Legitalk:

[Rep. Nicole Klarides-Ditria]: Yep. He's coming in and out to you.

[Sen. Saud Anwar]: Good morning, everyone. We will call our public health committee public hearing for 03/04/2026 to order. Welcome. I'm senator Soudh Anwar. I'm the cochair for the public health committee. Looking forward to hearing from, people in person and remote. With that, I'm going to have my cochair, esteemed cochair, make a few opening remarks by representative Kristen McCarthy Vehi.

[Rep. Cristin McCarthy Vahey]: Thanks for coming, everyone. We're looking forward to talking with you today and hearing from you more importantly.

[Sen. Saud Anwar]: And our ranking member represent representative Claire De Sticher.

[Rep. Nicole Klarides-Ditria]: Thank you, mister chair. Good morning, everybody. As always, we look forward to hearing from every single person in the public. Thank you.

[Sen. Saud Anwar]: Who has registered? That is good. With that, I I think, there are multiple public hearings and meetings happening. So we know that many of our colleagues are online, but also in different rooms. So we will see when senator Summers joins us, we will be able to have her speak. The first person person on our list is senator Looney. I do not see him here. So when he comes over, I know he's also in multiple different meetings. So when he arrives, we will have him speak. The next person on our list is Boyd Jackson who will be joining with Edlita as well. So you can come Welcome. Thank you for being here. We we are using a different room. We have another room usually, the two D, where the room is very personal, but the the sound system is not. And now we have the sound system, but room is a little distant, but you're very close to us. So go ahead.

[Boyd Jackson]: Good morning, senator Anwar, representative McCarthy Vehi, senator Summers, representative Clarity Ditria, and members of the public health committee. I'm Boyd Jackson, director of legislation and regulation at the Office of Health Strategy. I direct OHS's policy and legislative work, the legal team, and OHS's certificate of need program. Thank you for the opportunity to speak on the governor's proposal to reform, streamline, and revitalize the state's CON process. Last year, we collaborated to create a new emergency CON process so that OHS could review the transfer of ownership of a hospital in bankruptcy on an expedited sixty day timeline. That process was immediately implemented for the two prospect transactions. Each was completed ahead of the sixty day deadline and approved with conditions to ensure the affected communities would have continued access to high quality affordable health care. The emergency CON experience demonstrated what our program can achieve when focused on the right criteria, authorized with the right tools and timelines, and granted the flexibility to move a docket forward efficiently. That experience, lessons from neighboring states, and the past few years of feedback from the committee and stakeholders have informed this bill before you today. House Bill fifty forty five addresses each and pretty much every element of the CON program to ensure the process is efficient and minimally burdensome while enhancing the state's ability to protect Connecticut residents. More specifically, the bill would reduce the categories requiring CON for lower risk transactions going from 15 categories down to seven while expanding certain exemptions. It would expand or view to capture transactions that can sometimes evade state oversight, including sales of hospital property to real estate investment trusts, or private equity acquisitions of physician practices. It'll shorten and streamline the application process, create an expedited pathway for certain proposals, and sharpen the review criteria to focus on access, quality, affordability, and cost effectiveness of care. It'll replace CON review of hospital service terminations with a notice and wind down process to preserve access and continuity of care. And it'll authorize, the proposed panel, over the program to implement policies and procedures so the program can respond nimbly to changes in the healthcare landscape that is constantly evolving. My written testimony provides more detail. I'm happy to answer any questions, but I'll turn it over to the deputy commissioner from the Department of Public Health, Lita Orifici.

[Adelita Orefice]: Thank you. I'd like to thank the public health committee for the opportunity to testify in support of this proposed legislation. My name is Adelita Oraffici. I am a deputy commissioner at the Department of Public Health. I'm here on behalf of commissioner Jutani today who wanted to be here in person. Unfortunately, she had a scheduling conflict. She is in, Washington, DC with the federal delegation right now, talking through current and future status of public health issues that affect the state of Connecticut and the nation. We have submitted her written testimony for your review. I will say that during our preparations for this hearing, Commissioner Jutani wanted me to make sure that I communicated to the committee her commitment to the successful implementation of the proposed changes to the certificate of need program. We do believe that these proposed changes will help to make the CLN process more efficient, more predictable, more transparent, and more effective for the state. And we think that the leadership and administrative support from DPH can help do this. I'm happy to answer whatever questions I can alongside mister Jackson. Thank you.

[Sen. Saud Anwar]: Thank you so much for your testimony. I would divide the the questions probably many of us may have into two broad categories. One is about this transition. The second is about the actual process. And there's a historical concern we have about the process, and then we'll touch on that in a second. But I wanted to ask you some very fast questions and one yes, no kind of answers, which I know that I know the answers to, but I want them to be on the record so everybody knows. For this transition from office of health strategies to the department of public health, would would anybody lose jobs? No. Okay. Would the budget change total dollar amount?

[Boyd Jackson]: No.

[Sen. Saud Anwar]: Okay. And so that's important to have that on the record. And and what would be the two or three big reasons to make this transition? Because many years ago, this was part of department of public health. It was felt that the the bandwidth that was needed and the work that was needed was, taking resources away from the Department of Public Health, and and it was separated out. So what is different now?

[Boyd Jackson]: I think the the biggest thing that I would point to are are some of the efficiencies that will come about, and it's not about doing the same with fewer people or with less resources. It's about doing more with the existing resources. I think one big thing is that we're gonna see some economies of scale with the support that the programs can receive. We're a small agency. At a small agency, people have to wear a lot of different hats. As you heard, I wear a few between, my responsibilities. Certainly, a lot of my staff members are supporting either other programs. Certainly, the attorneys who support, the certificate of need program as hearing officers or as compliance investigators also are working on FOIA responses, contracts, data use agreements, our ethics policies. You know, the Department of Public Health has a much broader infrastructure across all of the administrative functions and support functions. I'm sure the deputy commissioner can speak to some of the efficiencies expected there. But this is really about making sure that programs are located where they can have the most support and the most success, in their operations. As it relates specifically to CON and one of the elements of this bill, one of the concerns that we heard raised last year were when there's a proposal, the number of stops that an applicant would have is has grown over time. They have to come to the office of health strategy. They have to go to the department of public health. Often, they have to go to the attorney general's office. There there may be other stops along the way. So, for example, this process, there's a change of ownership process at the Department of Public Health and there's a transfer of ownership CON requirement, which currently is housed at OHS. This would bring those two together under the Department of Public Health, and you would have one application with all of the materials necessary and then it would be on the state to coordinate, integrate those processes, and handle them all for you so that you're not having to figure out which papers do I file with which entity, where do I go for these things. It's a much more streamlined process. So as specific to this proposal and the relocation of CON, I think that's one of the biggest effects.

[Sen. Saud Anwar]: Thank you so much. One of the other parts is with respect to the actual process. I would divide them into three broad categories. One is which issues do we need the c o n for to have increased number of or access or increasing services. And the other end of that is leaving the services in some communities. And then the internal part is how long does that process take? So I I think, from what I understand from your testimony and our conversations, the central part of the process, which was a big concern to many of the public health committee members in the community at large, we have come to a point where it's getting the emergency process that was created has shown its results. And thank you for the good work that your office has done for that purpose. The issue comes down to is that for the emergency. For the regular, is it gonna be back to the same way of doing business, or it's going to be everything is going to be much more streamlined?

[Boyd Jackson]: Yeah. I I think it's definitely going to be streamlined. You know, the the OHS has made great strides over the last few years in our processing timelines going from somewhere around three hundred days on average down to about 180. It's somewhere in the ballpark of 58 to 60% reduction in the days that it took to process the average application. And we're really proud of that. But I think what we're recognizing in some of this legislation and some of what we've proposed in the past is we're bumping up on the edge of what we can do without changes to the law. So that's what we saw with the emergency CLN. We needed to change the law to be able to do that process efficiently, And that was really what we focused on here is what are the changes we need to make sure that we have the resources and the ability to to move this along. So one of the things that I've heard from, many members of this committee over the last few years has been Massachusetts seems to be doing it well. Why don't we learn something from their process? Our process as it exists is laid out with significant detail in the statute. Every step that we take through the process is dictated in the statute with a specific timeline. We're we're given a certain amount of days. Applicants are giving a number of days. It goes back and forth and back and forth, and it builds out this process that that can take some time. Massachusetts says much more, get it done in this time period. And what you need to do in the back and forth and asking questions back and forth can happen within that time period. And that's the approach that we've taken in this proposal today. It says much more, you know, fill in the application, get it in, deem it complete, and then you have a certain amount of time. You need to do your hearing in there, you need to ask your questions in there, and you need to get a proposed final decision out and ready for review by the panel on a given timeline. We think it provides a lot more regularity, clarity, equality between applications. And so we think that overall that that's going to streamline the process and provide the agency the ability to to get the job done.

[Sen. Saud Anwar]: Thank you. I just have one last question from my first phase of question that I I'll have my colleagues start the questions. And this is for, the deputy commissioner, Orefici. A deputy commissioner, you guys have a lot of work because of a number of things that are happening in the state, but outside of the state with policies. Is this going to slow any of the other things down? Because you need to ramp up quite a bit, I anticipate.

[Adelita Orefice]: I don't think so. I think we're pretty organized about doing that, and I think that commissioner Jutani and her leadership team are pretty committed to making this successful. And I'm not just saying that. I think we have a plan. We've collaborated well with, mister Jackson and his team. I bring to the table some CON, experience from Rhode Island and Massachusetts. So I think that we're pretty confident that we can help the staff successfully transition to the department and to give them the kind of administrative and leadership support they need to be successful.

[Sen. Saud Anwar]: Thank you. With that, my cochair representative, Kristen McCarthy Behney.

[Rep. Cristin McCarthy Vahey]: Thank you very much, chair Anwar. Thank you both for being here. And I am smiling because we have had lots of conversations about this topic at this committee since I have joined. And I know even before I was a member as well. This is a significant change in the way that we are currently doing things, and I appreciate the ability to have conversation here. And I will just note on the record after this hearing, I anticipate that we will be having many, many other conversations as well with you, with our with us those of us in the leadership of this committee and other stakeholders. So I just wanna share that publicly. But one of the questions that I have just looking at your testimony, mister Jackson, the the expanded review to capture transactions, and you use the example of the sale leaseback to real estate investment trust, otherwise known as REITs. And as, you know, we have a bill in this committee that has made its way through the JF process. There was testimony on that bill related to REITs versus other financial instruments that might be used. And sometimes here, we kind of interchange different things. So my question is, that expanded review and the ability to capture such transactions, would it also cover transactions that were not just REITs, but perhaps other financial instruments as was referenced in that testimony?

[Boyd Jackson]: Yes. So it's it's a broadening of the definition of what a change of ownership or control would be. Currently, it's a a transfer of ownership, which is tied to specific governance changes. This would expand that broadly for whoever was was buying a substantial part or or buying the ability to control a substantial part of a health care entity.

[Rep. Cristin McCarthy Vahey]: So just to clarify, substantial control, which would include the the land, the pro the real property, and potentially put into effect a sale leaseback. That's right. You're you're affirming that, yes, that that's what this language would do. That's helpful, I think, and important, even as we have a parallel conversation in that other bill. The other thing that I wanted to just ask you to do, as you often hear me say and my colleagues, our fourth grade level is what I welcome. And I think you've done a great job in your testimony outlining things in a very clear way. But there the changes, kind of the high level highlights of what the significant changes will be. I know you went through some of them, but there's more in your later testimony. And I wondered if you could just expand upon that a little bit, how the process will change. I know you talked about streamlining, but if you could just give us a little bit more detail on that, I would be grateful.

[Boyd Jackson]: Yeah. I think one of the big changes to the process is the final decision maker. The final decision currently lives with the commissioner of the Office of Health Strategy, and it has since it moved to the Office of Health Strategy. So the big change is to bring a panel as the final decision maker that would have three people as proposed, chaired by the Commissioner of Public Health as the person responsible for the program who's doing all of the work collecting the information and doing the analyses, the Commissioner of the Department of Social Services, and the Secretary of the Office of Policy and Management. The thought is it's important to bring a variety of perspectives to that final decision, and these are the people in the government who are most closely tied to all kinds of decisions made in the health care sector. So with DSS, obviously, over the Medicaid program, Medicaid access is a key part to the CON program. In our existing criteria, there are 12 criteria and I think three of them, so a quarter of all the criteria, reference Medicaid access. Obviously, that's an important part to this, whole analysis and so having their voice at the table to share information would be useful. OPM, obviously, the state is a major payer of a lot of health care services and and involved across the spectrum. Also, you know, certain elements of OHS are proposed to go, to be under OPM as well. And so I think having, ensuring that we have access to that expertise in the the final decision making would be really useful to to that process. So that was probably not fourth grade, but the key point is having a panel as the final decision maker is one of the big changes to the process.

[Rep. Cristin McCarthy Vahey]: Any other pieces that you would like to highlight and, again, with a little more detail is fine?

[Boyd Jackson]: I I'll highlight the change in how hearings are are handled in the process. Historically, you could demand a hearing or the agency could hold one under its own discretion. This would flip that and say, we're going to give a hearing to every application unless the applicants waive the right to a hearing. So they would automatically go to a hearing and have opportunity to hear that. They can waive that right unless there's an intervener, which is a little different than the current law. Currently, you can demand a hearing as long as I I get the numbers flipped. I believe it's if you have three people or you represent an organization that is made up of at least five members, you can demand a hearing. This would and it could be anyone. This would say that you have to have intervener status, which is a a higher threshold. It's under the Uniform Administrative Procedure Act. It involves articulating how your rights are tied up in the decision making. So it would it would reduce the ability of someone to force a hearing just because and require that it be someone whose rights are tied up in the proceeding in order to force that hearing. But it flips the presumption and and says that applications would go to a hearing. Then it makes sure that everyone produces a proposed final decision. Again, this goes under the Uniform Administrative Procedure Act. A hearing officer would preside over the hearing, collect all of the data and information, presented, and issue a final a proposed final decision. It articulates all of the legal considerations, all of the factual basis for making a decision. It proposes that decision. It could propose conditions to impose on the process. And then all of that's made public. It would be on the on the website, conveyed to the panel. And then at the panel, they would have an opportunity to hear from the applicants, whether they agree or disagree with the proposed final decision, whether they agree or disagree with any of the conditions that were imposed, and then the panel would take all of that information in and issue the final decision.

[Rep. Cristin McCarthy Vahey]: Thank you. And last question for now and here at the hearing, not the last question on this, but, can you tell us talk about some of the stakeholders who you have had conversations with as you have worked on this proposal and just share that with all of us here, that would be really helpful.

[Boyd Jackson]: Well, the first thing I would say is this proposal is the culmination of two and a half years of engaging with stakeholders. Obviously, I'm here in multiple capacities, legislative capacity, but I spend every day working on CON decisions. So I engage with the hospitals, the ambulatory surgery centers, the behavioral health providers, physician group practices, the radiologists. I'm sure I'm forgetting some of the people I spend every day talking to. I work with them directly. I work with their attorneys who do this across the spectrum. So I hear about what is and is not working every day. As we started gearing up toward this proposal, I met broadly across the government so that making sure that we were bringing all of our expertise to bear with the Department of Public Health, Department of Social Services. As you know, the Department of Social Services has their own certificate of need program. So we can we compared to say, how does their process work? How does our process work? What can we learn from each other? How can we streamline those processes? Since we've released the bill, we've obviously had a number of conversations with members of the committee, with other legislators who have particular experiences with the CON program, positive and negative, to hear what has worked well, what hasn't worked well. We've met with the, the medical society, with the ambulatory surgery centers, with the radiologists. I'm sure I'm forgetting several. They're in my notes, I promise, and we are collecting all of that. We appreciate the feedback. I think anyone who's engaged on this issue and looks carefully and honestly, I can identify something that points to every stakeholder that we've met with over the last couple of years and how we've tried to reflect the feedback that we've gotten. It I'm certain it doesn't address everyone's concern on every issue, but we've really made an effort to try to take that feedback in and make sure that the the process is working for everyone.

[Rep. Cristin McCarthy Vahey]: Mister Jackson, I would like to take this chance to say thank you because you have been in an unenviable position in many ways. It's a difficult, task that you have ahead of you, and I think we have had a lot of challenges and you and your agency has they have worked hard to try and address those. I know that this is another step in that conversation, but I appreciate the collaborative nature of the work that you've done with this committee and with those stakeholders. And I look forward to more of that as we go forward in this session. And with that, mister chair, back to you.

[Sen. Saud Anwar]: Thank you. Representative, clear this detail.

[Rep. Nicole Klarides-Ditria]: Thank you, mister chair. Thank you, Boyd, for being here today, both of you. I know I could probably speak for this entire committee. I hope this is the last time, the last time we're dealing, excuse me, with C O N. But thank you for all the work you've done. I know it's, it's not easy. You've always been there to answer our questions and our concerns. But a couple of my questions, the first one is, under this bill, what are what are the services that would be eligible for expedited CON?

[Boyd Jackson]: So this the bill would leave the designation of those categories up to the panel for for a number of reasons. We want to make sure that there's a broad stakeholder input on that process, so it would be done through policies and procedures. The panel would be able to designate which categories or subcategories are eligible for expedited review. So, you know, if you if you take a broad category, it may be that they say one element of those types of proposals would be eligible but not others because we've identified a particular need, and so we think that, you know, we want to expedite that as maybe it's an incentive to get people to go through the process, reduce that burden.

[Rep. Nicole Klarides-Ditria]: Thank you. And I hope this if and when this bill passes, that the goal is, as we know, access. We wanna streamline this process because we know it's been fragmented over the last few years. But another question on the panel, and one of the we had talked about having maybe considering not having the Office of Policy and Management there and maybe using the health care advocate in their place. Have you had any further discussions with anybody in regards to that?

[Boyd Jackson]: Yeah. I mean, we're certainly always happy to talk about who the right people are for that panel to make sure that we're getting the right voices in the room. I think that OPM has a lot to offer as I articulated. Obviously, they have a lot of experience in the health care sector, and they're going to be inheriting key parts of, OHS that would inform that. I have talked to the health care advocate about, what a role for that office could look like. Early conversations, I think I think the health care advocate will be here, later to to provide some testimony about the the perspective that they could bring. Obviously, they advocate for patients every day. I would like to believe that we all have patients at the center of our analyses, but certainly having a voice in the room could be useful, and we're happy to have those conversations.

[Rep. Nicole Klarides-Ditria]: Thank you for your answers. Thank you, mister Sher.

[Sen. Saud Anwar]: Thank you. Before we ask, senator Gordon to ask his questions, I just wanted to remind people who are online, who are attendees, when it's gonna be your opportunity to speak, you will get request to become a panelist. If you do not accept that request, you will not be able to testify. So please keep that in mind. With that, senator Gordon.

