the change that I wanted to see and the only way to do that is to work on policy that would allow myself and my colleagues to work to the full scope of our training and education thus my current role as the legislative chair of the Virginia Affiliate of the ACNM. These policy changes include being able to practice to my full ability without a piece of paper that tells me to do what I do already: consult, collaborate and refer as needed. Right now we are in a maternal health crisis. The CDC reports that African American women are three times as likely to die in childbirth as their white counterparts. That increases to five times as high when college educated. In Virginia African American women are twice as likely to die in childbirth. For me this is personal and speaks to my community, my families and my daughters. Historically the narrative of safety and need for tighter regulations of midwives is what has caused this maternal crisis especially within the black and brown communities. The evidence shows that midwives have better outcomes. The midwifery integration scores study reports that midwives when integrated into maternal health systems there is a reduction in cesarean rates, low birth weight and premature babies and maternal mortality and morbidity. This I knew but the most relevant finding in this study was the reduction of the gap between black and white women in maternal mortality and morbidity as well as the other measures/outcomes stated. In other words, the disparity was no longer present. The HHS action plan for maternal health that was just completed is significant in its finding regarding racial disparities and access to care. Increasing the maternal workforce, specifically midwives and doulas, are a priority in addressing these issues. Midwives can help address the shortage of maternity and reproductive health service providers and improve preventable maternal deaths and morbidity. Decades of research and hundreds of studies have documented that care by Certified Nurse-Midwives (CNMs) and Certified Midwives (CMs) is safe and the most prudent use of increasingly scarce resources. We keep talking the problem but what are we doing about the solution. We can no longer keep doing the same things and expect different results. Let us pass HB1817 so that Certified Nurse Midwives can practice to our full potential and actively participate in the solution while changing the outcomes for the better. In conclusion I thank you for your time and leave you with this quote “Change will not come if we wait for some other person, or if we wait for some other time. We are the ones we’ve been waiting for. We are the change that we seek.” Barack Obama

Chairman and members of the Health and Human Services Committee. My name is Mary Ellen Bouchard and I am a Certified Nurse-Midwife. I am also former academic faculty at Yale University and clinical faculty in several nurse-midwifery graduate programs. Bill HB 1817 is significant for the opportunity to remove the mandated written collaborative agreement with physicians. Thank you for this opportunity to testify for HB1817. I am a Virginia resident and homeowner in Virginia for well over 20 years. I am also a Certified Nurse-Midwife with a graduate degree licensed in Virginia, and a Fellow of the American College of Nurse Midwives (ACNM). I fell in love with Virginia while attending the Georgetown University Nurse Midwifery program for a Master’s degree. After graduation and passing the certification board exam, I worked as a certified nurse midwife in Massachusetts before being recruited to a faculty position at Yale University in the Nurse-Midwifery Graduate Program. Leadership positions and previous clinical experience as a nurse in neonatal intensive care units in Boston and a transport team serving the New England area proved to be valuable in educating nurse-midwives. I taught academic and didactic classes, worked in the faculty practice providing 24 hour on-call obstetric care and births, counseled and cared for pregnant women, provided gynecological care, coordinated and lectured in courses educating midwives-to-be in the multi-faceted role they were choosing to take on and serve. I also taught a Health Policy course under a federal grant given to several midwifery programs that has now become a key and essential piece of nurse-midwifery education for all midwifery programs. And when we could, the faculty slept. Moving back to Virginia, I, as well as most other midwives, served as a preceptor for midwifery students from Georgetown, University of Pennsylvania, Columbia, Frontier Nursing, South Carolina University, and others. However, the laws for nurse-midwifery practice were such that nurse-midwives were still tethered to physicians. Although highly educated, skilled, and accomplished, nurse-midwives must obtain jobs from physicians or physician groups or pay a hefty fee for physician consultation, collaboration, and transfer to satisfy the law. This is still true. Grateful to serve women, babies, and the families of Virginia, we pay the fees or work in situations to satisfy the law. Our professional responsibilities have not changed. We still care for women for obstetric, gynecological, and primary care. This remains the current situation keeping us tethered to physicians in a false sense of security and limiting our ability to serve the women of Virginia. When I manage a labor and birth, the responsibility is mine. If I consult with a physician, it is a consultation and discussion until such time as I transfer the care to a physician. The statute for practice should reflect this through removal of the requirement for written collaborative agreements with a physician.

Midwifery is not an unknown medical provider showing up to a birth with no information but what is written on a chart. It is a trusted medical professional giving you one-on-one attention to welcome your child into the personal atmosphere of your home. Someone who has the expertise and the experience to guide families through the process of pregnancy, labor, birth and postpartum care. I have had three home births by midwives who know me and my medical needs. I could not imagine giving birth with nurses and doctors who simply happened to be on call and did not know me personally. Home births with CNMs have facilitated birth experiences that empowered me and made me the confident mother I am today. They have made me feel powerful and capable. Without this care option, I would feel constrained and forced to violate my conscience. It would change the culture of our family, the liberty we are entitled to, and would negatively affect the life and health of our family. Women need this option for child birth to be MORE available, not to have to jump more hurdles to find CNMs in their area. I can personally attest that my three births with a midwife were safe, professional, wonderful experiences and I would not have any mother forced to choose a lesser option because CNMs were not readily available in their area. Please vote to allow CNMs to more easily provide care to mothers like me.

I am a mother of three beautiful babies, and am asking that you support this bill to help mothers continue to make their own choices for their births. After two negative and very stressful hospital birth experiences, I chose to have my third baby at home with the support of a midwife. I chose a CNM (Kelly Sicoli) because I wanted the combination of medical knowledge and personal care and attention. I really appreciated the midwifery model of individualized, compassionate care and felt very safe with her level of expertise. She submitted all routine lab work and always referred me to other providers as needed such as a maternal specialist doctor for prenatal ultrasound and physical therapy for pre and post-natal exercises. I feel it is essential for women to have options when it comes to all their health choices but especially for something as important and personal as their maternity care provider, including independently practicing CNMs. Without this bill, some CNMs may no longer be able to practice, taking away the option of a safe and medically supervised home birth for many mothers.

SUPPORT HB1817 I have been practicing as a CNM in Virginia for 9 years, serving over 400 families for their pregnancies and births. I have also practiced in Alaska, Washington DC, and Maryland, three of the 28 states where CNMs practice independently. Practicing in Virginia, where we’re currently required to have a signed consultation agreement, has been more difficult. I am fortunate to currently have a consulting agreement with a physician, however my ability to practice is dependent on this physician’s willingness and ability to maintain this signed agreement. If this physician retires or moves, I may no longer be able to serve the many families who are counting on my services. Passing HB 1817 and removing this requirement will not change the way we CNMs practice. We will continue to consult, collaborate and refer as we always have with the appropriate provider. HB1817 will simply ensure that we are not reliant on a signed document with a physician in order to keep our practices open. With the shortage of maternity care providers in Virginia, we should be supporting well-trained, highly educated providers such as CNMs, and removing barriers to their ability to serve families in our Commonwealth.

I am Katie Page, a Certified Nurse-Midwife and fellow of the American College of Nurse-Midwives. I serve as the president of the Virginia Affiliate of this organization which represents CNMs and Certified Midwives (CMs). I am also the chair of the Professional Liability Committee for the national organization. I am writing to ask your support of HB 1817. I am speaking to safety and competency of AMCB certified midwives. Midwifery care for CNMs and CMs is based on the Core Competencies for Basic Midwifery Practice, the Standards for the Practice of Midwifery, the Philosophy of ACNM, and the Code of Ethics. This framework is the foundation for clinical competency and patient safety. These standards and competencies adhere to international standards and guidelines for safe and competent entry level midwives. ACOG in their national guide on team-based care recommends that states rely on these uniform clinical guidelines and standards set by professional associations when licensing and regulating professionals. We meet these standards of competence prior to graduating and being granted admission to take our Board certifying examination. Our accrediting body for midwifery education mandates that we attend minimum of 60 individuals in labor with at least 35 where we are primary birth attendant. All CNM/CMs have attended this minimum prior to certification. The ACNM Position Statement on Independent Midwifery Practice is explicit that “independent” does not mean alone and that any prudent clinician will seek advice of other qualified clinicians. Collaboration can only occur where there is mutual respect and communication and where each professional provides care within their scope of practice. Our care incorporates appropriate consultation, collaboration, and referral as indicated by the health status of the individual receiving midwifery care. Midwives build relationships in their communities and regions with other clinicians. It is these relationships and our standards that lead to safe outcomes for people receiving care by midwives. In 2020, when the requirement for consultation agreements was lifted for the pandemic by Executive Order 57, there were zero disciplinary cases of CNMs before the Joint Boards of Nursing and Medicine. Members of our organization have found it challenging to open their own community-based practice because no provider in their area (sometimes region) will enter into a consultation agreement, though these providers have no objection to seeing patients when referred from the midwife. So, these clinicians will practice consultation and collaboration, but will not sign a legal document – the required agreement. Many practices that are part of large corporate offices or hospitals are restricted from having consultation agreements with midwives outside of the organization. In addition, many midwives have reported the experience of a request for payment in order to be available for routine or as needed consultation under the written agreement. Physicians fear increased liability by entering these agreements. 70 counties in Virginia are without a midwife and over 50 without an OBGYN. Independent practice for midwifery will increase our workforce’s ability to meet these needs.