[Sen. Jeff Gordon, MD]: Thank you, mister chairman and mister Jackson. I know we've had discussions. And as you know, I have a particular interest in this and detailed understanding of it. I've also been a huge public critic of the current c o n process in the way, I'm not blaming you, but the way that prior leadership of the office of health strategy used CUN, I think completely wrongly. But that that we can get into another time. But I as you know, I look at the nuts and bolts. I do believe we have to take care of CON. I know I've had proposals others had as well. I think we need to streamline the process in many regards, not a 100%, when health care facilities, especially hospitals, want to expand certain services or certain inpatient beds, for example, and really make certain our focus is when services are being cut by hospitals. For example, in Northeast Connecticut, decisions by OHS in the past have been detrimental to health care up in Northeast Connecticut, especially women who are seeking labor and delivery services. And that's another matter that has to be addressed. But I have a few questions, and I look forward to having follow-up meetings with you. What I have is, as you know, there's the rule the rural health transformation program application that the state of Connecticut submitted. Did get approved. The governor signed off on it. And I've read through forget how many pages this is, 70 something pages or so. And in there, there is I think it's c three. It talks about wanting to make substantive changes to the, CON process that's built in. And so, Connecticut is gonna be tagged to wanna do that. I'm just interested in your understanding and OHS's understanding of with that application. Is it that the state of Connecticut was saying to the feds, give us the money, approve our grant application, and changes in CON would be to try to streamline the process, but not necessarily try to expand it to start getting into folks who are not fully tagged now in the process, such as small group practices of physicians, things like that?

[Boyd Jackson]: I do know that that we made representations about streamlining the process. As to the specific commitments made, I'm not the best person to speak to that. So I I am not sure exactly what those commitments were. I do know that we view this as a major step towards streamlining and reforming the process to make sure that we're reducing the burden on applicants.

[Sen. Jeff Gordon, MD]: No. I appreciate that. And the reason I'm asking is I just wanna and we I can follow-up, mister chairman, officially outside of the hearing that we just want to make certain whatever is being proposed here and, gets worked on does not conflict with whatever I'll say promises were made in writing to the federal government in order to get the application for rural health transplant transformation money approved. So I'm happy to meet with you and we can discuss that further and I'll send a letter to ask because it's extremely important because if it conflicts it puts that money in jeopardy, and we don't want that. So I think we do need to take a look at that in detail. And one other item I have, I have lots of questions, but I'll just end with this one, is I'm trying to understand what is the, reasoning behind letting an applicant waive a public hearing. And then the public would have to seek through an intervener status, which, as you know, is not always straightforward, and most people in the public don't even know it exists or understand how to apply for it, versus just saying if there's gonna be a public hearing, there's gonna be a public hearing. Anything being proposed that has to go through CLN is deemed in the public interest. Why are we making it more difficult for the public as opposed to weighted more for the applicant to say, I waive the public hearing and thus the public may not even know how to then provide input if they wish.

[Boyd Jackson]: Yeah. Well, the COM process, as a whole is the public process. It requires letter of intent. This this proposal would require a letter of intent, which would be posted on the website. The quarterly application cycle, we think, will help people be able to track things a little better so that you're not having to constantly refresh our website to see if a new proposal has been posted. If there would be a little more regularity. All of the application materials are public, so there's an opportunity to comment publicly anytime. And I know many people on this committee have taken advantage of that. I'm sure many of people in the room have as well. I received the public comment this morning. So there's that opportunity to share information. We've historically treated hearings as an opportunity to pull out additional information that we might have had a hard time getting in written questions back and forth. It can just be more efficient to do that. I think the thought was hearings have an expense that come along with them, and so offering the applicants to waive that it's it's really about their procedural rights to have the hearing to come and present their application to the hearing officer. If they waive it, they also waive their appeal rights. So we think that, you know, that's also a deterrent if there's a reason to have a hearing. But it's really about the cost. I know that applicants have represented that engaging an attorney to show up at a hearing and prepare and do all of that work can be a burden. And so the goal is to offer that kind of that avenue for reducing the burden of applying by saying if you if you are satisfied with what you've submitted in your written application, again, the burden is on the applicant to demonstrate that they meet the criteria. So if if you're confident that you've demonstrated that and you don't have a need to present publicly, then then you can waive that right. Public is always able to comment in writing. We get voice mails left. So we we definitely want to hear from the public. It just may not be at the hearing, which history says is not where most of the public comments have been made.

[Sen. Jeff Gordon, MD]: I appreciate that. Thank you. And I look forward to following up more on that including about the, rural health transformation because I do think what was put into that conflicts with this proposal, And that's a serious concern. I'll just end saying that if we're trying to make the process better, we should not be expanding unnecessarily the time, resource and financial burdens on small physician and health care professional practices who are struggling already in Connecticut and This proposal trying to tag them more I think goes in an opposite direction And I believe based upon that in the wording of the governor's application to the feds for the rural transformation funds conflicts directly. So I look forward to having further discussions and also here in this committee. Thank you, Mr. Chairman.

[Sen. Saud Anwar]: Thank you so much. I just wanted to make a quick little comment. So when we have this confirmation because, we as as, the leadership of the committee would very be very much interested, because, we were also approached to see if the c one process would be streamlined, and and this federal grant is a multiyear grant. We do not want to lose any funds for technical reasons. I wanted to leave you with a thought, and I know one of my colleague has a question for the deputy commissioner. In the past, it felt that there was not a broader vision or operating principle. It was everything was technical, technical, technical. And, if there's a broader vision that the c one process is to and I've made a list of things to improve the access. Look at the disease pattern that has changed, demographic shifts, and, and, also, gaps in, in care for the communities, cost of healthcare and protection from private equity or, or people with the poor track record in the past. So if there was a broader vision that was in place that would help us as well, because once somebody applies, you'll you'll look at it from the technical part of it, but there's no broader vision that at least I have been able to see in the operational strategy. So I I wanna look at that and I've asked those questions from many people. And and I've asked where do you see the health of the state? What is a five year plan? What is a ten year plan? What is a disaster plan and the broader strategy? And then and, I have had answers, reasonable answers, not satisfactory to me, but it's it's worthy to have that conversation, not today, but another day. With that, I wanted to ask representative Kai Belton. She has a question for one of our panelists.

[Rep. Kai Belton]: Good morning. I have a question about, the opposition, for the menopause toolkit. Can you tell me more, about why that opposition is? Is it about capacity, outside expertise? Just tell me more.

[Adelita Orefice]: Thank you for that question. It's exactly that. It is about capacity and outside expertise. We would have to resource that. We would have to hire it, and there were not funds included in the governor's budget for that.

[Dr. Elise Courtois]: Thank you.

[Sen. Saud Anwar]: Representative Christian McCarthy Vehi.

[Rep. Cristin McCarthy Vahey]: Thank you for the second time. This one is just a follow-up to you, probably you, mister Jackson, in terms of the idea of streamlining versus not streamlining or streamlining and expanding, which I think you can have both happening at the same time, which is I think what your does streamline quite a bit. And it it expands. And this is a a conversation we've had, I think, at this table and others multiple times. Why? What is the why behind that? Can you talk to us a little bit more about what is the reasoning behind looking at this different strategy, which what, Senator Anwar and Senator Gordon are saying is accurate. We have many struggling practices, but I know that there's there two things can be true at the same time. We also have some other situations happening, and I believe that's the why behind this. But if you could expand on that, that would be great.

[Boyd Jackson]: Yeah. Thank you for the opportunity. Certainly, I don't have to tell the the doctors on the the dais that, the the practice of medicine has changed, over time and the the atmosphere and environment in which the physicians are practicing has changed over time. And we've heard a lot about the difficulties that small independent group practices have had to stay afloat, and and we get that. And I think that the proposal is really to have some oversight over what's happening when those small independent group practices are being acquired, taken over by these larger entities of various types. So we've talked in the past about insurance companies that are buying up group practices and what does that do to patients' care. We've seen commercial retail pharmacies buying up group practices. Certainly, the hospitals have acquired a lot of group practices. So that's private equity has has gotten involved in a lot of group practices. What we've heard in the past is private equity can be a lifeline for group practices to stay afloat and stay independent of all of those other large entities that I just described. And what we've tried to do in the proposal this year is acknowledge that there are business realities to the practice of medicine that may be completely appropriate. So we've talked over the last couple of years about managed services management services organizations, MSOs, and management services agreements, MSAs. There may be a role for these entities to provide some back office support. What we've proposed this year is an exemption from from this enhanced requirement. If you are contracting for these management business services and paying a fair market value under a contract. So that would be like saying, hey. We need support with our, you know, back office business work, and we're going to pay you x dollars a month for conducting those, business dealings. The same way that someone might hire an attorney and pay a rate for the legal services that they're providing to the physician office. We think that's fine. Where the concern arises is when significant portions of a group practice are sold off to these other entities, including management services organizations. Then we worry about there being a little more control in what's going on as a group practice with the practice of medicine, and we think that that that should just be reviewed. We don't propose to ban any of these arrangements, But we do think that it's the responsibility of the group practice to come in and just explain why this is needed, what they're doing, so that the state can look and say, yes. That seems completely reasonable. We support you. Go and take care of your patients. Or it looks like this financial institution is taking over the practice, directing care, maybe limiting how much time an individual can an individual physician can spend with patients, and we need to impose some conditions to make sure that practice that, you know, proper practice is maintained or, you know, setting staffing levels, setting what type of care is going to be delivered. Those are the kinds of things that we've seen examples in the past and that we would want to protect against.

[Rep. Cristin McCarthy Vahey]: So and thank you for your indulgence, mister chair. Just to follow-up to that. If I'm not a physician as you all know. If I'm a physician and I'm selling my practice and I have an entity that is telling me you're you are only allowed to do this or that, I'm my logical thought is I'm not going to agree to that or to those terms and conditions that doesn't seem right or practicable as the practitioner, as the provider of care. So are you seeing this? Have you seen examples of where this has happened and this has occurred? We often have that question here. You know, is this actually a problem that you've seen and or is this just something that we're anticipating might occur?

[Boyd Jackson]: At present, the CON program doesn't review these transactions because there's a a major exemption for if you're selling a practice to another physician or group of physicians. We know that these deals have been designed so that that is what is happening. And so what we see is an an entity that will sell off all of its nonclinical assets to one organization and all of its clinical practice to a physician associated with the entity that bought all of the nonclinical assets so that money is flowing in a certain direction. We've seen it in individual transactions. We've had it explained in very large commercial entities that say, we have seen press releases that say large commercial entity bought this group practice, acquired this group practice. And so the agency follows up to say, that sounds like the type of thing that requires a CON. Can you please explain why you did not get a CON? And then they say, what we said for the public was not exactly how it worked on paper. We spun off the non clinical assets to this entity, we spun off the clinical practice to this physician who works for us and owns a large number of group practices as the physician theoretically in charge, and so you don't need to worry about reviewing it. So we don't review most group practice transfers because of that exemption. But I have read significantly in this area. I have met with researchers, with people in practice. I've been an attorney on all kinds of transactions and seen how these things work. Often, you have a group practice that is selling, and physicians may have a set time that they're going to continue with the practice. Other times, they're leaving the practice, and they will be absorbed and replaced with other types of clinicians or practitioners. So I think often you hear a very different view of this from new physicians entering the workplace who are seeing these group practices being bought up and are seeing the type of influence that that we're describing. It's it's folks who who may be leaving the the practice and are leaving their practice to this other entity, and then it's the new people who are experiencing the new types of control.

[Rep. Cristin McCarthy Vahey]: Thank you. I just I just want to acknowledge it's really complex because our providers are just facing increasing pressure. And when it comes to thinking about, you know, passing on a practice, a succession, retirement with the difficulties of, you know, saving for retirement even, I I am very sympathetic to that, and I think it's something that we on this committee, you know, I will we get there on that this year? I don't know. I I will I appreciate the comments from the good ranking member that she hopes that this is the last time that we will be talking about this. I may not be quite as hopeful, but I do I do think that this is a worthy conversation. I just, you know, I'm being very candid here that I I don't know where we land on that this year, but I'm very encouraged by many parts of this conversation today. And, again, wanna say thank you, and thank you, mister chair.

[Sen. Saud Anwar]: Thank you. I just wanted to make a quick comment on this. I I want we had a a public hearing on on a private equity bill, and we have another one today. And we had a number of experts who came in, and we asked this question. If you have limited resources and then you wanna try to make the biggest difference, what is the area of opportunity to work? We wanna try to stop everything that from happening. That's easy part, but do we have the resources? Because our track record suggests that we may not have the resources. And in the current budget environment also suggests that. And the answer to that was that, well, the bigger transaction with hospitals is where the ROI is gonna be the best to protect the people. And then that's what it but if we were to go after one or two clinician practices, maybe you'll find something, but the number of personnel to look at that and the return would not be worthy. So again, that's something that some of the experts said, and you probably are privy to some of the previous conversation, and we may have more today as well. I have a question for the commissioner, deputy commissioner. A deputy commissioner in your testimony on on the question that represent Belton had asked that an act concerning provider toolkit for the diagnosis and treatment of menopause and perimenopause and postmenopause. When your testimony, is it the official position of the Department of Public Health whenever there's a bill where DPH is involved and if it is not in the governor's budget, you would say no right off the bat?

[Adelita Orefice]: I think that would really depend on whether or not we had existing resources that we could leverage or leverage or existing expertise. And in this case, we really don't.

[Sen. Saud Anwar]: So perhaps because and and and this is more of a suggestion for future because if somebody is looking at our state and even the people within the state are looking at it, and and to every policy suggestion that comes is that we don't have the money, so we are against it. But there's a intellectual, there's a public health component to it. So there needs to be an intellectual public health conversation that, yes, this is an issue. There is a big problem. We acknowledge this problem, and we feel it's worthy to have a conversation on this further. We do not have it in the governor's budget. We will try to see if we can have further conversation and look at it rather than say no money, goodbye. I mean, I'm just exaggerating, but but you know what I'm saying.

[Adelita Orefice]: Totally appreciate that. And we are certainly happy to have additional discussions. Yeah. And at this point where we are right now, we did not see places in the department where we could leverage existing resources or expertise to do this well. As you all know, we're losing a significant number of federal funds, and we're managing that. And so, I think until we get through this part of the year, it's kind of a conversation that's difficult to have in terms of resource allocation, but we're certainly open to having additional conversations about the policy ideas behind this and how we might be able to leverage other funding sources to do this kind of work. Yeah.

[Sen. Saud Anwar]: Thank you for that. And we are we are fortunate. We know people personally and we know it is far from the truth. But but for somebody else who does not know, they would say that DPH is not interested to do any public health policy issues. And and that's far from the truth because we know that you are all consumed by doing it, but you're also overburdened with dealing with so many other things that are on the table. So I appreciate you being here. Seeing no other questions. We have senator Gordon has a second round. Go for it, senator Gordon.

[Sen. Jeff Gordon, MD]: Thank you, mister chairman. I'll I'll be brief. I'm just trying to understand where I'm not blaming you personally, mister Jackson. I think you and I must be seeing different things in the state of Connecticut relative to, the private practice groups. Yes. There's been maybe one that was a blatant, in one large group trying to perhaps do an end run around CON. There's processes to tag that. I'm extremely concerned, and I agree with my colleague and fellow doctor, Senator Anwar, that, you know, there was statements made last year that, well, we gotta throw a broad net and see what we find relative to out there in the the group practices, including small. And that's a, I think, a bad mentality. I think we know where problems have been and failures of state government to act in a timely manner. And that should be the focus. If it's one thing where you have an insurance company or a large hospital buying up a group, a private group, well, sure, one can look at that to see what there might be, and there may well be concerns. But I think if one has a mentality to say for all these private groups, even maybe small ones of, like, three people, three health care professionals to say, come on into OHS or DPH, wherever OHS ends up and explain to us why you don't need a CON. That's a wrong way of doing it. I don't see at all, and I know nearly all of the group practices in the state of Connecticut, Where they would even fall under a CON so if you have a group practice of three doctors who Wants to merge with another group of three doctors because they find that's a way to survive in a difficult financial environment of Connecticut then we should say thank you and help them. I don't think we should drag them in and explain why they don't need a CLN. I think if one's looking at what to do, especially with limited resources, which we're just hearing now on a different matter, then we really should focus on where we know the problem is. And I'm happy to have further discussions with you. I agree there can be concerns, with large hospitals, perhaps putting conditions. Mean, there was one large hospital system in this state that's trying to make doctors and others see patients in fifteen minutes, including complicated cases. I don't know how you can even do that in thirty minutes, let alone fifteen. I think those are reasonable things that we should be looking at. I think we should understand the reality of the small group practices and try not to burden them more. So I just want to say we should endeavor to do that and pull back on some of this broad reach. And I think it would be more effective that way. And then one can take things off from there. Thank you, mister chairman.

[Sen. Saud Anwar]: Thank you. I take that more as a comment. So right?

[Sen. Jeff Gordon, MD]: Yes. Yeah. Any any of my questions were rhetorical then.

[Sen. Saud Anwar]: No. This is good. Perfect. With that, I don't see any more questions or comments. Thank you so much for your testimony and and your work. We look forward to working with you closely. The next person on our list is on number three, Kathleen Holt, state office of the health care advocate. Thank you for your patience. Welcome. And that'll be followed by representative Laurie Sweet. Thank you.

[Kathleen Holt]: Good afternoon. Senator Anwar, representative McCarthy Dahee, senator Summers, representative Clarides Ditria, and members of the public health committee. I'm Kathleen Holt, state health care advocate. The office of the health care advocate is an independent state agency with a consumer focused mission to help consumers locate, understand, and obtain appropriate health care coverage from all types of health care plans and to speak on behalf of consumers in policy discussions. I submitted written testimony on proposed bill house bill fifty forty five, which we've just had a very, robust discussion about, an act streamlining health care facility approvals. But I wanna speak to the OHA, the office of the health care advocate perspective on the proposed certificate of need unit and panel. Our ideas, our thoughts on strengthening it, and to points raised in other testimony about proposed revisions to the COWN process. To senators on to senator Anwar's point about a broader vision, I could not have listed a better, opportunity of all of the things that were said, about the concerns, about the demographics, the changes in procedures, what we're seeing in the changes of health care, in Connecticut and in in the country, and and in health care generally. Consumers, providers, and payers were all frustrated by a dysfunctional unmoored health care system, and we have to try to get our hands around the entire picture to keep it all afloat as best as we can. So I'll focus as an example on the reality of health care payment. That's something that the healthcare advocacy, operation, our office deals with, on a regular basis. Every day, dozens of consumers that contact us that need to have something fixed with their health care and their payment. That is our main focus of our organization. Ninety five percent of Connecticut residents have some type of health care insurance. Some people have state regulated plans, fully insured, the Affordable Care Act plans, some have Medicaid, but the majority of state residents have the, federally funded Medicare plans or the ERISA plans through, individual employers that that, provide their insurance for them. They are not substantially influencing Connecticut policy. When I say that, I mean, the majority of our plans we have, and an office of health care, advocate is highly involved in those types of plans every day, as we know, are all the providers. Where do you draw the line? How do you know? What we hear from providers at our office almost as frequently as we hear from patients because providers are up in arms. They don't know how to deal with all of the insurance companies that they have to face, and they want our help because they know that access is harmed for their patients. So they're turning to us to try to get them help, and we've had a lot of difficulty in in managing the volume of concerns that we have. In order for the the CON process and the approval process to operate as successfully as possible, the entirety of the payer systems have to be considered. We don't have to influence them as a state to understand and incorporate them into the calculus. Medicare should be considered and incorporated into the calculus. I submitted substantial comments to a proposed rule to CMS on changes to the private Medicare Advantage System that will take effect next year. We'll get the final rule next month or May, but the reality is the changes are horrible. The changes will significantly impact people in Connecticut, the twenty percent of people in Connecticut who are on Medicare, even in the the private even in the public Medicare, arena. We have to make sure that we are considering the impact that is happening. A growing number of high deductible plans may be increasing hospital length of stay. Why is that? People are not going to the hospital when they need care. They are waiting. And by waiting, their care is more intense, and so their their length of stay in the hospital is longer. And why are these, actions happening? Because we are not looking necessarily at the payers that are influencing these actions. It's critical, and the CON unit needs to have deep expertise and understanding of all payers, providers, and consumer needs and behavior.

[Committee Clerk/Timer]: Excuse me, miss Holt, but you've reached your three minutes. Thank you.

[Sen. Saud Anwar]: Thank you. We I have a question, and then maybe you can add a few more sentences that you have. If you if your office thank you for so much for your testimony, and thank you for the work that you do. When when we are struggling with the situation, we reach out to your office for helping out. If if your office was to receive a 100 calls, what percentage of those calls are about the insurance company making it difficult for the patients to get their care?

[Kathleen Holt]: Close to a 100%.

[Sen. Saud Anwar]: Yes. I think this is something that the public needs to hear that it has been written and published as well that one of the threats to the well-being of the citizens of a community and a state is the heavy handedness of the insurance industry of restricting care that medical personnel have written and identified as with trained individuals to give them the care. And then that's one of the biggest issue that we are dealing with. That tells you that the office of HealthEdGrid is not being impacted by patients not getting the the physician or a specialist to see them as much as it is for them to be able to get the medicines or get their tests and then and where the insurance have closed all doors. This is very helpful. Do you wanna add anything else?

[Kathleen Holt]: Yeah. I just wanted to mention, as if from the standpoint of what I was just the example I was giving about the payment, the the proposed panel of the commissioner of the Department of Public Health, the the commissioner of, DSS and OPM, all amazing, wonderful positions and opportunities. But again, it goes to the point that we have to consider that Connecticut is in a bubble, that we live in a federal system, that there are a lot of other considerations that should be happening, that that there should be a broader vision for that.

[Sen. Saud Anwar]: What do you think would be beneficial? Do you think somebody from your office or others should be there?

[Kathleen Holt]: I I think it would be helpful. But, again, my I am not I'm not deep into the understanding of whether or not the CON unit has that expertise. If that expertise is there and there are people who are, commenting on Medicare rules and are very familiar with how those processes work, then maybe that's already built into the system. I'm just suggesting that there should be that broader vision of how this how these, decisions impact one another and impact the residents of Connecticut.

[Sen. Saud Anwar]: In our previous conversation on CON, we always had a critical issue with them was that there's no clinician or person with a medical perspective in the room they don't understand at times. So everybody's a lawyer looking at the legal part, checking the boxes, and then it's taking away from the medical perspective in in many aspects. So your your testimony is very helpful. And I know rep my my co chair has a question and followed by representative representative Kristen McCarthy Behay.

[Rep. Cristin McCarthy Vahey]: Thank you very much, mister chair. And thank you so much for being here and for being our advocate here in the state. And you heard me say earlier, I love my fourth grade example, but just to very explicitly help us understand where and how that benefit of that perspective could practically impact a CON conversation and deliberation. And I I think it's important for us to understand as as concretely as we can, because I agree as a social worker, it's that systems perspective. And, certainly, there is no bubble. You if you pull on one thing here, it impacts over there. And, you know, what senator Amor is saying, yes, having the broader perspective on multiple fronts is important. But how do you think having someone you or someone from your office participate in those deliberations would have an impact practically in that process?

[Kathleen Holt]: Well, I think we come to the reality hearing the stories of consumers every day and and looking for the patterns that arise from those that that we can offer that perspective into the process so that we look at, geographic differences for, healthcare delivery and, and and the opportunities that come up, how how you you make a you make a decision in one, for one facility or one provider, how that impacts every other provider, and then how that, is overlaid by the residents and the impact that it has on, on the citizens of Connecticut.

[Rep. Cristin McCarthy Vahey]: Thank you. I appreciate that. And you mentioned that you weren't sure if that type of expertise currently exists within the CON unit. And I I won't ask, but just rather invite I'm hoping that you and mister Jackson can have a conversation more specifically about that because I anticipate, you know, based on the questions you've already heard here today and some of the comments that we'll be having further conversation about this. So if you all can have that direct conversation before we all do together, that would be wonderful. Thank you, mister chair.

[Sen. Saud Anwar]: 100% clear it is, D. C.

[Rep. Nicole Klarides-Ditria]: Thank you, mister chair. Thank you for being here today. And I know, we we touched upon the panel and and possibly having your office in there, instead of OPM. And what are, specifically, again, to my good chairs, fourth grade level, why your office versus OPM?

[Kathleen Holt]: I again, it it depends on the the over overview of the entire, operation. But my my my perspective comes from being on the ground with consumers on a daily basis and understanding all of the various different opportunities that come both from within the state and outside the state in terms of how they are insured, how the payers operate, the behavior of the the providers and the payers and the, the consumers together. It's all interwoven in a way that I think, that the state doesn't necessarily see how the Medicare process, how the ERISA process implements that influences that, and I think we could bring that part to the table.

[Rep. Nicole Klarides-Ditria]: Thank you for your explanation. And I do think you would be, your agency would be a wealth of knowledge compared to, the OPM. And hopefully, we can have further conversations about that to move this forward. And my other concerns about the authority that the panel has are separate from who I think should be on it. So thank you, mister chair.

[Sen. Saud Anwar]: Thank you. Senator Gordon.

[Sen. Jeff Gordon, MD]: Thank you, mister chairman. I appreciate the work you do, and thank you very much for it. I read through your testimony and certainly been listening today. I think your point is very well taken that if we can have people at the table literally, when these decisions are being made about CON, I think we would have a much better outcome. I think when you look at people out in the community, patients, others who are on the receiving end of medical care and health care, and then there are decisions by those who have probably nothing. They don't even really understand that Making some of these decisions. This is when we've seen bad decisions by prior leadership of OHS completely contrary to the actual Medical needs of people where they live in their communities for example in Northeast, Connecticut where there's been two blatantly bad decisions that were made about allowing inpatient labor and delivery to be removed and now there's really only one And some women have to hop the border now into Massachusetts. And that's a sad reality. So I think it's very important. One question I have for you, and I'm happy to take this offline to have a further discussion with you is are you looking for your office to have a seat at the table, or are you looking to have others when you talk about consumers or people out in the community, or you're looking for both as far as expanding beyond what is proposed to be a very small panel of folks who probably don't understand actual medical care, patient care, community health needs?

[Kathleen Holt]: Thank you for that question. I would say if there is an opportunity for consumer voice on the panel, if it's found to be, advantageous, that it would be a good idea for it to be the office of the health care advocate. We have the ability to to, to bring in the the the knowledge of of our work with insurance companies, with providers, with consumers. And, again, we we see the patterns, through thousands and thousands of cases every year that we resolve for people. I will say our our level of success, of being able to win 70 to 80% of the appeals that we take is is a a testament to my staff, but it's also a concern that that many overturned decisions are being made. And and we only see the tip of the iceberg in my office, but I do think that as far as the consumer experience that we are uniquely positioned within the state to be able to offer that perspective.

[Sen. Jeff Gordon, MD]: Thank you. I appreciate that, and that's very well said and should be very much taken into account. And just in closing, I can tell you in my other world as a doctor, I have appreciated the help you guys have provided. You're right. You only see the tip of the iceberg. For example, I'm not working in the hospital today, but I'm already getting texts from my office about appeals I have to make when I show up bright and early in my office tomorrow. It's multiple times a day, massive interference with actual patient care. So having your office have a seat at the table when these decisions are being made by state government is invaluable and I would say absolutely should be every single time to give you guys an opportunity to weigh in because right now that perspective no matter what we may hear is absent other than whatever testimony, quote unquote, from the outside your office is providing. So thank you, mister chairman.

[Sen. Saud Anwar]: Thank you. Seeing no other questions or comments, we wanna thank you for the work you do and your testimony today.

[Kathleen Holt]: Thank you very much.

[Sen. Saud Anwar]: That brings us to next person on our list, which is representative Laurie Sweet. And then we actually because it's close to an hour, we'll be switching back and forth after you're able to speak. And representative, Roberts, welcome.

[Rep. Lori Sweet]: Good afternoon, members of the public health committee. My name is Laurie Sweet, and I sit here today with representative Robert. We are the co chairs of the end homelessness caucus. First, I wanna thank the governor in coordination with the Department of Emergency Services and Public Protections for enacting the cold weather protocol many times over the last several months. Making those calls saved lives. I'm here today we're here today to speak in support of senate bill three sixty four. We need consistent protocol for severe weather, both hot and cold, since both can be deadly. These decisions need to be made as soon as possible so that our towns and shelters can prepare, and we need a clear communication structure. I'll give you an example. During the most recent storm, the end homeless caucus members were in touch with the governor's office and he initiated a protocol late in the day. It began the next day at noon. Columbus House, to the town of Hamden contracts with for our warming center had already made the decision to open at four. So folks could come inside and avoid the snow given the short notice. Columbus house wasn't prepared to open at noon Through communication with folks who were waiting outside our warming center and under the leadership of the director of Columbus House, who himself came to open our warming center at 01:30, we got folks inside. I'm not telling you this story to assign blame, just the opposite. I wanna point out how the director went above and beyond to get people inside, but directors and staff need time to plan. We need a system that plans ahead and gives as much notice as humanly possible to service providers. When we hear about pat bad weather like we did yesterday at 10AM, we need an immediate response so that people do not freeze to death and die. I close with gratitude for the committee for taking this on as I believe it is a public health issue. Thank you.

[Rep. Corey Paris]: A la Lori just to speak. She did a wonderful job. I'm just grateful for the actual committee bringing this forth to us. I can tell you guys, we have some data and people will testify again today. As you guys know, it's getting cold outside one day, snow outside the next day. We're in close contact with the governor's office on a regular basis to see if we're gonna enact enact like the cold protocol, and it should never be that. We should have it set. If it's gonna be till Good Friday or Easter, you know, we always have to contact the governor's office each week by week to see if we're gonna open up these hotels or we're gonna open up the Uber so that for our people to get out there. So we're honestly doing a wonderful service because that's what we signed up for. But in in a sense, it's, you know, hurting our homelessness population, and we're not really doing a a service to us. So you guys in this committee, thank you guys for bringing this bill forward because this hits it on a button. This is one of our caucus priorities as well as the end homelessness caucus. And we're just grateful for you guys. And anything that you guys need from us. We testified in transportation for a clean sweep bill, and we're just gonna be here all the time advocating for our community. So you probably will get sick and tired of seeing our faces. But other than that, we're just grateful for you guys.

[Sen. Saud Anwar]: Thank you so much for your testimony, and thank you for your advocacy and the work that both of you do. It's it's truly inspiring. I I wanted to just ask you. It is my understanding that the school systems listen to the news about the weather, that this building listens to the news about the weather. Most of the other industries and places be they look about what's the weather going to be, and more or less, it's fairly accurate. We we make fun of the weathermen occasionally and then say, well, you were wrong. But majority of the time, there is, accuracy to that. And I'm trying to understand why is this not automated? Is there something in the system which says that we are not gonna listen to the weather and we're gonna figure it out in the middle of the night that maybe it's a extreme weather protocol and let few people die, and then we'll make a decision? What is your understanding? Why is this not working for us?

[Rep. Corey Paris]: I think you hit on the button, and and I'm always a blunt guy. So I realized, you know, we'll take Bridgeport, for instance. They had a dead body. We'll take Stanford for a dead ends instance. They had a dead body. Then we'll start to, like, really wake up and see, oh, 45% increase in homelessness. Okay. I don't care if it's 10,008 thousand, 9,000 people. We live in a wealthy state. This is ridiculous. So I'm and I on the record, it it might take somebody to die for people to really wake up. It's sad. It's very sad. So you said it. You hit it on the on the head. We don't have a protocol. Hence why last night we had to text numerous offices to say, are you guys enacting this protocol? We can't keep going week by week. People are dying day by day, and it's really ridiculous. So that's why we're here all the time advocating for this. Rep. Sweet, we had a press conference with the and homelessness caucus and the CTCan, and rep suite held up a list of all the people that died this year alone from homelessness. We have to fix this. It's really it's heartbreaking because if you know my background, I come from this. I come from low income housing where we had to find a place to live to the point where we were homeless. And to see where I'm at today, I don't want nobody to go through what I'm going through. I live in Fairfield Counties, one of the wealthiest counties in the world. Why do I have people sleeping in their cars? I don't know. That's why I get upset.

[Rep. Lori Sweet]: Senator, to answer your question the same way that we do have protocols for kids. Right? Like, my kids afternoon was canceled because of the weather. Right? In the building yesterday, we weren't sure some staff were going home. We need something codified in state statute so that it is very clear that across the board, if this, then that. So that's what we're asking, the committee to do, and we wanna work with you, to develop that protocol with the relevant agencies that actually, you know, pull the trigger when it's really nasty outside.

[Sen. Saud Anwar]: And and I was reading there's a little bit of a pattern that I'm seeing. So I read the testimonies. I I read the work that you're doing, and I read about a number of people who are advocates. So just like we had a conversation that the the the information about menopause at Bill, everybody's in support except the state agency. In this one as well, everybody's in support except the state agency. So it's like what's happening is that the the answer is that we don't have the resources. And and so the people are saying and you're saying people are dying, and the state says we don't have it in the budget. So we should be looking at the merit of the issue rather than the money of the issue. And and and and right now, we have had some 14 deaths of people frozen in our state. And that's what when we when this committee brought this bill forward, the rationale was that the current system is not working. We have a situation where people are freezing to death, and we have no organized system in place. And it it's it's a failure when a legislator has to call every few days that, hey. It's too cold. It's too cold, and you have to advocate. Now let's say you are on a vacation. What would happen at that time? Right? Or if, God forbid, you're anybody's unwell. So we cannot have a system run because of the advocacy or two or three committed legislators, and thank you for your commitment. But this is not sustainable, healthy system for the state's protocols to be driven by the kindness of individuals to beg that, hey. People are freezing. Help us out. So I I hear you, and I I can't thank you enough. And I hope the people in this building and beyond are listening to this conversation because we are better than this. We are better than this as a state for waiting for the legislators to pick up the phone and say, hey. People are freezing. Can you have the protocol? Well, it is gonna cost too much. Yeah. Then fix it. Sorry. You can't answer my statement. Yeah.

[Rep. Lori Sweet]: I would just add for the record that the person advocating that we do the partial cold weather last night was at a conference on ending homelessness on the West Coast and was still caring and making sure that people didn't die last night and was texting us after a long day. You know, this work never ends. I'm not complaining. I was a birth doula before this. I'm used to getting calls at all hours of the night. But just to put a fine point on the fact that she was in California getting calls, providers weren't sure what to do. It took us a couple hours to coordinate that. We can do better. We can.

[Sen. Saud Anwar]: Thank you. Representative Belton.

[Rep. Kai Belton]: Thank you both for being here. Actually, my question was gonna be, you know, about what protocols actually exist. And it sounds like there aren't any. So I guess, my question now is when you talk to state agencies or the governor about the specifics of the protocol, what kind of feedback are you getting?

[Rep. Corey Paris]: Definitely. I mean, it's funding, of course. And also, you know, I honestly get you know, we're extending it another week. We're extended to a specific day, but that's not really enough. And I kinda, like, simply respond like, okay. Good Friday? Easter? I'm trying to give you months and weeks out of advance just because I don't know. We just snowed and hailed and did all that stuff yesterday. It's March. We don't know what April can be, you know, but I'd I I'll be honest with you. Funding wise is always in a conversation, and and that is something that bothers me when you're talking about someone's life.

[Dr. Elise Courtois]: Thank you.

[Rep. Tracy Marra]: Thank you so much, mister chair. Thank you for coming before us. I'm sorry I missed your testimony in transportation the other day, but sounds like you guys are making your rounds, and I really appreciate it. So I'm on board with you here. There's a lack of organization, complete lack of organization. I, I ran into a lady. It was the first night. It was the night before two people in Stanford, died, and I ran into her in in Darien. And I approached her. She wasn't able to speak to me, really. You could tell there was some mental health, maybe, issues that were going on, and I said, do you have a place to go? She walked away, and so then I'm scrambling to figure out who's gonna come pick her up. She's walking down Post Road in Darien. I, you know, finally get the two one one number, which you're not gonna get an answer on. You're not gonna get an answer on. I called the police. Now this was where there was a little glitch in the way. We've we've just talked to the police department now, so they're on the up and up. But the lack of organization of everybody looking left and looking right, And then I had my aide call the next day, 211. She was a 116 on the list. This is just not good enough. I talked to my family in Kentucky and they're like, oh, the Catholic church organizes everything in here. They go and they pick them up and they take them. And we're in the Northeast. What are we doing here? So I'm on board. I'm not sure if government is the answer. But but I think maybe the nonprofits need to get together and figure something out. And I'm I'm happy to support this, but I'm I'm happy to work with you because because I see a real real problem here. Thank you.

[Sen. Saud Anwar]: Thank you. Representative Kristen McCarthy, VAHI.

[Rep. Cristin McCarthy Vahey]: Thank you, representative Sweet and representative Roberts, for your work and advocacy. I just wanna clarify a few things. What are the current protocols? How does it work currently? Who is responsible for that? And what is the specific breakdown in the communication and process that you are seeking to change?

[Rep. Lori Sweet]: I believe there is a document that our emergency services put together. So I if I'm again, I would defer to Sarah Fox on this. I think she's testifying a little bit later. It has to be a certain number of consecutive nights below freezing. So we know if it's 40 degrees for an hour, that kinda kicks, you know, we're not in cold weather anymore. If we're having a big storm, we might be able to have cold weather, and then we might be able to extend it. So there there is a protocol. I think what might be helpful is feels like temperature outside because, remember, these are folks who are sleeping outside. So if we're running to our car and it's, you know, 40 inhaling, it's just a moment of discomfort. But for someone in a tent or someone sleeping outside, it it just it it could feel like zero. Right? So there are protocols that exist. We have been working with the Department of Emergency Services. We really just want to come together and make it really, really, clear. And then the communication piece. So we were on text message last night. A letter went out. 211 didn't find out until nine. The cans were trying to coordinate where they had beds. I was in communication with Hamden. We were almost full, but there was a there were some beds somewhere else. We know that cold weather keeps happening. We know that severe weather, hot weather, it's going to keep happening. Right? This isn't a surprise. We we act like it's a surprise every time. So how can we kind of come together? Maybe we need a round table. I don't know. I'm I'm all in on this fight and figure out what people need and then the communication structure so that we you know, the the governor's office was like, it'd be very difficult to call a 169 towns at 09:00. I agree. So how do we figure this out? We've got lots of smart folks in this room, lots of smart folks who are really, really committed. You know, is there an emergency text? I'm not sure what that looks like, but I will partner with you to figure it out.