My name is Dr Siva Thiagarajah. I am a high risk OB/GYN in practice for over 35 years in Charlottesville. I am writing in support of HB 1817. I have worked with a number of Certified Nurse Midwives (CNMs) over the past 24 years. In my experience with both in hospital and homebirth CNMs, I have found they are very aware of their knowledge and skills and the limits of the same. They have consistently consulted and collaborated in an appropriate manner and time frame-irrespective of any agreements. They are exceptionally well trained in providing care throughout pregnancy as well as for women’s general gynecological needs. Further, they truly excel in their care of laboring women. Being required to have consultation agreement in order to practice is redundant. It does not confer safety-CNMs have a long and excellent track record of safety. What it does is create a barrier to their ability to work that is unfair and unnecessary. It is discrimination against a class of very competent and committed practitioners. I respectfully submit that the time is now to remove this burden, please support HB 1817.

I would like to express my support for the HB1817 bill. I gave birth to my first born two weeks ago at home with the support and care of my CNM. In a time like this, a hospital birth would only allow one person to support me during labor. Having a home birth, I was able to have the support of my husband, mother and sister along with my CNM. My labor was three day and two nights long. My CNM supported me and my baby and my family the entire time. We had a very healthy birth and recovery. My CNM stitched up a small tear that I had and closely monitored my healing. I was able to stay in the safety and comfort of my bed without exposing myself or my newborn to a hospital environment. I also don’t have health insurance and so I would have had to pay about $17,000 more to give birth in a hospital. I have high respect for my CNM and we have developed a close relationship. She is also the CNM that helped my mom deliver my sisters over 20 years ago. I want CNMs to have more freedom because home births are much safer for healthy moms and babies. They are also much more affordable and allow for a more calm environment. Please give CNMs the freedom to practice without a physicians consent so that I am assured access to a CNM for my future children.

Dear Delegates, I am writing to advocate for the Practice of Certified Nurse-Midwives (CNMs) HB 1817. I gave birth to my second child last summer during the pandemic. When I got pregnant I had all intentions to give birth in a hospital but after the pandemic hit, the practice I was planning on joining (we were also moving during the pandemic) would no longer accept new clients. I reached out to other practices and it as much the same, not accepting new clients. I had no idea what to do. And then I found my CNM. I feel beyond fortunate to have not only found my midwife who took me on as a client in May but to have had the opportunity to experience a home birth (as it wasn't in my original plan). It was beautiful, peaceful, and I can't imagine my birth experience playing out any other way. I was already struggling with prenatal anxiety and the pandemic and my CNM made me feel safe, supported, and cared for beyond any experience I had had with my first child/delivery. She was experienced, knowledgeable, and prepared for any situation. The midwifery model of care is designed to not only take care of the baby but the mother as well. Women and families deserve the opportunity to have this experience. During my time with her, my anxiety lessened, my baby was born without complications, and my postpartum recovering was faster than with my first child. Thank you for listening. I hope you support this bill. Best, Joya Elmore

To the Health, Welfare and Institutions - Health Professions Subcommittee: My name is Milena Manos, I am a resident of Crozet, VA, and I am writing in support of H1817. Ten months ago, my CNM helped my first-born son into this world. Today I am writing this testimony because the midwife model of care allowed me the freedom to choose the care during one of the most important times in a family's journey together - pregnancy, delivery and the first days with a newborn. My husband and I knew from the moment we learnt that I was pregnant that we wanted our baby to be delivered by a midwife in the safety and comfort of our own home. The choice as to where, how, and with whose help to deliver a baby is one of the most personal and meaningful choices I have made as a woman transitioning to motherhood. My CNM was very competent, experienced and professional, and I received state-of-the-art medical care. She referred me to other providers as needed (including for ultrasound, physical therapy etc.) and coordinated directly with them on test results. I felt safe and comfortable throughout the entire experience, from the first prenatal visit to the check-up visit a few weeks after birth. This was not just because of the fact that statistically speaking, midwife-attended births tend to be safer for mothers and babies and involve fewer interventions, but also because of my personal experience, the attention and excellent medical care I received. It is challenging to express in words the respect and gratitude I have for my CNM in helping me to have the safe, meaningful birth experience that I wanted. My family is fortunate enough to live in an area where midwife care is available but in so many cities and counties in Virginia, no such options exist. Where CNMs cannot find a physician who is willing to sign a consulting agreement, they are forced to close their practice and move to another state, for example Maryland, which does not impose such burdensome requirements and restraints on this sector of the medical profession. As a result, fewer and fewer options for maternity care are available to citizens of Virginia where there is already a shortage in many counties. Independently practicing CNMs are a critical piece in Virginia's medical system and the options women have in delivering their babies. I urge you to support H1817 as a way to increase access to midwife care for pregnant women in the Commonwealth, improve outcomes and protect women's choices on how to welcome a new life into this world.  Sincerely, Milena Manos

Hi there, I am writing to voice my support of CNM’s and the midwifery model of care. As a mother of two, I cannot imagine wanting my prenatal, birth and postpartum experience to be altered in any way. I felt supported, heard and safe throughout the entire process. My personal CNM, Kelly Sicoli, used her vast resource network to ensure any additional care I was interested in/needed was available - specifically, she helped schedule an ultrasound and referred me to a fantastic chiropractor. Carrying and delivering a child is a vulnerable experience and having the choice of a CNM was paramount in assuaging my nerves. A consulting agreement is an unnecessary and difficult barrier for CNMs that I hope to not see implemented in Virginia. Sincerely, Abbey Biber

Regarding HB 1817: I have been a Certified Nurse Midwife in Virginia for 26 years. My birth practice has been almost entirely in community settings, at birth centers and in the home. The population that I serve is largely Mennonite families. Culturally they trust birth and prefer community midwives . They are also mostly self pay clients and access to safe, home birth and birth center options is a considerable saving to them, over a hospital birth. The challenge of finding a supervising or now a consulting physician predated my tenure. CNM’s have a long and proven track record of providing excellent care to the low risk mothers and babies we care for. We are grateful for access to our obstetrical colleagues and hospital care when needed. We are able to access any laboratory work, ultrasounds or specialist consultations that we need. We have excellent working relationships with physicians and hospitals in our communities. What is very problematic to obtain is a signature to attest to relationships that we already have without a signature. As hospitals have bought up physician practices and practices have consolidated, it has become even more difficult. There are very few solo physicians and even fewer solo obstetricians around who are able to commit for themselves without pulling a ship behind them in agreement. When the few solo practitioners retire, many community midwifery practices may have to close. Hence, the requirement of a signed consultative agreement is a restraint of trade for Nurse Midwives. It does not improve safety, and it is a barrier to access to care for our clients. We need independence of practice, like 28 (and counting) other states in the in the country. It is long overdue in the state of Virginia. Thank you for your time and attention to this critical matter for Virginia moms and babies.

I am a Certified Nurse Midwife who has proudly served the members of the Commonwealth for 13 years. I have been called into the profession of midwifery and believe that it is a privilege to have the opportunity to care for families, however, the restrictive licensure language in this state has made it challenging to provide the care that I been trained to do. In 2009, I opened a non-profit practice to provide Nurse-Midwifery care to low-income families. Prior to opening our practice, there were many women who came to the hospital to birth without ever having seen a provider for care during their pregnancies. Many women had medical concerns that were unaddressed due to a lack of prenatal care and many women were discharged home without plans for medical follow-up after their pregnancies ended. We were entrusted with the care of nearly 1,000 families during our tenure; members of our community who needed high-quality, affordable healthcare. My midwife colleagues and I were able to reduce the rates of preterm labor and preterm birth in a population of women that were similar to women receiving care at our local health department, by half. We were faced with many, many challenges due to the refusal of physicians to collaborate with us in our mission to care for the underserved. Despite being a Certified Nurse Midwife owned and operated practice with a combined 50 + years of professional nursing expertise, our ability to secure additional care for our patients with providers in other specialties, the ability to obtain lab contracts, and the ability to order diagnostic studies were often predicated on having a supervising physician relationship. I can only imagine how much more good could have been accomplished if the time we spent dealing with the restraint of the requirement for signed physician collaborative agreements, was spent serving and providing affordable, high-quality care for more members of our community. I sincerely thank you for presenting this bill for review. The families of the Commonwealth of Virginia need greater access to the care provided by nurse-midwives. Approval of HB 1817 will ensure that more midwives have the ability to care for women and families, and more families have access to midwives, without the barriers created by the need for collaborative agreements with physicians.