[Rep. Cristin McCarthy Vahey]: Thank you for that. And I appreciate you referencing that DESP is the really the lead and primary organization that the conversation that we're having is public health focused because this is obviously a public health issue. And I also appreciate you referencing. It's not just cold weather. Hot weather actually can kill more people, and be just as if not more dangerous to people. So I think you have a lot of people here who are very committed to this issue, and there is the the issue of justice, morality, and there is practicality too. So I think I'm interested in us trying to bring together the parties who are involved in this conversation and seeing where those specific points are. Because, certainly, we've seen and we know that there can be communication in things like superstorm Sandy. I remember when I was in local government. But I think there are it's it's a right now, a convoluted and complicated process, and I hear what you're saying, which is we wanna make it clear and very understandable for everyone along the spectrum in the end so that people can be sheltered. Thank you.

[Sen. Saud Anwar]: Don't go away. I we have representative Claire this teacher.

[Rep. Nicole Klarides-Ditria]: Thank you, mister Jhaer. Thank you, both of you, for being here today. Do you have any idea what other states have done? I don't know if I missed that as part of your testimony or not. That's a question.

[Rep. Corey Paris]: That's definitely a question for the cans today. For me, no. Like I said, when we started this call, because we started the last year and we had our top priorities and our priorities one of our big priorities, we have a line budget item in the in the actual budget. Never has been done before. $5,000,000 or cooling centers. You know? So that was a big thing for us just to, like, tackle that. And, clearly, we know where the funding is going now. You know? But as far as other states know, not too not too familiar, but the cans definitely can let you know. They'll be testifying today.

[Rep. Nicole Klarides-Ditria]: Yeah. Thank you. I think it's worth looking to see, as we always do, what other states are doing. And and this is an important issue, and we know things are getting extreme. We're getting more extreme heat, more extreme cold. So we need to address these issues, and, hopefully, we can come up with a solution, and, hopefully, not too much government involvement, but only what we need to get this accomplished as soon as possible. Thank you, mister chair.

[Sen. Saud Anwar]: Thank you. Seeing no other questions or comments, we appreciate you guys being here, and thank you for your patience. Thank you. And the next person is remote. That is number six, Sandra Ferreira Molina, who is the policy and advocacy director for Connecticut Oral Health. Welcome. Go ahead.

[Rep. Cristin McCarthy Vahey]: I can't hear.

[Sen. Saud Anwar]: Can you hear us? Sandra, can can you hear us?

[Adelita Orefice]: Let's see.

[Sen. Saud Anwar]: Can our colleagues on Zoom hear us? Blink twice.

[Laurie Gaglione]: I could hear you.

[Sen. Saud Anwar]: Okay. Good. You're on. Welcome. You it's your time to testify. Go ahead.

[Laurie Gaglione]: Okay. So my name is I wanna thank everybody, for listening to my testimony. I'm just trying to read it so I don't get emotional. Tier senator, Ian Moore, representatives McCarthy, Vahy, and members of the public health committee. My name is Laurie Gaglione, and I live in Newington, Connecticut. I am here to support h b five three ninety nine. I am not I'm testifying not as a policy expert, but as someone who has lived at this experience. I'm the legal guardian, sister connected to someone with an intellectual and developmental disability. My brother is 64 years old with severe autism and normal pressure hydrocephalus. He has been a resident of the Herbert Center for over fifty years. My whole life has been dedicated to his care, and for the past thirty three years, I've been his legal guardian and attend all his doctors and dentist appointments. Since he is not verbal, I speak for him. For decades, we were fortunate and spoiled to have doctor Ronald Albert providing all of Joey's dental care. Doctor Albert is a treasure. He knew how to work with Joey and all his staff did. Due to changes in his practice, he was no longer able to treat Joey, and that is when I realized how horrible it was to find a dentist to take his insurance and to be able to provide and understand his his this population. Somehow we found our way to the Yukon Dental Clinic. I would be lying to say that this was a smooth transition. The front desk has never been very friendly or helpful. During one of the visits, we were going to be turned away because the document from probate court stating that I was his guardian had expired a month prior. It didn't I it I if I didn't have a contact with the probate court and was able to change the date and fax it over, we would have been sent away and would have to wait several months to get another appointment. I sat and I watched several patients get turned away because the document had expired. This was heartbreaking because some of the patients were nonverbal like my brother and some spoke but that were clearly in pain. There were zero compassionate, there were zero compassionate shown. When I called probate court to get the revised document for the appointment, they faxed it over, and all they did was really just change the date. This was absolutely disgusting. It takes so much time and effort to get a patient to the clinic. My brother is in a wheelchair, so it is a process to bathe him, dress him, feed him, and get him into a van and then not to mention search for parking. Nothing is easy when it is getting someone to this appointment. The most recent provider we had at Yukon Dental was horrible. She was afraid of Joey and didn't communicate well with me. I always helped her with Joey. I sat on the floor and literally had my fingers in his mouth to help her with the exam and to help her with any kind of cleaning. On one visit, Joey had a loose tooth and she's and she said it was an abscess infected and needed the tooth needed to be pulled out. She said the tooth could be pulled out at the dental clinic. But the morning of the appointment, we received a call and said that the procedure couldn't be done there, and it need to be called the I need to call the oral surgery department. It was obvious he was afraid of my brother. There was no reason to be afraid be afraid. She didn't prescribe an antibiotic, which I specifically asked for. Since my brother His

[Committee Clerk/Timer]: name is Ferrero Molino, but your time has expired. Thank you. Okay.

[Sen. Saud Anwar]: I I think you signed on with somebody else's name. What's your name?

[Laurie Gaglione]: I didn't. I signed well, I did. My name is Lori Gaglione. I seen I signed on with Sandra Ferrera, but she was having complications. She's, a proponent of this HB, this this document for oral health. And I was gonna just share my testimony and just everybody

[Sen. Saud Anwar]: I think, Yeah. We appreciate your testimony. We wanna thank you for that, and and we heard you loud and clear. Thank you. So I don't see any questions or comments. We wanna thank you for your testimony. Thank you. Okay. And we'll go to the next person who is over here in person, Wayne. I'm gonna pronounce it inaccurately. You can correct me. Pesci Pesky. Pesky. Yeah. No. I'll let you do this. Welcome.

[Wayne Pesce]: Good morning, everybody. Good morning. Good afternoon. Senator Anwar. Yeah. Good afternoon. Been here since this morning. And other distinguished members of the committee, I I thank you for your time here today. I've submitted testimony on senate bill three eight two, which is edible food recovery. I represent the state's food retailers, food manufacturers, food industry, for lack of a better term. I try not to use that term. I I like to call us more more of a food community, And we've been working very closely with the legislature for the last six years on this specific topic, food recovery, food donation, food insecurity. It's a plank of the work that we do in our association to really just kind of blow life into the work that all of that are our members that are doing in the communities that they serve. We started this journey about six years ago with former representative Borer and senator Marilyn Moore. I served on the initial task force that they had created, and we, at that time, created a position in DOAG to put a person in place to really help connect the dots in terms of where are some of the gaps. What we were seeing at least back then was a lot of the hyperlocal food recovery groups. There were no two that were alike. They all needed different types of support. Some needed refrigeration. Some needed vehicles. Some needed more volunteers. So we created that position. That person has been in place for over a year now. We just finished a task force report with women's and children's the women's and children's committee, and that report is literally hot off the presses. I think it came out several weeks ago, and there are recommendations on closing some of these gaps in food insecurity in the state as well. I would also make a comment that there is a statute on the book that passed two years ago, statute 22 a two twenty six e, which requires food retailers to, report their food recover their food donations. So that does exist today. And I would, recommend to this group if if we really wanna be helping the food insecure, we need to figure out what's going on with SNAP in ways to support that particular program. I'd say that's the biggest gap right now that we're seeing. The the the donation process that's in place in food re retailers is very organic and very robust. I don't see more coming out of that. How do we get more people signed up for SNAP? How do we we're working with a company called Front Door Benefits right now, because we figure about 50% of eligible residents for SNAP are not signed up today. And how do we find those folks and help them get signed up. And then the other recommendation I would make is that we need to continue to help local, hyperlocal food recovery places that need the support, that need the truck, that need the refrigeration, help get them settled, help get them in place, and make sure that they're they're working well.

[Committee Clerk/Timer]: Excuse me, mister Pesci, but your time has reached three minutes. Thank you.

[Wayne Pesce]: Yeah. I got it. Thank you. So just in closing, you know, I saw this bill into it up to here, and and and we're committed to the communities that we serve. And I just wanted to come in front of this committee and talk a little bit about some of the work that we're doing to support our citizens that are the most needy here in our state and be more than welcome to answer any questions you may have. I can come up

[Sen. Saud Anwar]: for a few minutes. Thanks. Thank you so much for your testimony. And and more importantly, thank you for all your members for the work that they do. Actually, in in my interaction with various food banks, that is the one of the biggest resource that is there that is actually helping communities out across the state. And so you you're you guys are this bill is not to suggest that the good work is not happening, but the bill is also to suggest that we can probably see if there's an areas of opportunity. And I think what was recognized was that still at times, some of the stores does not represent all the members or any one of your members perhaps, but some of the food, is going to anaerobic digesters. They're going to, waste and landfills. And then there's probably areas of opportunity around this. So that was one of the purpose to see if we can do collectively better and also reduce the burden on the side of the various stores because, the groups can actually take that ownership and responsibility of how they would be able to pick up and then have centralized location for further distribution. So there may be areas to look at how we can do better collectively. On the, on the Snap side, you're absolutely right. There's an opportunity, but there's also a little, challenge because of the federal laws that are just were passed. We're gonna lose 38,600 people, to get Snap. So that's another reason why there's a panic on our side because we know that already, even before that law, a lot of people were not getting full nutrition. And and and we felt that with the thirty eight thousand plus people who are going to be impacted, we needed to see what are the various things we can do. But collectively, it's also our responsibility that the food does not go to waste when it's edible and then useful. So that was the broader perspective on on this. I do have one of my colleagues who has a question, representative Claire de Stietra.

[Rep. Nicole Klarides-Ditria]: Thank you, mister chair. Thank you for being here, Wayne. I mean, some of the supermarkets in Connecticut are already donating a good amount of their day old food.

[Wayne Pesce]: All of them.

[Rep. Nicole Klarides-Ditria]: All of them. And are all of them donating and doing the anaerobic digesters or or testing?

[Wayne Pesce]: It's a different so so organic waste, which was has been man which was formerly trash. Right? Right. And it's the and it's and it's all soluble. So it's all very heavy. Is now going back to either composting or the digester in Southington today. So and Stop and Shop has their own digester, up in Freehold, Mass. So they backhaul all of their food waste, but these are these are two different conversations. Our our first goal is to sell product. Our next goal is to donate product. So there's a hierarchy in terms of where this food goes. You know, we're not giving away the stuff at the hot bar. Right? That's going to an anaerobic digester, unfortunately. It has to. There are safety issues. There are, you know, concerns about where does that food go if you donate it. Right? So so canned goods, frozen goods, frozen meats, things of that nature are are basically on the donation list. I mean, if you look at the list, it's it's it's it's very interesting. And then baked goods the day of, but you're not gonna see prepared foods, you know, given to because we've had those requests. It's like, why why why are you throwing that food out? Because there's a safety issue here. We don't know where that food's going. Can't give you that food.

[Rep. Nicole Klarides-Ditria]: Is it an OSHA issue?

[Wayne Pesce]: Sure. Yes. Absolutely. So there's a difference between anything that's going to the digester and anything that's donated. And believe me, we're donating before anything goes to a digester. Think about this, and your family was in the business. Costs a lot of money to transport trash and organic waste as well. It's a hell of a lot cheaper for a business in the state of Connecticut to donate food and give that to their local, you name it. I I think there are thousands of organizations that our members donate to throughout the state, thousands. And it's it's a lot better to give it to them than it is to pay a tipping fee for organic waste. So we are looking to donate product before we put it in a digester.

[Rep. Nicole Klarides-Ditria]: And you typically and and I'm assuming this varies. Do these organizations, these food banks come and pick it up, or do the supermarkets drop it off?

[Wayne Pesce]: Both.

[Rep. Nicole Klarides-Ditria]: Both.

[Sen. Saud Anwar]: So

[Rep. Nicole Klarides-Ditria]: You think it's more one than the other?

[Wayne Pesce]: Well, I mean, you know, it's really about resources. Right? So food share and feeding America has an amazing network of trucks and distribution. And if they can come get it, they will. But most of the time, we'll we'll drop off, to food share by trailer, frozen and things of that nature. And then, what we see is you'll see, the local church organization, Saint Vincent de Paul in my hometown community, Waterbury. They come. They send their folks out pretty much daily, church groups every day. So they come to the store, and they build a relationship locally at that store. So it's a it's a hybrid

[Rep. Nicole Klarides-Ditria]: Yes.

[Wayne Pesce]: In terms of how the food is donated. I would tell you the bulk, the frozen, and and the can, the bulk stuff that goes to FoodShare is is generally delivered there, and the hyperlocal food that is donated is generally picked up by a local entity.

[Rep. Nicole Klarides-Ditria]: Okay. Thank you. And I know, as you said, my family was in the supermarket business for years, and that is the cornerstone of what these supermarkets like to do. There a lot of them are family owned businesses or were, many years ago. And they want to give back to their community. And they want to donate this food. And I think it's something and and I commend them. And I thank all of them for doing the great work that they're doing. Hopefully, we could figure out a way to get even more food donated to all these organizations. So thank you for being here today.

[Wayne Pesce]: Yeah. Of course. And, senator, I just wanted to go back to one point you made in terms of, you know, how this food is is is getting there and how it's parsed out. Right? So for example, you know, we we talk about a large entity and all take an Aldi, take a take a Walmart, you know, the the the nonlocal, so to speak. Right? There's data that we share every year in terms of the tonnage that they are donating. So there there's a line of sight to the tons of how how big this is, And and most folks, unless they get into that data and take a peek at it, don't realize. So it's not just the local guy, the local family owned business. You know, it it's it's all of them, and I would be more than happy to share the latest report that I had, and that was a food share report based on who donated and how much they donated. It it it's it's an eye opener how much actually goes there.

[Rep. Nicole Klarides-Ditria]: That would be great if we could get

[Rep. Cristin McCarthy Vahey]: a copy of that report for the committee too.

[Wayne Pesce]: And I don't have the latest, but I'll I'll ask for the latest before I send it. If not, I will send you the 2023 data, which is the last I had representative. Of course.

[Sen. Saud Anwar]: So just wanted to clarify. Help me understand. When is the decision being made for sending the food or the material to the anaerobic digester rather than having the donation?

[Wayne Pesce]: Well, a lot of times, it's what is it. Right? So there's certain food that has to go to the anaerobic digester because we're not going to donate it. So Why not? Because it's in a there there there are liability issues where, you know, you're not getting the the leftover rotisserie chickens, not

[Sen. Saud Anwar]: happening. Okay.

[Wayne Pesce]: Right? You're not getting the the the chicken wings that are in the hot bar or or the leftover stew that's in the hot bar. That it's unsafe. You don't know where that's going. So that that'll go to a digester. That that's the food that goes to a digester, the food that's in the Foods To Go that you can't donate. The food that's donated is generally, you know, cans of product that are dented or that are close to code, frozen products, beef, pork, chicken, you name it. If it's frozen, we can control it. So lots of lots of deli items will go. Breads, stale breads will go and be donated. Stuff like that's fine. It's it's cooked products that are potentially in a hot bar that are are not that that's not going for donation. That, unfortunately, you know, is not salable and and and, you know, because of liability issues, it's not gonna be donated.

[Sen. Saud Anwar]: Okay. This is helpful. And and the the there are dates on expiration on on material as well, but but they're written in two forms. It's best before is one thing that's written. And then another group of, food items have expiration dates. So, the best before can be still be used. Correct. Okay. So you guys are aware of some of those intricacies.

[Wayne Pesce]: Well, there's some really neat entrepreneurial ventures out there where companies are actually coming in and getting that product and reselling that product at a at a at a large discount. So there's some entrepreneurs that have kinda come into that space on the close to sell by date, and they're willing to, take fruit that doesn't look good. Right? So, you know, we don't wanna sell it if the cucumber looks like kinda strange. So that product's still edible. And and so what we're seeing is is there are a bunch of entrepreneurial organizations out there that are coming in and collecting that food, and and they're reselling it at large discounts to consumers online.

[Sen. Saud Anwar]: And and this report, do you submit it to somebody in the state, or it's just within your organization?

[Wayne Pesce]: Oh, no. The the the statute that requires us to report goes to the state every March 1, and that is, again, statute 22 a, twenty two six e. Which agency? I'd have to get back to

[Sen. Saud Anwar]: you. No worries.

[Wayne Pesce]: I believe I believe it's DOAG. Okay. I believe it's STOWAG.

[Sen. Saud Anwar]: Okay. Good to know. And is it okay if we reach out to you after this hearing and then have a good discussion? And

[Wayne Pesce]: Well, we've done over 75 store tours with legislators in the last forty forty months or so, and I would welcome any one of you into any one of our locations to tour with us and talk about, you know, what's happening in your local supermarket. So the answer to that is absolutely anything I could do to get you more information. Anything we can do to help support this particular issue, we're we're all in.

[Sen. Saud Anwar]: Okay. And one more thing. We love FoodShare. They're doing good job, amazing work, and they do not have coverage across the state. So there are other groups as well which have broader coverage and and

[Wayne Pesce]: So for example, there's the large organization down in Stanford. Yeah. That gets all of our ShopRite, all of our Stew Leonard's, all of our entities down that way in the state are working. This for us for us, it's the neighborhood that they come. We if if we give it to FoodShare, it goes to FoodShare, but we're working in Madison, New London, Waterbury, Stanford, you name the community, Bridgeport, you name the community. There's somebody coming to one of our stores right now who we're donating to.

[Sen. Saud Anwar]: Love it. Thank you so much. Thank you for your testimony. Thank you for being here and then the work that you guys and your team does every day.

[Wayne Pesce]: Please come and take a store tour. We'd love to to take you through.

[Sen. Saud Anwar]: I'll take you up on that. Thank you. Alright. That brings us to the next person on our list, which is doctor Dinesh Kapoor. Doctor Kapoor, you're online. Welcome.

[Committee Clerk/Timer]: We just need to pull him

[Committee Staff (Zoom/Tech)]: from an exam room, but maybe he

[Committee Staff (Zoom/Tech)]: can hold for one moment.

[Sen. Saud Anwar]: Okay. Doctor Kapoor, or we can move to the next person. We'll wait for

[Committee Staff (Zoom/Tech)]: He's coming. I'm so sorry.

[Sen. Saud Anwar]: It's okay. I I we we can come back to him if he's in the middle of an important conversation. I know.

[Committee Staff (Zoom/Tech)]: He's coming. Okay. He's coming from the room. So

[Committee Clerk/Timer]: Waiting some of the doctors.

[Committee Staff (Zoom/Tech)]: Yeah. Okay.

[Sen. Saud Anwar]: Yep. Hi, doctor Kapoor. Welcome. Thank you. I know you're in the middle of seeing a patient. Sorry. We apologize to your patient, and you're on. Welcome. You are muted. You're muted.

[Dr. Dinesh Kapoor]: There we go. No problems at all. Thank you. Dear members of the public health committee, thanks a lot. And I apologize that I'm not there in person because I like my interaction with all of you. But due to all these weather delays and all that, I have a pretty busy busy clinic due to rescheduling. So my name is Dinesh Kapoor, and I'm an oncologist and hematologist. I'm board certified, and I've been taking care of patients in North And Southeastern Connecticut actually, in all whole of Connecticut for the last twenty eight plus years. I'm the president of my independent medical practice, Eastern Connecticut Hematology and Oncology Associates. And we take care of almost multiple thousand of patients a year. I stand in opposition to house bill fifty three ninety eight because it threatens the ability of practices like mine to continue providing patients with access to the highest quality, cost efficient care, inconvenient, independent, in a practice and in their own communities. About seven years ago, my practice partnered with a management services organization to, reaffirm our commitment to our community. The only other option at that time was that we either joined one of the bigger hospital networks, but we chose to remain independent. Little did we know that how important our partnership would end up because COVID hit, and we were able to get all the pandemic supplies, the flow of PPP, medications, vital supplies like saline flowing into our practice. Our cancer patients' treatment did not stop because of the pandemic. And our partnership with our MSO has led to many other things in our practice. And I apologize if I'm digressing from my testimony which is in writing because I really wanna convey what we have been doing. Even years after the pandemic, our partnership continues to help us obtain life saving and curative chemotherapy such as cisplatinum, which was a shortage a couple of years ago, but we were able to get it. Patients come to us from out of state because of how quickly we are able to get personalized therapies for our patients and clinical trials that we so cherish in our community. Our partnership with our MSO and our commitment to our patients allows to bring state of the art infusion therapies and infusion services in our practice, for blood cancers as well as solid tumors. And I am very proud to say that we were the first practice, first independent practice in the state to do bispecific antibodies for our patients in multiple myeloma. And now we do it in lymphomas, leukemias, as well as small cell cancer of the lung. And in fact, we are the only practice that has developed an outpatient protocol in our community, on an outpatient basis. No other practice has done it, but we have been able to do it. The MSO investments in our practice and our medical group in Norwich have kept, cancer care local and in a lower cost, high value setting. These have helped us compete with the compete getting the best talent into our practice and expand our care. And we like to say that we are at a very high level and pretty much give as much care as a university would. Except

[Committee Clerk/Timer]: me, doctor Kapoor, but you've reached your three minutes. Thank you.

[Dr. Dinesh Kapoor]: Oh, okay. Well, I'll just end with a couple of things, which is I will remind the committee of a critical point that while our partnership with the MSO means that I'm always one call one phone call away for any decision, all the decisions that need to be made are made at a local level. The MSO does not control anything apart from helping us with business support. My final point that I wanna really convey to all of you is that house bill fifty three ninety eight gives the attorney general a shocking, and I mean it shocking amount of authority to impose conditions on transactions, so that they may go forward or not. I'm not aware of any state in the union, that puts this kind of power in hands of a law enforcement officer. Our patients demonstrate every day the need for medical care that we provide. And it is unclear to me why Connecticut wants to take a step backwards, and really penalize independent practices from being able to practice medicine in their own

[Sen. Saud Anwar]: community. Thank you,

[Dr. Dinesh Kapoor]: doctor Kapoor. Perfect. So I will be more than happy to answer any

[Sen. Saud Anwar]: questions. Doctor Kapoor, I wanted to thank you for your testimony. You're you're no stranger to this committee because, you've spoken to us pretty much every year for the past few years. And then you have helped us understand the intricacies about private equity and the outpatient setting and then for specialty practices. And the fact that you have sort of educated us that it does not impact access, which is different from the private equities that we have seen. So there are two bills. One was Senate Bill 196, and and which actually accommodate some of your previous testimonies and and the previous bill that we were able to get many of the physicians to recognize, and then was not gonna negatively impact existing practices. This bill is a little different. It's also coming to us to address some of the areas and, and, your testimony is, is helpful to us. I I know, one of my colleague has a question, and that's gonna allow you to answer that question and perhaps expand more. So I wanted to have, one of your colleagues and our colleagues, senator Gordon, ask you questions. Senator Gordon?

[Sen. Jeff Gordon, MD]: Thank you, mister chairman. And doctor Capert, it's nice to see you again. I I think if I recollect, we've known each other and been colleagues in oncology for at least twenty seven years. So I understand very well what what you do out there in the community. And I know you, like me and others, have a very strong and deep and continued, focus on patient care and the importance of the patient physician relationship. And a question I have for you to follow-up on your testimony is that when the legislature is trying to sort through what we do about certificate of need with regards to keeping private equity completely away, I hope, from hospitals, that the problems that have been created, that have made the news have not been by private practice groups such as yours. And in fact, your testimony highlighted about the, MSO, that you have, for your group practice. And I just wanna clarify from you that given the number of years that you have, worked with an MSO that you have not found it in any way unlike we've seen other things with private equity with hospitals to be making medical decisions for you, telling you what to do for patient care, or in fact interfering in any way with regards to the care that you provide every day and night, but in fact, you found it to help you actually do those things and continue to move forward strongly.

[Dr. Dinesh Kapoor]: I absolutely agree with you, doctor Burkhard. We and our partnership with our MSO actually has enhanced our care and our ability to deliver the care. And then I'm talking about the bispecifics that we first we were the first ones to start in our practice and having developed the outpatient protocol was in conjunction with our MSO and other practices around the country that are also doing it in an outpatient setting. And I'm proud to say that we are the only practice in North And Southeastern Connecticut providing these services. So if anything, RMSO stays out of any clinical decision making that we have in our practice, and they help us on the back end support with the human resources, financing, business, etcetera. So all medical decisions are totally totally made by clinicians in our practice. It would not work any other way.

[Sen. Jeff Gordon, MD]: Thank you, and I appreciate your testimony. It's been to the point and very powerful as we're trying to make certain we can focus on where we need to focus and leave alone, hopefully, group practices such as yourself that are doing well and doing well for patients and not to have any interference by state government. Thank you, mister chairman.

[Sen. Saud Anwar]: Thank you. So, doctor Kapoor, thank you for your testimony. We will let you go back to your patient. You have testified

[Dr. Dinesh Kapoor]: Can I add some one one thirty second thing, doctor Anwar, if I may? So, you know, just to reinforce it from my side and my practice's side, as I said, we are the only practice practice providing these new newer treatments in our practice in North And Southeastern Connecticut. Even our hospital employed clinicians that are employed by the big networks are not doing it. So our patients who are treated by them have to travel either to Bridgeport or to Hartford to get the same treatments in the step up dosing. We are doing everything in our local community for these patients. So I just wanted to bring that in as well.

[Sen. Saud Anwar]: Thank you. We appreciate your testimony and and your good work, and that really helps us make better decisions.

[Dr. Dinesh Kapoor]: We'll Thank you very much.

[Sen. Saud Anwar]: We'll move to the next person on our list, which is Sarah Pavone on remotely. Sarah, you're on. Welcome, miss Pavone.

[Sarah Pavone]: Hi. Thank you. Good afternoon. Wanna thank the public health committee for hearing my testimony in support of SB three six four, an act concerning extreme other protocols. So my name is Sarah Pavone. I'm director of strategy with Journey Home, and we serve the Greater Hartford and Central Coordinated Access Networks or the capital region in the state. This bill is about making sure that when weather becomes life threatening, our response is clear, it's predictable, and it's coordinated across the state. So our activations are lifesaving interventions for people experiencing homelessness. And when temperatures drop to dangerous levels, our warming centers, outreach workers, and our coordinated homeless response system mobilizes quickly to ensure that we can have people access safe indoor spaces. While these responses save lives, the current system places tremendous strain on providers and workers responsible for carrying this out. Many warming centers operate with very small teams and staff frequently work two to three jobs to make ends meet. When activations are announced with little advance notice, providers face significant challenges securing enough staff to keep doors open and extend hours. Backbone organizations and system coordinators like Journey Homes spend countless hours helping providers create staffing plans, troubleshoot gaps, and problem solve operational challenges in real time. We stay on call twenty four seven for these system barriers. And despite these efforts, the strain on frontline staff has been significant. Street outreach workers, street medicine workers also shoulder an enormous responsibility during these events. When an activation occurs, our teams shift immediately into emergency response. Workers extend hours, work overtime, actively searching for individuals outside so that they know that there's a safe space available and that they can come indoors. Beyond outreach and engagement, we also have these workers providing transportation to shelters, hotels. They assist with meal delivery, ensuring clients placed in hotels have access to food, conducting daily check ins to ensure people remain safe and connected to services and medical appointments and have access to medication. The responsibilities dramatically expand the scope of this work during extreme weather responses. And for individuals experiencing homelessness that these systems serve, last minute activations cause confusion, anxiety, barriers to accessing safety. People living outside have a right to know what resources exist in their community that will allow them to stay safe and quite literally to stay alive. Coordinators must ensure individuals have access to transportation, medication, medical appointments, food. We accommodate for pets. When placements occur outside of someone's community, the level of coordination required also increases significantly. These efforts are essential, but the current approach relies heavily on emergency response that plays a significant strain on providers and individuals they serve. Extreme weather protocols are not simply an administrative procedure. They're lifesaving systems and strengthening them will help ensure no one in Connecticut is left outside without experienced this winter. We must standardize extreme and hot weather protocols with clear triggers, temperature, wind chill, heat index that prompt required opening of warming and cooling centers statewide. And also requires of, but you

[Committee Clerk/Timer]: have reached your three minutes. Thank you.

[Sarah Pavone]: Well Thanks so much.

[Sen. Saud Anwar]: Thank you for your testimony. This is very helpful. So I think what what I heard you say is that if you are not informed in advance, the amount of work and coordination goes up significantly. And if if there is a predictive modeling that tells you what to anticipate, then that helps not only the people who are doing hands on work, but also the people that you're doing the work for. Correct?

[Sarah Pavone]: Yeah. Abs yes. Absolutely. And I know, reps, we, you know, reference the activation that was called extremely late last night. But that is a clear example where by the time it was called, there was not enough time to coordinate outreach or any services to inform anyone that an activation had even been called. I think across the state, maybe only two people accessed a hotel room, because just no one knew about it. So having a lack of notice and a lack of coordination across the state of when these get called, significantly hinders our ability to provide services and coordinate locally.

[Sen. Saud Anwar]: I I think your your voice really is very helpful that that that reaffirms, at least to me and I'm sure many of my colleagues, that we can do better. Thank you.

[Sarah Pavone]: Thank you.

[Sen. Saud Anwar]: And we go on to number 11, Amanda Gunthal, who is online. Welcome. You're on.

[Amanda Gunther]: Hi. Thank you. We have submitted more lengthy testimony. I've condensed it for today's purposes, hopefully, adequately. Good afternoon, senators, representatives, and distinguished members of the public health committee. My name is Amanda Gunthal, and I'm here today as president of the Connecticut Association of Ambulatory Surgery Centers, representing our 61 freestanding ASCs that provide high quality, lower cost surgical care to patients across our state. Thank you for the opportunity to speak on HB 5,045 and HB 5,398. ASCs are among the most regulated healthcare facilities in the country, subject to state licensure, federal CMS certification, national accreditation, and participation in patient safety organization. We are committed partners in patient safety and quality while making health care more accessible and affordable for Connecticut patients. We appreciate Connecticut's efforts to modernize the certificate of need process. Regarding HB fifty forty five, we strongly support removing CUN requirements for cardiac services already approved by Medicare to be performed in ASCs, expanding access to important procedures at lower costs without compromising safety. We also support eliminating CUN review when facilities reduce or eliminate services. Physician recruitment often drives those decisions and facilities should not be penalized for market realities. The 10 mile relocation safe harbor is a positive step. We respectfully ask that it be expanded to 20 miles, reflecting real world requirements of health care facility siting needs, including building requirements, parking, and roadway access. On process, we ask the committee to consider three refinements, enforcing the thirty day statutory deadline with deemed approval if not met, limiting completeness letters to no more than two per session per application, and providing clarity that public hearing and decision deadlines affirm. We also seek to further further discussion to better understand how the three agency panel will function efficiently given given differing priorities of each agency. And finally, we have significant concerns regarding the 20% ownership change threshold triggering a full CON review. Recent hospital bankruptcies, the apparent driver of this provision, did not involve surgery centers. And applying this broad standard to surgery centers discourages investment, limits access to capital, and makes physician recruitment harder at a time when Connecticut already faces provider shortages. Regarding HB 5,398, we do have concerns and we respectfully ask to collaborate on a better path. While we understand the intent behind greater transparency in healthcare transactions, HB 5,398 creates a duplicative layer of oversight. ASCs already report ownership through both the CON process and DPH licensure requirements. Adding attorney general review of a broad range of changes will create delays, increased costs, and will disadvantage Connecticut relative to neighboring states when recruiting physician investors. We are asking that this committee work with us to ensure that new oversight is targeted, efficient, and does not inadvertently harm the facilities that Connecticut patients depend on. We look forward to a continued dialogue on both bills, and thank you for your time and consideration.

[Sen. Saud Anwar]: Thank you so much for your testimony. You're right on time. We actually had our alarm go off exactly at the time. So

[Amanda Gunther]: That's a first for me, Thank you. Senator.

[Sen. Saud Anwar]: I just wanted to is there do do you have an insight into how many of your facilities of your your different group are owned by private equity?

[Amanda Gunther]: Or or have that kind of relationship? I don't. But we can certainly pull the membership, and I can get back to

[Committee Staff (Zoom/Tech)]: you guys with that for sure.

[Sen. Saud Anwar]: Okay. And this is outside the scope of our conversation, but but but I just gonna put that on the radar. If, if, if it would be helpful to know how many are owned by private equity, is there any one of them who restrict Medicaid access? And, and, so I just, because I think there is a perception that, some of them are pure business financial entities, but, but I think there's more to that. It, it actually, reduces the risk of infections. You're outside of, a larger health care facility. The service area is easy access and then has better coverage. So there are multiple other positive things that happen as well. But but because of some situations, we have heard, that access may be impacted. So I will probably if if there's a way to follow-up on that at some point

[Amanda Gunther]: Certainly.

[Sen. Saud Anwar]: And then my my co chair has a question or comment for you.

[Adelita Orefice]: Sure. Represent.

[Rep. Cristin McCarthy Vahey]: Thank you. Thank you, mister chair. And, Amanda, thank you very much for being here, with us and testifying. I'm just wondering if we can just make sure to get your written testimony. I was scribbled Oh. But I wanna make sure that we have that. Have you submitted that already?

[Dr. Mahesh Bhaya]: Yes.

[Rep. Cristin McCarthy Vahey]: Okay. Great. So it will, I'm sure, be posted, and I may not be finding it so quickly, but I think you had some good concrete suggestions and thoughts. So thank you for your testimony.

[Dr. Linda Sprague Martinez]: Thank you.

[Sen. Saud Anwar]: Thank you. And with that, the next person on our list is doctor Robert McClain. Doctor McClain, you're on. Welcome.

[Dr. Robert McLean]: Yes. Can you hear me and see me okay?

[Sen. Saud Anwar]: Very well. Yes.

[Dr. Robert McLean]: Super. Okay. So senate senator Anwar, representative McCarthy Vehi, senator Summers, representative Claridis Ditry, and members of the public health committee. My name is doctor Robert McClain, and I'm president-elect of the Connecticut State Medical Society. I'm here on behalf of the physicians and physicians in training of CSMS to testify on house bill five zero four five. We have submitted more detailed written testimony for the records. I will focus my remarks on the central policy concerns. CSMS is concerned that house bill five zero four five significantly expands CON requirements into routine physician practice transactions at the very moment that small and medium physician practices are under intense financial pressure. Under current law, a CON is required for the merger or acquisition of a physician group practice of eight or more physicians. HB 5,045 lowers that threshold dramatically. It would require a CON for transactions involving as few as two physicians if the practice meets a $10,000,000 revenue threshold or involves private equity. That's a major policy shift, and the rationale behind it is unclear. The $10,000,000 revenue trigger is flawed in the physician context as others have stated. Revenue is not profit. In many specialties, particularly those that bill for high cost drugs and infusions and maybe some diagnostic testing, revenue can artificially can be artificially inflated due to pass through billing. A small three physician practice can exceed $10,000,000 in revenue, while a larger group may not. Revenue does not reflect market power, yet it becomes the regulatory trigger. For many physician practices, mergers are about survival. Rising administrative costs, low reimbursement, and persistent Medicaid underpayment are forcing physicians to combine resources just to keep their doors open. Imposing the CON processes on these transactions adds cost, delay, and uncertainty. Some practices will simply close rather than navigate that process. Others will default to hospital or health delivery system employment that accelerates consolidation rather than preserving physician practices and patient access. With respect to private equity, we recognize the concerns, particularly in light of the prospect hospital experience. Oversight is appropriate. However, HB 5,045 responds with a blanket CON trigger based solely on the presence of a private equity entity without defining the term and without distinguishing between minority investment and full operational control. That is an overly broad solution to a nuanced issue. We also note the framework in HB five three nine eight, which places review of private equity transactions with the attorney general. Conceptually, that is more appropriate than an automatic CON trigger. However, five three nine eight still lacks clearly defined standards, objective criteria for review, and concrete guardrails. Practices must be able to understand exactly what is being evaluated, what benchmarks will be applied, and what timeline will govern the review. Without that specificity, the CON process creates uncertainty rather than meaningful oversight. Finally, HP five thousand and forty five also restructures the CON process itself, moving it to DPH and replacing rolling review with quarterly cycles and other time sensitive requirements. The timelines outlined could approach a year for a standard decision, not including appeals or other issues.

[Jennifer Paradis]: For physician practitioners, we're gonna go

[Sen. Saud Anwar]: through

[Committee Clerk/Timer]: three minutes. Thank

[Dr. Robert McLean]: you. Okay. Thank you. One last sentence then. Thank you. Yes. In short, this bill expands CON into smaller physician practice transactions at the worst possible time. It risks accelerating closures rather than preventing them. I do not think that is the goal of the legislature. So I respectfully urge the committee to reconsider this expansion of the CON process, and I'm happy to take questions.

[Sen. Saud Anwar]: Thank you so much, doctor McLean, for your testimony. Thank you. And and you have submitted a written testimony as well. Correct?

[Dr. Robert McLean]: Yes. Two different the two different bills. Okay. More detail. Yep.

[Sen. Saud Anwar]: This is very helpful. And then I think you you're you've covered a lot in in the three minutes. It's it's a pretty filled testimony, but, very substantial information for us to look at to this. Do you think that we we have been talking about the shortage of physicians in our state. Do you think if the bill passes in the current form, that's gonna make it worse?

[Dr. Robert McLean]: I think it could. Yes. And I say that because I think that, first of all, you're gonna have more practices that may well, either merge, become part of larger groups, or you I think some of the doctors on the on the latter half of their career may actually decide to to just retire and hang it up. They just can't handle trying to do it alone. So the small practices, two, three people maybe, may just say I've had enough or I'm going elsewhere.

[Sen. Saud Anwar]: Okay. Thank you. This is helpful. And and, senator, Gordon has a question or comment for you. Senator Gordon.