I am the current president of the Virginia Association of Clinical Nurse Specialists and am writing to support our certified nurse midwife colleagues. Allowing advanced practice nurses to practice to their full extent of education and certification improves access to care for Virginia residents, improves quality outcomes, and reduces cost. I support HB1817 to eliminate the requirement that certified nurse midwives must have a practice agreement. The practice agreement requirement is a barrier to patient care and discourages certified nurse midwives to practice in Virginia.

I am a Certified Nurse Midwife and I have been in practice in Virginia for nearly five years. I am opening a practice that will reach many women - I will be offering in home health care services across the life span. However, I am not going to be able to bring my practice to Virginia (where I live) due to the burdensome requirement for a practice agreement with a physician. All of the physicians I have talked to either aren't allowed to take freelance agreements such as this, or they have told me they would be able to do this if I pay them 10,000 dollars for the first year of the agreement which I am unable to do as a small business owner. Due to this mandate, I will instead be providing services to women in Maryland and the District of Columbia, neither of which has this requirement. Neither state has seen quality of care indicators fall since removing this requirement for Certified Nurse Midwives. Due to this mandate I won't be able to maintain my business presence in this state or hire any employees or pay my business taxes here. Please change this outdated requirement. Virginia women and families deserve as much access to care as their counterparts in DC and Maryland, and this burdens them as well as their care providers. Virginia removed the physician agreement requirement on a temporary basis during COVID-19, and has not seen any patient safety issues. Midwives practice safely in this state without collaborating physicians already, and just need to be allowed to continue doing so.

It is essential to address the demand for healthcare in a practical way - and these proposals are safe, evidence based, and needed. HB1987: Reimbursement for remote patient monitoring is proven to improve quality of care, lower readmissions, and lower travel and treatment costs. Remote patient monitoring is an essential benefit that allows patients to leave the hospital and get the same quality of care at home. For high risk pregnancies, it can cost as little as $26 a day to provide this service with higher convenience, better care, and keeps a hospital bed open for someone else who might need it more. Compare that to a $5,000 a day stay in the hospital with lower convenience, higher costs, and lower satisfaction. The Governor wisely removed reimbursement barriers to providers to offer this service to those suffering COVID-19 with great results. Virginians deserve access to this benefit and remote patient monitoring needs to be reimbursed immediately. HB1737: Nurse practitioners have safely served their communities with 2 years experience during the pandemic, and states across the country already allow for them to practice with the scope of practice with less restrictions that we have in Virginia. We need frontline healthcare workers practicing to their full capability and this reform achieves that safely. HB1747 / hb1817 : Enabling providers s to practice to their full capability is essential. Nurse practitioners deserve the opportunity be certified and practice according to their skills and education. This common-sense reform helps front line care providers to be more efficient and useful in serving in care deserts. In the same way, we should better leverage physician assistants in the field who could do more but are restricted by regulatory barriers. HB1769: Virginia law, unfortunately, puts walls between patients who are seeking care from licensed providers beyond our state lines. The commonwealth of Virginia does not care if a patient gets in the car and travels to another state to get treatment from an outstanding provider, but if a Virginia gets on the information highway, it can lead to criminal charges who is merely offering care to a Virginian in need of it. When the law was written, a phone was tethered to the kitchen wall. Today, our phones are supercomputers that can provide detailed healthcare information to a doctor in real-time. Our laws are still looking backwards in healthcare - not forward. Patient behavior is seeking better care with more convenience. This bill removes barriers between patients and providers across the country.

I am for nurse practitioner to be able to practice without a doctor being there

To get the best healthcare outcome, you should have a highly educated doctor making the decisions, right? Maybe not. The maternal mortality rate in the U.S. is higher than in other developed countries. Our current approach to maternity care is not working. It’s time to let Certified Nurse-Midwives and Certified Midwives have the autonomy to provide the kind of maternity care that exists in countries with better outcomes; countries where midwifery care is the norm. Over the 18 years that I have been a Certified Nurse-Midwife in Virginia, major changes in obstetric practice have occurred which are nothing more than a return to long-established midwifery practices. • no longer making women in labor lie on their back for fetal monitoring. • letting women drink fluids during labor. • giving women have more time to labor normally. • not making women start pushing before they are ready. • delaying cutting the umbilical cord so newborns can get all their stem cells. • keeping newborns in continuous, early physical contact with their mothers because it improves vital signs, breastfeeding success, and establishment of a healthy microbiome in the newborn. These and other midwifery practices never should have been abandoned in the first place, but our country put surgeons in charge of maternity care. Midwives are not only required, but happy and grateful, to consult physicians when the mother or her baby need such expertise. Women need us to fully employ our own expertise as well. Removing the requirement for a written consultation agreement makes that possible. Please support HB 1817. Thank you, Regina Foran, CNM

To the Committee Chair and Distinguished Members: Re: HB 1817 Practice of Certified Nurse-Midwives, I am Leslie Fehan, CNM,WHNP-BC, IBCLC. I am a certified nurse midwife, women’s health nurse practitioner and board certified lactation consultant. I have worked in an advanced practice role for over 30 years and currently am the lead nurse midwife at an academic practice. Nurse midwives already are required to consult and collaborate with physicians based on licensure and standards of practice. It is critical to support and pass this bill to expand women’s health services for women and work to reduce maternal morbidly and mortality. The current requirement for a practice agreement creates a burdens barrier for practice for nurse midwives. I have experienced this personally, when a practice I worked for decided to end having non physician providers. I then was unable to practice as I had to have a physician agreement and could not get hospital privileges without a sponsoring physician. My ability to practice, to provide the care I have have been well trained , certified and licensed to provide should not be dependent on another provider. This just restricts access to care for families of Virginia. We know more midwives means improved outcomes for families, decreases maternal morbidity and mortality as well as reduces racial disparities. Please pas HB 1817 to recognize the autonomous practice of nurse midwives and expand care in Virginia

Nurse practitioners are more qualified and more caring than most of the medical practitioners you deal with. They have the skills, the education and take time to hear their patients .

I support these bills that will give nurse midwives, certified midwives and nurse practitioners autonomy and authority in their respective practice.

Tying the NP/midwife to a doctor unfairly restricts access to providers who are credentialed and licensed to practice in the Commonwealth. The physicians are positioned to unreasonably limit or control access to more affordable health care options in low-risk scenarios because they may arbitrarily want to maintain economic superiority. Thank you for doing what is best for the patient.

I am a certified nurse-midwife (CNM), now retired after over 30 years as a midwifery clinician and educator. I completed my midwifery education in 1981, and also hold a master's degree in public health and a PhD in midwifery. I am a Fellow of the American College of Nurse-Midwives. The requirement that CNMs maintain a formal agreement with a consultant physician in order to practice has the effect of denying CNMs who cannot find a consultant, or whose consultants retire or move away, the ability to practice their profession and earn a living. In some cases the CNM must pay a fee to the consultant physician to initiate such an agreement and/or to maintain it, further restricting the ability to practice of CNMs who cannot afford to pay these fees. When midwives are unable to practice, women are denied access to care that is safe and has excellent outcomes. Midwifery care is recognized as part of the solution to our appalling maternal mortality and morbidity rates as well as the high cost of maternity care and an absurdly high rate of cesarean section births following uncomplicated pregnancies. Requiring a formal agreement is redundant in that CNMs’ professional practice standards mandate that we work within our scope of practice at all times, and we collaborate, consult, or refer when the client’s needs or condition falls outside of that scope. We can be censured or decertified for failure to do so. In addition, the bill includes language that codifies the CNM's responsibility to consult. A family practitioner is trusted to consult with a specialist when the client’s needs dictate it, without the need for a formal agreement. Similarly should CNMs, as responsible professionals, be trusted to practice within our scope and without the need for a formal agreement . Thank you for considering my testimony.