[Sen. Jeff Gordon, MD]: Thank you, mister chairman. Doctor MacLean, thank you for your, to the point, a very powerful testimony. I can as a past president of the Connecticut State Medical Society, I look forward to you becoming our next president. I won't say if that congratulations or condolences yet. But one question I had for you in follow-up, and I think it's an important point. When we look at various provisions of this bill, and it's also built in the current CON policy is relative to Medicaid. And I'm not saying we shouldn't be providing access to Medicaid. I think we need to be doing what we can to be of help. But one thing that you know well, and I wanna ask you a question on this, that when we talk about CON provisions and unnecessarily lowering the bar to tag, small group practices, many of which are trying to make ends meet, keep their employees paid, literally keep the lights open and the heat going so as to provide patient care, more provisions that tag them to Medicaid during a time of continued massive under reimbursement for Medicaid, including actually at a loss, which makes things more financially difficult. Do you see that as part of the problem with regards to the CON relative to, Medicaid provisions that we should also be looking at, what we can do relative to Medicaid reimbursement so we can have more private practices in the state and not try to be burdening them with, a lot of different CON provisions?

[Dr. Robert McLean]: Yes. Yes. I completely agree. I think one can envision, the small group practices that are potentially merging, a two third three person group, whatever, who now may hit that threshold of dollars and have to go through the CON approval process. Those are exactly the practices that really have a hard time surviving on Medicaid rates. And when Medicaid rates are so low, and we all know there's reports showing that, it is an increasing barrier that will that may make some of those practices not try to merge and potentially try to merge, if anything, with one of the larger health systems, which doesn't have as much of an issue with larger administrative burden, although they have plenty on their own. So I do think tagging Medicaid participation to the CON could definitely have negative, consequences to the small groups that are being hit by this the hardest.

[Sen. Jeff Gordon, MD]: Thank you for your testimony, and thank you, mister chairman.

[Sen. Saud Anwar]: Thank you. Seeing no other comments or questions, thank you, doctor McLean. We appreciate your testimony and and your recommendations.

[Dr. Robert McLean]: Thank you.

[Sen. Saud Anwar]: Next person is doctor Mahesh Bhaya. Welcome, doctor Bhaya.

[Dr. Mahesh Bhaya]: Thank you. Good afternoon, senator Anwar, representative McCarthy Wehie, and other esteemed members of this committee. My name is doctor Mahesh Bhaya. I'm a practicing otolaryngologist in Waterbury for the past twenty three years. I'm here to testify against the governor's bill five zero four five that restructures the certificate of need process and expands into small physician groups in Connecticut. I want to speak to you not only as a physician, but as someone who may have been impacted by this proposal. I'm currently part of a two small two full time physician independent practice. We have a pending merger with another small otolaryngology practice. The resulting merger will be a five physician practice. We are merging for practice survival. Remaining independent in today's healthcare environment is increasingly difficult. Reimbursement pressures and administrative burdens continue to rise. For small practices like ours, combining resources is often the only path forward that allows us to remain independent and continue serving patients in our inner city community. We are not eliminating competition or creating market dominance. We are local physicians trying to keep our practices viable without selling to a hospital system or a corporate entity. Small community based practices combine resources to survive in an increasingly complex healthcare environment. If this bill had been in effect, our merger may have required a CON. For a small physician group, the CON process is expensive, time consuming, burdensome. It requires attorneys, formal applications, and months of uncertainty. That kind of regulatory hurdle can be the tipping point that pushes independent physicians to either abandon a merger or sell to a larger corporate system that has the infrastructure and the capital to navigate this process. What is the policy rationale for requiring a small merger like ours to go through a COV? We are not consolidating across regions. We are not driving our prices. We are trying to stay independent.

[Sen. Saud Anwar]: Should I start by saying I'm I'm a doctor?

[Dr. Mahesh Bhaya]: Moreover, independent physician groups typically deliver care at lower total cost than hospital owned practices. Supporting their viability helps prevent further cost shifting into higher priced hospital systems. Thoughtful policy can ensure safeguards remain in place. Transparency requirements, size thresholds, and oversight mechanisms can distinguish between harmful consolidation and pro competitive collaboration. The goal should not to be block small practice from working together, but to ensure that collaboration strengthens access and affordability. If we fail to provide clear and reasonable pathways for our small physician mergers, we risk accelerating the very consolidation that drives higher costs and reduces patient choice. Thank you very much for your time and consideration.

[Sen. Saud Anwar]: Thank you, doctor Bhaiat. Thank you for your testimony. This is very helpful. I was just saying that we hear you loud and clear, and then I I know this is that this bill is probably, going to have a negative impact on a number of practices like yours and not necessarily protect us from what it's intended to do. So your testimony really helps us out. So I wanted to thank you for that. I have one of my colleagues who has a question, representative Steinberg. Thank you, mister chair, and thank you for your testimony, doctor. Yep. We're trying to address a problem we're seeing in the marketplace, and we're very sympathetic to the role independent physicians play in our state. What should we be doing to help you? If it's not this bill, are there other things we might do that are gonna be effective in allowing you to maintain a at least a profitable business?

[Dr. Mahesh Bhaya]: So the biggest problem that I see in Connecticut for otolaryngologists and our practice in particular, we are a shrinking specialty. And I have another written testimony on behalf of our Connecticut otolaryngology society stating that shrinking ENT population, very hard to retain, the physicians who graduate from Yale and from UConn to stay in state. Obviously, the medical malpractice environment does not help. In the small in the city area like ours, the Medicaid population rose from about twelve percent to twenty percent in the last five years, and this is just based on, statistics from my practice. On the other hand, the Medicaid reimbursement, as you all know, has not been has not gone up in the last twenty years or so. So, you know, when we run the analysis for every $1 that we spend on seeing a Medicaid patient, we probably get reimbursed 40¢ to a dollar. So very obviously, I know the governor has looked at this. The committees have looked at it. I've discussed it this with senator Anwar in the past. We definitely need to help, inner city communities and physicians like ours who take care of Medicaid patients, and we don't shirk away from that responsibility. But definitely, if something can be done about that, we can probably stay more viable.

[Sen. Saud Anwar]: Thank you. It's just that easy. Reform the whole system.

[Dr. Mahesh Bhaya]: No. It's not. I understand. I've been I've been doing this

[Sen. Saud Anwar]: I'll be prestigious. I'm sorry. It's just that, unfortunately, we're dealing with so many ramifications of a broken system. We're gonna basically kill off independent physicians at the same time. And I wish we had a better answer. Thank you, mister chair. Thank you. Again, doctor Baia, we hear you. And then and your testimony is gonna help us make better decisions. Thank you.

[Dr. Mahesh Bhaya]: Thank you much.

[Sen. Saud Anwar]: Seeing no other questions or comments, we'll move to the next person on the list, which is doctor Adam Kaye. Doctor Kaye, you're on.

[Dr. Adam Kaye]: Thank you, senator Anwar, representative McCarthy Vahy, and the other student members of the committee. I'm Adam Kaye, doctor Adam Kaye. I'm a radiologist practicing in Connecticut and a counselor with the Radiology Society of Connecticut. I'm here to offer comments on on bill fifty fifty forty five. We we do appreciate the fact that governor of Vermont has proposed a bill to improve and streamline the CON process. We support the provision in section four that retains CON for the acquisition of imaging equipment. We, in particular, thank members of the committee and and other members of the legislature for their support on that, including, keeping provisions for MRI, CT scan, and PET CT scanners, within the c o n process. We believe it's critical that the c o n process remain in place. Otherwise, we'd see an immediate migration of units to affluent areas with high proportion of self pay patients and taking the access away from areas of the state that may, may may be in more in need of, of medical care. The law plays a key role in ensuring that the access to this life saving equipment exists throughout the state. One important issue that's been raised is the expedited review process for CON proposed in section seven. We do not have an issue with expedited process, but we do believe this should include a hearing when requested by an affected party. We act we do have provided we we and it's provided in my testimony, a draft language that might accomplish this, specifically in section seven lines 404 400 to four zero six could be amended to say, in accordance with the provisions of subsection d of section six of this act, any person seeking to participate as an intervener in an expedited CUN proceeding may request a hearing and status as an intervener in the same manner that such a request would be made in non expedited CUN proceeding. In addition, the panel may hold a public hearing regarding to any complete and eligible expedited certificate of need application. As I mentioned, this is in my written testimony as well if there are concerns if there are questions about the language. We do have some other areas of concern, regarding the three person panel of the commissioners of the Department of Social Services, the d DPH, and, the secretary of the office policy of of OPM. We'll make all the decisions on CON applications. It's outlined in section two, but there are no specific as to how the process will operate. We might be be able be open to discussing how we might memorialize this in writing within the within the within the bill. Section 11, policies and procedures developed and implemented prior to the adoption of formal regulations. It's silent as to whether or not the public can offer written comments about draft document or participate in the hearing prior to its adoption. As mentioned, we believe these procedures should be mandatory and written in the bill. And section six and seven outline the process for timing of the consideration of CON applications, both standard and expedited. As we reviewed, it appears possible this can make the process longer, not shorter. I realize I'm probably running short on time. So I will simply finish by thanking thanking the members of the committee as well as our entire legislature and and and the governor in his office for keeping COVID on imaging. We we truly feel that getting rid of COVID on imaging would further the shortages we have of radiologists and particularly shortages of radiology technologist shortages, further depleting an already diminished workforce. And we also obviously appreciate the work that was done last session on that issue as well. So I'm happy to take questions.

[Sen. Saud Anwar]: Sure. Thank you so much for your testimony. My cochair representative, Chris McCarthy, but he has a question now.

[Rep. Cristin McCarthy Vahey]: Just to thank you, doctor Kaye. Very helpful testimony, and we'll be talking further.

[Sen. Saud Anwar]: Wonderful. Thank you. So I I have a question, doctor Kaye. You know, your your industry has been impacted quite a bit. In the recent past, private equity just pretty much impacted one third of all radiologists in our state. It was a pretty sad situation. How are we gonna be able to address some of those challenges to protect that from prevent that from happening?

[Dr. Adam Kaye]: Yeah. So to paraphrase representative Steinberg, you know, a complete overhaul of our health care system might might be a good way to start. But, it's a very difficult issue, and I really appreciate the, the both the legislature and and the governor's office and everybody's, efforts on this. It's a very difficult question because no matter what gets drafted, there are always workarounds, and there's always ways that, say, a private equity investor led group might get around them. So, you know, we in general, we support things that will keep things that will keep health care local, things that will keep both small independent practices as well as, you know, some of these issues are not unique. We we always talk about the small independent practice. They're not unique to some of my colleagues that work in, say, Yale or at larger practices out of Hartford. And so things that give doctors control. So tackling, you know, things that tackle, you know, prior authorization, issues of prior authorization, things that tackle, maybe malpractice reform, mentor reform are things that would go a long way towards making it easier for small groups not to have to consider selling to a large group, and that's for radiology, but, as well as, probably every other specialty and every other medical provider and health care provider in the state. So, I know that probably skirted your question a bit, but I hope it helped a little bit answer.

[Sen. Saud Anwar]: Sure. Thank you. I have more questions. So so I wanted to also ask you, you know, we're trying to streamline the process, and and one of the commonest thing that, has not never been rejected is a request for a CAT scanner. And in the past, the office of health strategy would say, we should probably not even have that on a CON list. And then right now there is, the CT angiogram are something that the cardiologist, can hopefully identify illness far faster and then manage those patients more efficiently. And and if they were to go to a radiology lab, it takes a much longer time to a to a radiology facility, to get the answers. So I know you and and others, and I'm I'm sure we're gonna hear from doctor Farquhar soon. Where what is the area that you would be willing to say as radiologists that, okay, we will not want to have a CUN for that?

[Dr. Adam Kaye]: Okay. I tough question. I think we you know, my official answer is that we would like CUN as, you know, we like CUN as it is for CT, for PET CT, for advanced imaging, for MRI. I think those are the those are the I I understand the need, that that can arise for, especially more acute, more acute need for CT scanners since they are so, incredibly, incredibly necessary, say, in emergency care and hospitals. As you mentioned, you know, there's chest there there may be chest pain imaging centers open that might need access to to coronary CTA and and and chest CTA and things like that. You know, I think that the expedited process can help with that. I think that the expedited process, when done appropriately, can make sure that hospitals or cardiology groups or whoever really needs these for an in in short order. I would I think I think I would push back on the fact that, you know, the the that the idea that there has never you know, we have never rejected a CTCON is not necessarily a sign that it's not working or that it's not necessary. I would counter that it may be a sign that it's working just as intended and that people aren't, that we don't have groups coming in, unnecessarily asking for CONs because they know that the process works. Now is it taking, longer than it should? We we wouldn't disagree with that. We we would agree with the need for an expedited process, but, you don't wanna get rid of a process that actually in reality might be working pretty well to protect patient access and pay and and and patient care.

[Sen. Saud Anwar]: Thank you so much for your testimony. I see no other questions or comments. Thank you.

[Dr. Adam Kaye]: You're welcome.

[Sen. Saud Anwar]: Thank and, Sarah Bromley, I just wanna check. She's not here in the room. She's not in the virtual room. Okay. That's, doctor Farquhar, you're on. Welcome.

[Dr. Thomas Farquhar]: Hi, Senator Anwar, Representative McCarthy Behay, Senator Summers, Representative Senator Estitra, and members of the committee. For the record, my name is Thomas Farquhar. I'm a radiologist practicing in Connecticut, and I serve as the legislative chair for the Radiological Society of Connecticut and would like to offer some more comments on, House Bill, 5,045. Basically, I'll just kind of emphasize some of the things that Adam had already spoke to about, my colleague. We're in support of an expedited process in making the CON process easier, but we would also want to see a few things in the bill hopefully be addressed. One is to make sure that they keep the possibility of public comment, especially in intervener status. The reason behind that is we have seen other ones where CON applications have gone through with and, basically, whatever's put in the application is just accepted as fact. And we think that, especially other radiology or hospital groups that are experts in the area should have the opportunity, to make public comment and provide that information as well. There were also the number of, different kind of operational decisions about how things would work, that were not specified in the bill, and we have concerns that that could make it longer and more complicated rather than easier. So we would hope that those would be fleshed out before being finalized. And the last thing that we wanted to do is we just wanted to make sure that, yeah, the more information around the administrative aspects of the process and the timing. And then the last part was to reemphasize what Adam was mentioning was about dropping the number of the size of a group that counts as a small physician group. We do think that this will have sort of a negative effect. It'll require CONs for it went from seven physicians down to two physicians. So now a three physician group is gonna require us going through the CON process, which will make things more difficult. And and so we think that's kind of a a step backwards, and and we'd like that to be at least considered in that direction. Thank you.

[Sen. Saud Anwar]: Thank you so much for your testimony. I you you you heard some of the questions we asked doctor Kaye when they

[Dr. Thomas Farquhar]: I do. May I

[Sen. Saud Anwar]: Yeah. Do you wanna answer them? Yes.

[Dr. John Wysocki]: May I yeah. I was

[Dr. Thomas Farquhar]: just gonna say I didn't wanna interrupt. So one of the questions about what to do with private equity, as Adam said, it's a difficult problem. I don't actually think that private equity is the problem. I think it's the final behavior that ends up being a problem. But what I do know is his statement about trying to empower physicians is the most important things. The, groups don't, do these types of mergers, for any other reason than because, it's all a consolidation thing in order to be able to survive in health care. So the hospitals will tell you that the insurance companies are so big, they push them around, And the physician groups will find that the hospitals, have the all the leverage and that the physician groups need to get bigger in order to be able to to be able to buy in health care with the size of, you know, hospital systems and insurance companies. So how we how do we reverse that trend? I don't quite know. But anything that's gonna make it easier for physicians and physician groups is is gonna keep them from from trying to consolidate. And then the other question about the c the CT scanner is always being approved. The the last CT scanners that were not approved was a CUN application that was put in during COVID. It was for three CT scanners to scan asymptomatic patients in the very beginning of COVID when we had no treatment for it whatsoever. And there was a a physician who subsequently made the New York Times for overbilling for dozens and dozens of lab tests that he would do in addition to a COVID test. And he wanted to scan down at Fairfield County patients with CT scans. So because there was a public comment for that, we were able to provide information from the radiology, literature at the time showing that there was no role for CT scan for the diagnosis, particularly back when it was untreatable, and that those CUN applications were not approved. So I I wholeheartedly agree with Adam that the CON process is is, you know, working from that standpoint that we usually don't get spurious ones. As far as CTAs for cardiac studies, there are, decades of data showing that if providers order the studies and they own the equipment, utilization goes up. It's true for knee MRIs, back pain, CT scans for stones ordered by urologists. And so my question was, do we really want Connecticut to run the natural experiment of seeing how much CTA coronary utilization will increase if cardiologists own the CT scanners? Because that would be the concern for self referral and overutilization.

[Sen. Saud Anwar]: Thank you so much for your testimony. This is very helpful. I see no other questions or comments. Thank you.

[Dr. Thomas Farquhar]: My pleasure. Thank you.

[Sen. Saud Anwar]: And that brings us to the next person on our list, which is number 17, Erica Rojaveen Byrne. I hope I pronounced it correctly.

[Laurie Gaglione]: You were pretty close, senator.

[Sen. Saud Anwar]: Thank you. Go ahead.

[Erica Ruggavain Byrne]: Good afternoon, Senator Anwar, Representative McCarthy Vehi, and esteemed members of the Public Health Committee. My name is Erica Ruggavain Byrne, and I'm the Development Director at She Leads Justice, a statewide nonprofit that uses a justice and equity lens to advocate for under resourced and marginalized women and girls in Connecticut. For over fifty years, we've been a leading advocate for policy solutions to enhance women's economic security, combat discrimination, and increase gender equity. She Leads Justice stands in support of House Bill 5,389, an act concerning a provider toolkit for the diagnosis and treatment of menopause, perimenopause, and postmenopause. My written testimony cites new research and data points about how undiagnosed and untreated perimenopausal and menopausal symptoms exacerbate economic and racial injustices. A toolkit would be a step towards addressing those injustices. But in my time before you today, I want to share a personal story of how this bill would help close a gap that I've experienced myself. I'm 44 years old, and I'm experiencing symptoms of that can be attributed to perimenopause, including heavier periods and changes that are impacting my quality of life. I had my annual visit to my gynecologist a few weeks ago. She's been my care provider for over a decade, and I've always found her to be well informed and supportive. I got there. I undressed. I put on the gown and sat down on the exam table. My doctor conducted the exam and asked if I had anything I wanted to bring up. I mentioned my symptoms, and I waited for her response. I was prepared to be asked about my family history and told about different evidence based options, including the use of topical estrogen. Instead, I was honestly shocked to hear her say that she didn't prescribe any form of hormone replacement therapy for anyone who is still having what she called regular periods. If you've been in the vulnerable position in an exam room, you know that arguing with your care provider is the last thing that you want to do. So I didn't. I nodded. She left the room. I got dressed, and I left. It was painful to realize that my trusted care provider was less well informed than the perimenopause and menopause subreddits, which are amazing, by the way. Although it would be designed for providers, a toolkit would have empowered me as a patient to continue the conversation with her. I'm very grateful to representative Belton for her advocacy on this issue. This bill deserves to pass, and it deserves to be funded. For every person who can be here today to testify in support of this, there are thousands of tired, busy women going through perimenopause. If they all have the time and energy to be here, their collective rage about how our very real symptoms are ignored or dismissed by medical professionals could get this bill emergency certified tomorrow. As this bill moves forward, I encourage the inclusion of guidance addressing racial and ethnic disparities and common comorbidities such as metabolic conditions. This is also personal to me as someone who developed a rare estrogen sensitive liver condition during pregnancy and I'm struggling to find any care provider who works at the intersection of these issues. Ensuring that providers receive comprehensive equity informed education will address racial and economic disparities and will help all patients receive evidence based compassionate menopause care. I respectfully urge the committee to pass this bill. Thank you for your time, and thank you especially to the committee staff for keeping this hearing moving smoothly. Happy to take any questions.

[Sen. Saud Anwar]: Thank you so much, miss Roggeline Berne. Sorry to mispronounce your name initially. I have representative Belton who has a question for you.

[Malia Hunt]: Wonderful.

[Rep. Kai Belton]: Thank you, Erica, for your testimony. And I wanna say that I'm sorry for your experience, and I can speak for myself and say that I had a very similar experience. And I know that there are many women who have their symptoms dismissed, and they just don't know what to do next. So I am very happy, that we have the opportunity to move forward this toolkit. But what I wanna ask you is, you mentioned something about an economic study. Can you tell me more about that study?

[Erica Ruggavain Byrne]: Yeah. Thank you for the question. I'd be happy to. So as I was preparing to give testimony today, I did some some research and found a new working paper from 2025 that was produced by the Stanford Institute for economic policy reach research that found that women who visit a health care provider with menopause related symptoms are earning ten percent four years later and that those effects are concentrated among women without college degrees and who are already in lower paying jobs. And so we know that women of color are disproportionately represented in these groups, and we also know that there are racial disparities in terms of who experiences menopause related symptoms, with black women reaching menopause eight and a half months earlier than white women and having worse symptoms, but are less likely to receive hormone therapy as well as mental and, mental health and medical services. So this really is a both an economic justice and a racial justice issue. We can see we know the overall impact on the economy and businesses in terms of hours lost, but we can really now see some real data about the impact that this has on individual women in terms of their ability to support their families.

[Rep. Kai Belton]: Thank you for sharing that, Erica. I really appreciate you lifting up the economic impact that menopause symptoms have on women, but also the disparities that exist when it comes to black women. So thank you for your testimony. Thank you.

[Sen. Saud Anwar]: Thank you, representative, Kristen McCarthy Vehi.

[Rep. Cristin McCarthy Vahey]: Thank you very much. And, Erica, it's wonderful to see you, and I love that you gave a shout out to our team behind the scenes who's always helping We wouldn't be able to do this without them. I yes. As you know well. I just wanted to ask a question about the passing comment that you made about the Reddit subreddits that are helpful. And it really raises an important question for me, which is, how do you know where to get good and helpful information that is reliable about, menopause symptoms? I think it speaks to why we would want this toolkit, which you referenced, but how do you make that decision for yourself?

[Erica Ruggavain Byrne]: Yeah. No. Great question, representative McCarthy Vahyan. Great to see you. So I have a background in public health. I am an adjunct professor at the University of New Haven in their School of Health Sciences. I teach master's in public health students and also had the opportunity last semester to teach undergraduates in a research design and writing class. So I think a lot about how do we find evidence based information, and how do we understand it, and how do we communicate it? And, you know, in the last five or so years, we've seen an explosion of interest and information around, perimenopause and menopause kind of as our age group, has has aged into, these experiences. And it is really hard. I mean, I'm someone I I don't have TikTok, and so I don't see what's what's on there. But I know that, you know, on social media, TikTok and Instagram, there's a lot of folks who are doing a lot of content related to it. And some of it, you know, accurate, and some of it, you just you don't know where people sharing their own personal opinions, and anecdotes about things. And so I am always really skeptical when I encounter information and always wanna figure out where it comes from. And so in these subreddits, which are both moderated by the same people, actually, they have actually, it's an incredible resource, this Wiki page of information that is all linked back to the studies and to the professional associations and to the guidelines that, connect with the specific symptoms, issues, treatments related to, to menopausal care. And so it's but it is it is really heartbreaking to know that. And I think many women, especially, have experienced this in medical care environments where you go in and you have to know more than than your care provider does in order to get the treatment and the care that you need for your quality of life. And so it's it's really it's really then becomes incumbent on the individual and having a toolkit like this for providers, not just, you know, gynecologists, but all different types of care providers. I mean, we see, you know, how important estrogen is to dent to your dental health, to your heart health, to your liver health, to all that stuff. So this would be a really great step.

[Rep. Cristin McCarthy Vahey]: Thank you so much. And I I think you're pointing out two really important things is you have a background and know how to discern. Some of the rest of us don't know how to do that in the same way. So how do we know? And you also said there was an explosion of interest in information, but I think one of the things is impacting providers and maybe with just a yes or no, because I know we wanna keep things moving. But with providers is that there hasn't been an explosion of research on women's health issues in this way relative to many of the issues that we've seen, you know, with a few notable exceptions. I think we've come a long way, for example, with breast cancer. But we don't have the same kind of body of of research and background information. So I think would you agree with that statement?

[Erica Ruggavain Byrne]: Yes. Yes. I would.

[Rep. Cristin McCarthy Vahey]: Well, thank you so much for your advocacy and testimony, and I would echo what representative Belton said as well. And I appreciate you very much, highlighting for us and informing me of the disparity for black women, and other women of color. I I think that's something important and something I hadn't realized as clearly before. So thank you so much. Thank you, ma'am.

[Sen. Saud Anwar]: Thank you. Thank you for your testimony, and then thank you for your advocacy as well and and also sharing your personal experience to highlight even some of the most basic things that we can do better at. So with that said, I don't see any other questions or comments. We'll move to the next person on our list, which is Kelly Craft, number 18. Welcome. You're on.

[Committee Staff (Zoom/Tech)]: Hi. Good afternoon, distinguished members of the public health committee. My name is Kelly Craft, and I serve as the director of the Meriden Middlesex Wallingford Coordinated Access network at new opportunities, also known as the MMW CAN. So I serve as the CAN backbone for our regional coordinated access network in this region. I also oversee one of our regional warming centers in the Meriden area. So I am here to speak in strong support of s b three sixty four, an act concerning extreme weather protocol. So I am here to, discuss on what the lack of standardized protocols affects me, my staff, and our community. So first, I wanna mention, like, staffing is our largest challenges when we're receiving a activation with hours, minutes, or sometimes even after the fact. We are scrambling to try to get our sites up and running so we can ensure that people in our community have a warm place to stay and are safe from the extreme weather. As many of you know, and I know some of my predecessors spoke on it as well, our seasonal warming shelters run off of very small seasonal staff who sometimes have two or three other jobs. So trying to locate people who are free that day and able to work is a challenge. It to get these sites up and running with little notice. We are often, myself included, supervisors and other, managerial staff are often going to provide the coverage themselves. And if we had a protocol that was standardized, we would know beforehand, and we would be able to plan a little bit better for for these things.

[Sen. Saud Anwar]: So

[Committee Staff (Zoom/Tech)]: that's that's on the staffing end. On the short notice end for clients, it is incredibly challenging because we're reaching out to our outreach committee our outreach, case managers to go out into the community. We're reaching out to our police departments, our mobile crisis, and our local mental health authorities who are working with people who are currently unhoused to locate, and identify people who need to come in. And sometimes that is utilizing hotels because congregate living centers are are not suited for those clients' respective needs. And I wanna share an example of prior to the one of the blizzards that we encountered this year. We had a client. I was working with one of our local mental health authorities who has an act contract oops. Sorry. Who has an act contract in our region. They had a client who was very skeptical about coming in out of the cold. We were trying to coordinate a hotel, with our 211 providers. However, due to the late notice of the 211 activate the activation, 21 is inundated not just from myself, but from my other state backbone providers in getting ensuring people are getting out of the cold. We're ensuring our cold weather spaces have ample room for people who are coming in off the street. This it took this client four hours

[Committee Clerk/Timer]: to get ahold of her. Miss Kraft, but you have reached your three minutes. Thank you. Thank you.

[Sen. Saud Anwar]: I'm sorry. Thank you for your testimony. This was very helpful. May I ask you a question? So if if, let's say, extreme weather protocol is is enacted right now, How do you reach out to the people who are homeless? As a director of a can, what is the next steps? What are the few things that you would do?

[Committee Staff (Zoom/Tech)]: If you can keep it

[Sen. Saud Anwar]: short, but yeah.

[Committee Staff (Zoom/Tech)]: Yeah. So I reach out to our local mental health authorities, so mobile crisis group, our local police departments as well as our outreach team who are working with people who are known to be outside and let them know that there's been an activation. And if anything, is being risen, if they find anybody who need is in need assistance to contact me, we'll immediately find some kind of sheltering option for those individuals.

[Sen. Saud Anwar]: And on an average when that's happening, how many people would you usually connect with during that time? Who who would need the immediate help?

[Committee Staff (Zoom/Tech)]: So in our region, it's I think we currently have about roughly 25 peep well, unhoused. So it's roughly that 25 people population. We are one of the smaller coordinated accesses regions in the state.

[Sen. Saud Anwar]: Okay. So and then and so that's why you wanna be ahead of the curve rather than having to catch up and then and try to navigate all of that with unlimited resources in the evening or late at night?

[Committee Staff (Zoom/Tech)]: Yes.

[Sen. Saud Anwar]: Okay. I I I think your testimony is very helpful. It continues to highlight the issue that we are all learning more about and and and recognizing we need to do better. So thank you so much. I don't see any questions or comments. Thank you.

[Dr. Kirsten Ek]: Thank you.

[Sen. Saud Anwar]: And we that brings us to in person over here, Kathleen Garrity.

[Rep. Cristin McCarthy Vahey]: I have comments online.

[Adelita Orefice]: Or is Goldman on the phone?

[Sen. Saud Anwar]: We'll have doctor Goldman we'll have you wait for a second because we called Kathleen Garity just now, so we'll start with her. Kathleen, go ahead. Yeah. The press the button. Bear. Thank you.

[Kathleen Garrity]: Thought I did. Thank you. Good afternoon, senator Anwar, representative McCarthy Vehi, ranking members, co chairs, and members of this committee. My name is Kathleen Garrity, and I'm the executive director of the Connecticut State Dental Association representing the licensed dentists in Connecticut, our oral health care teams, and the patients that we serve. I am here today to represent those groups and in strong support of f excuse me, fifty three ninety nine. There are two parts of this bill I'd like to address today. One is regarding a scope of practice expansion to allow dentists to do cosmetic injections And the second regards are mandatory continuing education requirements that are addressed in this bill. Last year, CSDA worked with Department of Public Health to initiate a scope of practice regarding cosmetic injections and stakeholders were allowed to participate in that including those in our state that can already do these injections which include plastic surgeons, dermatologists, APRNs, PAs, and RNs. At the end of that report, which was an extensive collaboration over several weeks, the groups, the stakeholders that were there acknowledged that dentists are highly trained to do these injections. We have the both the education, the anatomical expertise of the head and neck area to be able to do these safely and the clinical techniques and education to do so. In fact, dentists do these injections regularly as part of their therapeutic practices. Connecticut dentists graduate from a CODA accredited program with extensive training in head and neck anatomy, neurovascular structures, pharmacology, injection techniques, and emergency management. In fact, a DDS is a doctor of dental surgery. Dentists complete thousands of hours of supervised clinical training and administer injections in the head and neck every single day. There are very few health care providers that do these types of injections as much as we do. Notably, dentists in Connecticut may already administer Botox therapeutically for conditions such as TMJ and bruxism. The medications, anatomical landmarks, pharmacology, and techniques are identical, whether we are doing it for therapeutic reasons or cosmetic reasons. The state has already determined that dentists are capable to do these agents safely and regularly. Prohibiting cosmetic use while allowing therapeutic use is not grounded in public health distinction. Nationally, there are at least 37 other states that allow dentists to do these types of injections. And I would actually like to note that the American Society of Plastic Surgeons in their latest annual report has noticed that this is a minimally invasive procedure, and it is very different from cosmetic surgery. With respect to the continuing education provisions in this bill, I would like to raise a few things. First of all, CSDA has reached out to the commissioner of DPH as well as our state dental associate commission to talk about the inclusion of identifying potential patients who may have triggers that show us they might be victims of human trafficking. This is something very important to us. We would like to include this in our mandatory requirement that already covers looking for victims of potential sexual abuse and or domestic violence. It's a natural pathway for us to try to help victims and identify pathways to get them out of their situations. However, that's not a statutory requirement. That is something that is being handled by biannual review that happens every two years with the department of DPH and the dental commissioner. So I would ask respectfully that that not be included in this bill because it's already being handled.

[Committee Clerk/Timer]: Excuse me, miss Garrity, but you've reached your three minutes. Thank you.

[Sen. Saud Anwar]: Why don't you complete your your testimony, please?

[Kathleen Garrity]: Thank you. The last part of it is there's a a piece in this legislation that would ask that there be a mandatory requirement on dentists to learn to be trained to handle patients that are in the IDD population. We already do this routinely. We have a mandatory that covers access to care. Dentists that are providing for this community are highly trained. It is not a one to three hour training. This is a very extensive training program that includes clinical expertise, specialized equipment, specialized techniques. So I would like to ask again that that be deferred to the existing process and that the content experts being the commissioner and the dental commission work collaboratively. If they identify a need, of course, we would embrace that. We have many wonderful providers in Connecticut that are already serving this population. We understand there need to be more of them, but there's other pathways to do that that are not training specific, but I can talk about those a little bit more extensively. A lot of the issue in this area falls to another committee, which would be health and human services. So thank you for your time.

[Sen. Saud Anwar]: I'm happy

[Kathleen Garrity]: to take questions.

[Sen. Saud Anwar]: Yes. Thank you so much, representative Kristen McCarthy Vehi, our co chair, has a question.

[Rep. Cristin McCarthy Vahey]: Thank you, senator Amar, and thank you, Kathleen, for being here and for working with us, and also thanks to the dentist for going through the scope process. We really appreciate that as a committee, and thank you for, referencing that and for sharing that it's 37 other states, which was actually one of my questions. So just to clarify two things, one, which is in the bill before us and another, which is something we've talked about but and came up at the hearing but, is not in language right now. The continuing ed requirements, basically, your ask is that both of these things, one that you want and one that you don't want, be allowed to go through, the process as it is right now. Can you just walk us through a little bit about the mechanics of that process and how how that works?

[Kathleen Garrity]: Sure. Under statute, there's twenty four hours twenty five hours every two years that dentists are required to do of continuing education. Those are our requirements. Most dentists do actually hundreds of hours every year because they wanna learn new techniques, they wanna understand new possibilities and how to treat a certain type of patient that they're presented with. However, those mandatories are well thought out in terms of reviewing what our populations are here in Connecticut, what new techniques are out there, and what new pieces of information dentists need to be educated on. One of those mandatories is requiring dentists to learn how to treat patients with access to care issue. That could be a special population, it could be geriatric, pediatric, IDD, etcetera. But it could also mean just making sure that your office is accessible, that you have office is accessible, that you have transportation ideas in terms of how to get people to you. So it's really well thought out and that scope process, excuse me, the review process happens every two years and so DPH and the Dental Commission that's been set up review it and they ask for our input of course, but they also are looking at other stakeholders including patients.

[Rep. Cristin McCarthy Vahey]: Oh, I was I'm interested in a little bit more specific. So, the about the review process, just that last part of what you said which is every two years, there's a review process. So what happens? Is there a public meeting where the commissioner and the dental commission get together? Is it a conversation that they have? Just just a little bit of detail about that process itself. That's what I'm interested in.

[Kathleen Garrity]: Of course, I would actually say that obviously the commissioner and the commission should be addressing that question. But I will tell you from my perspective on it and my participation through that two year process is kind of a living conversation that goes on and where we identify gaps, where we identify new issues that are arising in the profession that I wanna make sure both of those parties are aware of. And they're also hearing obviously from other stakeholders including others on our oral health care team and the patients. And when they come together and say, we've identified a gap or we're identifying the language that's currently in those mandatories is not befitting what's going on in society. So it's an ongoing discussion. And at the end of it, they sit down, huddle, have their conversations that I'm not privy to, and make a decision and determination.

[Rep. Cristin McCarthy Vahey]: Okay. Thank you. So fair point that we should ask them directly. The last thing is we had talked, here among the committee and we'd had some conversation about allowing and there was a request from from, dentists specifically about allowing x rays to be taken, when a dentist, a single practice dentist, was not in the office. And I just wanted to give you a chance to comment on that.

[Kathleen Garrity]: Thank you very much. So right now, under Connecticut law, in order for a dental assistant or anybody else on the team team to be able to do an x-ray, they have to be well trained on it. A dentist can authorize an x to be taken by a dental assistant if the dentist is there for direct supervision, meaning that they are in the in the space. Indirect supervision is probably more appropriate because that would mean the dentist is in the facility. They're in the building. But to advance it a little bit further, it probably should be generals, excuse me, overall supervision that the dentist is the one that authorizes it to happen, specific shoot of whatever it is. It's usually not a whole panorama. It's an issue where a patient comes in with an emergency. They wanna see something very specific. Technology allows that dentist to be miles and miles away, get a picture on their phone or their tablet, identify it, and I and give some idea back whether they need to be emergency care or whether we should schedule an appointment for the next twenty four hours to see you. And also whether antibiotics or other medications should be prescribed. So that particular piece of, the that specific statute probably does need to be updated just to evolve with technology and also access to care. If a patient is in your room, you wanna get an x-ray, you wanna treat them appropriately.

[Rep. Cristin McCarthy Vahey]: Thank you for that. And perhaps to evolve with what's happening in practice and the reality of what's happening in many offices. My teeth are hurting just having this conversation. So some of you know

[Kathleen Garrity]: I'm a big fan of your dentist.

[Rep. Cristin McCarthy Vahey]: I'm a huge fan of my entire dental team, and I have not just a a dentist. I have a number, but I certainly have learned a lot through my own personal experience and, have a lot of empathy for what they are facing as well. So thank you for your testimony. Thank you.

[Sen. Saud Anwar]: Thank you, madam cochair, representative Clarity's teacher.

[Rep. Nicole Klarides-Ditria]: Thank you, mister chair. Thank you for being here today. And I just have a, few questions, some follow-up on the on the dentist doing injectables and and neurotoxins. What is the how does the UConn School of Dentistry feel about the injections?

[Kathleen Garrity]: Well, I can't speak on behalf of UConn, of course, but I have had conversations with them. A lot of the UConn health team is already teaching these practices because, of course, their medical students can learn these practices. They're also teaching it to the dental students in the sense of doing pain management. So the transition from pain management to to cosmetic, there is none really. So they are learning it, but they can't practically use those skills here in Connecticut. A lot of dentists that are taught in other schools are coming to Connecticut with the skill set, but they're unable to use it for cosmetic reasons. So if I had to hedge a guess, I would say that it's a little bit of a disadvantage to Yukon at this point in time that our students can't come out with the robust education. They get up there and use all their skills to a patient's needs and desires.

[Rep. Nicole Klarides-Ditria]: Alright. Thank you. And as of today in Connecticut, who can do injectables and neurotoxins?