To the Committee Chair and Distinguished Members: Re: HB 1817 Practice of Certified Nurse-Midwives I am Katie Page, a Certified Nurse-Midwife and fellow of the American College of Nurse-Midwives. I serve as the president of the Virginia Affiliate of this organization which represents CNMs and Certified Midwives (CMs). I am also the chair of the Professional Liability Committee for the national organization. I am writing to ask your support of HB 1817. I practice in the largest CNM group practice of its kind in the state. We provide full-scope care meaning we see people from puberty to beyond menopause and provide wellness, reproductive, menstrual, and perinatal care. We collaborate, consult, and refer to other physicians (primary care, family medicine, gastroenterology, dermatology, gynecology, etc.) based on the needs of the patient. In pregnancy, if a complication is found or suspected we order tests as needed and collaborate with an OBGYN or maternal fetal medicine physician. We have a consultation agreement with a private practice physician group. Most of our collaborative work occurs with professionals outside of that practice. This agreement, however, is required for us to continue to see patients, to prescribe medication we are trained to provide, or to order medication or supplies for our office such as rhogam to prevent blood transfusion reactions for some pregnant people and their babies and saline which is used for minor procedures or diagnostic tests. This is a small representation of our experience with a consultation agreement. Other members of our organization have found it challenging to open their own community-based practice because no provider in their area (sometimes region) will enter into a consultation agreement, though these providers have no objection to seeing patients when referred from the midwife. So, these clinicians will practice consultation and collaboration, but will not sign a legal document – the required agreement. Many practices that are part of large corporate offices or hospitals are restricted from having consultation agreements with midwives outside of the organization. In addition, many midwives have reported the experience of a request for payment in order to be available for routine or as needed consultation under the written agreement. Physicians fear increased liability by entering these arrangements, especially if the CNM is prescribing or providing care within the scope of midwifery but different from the physicians medical practice. Certified Nurse-Midwives, CNMs, have been licensed in Virginia to practice since 1975. Midwifery care is a distinct profession from nursing and medicine. We are educated at the masters and doctoral level complete clinical training hours that meet national and international standards for competency and scope of practice. We must meet competency standards before we can become board certified. These standards are available publicly from the American College of Nurse-Midwives – Core Competencies for Basic Midwifery Practice and the Standards for the Practice of Midwifery. Central to and explicit in our standards and philosophy of care is collaboration, consultation and referral based on the needs of the patient. National nursing and medical organizations affirm our competency to practice independently – meaning without additional requirements for written agreements or supervision in order to be licensed to practice and prescribe.

Addressing topics for perspective is a form of growth.

Hello I am giving testimony in support of HB 1817 Certified Nurse Midwife Practice My name is Claudia Sencer, I am a Certified Nurse Midwife (CNM) and have been in practice in Charlottesville for the last 31 years. I attended births for the first 16 years and have provided gynecology care only, subsequently. As with all members of the healthcare community, CNMs safety record is based on how we practice. It is in our training, in our culture—in our Standards of Practice: we work in a healthcare team. We all have our skill set. No one provider type has global knowledge. The system works only when we work together. Midwives, OB/GYNs, Maternal Fetal specialists, Family Practitioners, Neonatologists, Nurses, Genetics Counselors, Lactation Consultants-we work together and all consult with each other as we need to. There are 2 CNM owned practices in Central Virginia. My practice, and one small homebirth practice. Both of our consultant MDs are well into their 70’s. When they are no longer available, it is unclear if there will be anyone to replace them. That means my thousands of patients, some of whom I have cared for over decades, will be forced to find other care providers should I be unable to practice. MDs have little motivation to have a formal consultative agreement with CNMs. They mistakenly fear liability risk. They don’t want to be bothered. They see competition not colleagues. They don’t understand what we do, and often do not respect it. I have been offered work in MD practices. However, I schedule one hour long appointments with each patient. This is a model of care which does not lend itself to typical medical “productivity” levels. But it is satisfying to me and my patients. Physician colleagues have been confused by how much time I spend on an annual exam or problem visit. It is a different model of care. Not better or worse. If I worked in an MD owned practice, this low level of productivity would not be tolerated. I have been fortunate to have found MDs willing to have consultative agreements with me, enabling me to have my own practice and work in the way I prefer. Many other CNMs have been less fortunate. I have known CNMs who left Virginia, who lost their practices for lack of MD support. Others whose only option is working for MDs with productivity levels inhibiting the time focused care that CNMs often prefer. We have a long track record of safety: since 1975 in Virginia since the early 1900’s in the US. Consultation agreements inhibit practices, they are not a safety issue, they are a restraint of trade issue. 28 states support independent CNM practice-it is a safe model of care. I implore you, please support HB 1817.

As the Director of a hospital-owned midwifery practice, I have experienced first-hand the unintended consequences that practice agreement requirements have on our care of women. This year we were unable to order Rhogam, a life saving blood product which prevents isoimmunization in mom and fatal outcomes in babies. Once isoimmunized there is nothing that can be done to reverse the permanent negative consequences for mom and any future pregnancies. The company which provides this product quoted our Virginia law as their rationale for the requirement. Our patients suffered delays in care, with the potential for permanent consequences because of this unnecessary requirement. We were also unable to order saline to use on microscope slides for the same reason. There are no physicians in our practice, but because of this requirement we have been forced to contract with a private MD group. This physician group requires a financial incentive to provide this relationship, which is significant and not something a smaller group or individual midwife could afford. Without this financial incentive the physician practice would not maintain our practice agreement. At any point if they discontinue the relationship, ten midwives would be unemployed and over 500 women would need to seek prenatal care elsewhere. Our practice routinely consults, collaborates and transfers patients to our physician colleagues as appropriate. Our relationship with the community OB/GYNs is positive and based on a team approach to the care of the women in our area. This is the standard of care for midwives and the removal of the requirement for a practice agreement will not change our processes. We will continue to follow the standards set forth by the American College of Nurse-Midwives (ACNM) and provide evidence-based care to our patients. The requirement of a practice agreement is not about patient care, it is restraint of trade and unnecessary regulation of a profession that is already sufficiently regulated. Thank you,

On behalf of the American College of Nurse-Midwives (ACNM), I write in support of H.B. 1817 (Adams), legislation to amend and reenact §54.1-2957 and §54.1-2957.01 of the Code of Virginia, relating to practice of certified nurse midwives. If enacted, H.B. 1817 would increase access to evidence-based, high-value maternal health care and improve maternal and newborn health outcomes during a time in which the Commonwealth faces a shortage of high-quality maternal health providers and significant race-based disparities in maternal and infant outcomes. Midwifery care provided by CNMs and CMs is evidence‐based and can reduce maternal and neonatal mortality, rates of stillbirth, perineal trauma, instrumental births, intrapartum analgesia use, rates of severe blood loss, preterm birth, low birth weight, and neonatal hypothermia. Midwifery has been associated with more efficient use of resources and improved outcomes including increased rates of spontaneous labor, vaginal birth, and breastfeeding. Additionally, women who receive midwifery care have higher rates of satisfaction with care, pain relief in labor, and maternal–newborn interaction. When pregnant and birthing people are placed in an appropriate level of care with the appropriate provider, maternal mortality and morbidity rates decrease. Numerous studies show that better integration of CNMs/CMs practicing to the full extent of their education, clinical training and certification within a team-based care model with the patient at the center can help prevent maternal deaths, reduce racial disparities, improve maternal and neonatal outcomes and improve access to health care for individuals and families. Despite the role midwives could play in efforts to expand access to care, reduce maternal mortality and morbidity and improve overall health outcomes for women and their families, midwives and the midwifery-led care models remain regrettably underutilized in the United States health system. There are several reasons for this including, restrictive supervisory and collaborative practice requirements, like those currently in place in the Commonwealth, inequity in third-party reimbursement structures, restrictions on hospital credentialing and admitting privileges, and limited recognition of the Certified Midwife credential. There is wide support for reducing unnecessary scope of practice restrictions and barriers to accessing care provided by midwives and other advanced practice providers. The National Governors Association, the National Academy of Science and Medicine, the Federal Trade Commission, the Medicaid and CHIP Advisory Commission, the American Nurses Association, the National Rural Health Association, AARP, the American Hospital Association, the American College of Obstetricians and Gynecologists, the March of Dimes and countless other provider and consumer groups and think tanks support or have recommended increased access to midwives and midwifery-led care models and/or that CNMs and CMs be able to practice to the top of their competency-based education, clinical training and national certification. ACNM strongly supports passage of H.B. 1817 and elimination of the statutory requirement that CNMs practicing in the Commonwealth enter into a written collaborative agreement with a physician as a condition of practice. Please don’t hesitate to contact me at akohl@acnm.org with any questions on the provision of care, treatment or services as provided by CNMs and CMs.

As a person of Faith it is my calling to support these areas of concern and I ask you to consider how important these issues are and to vote to approve them!

Chairman & Committee Members: On behalf of SALT's 1300 members I urge you to vote for HB 1820 to increase Access to SNAP: Implement Broad-Based Categorical Eligibility by (Delegate Helmer). The Supplemental Nutrition Assistance program (SNAP) is a federal food assistance program that helps low-income families put food on the table. Broad-Based Categorical Eligibility (BBCE) streamlines SNAP enrollment for all individuals receiving a TANF funded service. 43 states have implemented BBCE. Virginia is one of the seven who have not. As a result, Virginia is missing out on: • Helping over 25,000 families put food on the table and • Millions of federal dollars entering our economy. Federal regulations allow for states to set SNAP eligibility levels between 130% and 200% of the Federal Poverty Line (FPL). Virginia is at the bare minimum of 130%. Currently, to qualify for SNAP in Virginia, an applicant must: • Have a gross income that must fall within 130% of the FPL, • Have net income fall within 100% of FPL, and • Pass an asset test. The Solution: Increase the gross income eligibility level to 200% of the FPL and remove the asset test. The Wins: This will increase access to SNAP for more children. • Children who are eligible for SNAP are then also eligible for free school meals. • This will help reduce school meal debt, which is a growing issue in VA schools. Increasing the number of SNAP recipients in Virginia will pump more money into local economies, helping smaller grocery stores. • Every SNAP dollar will generate ~$1.50 in economic activity. The state’s investment in BBCE will result in an e $10.5 million of economic activity. Budget Request • General Fund: $281,292 / Non-General Fund: $342,558 If funded, this budget amendment will help over 25,000 more families . SALT urges you to Vote for HB 1820.

Voices for Virginia's children is supportive of HB1820. Families are witnessing the closing of nearby community centers they may have relied on, unemployment, choosing between going to work, staying home sick, or putting food on the table. Economic Trauma occurs when financial stress and/or economic shocks impact a person’s feelings of safety, their ability to remain calm, manage healthy relationships with others, and maintain the belief that their situation can improve, which can lead to an impaired ability to function in daily life. Currently, families are facing financial stress, economic shock, and financial health. The temporary assistance for needly families would further put families in a position where they can experience the supports to achieve financial independence, which means children are able to be resilient and live, long, health, and successful lives without trauma.

Hunger for the very poor is an ongoing problem. It has been exacerbated by the pandemic. Many Virginia families are suffering. I, along with many others, have been contributing to charitable food sources. It is not enough. Virginia can help alleviate this problem by, among other things, expanding SNAP benefits. This is not only a good thing to do, it is the right thing to do. I respectfully urge you to act favorably on HB1820.

Our families drive our economy. We are leaving them behind. It is long past time for us to join the other 43 states making it easier for families to get enough to eat. We have to give the families of Virginia every opportunity to succeed. As long as food is a luxury we can't do that. Please ensure we can feed Virginia's most vulnerable families.

The Virginia Community College System supports HB 1820 provided that the language changes that VDSS requested are made so that the bill aligns to Federal regulations.

I am writing today in support of HB1820- which has the potential to help more than 25,000 more families feed their families. I was born in Virginia, while my father was stationed in Norfolk as a submariner. In adulthood, I found my way back to the state and now live in NOVA and work for the National Governors Association Center for Best Practices. I am submitting these comments as a private citizen and not on behalf of my employer, but the work that I have been able to do with state leaders has certainly informed my perspective on supporting students and families. 43 states have already implemented Broad-Based Categorical Eligibility (BBCE) which streamlines SNAP enrollment for all individuals receiving a TANF funded service. I hope that, through this bill, Virginia will join that large group of states to streamline access to these programs to support their families. This type of effort is a perfect example of the ways that state can leverage federal programs to maximize the impact of every dollar to support Virginia families. I approach this issue from a postsecondary education perspective, which is my policy area. I am so proud that Virginia is so proactive and strategic in it's efforts to build a future workforce and provide economic opportunity to it's residents. HB1820 is yet another opportunity to move towards these goals. Providing accessible basic supports for Virginia families while they work to obtain quality education and employment opportunities can break cycles of poverty. Postsecondary attainment and workforce participation are not just numbers, they represent people. People who have pathways to support their families and children who have their needs taken care of and can focus on their future opportunities. My policy work has taught me that when federal and state support programs can be better connected and made more accessible for families- positive impacts can be maximized. HB1820 is a relatively small step that will make huge impacts in the lives of families in need in Virginia. I hope that delegates will vote to pass this bill and continue to double down on state efforts to provide support for Virginia residents as they work towards a brighter economic future.

Delegate Helmer, I am writing in support of HB1820. I was made aware of this by a friend and must say it is embarrassing to see that Virginia is one of a handful of states that has such restrictive requirements to qualify for the most basic of human needs - food. The dollar amount to support increasing the gross income eligibility to 200% of the FPL and remove the asset test is minimal, and should absolutely be passed to ensure that Virginians so desperately in need of support receive it. There are so many positive things that would result in the passing of HB 1820, and it is critical to increase the eligibility so that children and families can benefit and ensure they are not presented with yet another obstacle to being food insecure. Thank you.

On behalf of Virginia's seven regional food banks, I am requesting your support for HB1820. The bill will significantly improve food security in our Commonwealth at a time when we are seeing unprecedented levels of demand for emergency food service. First, it is long past time for Virginia to implement Broad Based Categorical Eligibility - a policy option which 43 other states have already adopted. Increasing the gross income limit to 200% of the federal poverty level and removing the asset test will help 25,000 families put food on the table and generate much-needed economic activity in local communities. Second, HB1820 will expand SNAP access for college students, who often fall through the gaps of the nutrition safety net. Two surveys conducted at James Madison University in 2019 found that 30% of JMU students suffered from food insecurity, which is comparable to national estimates. Despite high levels of need, college students face restrictive eligibility criteria in order to qualify for SNAP. With the passage of this bill, we can take important steps to increase SNAP participation among college students, which will allow them to focus on their studies instead of worrying where their next meal will come from. The Federation of Virginia Food Banks strongly urges the passage of HB1820.

As the Legislative Affairs Chair for the Student Government Association of James Madison University, I support this legislation’s recognition of the laborious demands of postsecondary education. This bill needs your support in order to help students receive the VIEW assistance and SNAP benefits that will support them as they earn their degree. Food insecurity on college campuses has only increased during the COVID-19 pandemic and this legislation would help alleviate a lot of the burden on students who are balancing a full course load and also trying to find income to cover food costs.

I urge passage of HB1820, which would relax the eligibility for the Supplemental Nutrition Assistance Program (SNAP). By increasing the gross income eligibility level to 200% of the Federal Poverty Line, many more families would receive federal assistance for food. Additionally, this law would also pump more money into local economies. I also urge others to support this legislation. Andrew Rhodes

To whom it may concern, I am writing to voice my support for HB1820 and to encourage Delegates to support this important legislation that will extend SNAP benefits to more Virginians and address food insecurity. In doing so, Virginia will join 43 states that have already implemented Broad-Based Categorical Eligibility (BBCE) to streamline the enrollment of individuals receiving a TANF funded service for SNAP benefits. By funding HB1820, Virginia would extend benefits to an estimated 25,000 residents. Children of these families would also receive access to free school meals. And, Virginia’s estimated investment in BBCE would generate an estimated $10.5 million in economic activity. This is a win-win for the Commonwealth. Thank you in advance for your support of HB1820. Best, Harmony Knutson Alexandria

I respectfully submit the following comments on behalf of the Hope Center for College, Community, and Justice in support of HB1820. HB 1820 accomplishes two goals; it will expand access to food assistance through the Supplemental Nutrition Assistance Programs (SNAP) to an estimated 25,000 Virginia families. The children in these families will then be newly eligible for free school meals. It will also improve access to SNAP and the VIEW program for college students, many of whom are struggling to complete college credentials during COVID-19. SNAP, the nation’s largest and most effective food assistance program, provides a monthly supplement for purchasing nutritious food. HB 1820 improves access to SNAP by allowing Virginians living at up to 200% of the federal poverty level to access nutrition assistance. This policy change is critical because it allows a household’s SNAP benefit to decrease slowly as their income rises, providing a smoothing effect as people transition off assistance programs. Virginia’s current policy of cutting families off at 130% of the federal poverty level means that a very small raise could leave someone worse off than they were before the raise due to the total loss of SNAP benefit, essentially penalizing a household for getting a raise. Evidence from our latest #RealCollege During the Pandemic survey, completed in the spring by more than 38,000 students, revealed that 44% of students at two-year institutions and 38% at four-year institutions experienced food insecurity due to the pandemic. Students were also impacted by record unemployment. The survey showed that two-thirds of students were experiencing job insecurity, with one-third having recently lost a job. As this crisis rages on, these challenges will likely grow. HB1820 recognizes the reality of the job market during the COVID-19 emergency -- and the importance of an educated workforce to Virginia’s future – by improving access to critical basic needs supports for college students. This bill maximizes federal rules in student eligibility and eases the restrictions that force students to choose between continuing their education or subsisting in a low-wage, limited-growth job. College completion is critical for individuals, their families, and for the national economic recovery. People without college degrees were harmed most by the Great Recession. They did not experience the same recovery that college degree holders did and in many cases, they are now worse off. In an economy in which the vast majority of new jobs require some form of postsecondary credential, improving college student success will improve the likelihood that our nation can recover economically and do so faster. Given the extensive research that shows college improves a vast array of social and economic outcomes, improving student access to support programs that bolster their educational success should be a priority for all policymakers. Thank you, Carrie R. Welton Director of Policy & Advocacy The Hope Center for College, Community, and Justice

I am for nurse practitioner to be able to practice without a doctor being there

Addressing topics for perspective is a form of growth.

I thank the Social Services subcommittee of the Health, Welfare and Institutions Committee for including my testimonial in the hearing of bill HB1957. I am a different person, a better citizen, and a happier human being because of my adult adoption. Jack and Jacque Blundell, the couple that raised me as a child, were not my parents by birth. My childhood was a challenging one, only made survivable by their influence and guidance. Without their steady and true devotion, I would not be the person I am today. Since being adopted, I have been able to address the abuse and trauma that I experienced by the hands of my biological parents. I have held a full-time job for the past 8 years. I am happily married and we have a home and a life in Williamsburg, Virginia. I mention these accomplishments because they are all results of feeling secure. The security I felt after being adopted by the family that truly raised me cannot be understated in this case. While it is commendable that VA is a state that allows adult adoption, the process was far from easy. Without the wealth, privilege, and time that I and my adopted family have, it would be nigh on impossible to complete this process financially. The process was laborious and the investigation and report were painstaking and convoluted. The financial toll on local divisions of social services in Virginia is also apparent. Additionally, the emotional toll of an investigation and report were exceedingly painful for me. Not all social services workers are familiar with adult adoption law and/or protocol. This lack of understanding was triggering for me. Several times I was told that my biological parents - and abusers- would be required to approve of this adoption. Legally this is not so, but the social services worker was not aware of that. Without our attorney guiding us, I may have given up on my dream of having a true set of parents who love me. I hope that this subcommittee seriously considers the impact that implementing bill HB1957 would have on potential adult adoptions in the state of Virginia. I am one of the lucky ones who is able to call the family that raised me my parents. I was able to navigate this process that is counterintuitive, expensive for individuals and the state, and emotionally taxing. I no longer fear being in an accident and my mother and father not having the ability to visit me in the hospital. My hope is bill will change that for those who are not of the socioeconomic bracket that I and my parents are part of. Nicole Blundell Brown

I am for nurse practitioner to be able to practice without a doctor being there

HB1915- Children are the future. Teachers care for our future and should be paid in a way that reflects the sentiment that we care for the future of our country. HB1987- This should be allowed for mental health especially. Many mental health in-person appointments are missed because someone’s mental illness keeps them from leaving the house or the person doesn’t have childcare at the time where they need to make the appointment. Telehealth will help with accessibility.

The Virginia Poverty Law Center strongly supports HB 1987 which extends and clarifies Medicaid telehealth services and remote monitoring of many health conditions. During this horrible COVID-19 pandemic, Virginia (and the U.S.) has gained new appreciation for the value of tele-medicine. Both providers and patients have benefited from easier access to medical care and improved monitoring of chronic conditions. The Medicaid program has fully participated in authorizing more telehealth during the pandemic. HB 1987 builds upon this experience and maintains valuable telehealth services to Medicaid enrollees. I have two concerns about the FIS for HB 1987. The estimated costs to DMAS appear inflated because (1) the FIS seems to count all telehealth services as ADDITIONAL services, rather than replacements for appointments and services that would normally occur; and (2) the FIS doesn't consider any cost benefits or reduced hospital/ED services which are very likely to result from better access and monitoring through telehealth. Thank you for supporting HB 1987. Jill Hanken, VPLC Health Attorney

We support this bill. Extending the use of telhealth in Virginia will benefit those with chronic conditions that live in our underserved communities. It can also reduce hospitalizations and other health care costs by helping to control conditions such as diabetes, high blood pressure, etc.

Chairman Sickles, members of the Subcommittee, good morning. I am Dr Karen Rheuban, Director of the UVA Center for Telehealth and board chair of the Virginia Telehealth Network. Thank for the opportunity to speak to HB1987, which directs the Department of Medical Assistance Services to cover remote patient monitoring services for priority, high risk, high cost patients and conditions. Remote patient monitoring programs improve patient outcomes, and lower the cost of care. I would respectfully like to address the fiscal impact statement prepared by the Department of Planning and Budget. UVA began our remote monitoring program in 2014. Based on our prior data, and the first 6 months of FY 21, we anticipate monitoring approximately 6200 high risk patients this year. For those monitored patients with the conditions identified in this bill, we project a reduction of 25,034 hospital bed days. These reductions result from hospital admissions and readmissions avoided and shortened length of stay. With an average total cost per bed day of $2015 for low case mix index patients, we conservatively project cost savings across all payers of $50,443,510 in FY21. In addition, our data demonstrated a reduction in emergency department visits for our monitored patients by 14%. One additional note for consideration as it relates to the costs of remote patient monitoring: many patients only require 30 days of monitoring, others only 3 months, rather than as projected, all patients for a full year. Medicare has covered remote patient monitoring for a broad range of conditions since 2018. We urge the committee to consider this additional information, particularly regarding cost savings to the Medicaid program, when considering the true fiscal impact of HB1987. Thank you.

My name is Stephen Grammer, from Roanoke. I encourage you to pass HB1987 and HB2124. HB1987 would allow people who without transportation easier access to being able to communicate with their primary doctors. This also would be cost-effective, due to the fact that people will not have to get ambulances going to hospitals over non-emergency situations. HB2124 would allow people with disabilities to get treatment for COVID. We are on a very low-budget, and can not afford to pay out of pocket for treatment. Again, I encourage you to support HB2124 and HB1987. Thank you for your time and consideration.

January 20, 2021 Chair Mark Sickles Health Welfare and Institutions Committee Virginia General Assembly 1000 Bank St Richmond, VA 23219 RE: HB 1987--Physical Office Location Amendment to Conduct Telehealth Chair Sickles and Member of the Committee, On behalf of Hims & Hers, a direct-to-consumer digital health company, we urge you to preserve access to healthcare treatment for thousands of Virginians by removing language recently added to HB 1987 that would require a physical office or relationship with a practice” in order to conduct telehealth in the Commonwealth. This onerous and unnecessary language will have a chilling effect on direct-to-consumer health platforms like Hims that are providing care to thousands of Virginia residents during a global pandemic but do not have a physical location. Especially during the COVID-19 pandemic, it is critical that we encourage, not curtail telehealth usage, and reduce nonessential, face-to-face encounters between patients and healthcare workers while maintaining the highest quality of care. At Hims & Hers, we connect patients to licensed healthcare providers for medical consultations and treatment across all 50 states. Our platform is powered by virtual care, without an in-person visit, which is a care delivery model that has been embraced by state legislatures, hospitals, healthcare providers and patients across the country. Since our launch in 2017, we’ve powered more than two million digital healthcare visits across a variety of conditions, ranging from sexual health to psychiatric health. In response to the pandemic, Hims & Hers has incorporated access to additional telemedicine offerings, including primary care services, mental health support groups, and access to at-home COVID-19 testing kits. We believe providers should always be held to the highest standard of care regardless of the mode of delivery, and that is why providers on our platform are licensed, highly-credentialed, and held to evidence-based clinical standards. Our executive team and board of directors are composed of some of the most experienced minds in healthcare, like Dr. Toby Cosgrove, former CEO and current Executive Advisor of the renowned Cleveland Clinic, and Dr. Patrick Carroll, our Chief Medical Officer (CMO), the former CMO of Walgreens. We recognize that telehealth is not an appropriate mode of care delivery for all conditions, and that is why we rely on licensed providers to make those determinations and refer patients to the appropriate healthcare systems and platforms. However, the current proposed physical location requirement in HB 1987 would effectively ban Hims and other direct-to-consumer digital health platforms from providing care in the Commonwealth. This is especially troubling for those in underserved areas, where telehealth is a lifeline for receiving quality care. We hope that you will remove this language from the bill, and ensure that quality care is preserved for thousands of Virginia residents. Sincerely, April Mims VP of Public Policy Hims & Hers, Inc cc: Vice Chair Rasoul, Committee Members, and Clerk Rushawna Senior

To the Members of the Committee: On behalf of the Virginia Community Healthcare Association and the 155 community health center sites across the Commonwealth that serve over 355,000 Virginians in medically underserved communities, we ask for support for House Bill 1987. Remote Monitoring Services would be invaluable in monitoring the health conditions of some patients, particularly those recently released from a hospital setting. In North Carolina, a pilot program conduced several years ago in a community health center led to significantly reduced A1C numbers in diabetic patients. For cardiac patients, one can cerrtainly see the benefit of having remote monitoring at home after having stents, or having a heart attack. On the last paragraph on audio only services – this has been an important part of delivery of services in medically underserved areas that have limited access to internet broadband services. In some parts of the Commonwealth, video is not available due to limited bandwidth. Although not mentioned in the bill, I would ask the committee to remember that when a health provider does provide services by audio only, they bring to bear their full knowledge. Reimbursement for audio only services should be at a full and regular rate, not a discounted rate, as the services of the provider requires their full abilities. Thank you, Rick Shinn - Director of Government Affairs Virginia Community Healthcare Association

VACo supports this legislation in keeping with our long-standing position in favor of the use of telemedicine to provide long-distance clinical care, patient and professional education, and public health, as well as support for flexibility in the delivery of these services.

On behalf of the Virginia Association of Community-Based Providers (VACBP), the largest association of private-sector providers of community-based behavioral health services to Virginia's Medicaid population, I want to express our support for HB1987. The ability to provide and be reimbursed for behavioral health services delivered via telehealth and telephone has been absolutely critical to our members as they have worked to meet the needs of Virginia's most vulnerable residents. We applaud DMAS, DBHDS and DMAS for their quick action to develop the regulatory framework within which services could be provided early in the pandemic and in close coordination with providers. We support efforts to continue to allow use and reimbursement for telehealth and telephonic delivery of services where appropriate throughout the duration of the current public health crisis and beyond it. Thanks to Del. Adams for introducing this bill and for her commitment to identifying how telehealth can continue to be leveraged to increase access to quality healthcare services for all Virginia residents. The VACBP also supports HB2197, which would create a workgroup to evaluate and provide recommendations for the permanent use of virtual supports and assistive technology for the ID/DD population in Virginia. We believe that such an effort that is collaborative and inclusive will yield valuable insight that can guide future policy in this space. Thanks to Del. Runion for introducing this bill.

Teladoc Health would like to register our concerns with amendments to House Bill 1987. Recognized as the world leader in virtual care, Teladoc Health directly delivers millions of medical visits across 175 countries each year through the Teladoc Health Medical Group and enables millions of patient and provider touchpoints for thousands of hospitals, health systems and physician practices globally. Specifically, we strongly oppose the amendment to Section 54.1-3303 B. As written, the bill would require that a Virginia-licensed health care provider practicing using telemedicine and prescribing Schedule II–V controlled substances also have a physical office practice in the Commonwealth or an immediately contiguous jurisdiction. This provision has no clinical basis and is an arbitrary restriction to Virginia-licensed practitioners who treat patients using remote technology. The clinical guidelines for telehealth and telemedicine are anchored in standard of care, and the Commonwealth should maintain such standards and continue to tie state policy to federal restrictions on prescribing controlled substances. A requirement for a physical practice in Virginia or an immediately contiguous jurisdiction is an artifact of “old thinking” and would gut the ability of telehealth to deliver access to affordable quality health care. This bill fails to acknowledge the capacities of technological innovations in medicine. Today there is no other state with such an antiquated requirement in statute or regulation. Federal law (Ryan Haight Online Consumer Protection Act of 2008) already imposes rules around the prescription of controlled substances (Schedules II–V). This is simply bad public policy and ill-advised. Simply stated, the standard of care should dictate whether or not a prior physical examination of the patient is required prior to diagnosis and treatment of the patient, including prescribing Schedule II–V controlled substances. After the establishment of the valid professional relationship and treatment in accordance with the standard of care, geographic restrictions on follow-on care are arbitrary. We are very appreciative of the hard work that has gone into this legislation and respectfully request the sub-committee reject the proposed amendment. Thank you for your consideration. We are happy to answer any questions.

On behalf of the ATA and the 400 organizations we represent, I am writing to express concerns about an amendment made to HB 1987 in §54.1-3303 (B). In its revised form, HB 1987 would create unnecessary and impractical barriers to the establishment of telehealth services across Virginia, limiting practitioners’ ability to prescribe vital medications to their patients throughout the state based on arbitrary geographic restrictions. Currently, the bill would place geographic restrictions that determine the practitioners who can provide prescriptions to their patients, the language reading: “To prescribe a Schedule II through V controlled substance utilizing telemedicine, prescribers must maintain and practice or maintain a relationship with a practitioner at a physical office practice in the Commonwealth or in an immediately contiguous jurisdiction in order to unsure availability for an in-person examination when required by the standard of care.” In mandating the existence of a physical presence for practitioners to prescribe Schedule II through V controlled substances, the language establishes an arbitrary geographical barrier that would limit Virginians’ access to the prescriptions they need to lead healthy lives. When applied to real-world scenarios, the requirement proposed in this amendment is not practical in protecting Virginians’ safety or ensuring their access to accessible and high-quality care. If this bill were passed with the amended language, a Virginia citizen located in Alexandria could legally receive a prescription from a provider in Memphis, Tennessee (as Tennessee shares a border with Virginia), 881 miles away. However, a practitioner in Philadelphia, Pennsylvania, just 146 miles away from that same citizen, could not prescribe this patient’s medication simply because Pennsylvania does not border Virginia. Moreover, this language is not needed because if an in-person examination is needed to meet the standard of care for prescribing, then the practitioner would already be violating the standard by using telehealth technology to do so - regardless of whether they have a physical office or a relationship with a practitioner in Virginia or a “contiguous jurisdiction.” Simply put, there is no overlap between when a practitioner can use telehealth to prescribe medication and when an in-person exam is needed to prescribe, making this proposed amendment unneeded. Finally, the language also is likely in violation of the 10th Amendment. While the 10th Amendment gives broad discretion to states to regulate the health, welfare, and safety of its citizens, it still cannot “arbitrarily” or “capriciously” violate the Commerce Clause when doing so. The requirements imposed by this bill certainly would legally violate the Commerce Clause by limiting an out-of-state practitioners’ ability to practice medicine in Virginia despite the fact that they are licensed to practice there. The ATA applauds other aspects of HB 1987 which guarantee that nothing shall preclude coverage of telehealth services by insurers, including those services which involve remote patient monitoring. However, the ATA strongly objects to the amended language, and we believe that passing House Bill 1987 in its current form would be a step backward for patients and practitioners in the Commonwealth. We urge you and all of your colleagues to strike the amended language in §54.1-3303 (B) before considering the approval of this bill.

It is essential to address the demand for healthcare in a practical way - and these proposals are safe, evidence based, and needed. HB1987: Reimbursement for remote patient monitoring is proven to improve quality of care, lower readmissions, and lower travel and treatment costs. Remote patient monitoring is an essential benefit that allows patients to leave the hospital and get the same quality of care at home. For high risk pregnancies, it can cost as little as $26 a day to provide this service with higher convenience, better care, and keeps a hospital bed open for someone else who might need it more. Compare that to a $5,000 a day stay in the hospital with lower convenience, higher costs, and lower satisfaction. The Governor wisely removed reimbursement barriers to providers to offer this service to those suffering COVID-19 with great results. Virginians deserve access to this benefit and remote patient monitoring needs to be reimbursed immediately. HB1737: Nurse practitioners have safely served their communities with 2 years experience during the pandemic, and states across the country already allow for them to practice with the scope of practice with less restrictions that we have in Virginia. We need frontline healthcare workers practicing to their full capability and this reform achieves that safely. HB1747 / hb1817 : Enabling providers s to practice to their full capability is essential. Nurse practitioners deserve the opportunity be certified and practice according to their skills and education. This common-sense reform helps front line care providers to be more efficient and useful in serving in care deserts. In the same way, we should better leverage physician assistants in the field who could do more but are restricted by regulatory barriers. HB1769: Virginia law, unfortunately, puts walls between patients who are seeking care from licensed providers beyond our state lines. The commonwealth of Virginia does not care if a patient gets in the car and travels to another state to get treatment from an outstanding provider, but if a Virginia gets on the information highway, it can lead to criminal charges who is merely offering care to a Virginian in need of it. When the law was written, a phone was tethered to the kitchen wall. Today, our phones are supercomputers that can provide detailed healthcare information to a doctor in real-time. Our laws are still looking backwards in healthcare - not forward. Patient behavior is seeking better care with more convenience. This bill removes barriers between patients and providers across the country.

Managed care organizations are contracting with third party audit organizations to recoup payments made to home care providers. Often times, these third-party organizations are aggressive, are paid based on the amount of reimbursement recovered and apply arbitrary standards inconsistent with both Medicaid and Medicare guidelines. House Bill 2022 (2021) introduced by Delegate Chris Head would require plans operating in Virginia to develop clear and transparent audit processes. Any changes made to provider requirements must be communicated in writing to all home care, home health or hospice providers 90 days prior to their effective date. Home care and hospice agencies shall have access to clear and consistent training on the audit expectation and process prior to implementation. These audit processes would consist of an opportunity for home care and hospice agencies to work collaboratively and correct any technical errors identified, provided the plan of care was followed and patient care was delivered. Managed care organizations shall not contract with a third-party audit organization that are paid on a contingency basis. All appeals processes shall be conducted by an organization that is not a subdivision of either the managed care organization or the third-party audit organization. This bill would restore a fair and equitable audit process.

The Virginia Osteopathic Medical Association (VOMA) is a professional medical organization that represents over 2,000 osteopathic physicians (DOs) providing patient care in Virginia. We are writing to express our strong concerns regarding HB 2039, which expands the practice authority for physician assistants (PAs) and puts patient safety at risk. If enacted, HB 2039 would greatly expand the practice authority for PAs by removing the requirement that PAs maintain a practice agreement with a physician or podiatrist, and instead allow PAs to practice pursuant to an agreement with a health care team that contains “guidelines for [PA] collaboration and consultation” with other clinicians. Physician input is only required in “complex clinical cases…patient emergencies, and for referrals,” and there is no requirement that physicians visit sites where PAs practice. Our organization is very concerned that authorizing what amounts to the independent practice of medicine by PAs, without requiring them to complete a similar level of education, supervised training and testing to physicians, could place the safety of Virginia’s patients at risk. Further, the Physician Assistant Education Association, which represents PA educational programs, has stated in its “Optimal Team Practice Task Force Report” that they “[do] not support the elimination of legal provisions that require a collaborating physician for PAs” due to potential negative consequences, including harm to patients. The VOMA supports the “team” approach to medical care because the physician-led medical model ensures that professionals with complete medical education and training are adequately involved in patient care. Physicians across the United States must meet the same education, training and testing requirements and practice in supervised environments that afford progressively greater autonomy before ultimately becoming eligible to treat patients on their own. These requirements ensure that all patients are treated safely and with the same standard of care regardless of their location or ability to pay. They also uniquely prepare physicians to understand and recognize the subtle differences between many minor ailments (i.e. the common cold, indigestion) and serious ones (i.e. pneumonia, heart attack) that share similar symptoms, and to engage in safe prescribing practices. While our organization supports the bill’s goal of increasing access to health care, we are concerned that granting PAs similar practice rights to primary care physicians, without requiring similar education, training and testing, could create a two-tier health care system wherein only certain patients are able to access fully trained and licensed physicians. Further, allowing another class of clinicians who receive less education and training than physicians to independently prescribe dangerous drugs could exacerbate the widespread prescription drug abuse, misuse and diversion that our nation is currently facing. For these reasons, the VOMA urges you to prioritize patient safety and oppose HB 2039.

It is essential to address the demand for healthcare in a practical way - and these proposals are safe, evidence based, and needed. HB1987: Reimbursement for remote patient monitoring is proven to improve quality of care, lower readmissions, and lower travel and treatment costs. Remote patient monitoring is an essential benefit that allows patients to leave the hospital and get the same quality of care at home. For high risk pregnancies, it can cost as little as $26 a day to provide this service with higher convenience, better care, and keeps a hospital bed open for someone else who might need it more. Compare that to a $5,000 a day stay in the hospital with lower convenience, higher costs, and lower satisfaction. The Governor wisely removed reimbursement barriers to providers to offer this service to those suffering COVID-19 with great results. Virginians deserve access to this benefit and remote patient monitoring needs to be reimbursed immediately. HB1737: Nurse practitioners have safely served their communities with 2 years experience during the pandemic, and states across the country already allow for them to practice with the scope of practice with less restrictions that we have in Virginia. We need frontline healthcare workers practicing to their full capability and this reform achieves that safely. HB1747 / hb1817 : Enabling providers s to practice to their full capability is essential. Nurse practitioners deserve the opportunity be certified and practice according to their skills and education. This common-sense reform helps front line care providers to be more efficient and useful in serving in care deserts. In the same way, we should better leverage physician assistants in the field who could do more but are restricted by regulatory barriers. HB1769: Virginia law, unfortunately, puts walls between patients who are seeking care from licensed providers beyond our state lines. The commonwealth of Virginia does not care if a patient gets in the car and travels to another state to get treatment from an outstanding provider, but if a Virginia gets on the information highway, it can lead to criminal charges who is merely offering care to a Virginian in need of it. When the law was written, a phone was tethered to the kitchen wall. Today, our phones are supercomputers that can provide detailed healthcare information to a doctor in real-time. Our laws are still looking backwards in healthcare - not forward. Patient behavior is seeking better care with more convenience. This bill removes barriers between patients and providers across the country.

Thank you to the committee, my name is Shaddai R. from Richmond, Virginia. I am here to encourage you to.. 1. Increase the allocation of tax revenue towards the reinvestment fund from 30% to 70% because anything less than a majority of the revenues is disingenuous to the priorities of the bill. 2. Allocate 50% of all licenses towards Virginia social equity license holders as no other licenses are required to be owned by Virginia residents. 3. Add another tier of license, micro-business licenses, so that smaller applicants can enter with unique integration privileges. 4. Do not add any new crimes nor criminalize another generation of youth because of a fake war on drugs

I am a constituent of the 7th district but I feel it is necessary to work together to protect the younger members of our society and stop the criminalization of the Hispanic and African American communities. Rules must be stated clearly now so we are better prepared to face a future when marijuana is officially legalized in the Commonwealth of Virginia. Please increase the reinvestment from 30% to 70% for new companies and entrepreneurs. Make sure the new market is equitable and accessible to all not just large corporations.

The Virginia Academy of Nutrition and Dietetics and the Virginia Nurses Association strongly supports Delegate McQuinn's efforts around food access and security to improve the health of all Virginians. We hope the General Assembly will support this legislation. COVID-19 has increased Virginia's food insecurity rate from 9.9% to 13.1%. Numerous studies have demonstrated correlation between food insecurity and poor health outcomes, particularly higher levels of chronic disease such as diabetes, hypertension, coronary heart disease, hepatitis, stroke, cancer, asthma, arthritis, COPN and CKD. Similar programs in other states have demonstrated efficacy for increasing participants' consumption of fruits and vegetables.

Virginia First Cities' 16 older, core city members are supportive of HB2065 and all investments to ensure our cities and citizens have access to thriving, sustainable food options. Delegate McQuinn's bill will help remove barriers and costs of access to healthy foods so that no one has to experience food insecurity.

On behalf of our 57 free clinic members located throughout the Commonwealth, including 11 clinics are also Medicaid, providers, the Virginia Association of Free and Charitable Clinics supports HB2065. Our clinic members serve over 60,000 vulnerable Virginians each year, many of whom suffer from chronic conditions such as diabetes and heart disease and would benefit from improved access to healthier foods. Our clinics that currently offer food pharmacy programs similar to the Produce Rx Program pilot proposed in HB2065 have experienced positive outcomes from these programs with their patients, including lower blood sugar levels, weight loss, and lower blood pressure readings, and in some cases a decreased level of need for prescription medications to address certain conditions. Based on this positive experience our clinics are having with their food pharmacy efforts, we strongly believe the proposed Produce Rx Program pilot will yield improved health outcomes for the Medicaid patients who participate in it, help to decrease the need for prescription medicines among these same patients, and ultimately reduce the overall cost of their care.

Virginia First Cities' 16 older, core city members are supportive of HB2065 and all investments to ensure our cities and citizen have access to thriving, sustainable food options. Delegate McQuinn's bill will help remove barriers and costs of access to healthy foods so that no one has to experience food insecurity.

LeadingAge Virginia supports House Bill 2154 with the amended language provided by the Virginia Health Care Association.

Support with Amendments

This is Scott Reiner, Executive Director of the Office of Children's Services. The administration has no position on this bill. I can be available to respond to questions at the request of the Chair r members of the committee.

Voices for Virginia's Children and the Foster Care Policy Network comprised of 25 organizations is in support of this bill.

The Arlington Chamber of Commerce supports HB 2328 and HB 2333, making provisions for the widespread administration of the COVID-19 vaccine. Completely vaccinating Virginians is an “all hands on deck” operation. Looking ahead to a time when the supply of vaccine is more plentiful, these bills will facilitate getting those shots into Virginians’ arms. We encourage the committee to report the bills.

The Arlington Chamber of Commerce supports HB 2328 and HB 2333, making provisions for the widespread administration of the COVID-19 vaccine. Completely vaccinating Virginians is an “all hands on deck” operation. Looking ahead to a time when the supply of vaccine is more plentiful, these bills will facilitate getting those shots into Virginians’ arms. We encourage the committee to report the bills.

HB 2333 - should the committee decide to use the same language as in SB 1445 's amendment, paragraph 4, this language completely excludes volunteer emergency medical services providers any where in the Commonwealth. This would, in its current state, would deplete the Virginia Beach EMS of approximately 20% of their vaccination staffing that come from the Virginia Beach Volunteer Rescue Squad. I would suggest in addition to removing the words, “non-volunteer”, the words “employing” and “full-time” should also be omitted or revised in favor of language that would include full and part-time paid or volunteer EMT’s or paramedics. Thank you Ed Rhodes