[Kathleen Garrity]: Certainly, MDs. So for instance, the plastic surgeons and the dermatologists. Also, nondoctorial, professions such as APRNs, PAs, and RNs are are able to do these injections. Some of them with oversight of a dentist, but excuse me, an MD, but they're not usually on-site when these injections are happening.

[Rep. Nicole Klarides-Ditria]: Okay. And then as a follow-up to that, as we know, neurotoxins and fillers are relatively new, twenty five years or so. So if there was, a doctor, an APRN, a PA, or an RN that's a little bit older, and didn't learn these skills in school, med school or PA school or APRN, they would have to go back and take a course to learn how to do these, which is exactly what the dentists are asking to do. Is that correct?

[Kathleen Garrity]: Anytime there's a new procedure, that's what we would do in the dental profession. I won't speak for medical, but, certainly, anytime there's a new implant that comes out or a new way of providing, therapy for our patients, we go to and do not just didactic, but also hands on clinical observation, those sorts of things. So any type of new procedure, that's what we do. I mean, do no harm to your patient is what we live by.

[Rep. Nicole Klarides-Ditria]: Okay. Thank you so much for your answers. Thank you, mister chair. Thank you.

[Sen. Saud Anwar]: Thank you. Thank you for being with us this entire morning and and part of the afternoon. All the questions I had have been asked by my colleagues, so we're good.

[Committee Staff (Zoom/Tech)]: Very good.

[Sen. Saud Anwar]: Thank you. Thank you. With that, we're gonna go going to go back to doctor Boris Goldman. Doctor Goldman, sorry about the wait. You came at right at a tricky time, so we had already invited somebody else. So you're on. Welcome.

[Dr. Boris Goldman]: Thank you so much. Good afternoon, senator Anwar, representative McCarthy Veggie, senator Sommers, representative Claire Deese Dittria, and the distinguished members of the public health committee. My name is doctor Boris Goldman. I'm a board certified plastic surgeon and the current president of the Connecticut Society of Plastic Surgeons and the chief of plastic surgery at Norwalk Hospital. And I'm here today on behalf of the Connecticut Society of Plastic Surgeons, the Connecticut State Medical Society, and the Connecticut Dermatology and Dermatologic Surgery Society, literally representing thousands of physicians across our state to express our opposition to HB fifty three ninety nine. The provisions in this bill would allow dentists to administer cosmetic injections such as neurotoxins and dermal fillers as you've heard. While these procedures are often perceived as simple cosmetic treatments, they are in fact medical procedures, and they carry significant risks when performed improperly. Under Connecticut law, the practice of dentistry is defined as the diagnosis, prevention, or treatment of conditions of the oral cavity, the jaws, and associated structures. The statute specifically excludes treatment of dermatologic conditions of the face and cosmetic procedures unrelated to the oral cavity. HB fifty three ninety nine would expand dental scope well beyond these established boundaries. The face is one of the most anatomically complex regions of the body. A surgical or injection error of even just a few millimeters can cause catastrophic complications. An injection in the wrong location can puncture a blood vessel that connects to the back of the eye resulting in immediate permanent blindness. In other cases, improper technique can cause tissue death, severe disfigurement, stroke, or nerve injury. There's also risk of misidentifying a cancerous skin lesion and inadvertently injecting it rather than properly diagnosing it and then treating it appropriately. These complications are not theoretical. As a plastic surgeon, I routinely see patients referred to me after procedures performed elsewhere who require corrective surgery or procedures to repair significant damage. It's also important to understand the differences in training. Dentists complete four years of dental school following their undergraduate education. In contrast, plastic surgeons complete medical school followed by seven to ten years of intensive surgical training and accredited residency programs with extensive experience in full facial anatomy, complication management, and hospital based patient care. Some dentists pursue additional medical education in surgical residency training in oral and maxillofacial surgery. And those individuals after completing medical school and extensive surgical training can obtain hospital privileges to perform advanced procedures, but that level of training is not stipulated in this bill. Allowing dentists without medical school and surgical residency training to perform cosmetic injections without clear limitations would lower the standard of care and put patients at risk. Additionally, dentists typically do not have hospital privileges, raising the question of who will manage serious complications when they occur. Let me be clear. We have tremendous respect for our dental colleagues and the important work they do treating diseases of the oral cavity and jaw. However, expanding the scope beyond the training that's without equivalent medical education and surgical experience raises serious patient safety concerns. For these reasons, on behalf of the Connecticut Society of Plastic Surgeons, the Connecticut State Medical Society, and the Connecticut Dermatology and Dermatologic Surgery Society. We respectfully urge the committee to oppose HB fifty three ninety nine. I thank you for your time and your consideration.

[Sen. Saud Anwar]: Thank you so much, doctor Goldman for your testimony. Doctor Goldman, I wanted to ask you a question. You know, in this arena for the Botox and some of the other things, we have, APRNs and physician assistants who are providing some of those treatments, and their training is much less than what a dentist goes through and much more, the the dental treat training is far more extensive and especially around the the part of the face. They're probably far more comfortable with that area. So help me understand that you have individuals with far less training. It's okay for them to do it, but another group you feel uncomfortable with. Could you share your thoughts?

[Dr. Boris Goldman]: Sure. Thank you for the question. I'm happy to address it. So the first thing is that there are health professionals with training that's not as comprehensive as dentists that do injections. For instance, PAs, and and nurses. However, they have to do injections under the supervision of a physician. Now APRNs can practice independently, for instance. And APRNs, however, have to spend at least two thousand hours in training as part of a care team model where they're specifically trained on how to do these types of, procedures. The the question is not whether or not our dental colleagues are skilled and whether or not they can perform injections. The question really is what defines their scope of practice. They certainly know the anatomy of the mouth and its adjacent structures in the jaw. But we aren't talking about treatment of bruxism, for instance, with a neuromodulator. That's painful biting or clenching of the jaw. We're talking about with this bill, potentially injecting fillers and Botox anywhere on the body. I don't see limitations to the mouth or structures adjacent to the mouth. I was part of the work group last year with the with the Department of Public Health where we discussed these issues along with other, professionals, representing other specialties. And it was it's almost unanimous where we felt uncomfortable with the request at that time. And at that time, the dentist were requesting the ability to increase their scope of practice, perform procedures basically from the clavicle to the top of the head and not limited to injections. So we have to understand what this is, which is a stepping stone. And if we're gonna do that, there needs to be clear limitations on what these fillers and and neuromodulators are gonna be used for. Currently, there is no such stipulation in the way that this current legislation is written, and that's our objection.

[Sen. Saud Anwar]: Thank you. That that's that helps me understand this better. So so if it was limited to the area, the facial area, that was part of the the initial conversation, then then you and the group of physicians you're representing today, they would be more comfortable if we move forward in that direction?

[Dr. Boris Goldman]: I I believe that if there were limitations on the request that that we would certainly have to go back and discuss this depending on what the what limitations were placed on this. But but, yes, I I believe that right now, there is there is no limitation on where these injections are gonna be performed. It doesn't limit it to the masseter muscle. It doesn't limit it to diseases associated with the mouth or mastication. So so, yeah, I think that's a fair statement, senator on that.

[Sen. Saud Anwar]: Okay. Thank you. Representative Claire DeSietro has a question as well. Thank you.

[Rep. Nicole Klarides-Ditria]: Thank you, mister chair. Thank you for being here virtually today. So you stated you don't have an issue with RNs, PAs, or APRNs injecting, but dentists who that's their background. They have extensive education on the face only. I'm just not understanding why this is an issue, and they went through scope of practice review, and there weren't any issues from any of the other disciplines.

[Dr. Boris Goldman]: Let me address each of those questions in turn. So the the first is, it's not that we don't have an issue with RNs or PAs injecting. Those injectors have to be supervised by physicians. Dentists would not have to be supervised by physicians. APRNs do inject, but after two thousand hours in a in a care team model, learning how to perform procedures like this before they can go out and inject independently. And the next part of this is that dentists are trained and they are experts in the anatomy of the mouth, not necessarily the face or the head or other parts of the body. In order to become an expert in anatomy of the face or the periorbital region region or the head or the neck, these people would have to go back. These professionals, these these DMD or DDS professionals would have to go back, complete an additional two years of medical school, or go on and complete an oral maxillofacial residency in order to obtain the type of expertise in anatomy that surgeons and and other physicians like us have. And I was part of the work group last year, and there were objections. So I'm I'm not sure if we're talking about the same scope of practice review, representative Clarity's, Ditria. But but I was part of that work group, and there were lots of objections to the scope of practice increase.

[Rep. Nicole Klarides-Ditria]: Okay. Thank you for your testimony here. Thank you, mister chair.

[Dr. Boris Goldman]: Thank you.

[Sen. Saud Anwar]: Thank you. This is very helpful. We appreciate you you waiting and and and testifying. Seeing other questions and comments, we'll move to the next person who is online, Diane Santos. Thank you, miss Santos. You're on. Welcome.

[Diane Santos]: Hi. Good afternoon. Can you hear me okay?

[Sen. Saud Anwar]: Very well.

[Diane Santos]: Okay. Thank you. Co chair senator Anwar, representative McCarthy Vehi, and distinguished members of the public health committee. My name is Diane Santos, and I fully support Senate Bill three sixty five, an act establishing a bridge program for emergency treatment of opioid use disorder because it could have literally saved my child's life. The evening of 12/28/2023, my son, Mark, sought help for his opioid use disorder at the Bacchus Hospital emergency room. He'd been given an appointment to start outpatient medically assisted treatment with buprenorphine for two weeks out, and there was no way he could be abstinent for that long. I was terrified of losing him. Mark was honest, telling the ER triage nurse he had last used fentanyl earlier that morning and wanted to stop. He kept nodding off, and the nurse told me she was concerned about that, but seeking treatment for opioid use disorder was no reason for a hospital stay. Their protocol was to have a recovery coach come from an outside agency to speak with Mark about his options. After about ninety minutes, the coach arrived. He handed us an access line number to call the next day, then told us we could stay there if we wanted to, but the doctor would only send us home because in his words, hospitals are not detox facilities. The nurse and the coach made it clear that Mark would get no help there, so we left. Thirty six hours later, I found my 26 year old son crouched in a corner on his bedroom floor. His body was stiff and cold to the touch, something no parent should ever have to see. That ER visit was our tiny window to save Mark's life, but it was slammed shut by protocols that create deadly gaps in care. Imagine the outcome if Mark was given a dose of buprenorphine in the ER, then sent home with a few doses and a warm handoff to follow-up care. Exactly what this bill proposes. He might still be here with us today. There is no tomorrow for someone using opioids in today's toxic supply. Treatment has to be immediate in the moment that it's asked for. SB three sixty five will make this a reality. Our tragic story clearly shows the dire need for this bridge program to become Connecticut law. I work at Bacchus Hospital. Two weeks after Mark's overdose death, I returned to the place that didn't help us, determined to be part of closing this gap. Hartford HealthCare has invited me into their conversation on this subject because they recognize the need to do more. Passing this bill will make a life and death difference for someone who is ready to get their life back the way my Marquee was. Please, please vote yes for SB365 and give families what ours was denied, the chance to heal and remain whole. Thank you.

[Sen. Saud Anwar]: Thank you so much, miss Santos, for your testimony. You are my hero because you relive your pain to make sure nobody else has to experience that. And and and thank you for highlighting the fact that if this bill had passed in 2022, this was never brought before. But but had this been bill been brought before and had passed, Mark would be here with us and then and so many more. I I think part of the issue that this bill would address is that right now, the access remains a big problem. And individuals who are willing and are are interested to get to rehab, the doors aren't that easily available. And then this is exactly the part. Do you wanna add anything else?

[Diane Santos]: I will add, senator Anwar, that I will be speaking on May 19 at Hartford Hospital, as I do work for Hartford HealthCare, but as the parent of someone who we lost tragically because he wasn't helped in the emergency room. I will be the keynote speaker, doctor Jason Wang, who's an addiction medicine doctor, has invited me. It's a program where they're looking to close the gaps in hospital based care for people with substance use disorder. So they caught wind of our emergency room experience at Bacchus, and they would really like, to hear my story and hopefully allow, Mark's story to not help happen to anyone else.

[Sen. Saud Anwar]: Thank you. I I I want you to know doctor Wang is here as well, and he's been very helpful with the bill too. So thank you for for your good work. With that, I do not see any questions or comments. Thank you again, miss Santos. Thank you for your work that you do and your advocacy. Thank you.

[Diane Santos]: Thank you, senator. Thank you.

[Sen. Saud Anwar]: Yeah. That brings us to the next person on our list, which is Carson Ferrer, who's here in person. Welcome, Carson.

[Carson Ferrara]: Hello, everyone. Good to be back. My name is Carson Ferrara, and I'm the hospital liaison for the community and law enforcement for addiction recovery initiative with liberation programs, where I work with people at highest risk of overdose in Fairfield County. I'm also a recent graduate of the Yale School of Public Health where my work centered on medications for substance use treatment and overdose prevention, and today I'm testifying primarily based on my experiences as a research assistant at Yale during grad school on the largest randomized clinical trial to date, looking at the effectiveness of long acting injectable buprenorphine versus sublingual, an emergency, initiated in the emergency department. That work helped inform my desire to pursue a career long term as an addiction medicine physician. And so I'm very passionate about this issue and here today to testify in support of SB three six five with some suggested amendments. So the research is clear that starting MOUD in the ED and connecting people to follow-up care leads to them being more likely to stay in treatment and less likely to die. And many of the people that I work with use the ED as their usual source of care. So being able to treat withdrawal and craving in real time and then bridge them to ongoing care is often the difference between seeing someone alive again or perhaps hearing from a family member that they overdose and pass after being discharged. As such, I strongly support the intent of the bill, and urge you to strengthen it with a few key ways that align with the evidence and with recommendations you'll hear from addiction medicine folks, later today. So first the bill should explicitly include both buprenorphine and methadone. Those are the two gold standard medications for OUD and clinicians need the flexibility to offer the right medication for each patient, especially in the fentanyl era. Second, starting medication, the ED is only half of the bridge. The other half is making sure that patients get to the other side after being discharged. So for buprenorphine, that means requiring an adequate bridge prescription at discharge so that patients don't run out of meds before they can attend an outpatient appointment afterwards. And then for methadone, that means a clear pathway to an opioid treatment program the next day, ideally, including a last dose letter so dosing can continue seamlessly. And a discharge prescription for a day or two or a vague referral with no confirmed follow-up isn't really a meaningful bridge for someone living with OUD. Third, the bill's definition of referral destination should be broadened. So as written right now, treatment programs are limited to those operated by DMIS, which excludes many office space and community providers. So primary care psychiatry, addiction medicine practices, and telehealth practices, who routinely and safely prescribe buprenorphine and can often see patients sooner than traditional programs. So EDs should be able to refer to both DMIS programs and then also community providers. Also, hospitals need to train and support ED staff to do this work, including access to addiction specialists when needed. And the bill, of course, should preserve clinical judgment so medications are used when clinically appropriate and with patient consent. Later today, you'll hear from physicians who have dedicated their careers to building the evidence base for ED initiated treatment and to implementing it here in Connecticut, including doctor Gail D'Onofrio, who, was my principal investigator on the trial I worked on and who's

[Committee Clerk/Timer]: miss for, mister Farrar. Your three minutes is up. Thank you.

[Carson Ferrara]: Thank you. So just in wrapping up, I urge you to pass s p three six five with these amendments so that no matter which ED someone with OUD walks into in our state, they're offered not just survival and withdrawal management, but a real path to treatment and recovery.

[Sen. Saud Anwar]: Thank you so much, mister mister Ferreira, for your testimony. I I wanted to ask you, is your, the work that you're doing, is that published now?

[Carson Ferrara]: Yeah. It was published on February 11 in JAMA. It was a trial looking at 29 emergency departments across the country. And the focus of the study was looking at which formulation of buprenorphine led to better outcomes seven days and thirty days post discharge. And there was no significant difference in that, but it does highlight that still ED initiated buprenorphine as a whole leads to better outcomes, and more like linkages to treatment, things like that.

[Sen. Saud Anwar]: So, I'm just, so there's a long acting version that goes up to thirty days?

[Carson Ferrara]: Yes. I believe so.

[Boyd Jackson]: There is.

[Sen. Saud Anwar]: So if if a community has far less access for formal rehab facility, perhaps that kind of a treatment may be better and then emerge. I'm just extrapolating that.

[Carson Ferrara]: Yeah. No. I mean, that's what I thought too. And anecdotally, with the within the RCT, you know, which was across multiple different settings in hospitals, there was no significant difference in treatment engagement compared to, like, sublingual form of buprenorphine. But, I still think it's a great time to give that options to patients, especially for those who, highlighted might have coverage gaps or

[Sen. Saud Anwar]: And and and we'll have these conversations later with other, clinicians who are doing this, but there's no special training outside of the actual training that the physician and the ED doctors receive that that's part of it that they will just provide the medicine and give them prescription perhaps and be able to give them Narcan and guide them to a place to go to. This is like a common sense thing.

[Carson Ferrara]: But Yeah, absolutely. I think the idea and your point of bringing this bill up was just to kind of make it standard of care that medications for opioid use disorder are offered in emergency departments. I know that they have been for a while in the Yale system just because that's where I've worked, but it's not it's incongruent across the state. And, you know, some people may bring up the issue of, like, provider burnout and being pulled in many different ways. But if you think about it, being able to initiate them on the medication before they're discharged and knowing that it provides better outcomes once they are released, will likely reduce return ED visits and things like that. So I think it should be standard of care across the state.

[Sen. Saud Anwar]: And now you have not submitted a written testimony this time yet.

[Carson Ferrara]: I was I was working on it before I came up here, but it's submitted now and should populate in a Okay.

[Sen. Saud Anwar]: Good. This will and and you have outlined some of the suggested changes in there?

[Carson Ferrara]: Yeah, absolutely.

[Sen. Saud Anwar]: Okay. And I I've received a letter from Doctor. Wang as well. We'll address all of that. Yes. Good. This is very helpful. Seeing no questions or comments, I wanted to thank you for being physically here and and your testimony and your work. Thanks, senator Manuel. Thank you. Thank you. Alright. We move to the next person on our list, which is Caitlin Crawford. I just wanna make sure. I think she's not there. Tricia Pitter. Miss Pitter, welcome.

[Tricia Pitter]: Thank you. Good afternoon, Senator Anwar, Representative McCarthy Vahay, and distinguished members of the public health committee. My name is Tricia Pitter and I'm a resident of West Hartford. I am here today in strong support of HB 5,389. I have also submitted written testimony with additional detail. In my mid-40s, I was medically induced into menopause following surgery. I was told I would enter perimenopause, but no one prepared me for what that would actually mean. Soon after, I began experiencing intense hot flashes, anxiety, insomnia, and brain fog. It felt like my body and my mind were changing all at once and I could not keep up. When I saw care, I was told it was not menopause because I was not having night sweats and because this was considered a natural progression. Instead, I was prescribed anxiety medication and referred for a sleep study. I left those appointments questioning myself. Similar to what Erica shared from She Leads Justice, I felt dismissed. And I also felt alone. And I wondered if I was somehow losing control of my health. So I did what too many women are forced to do. I became my own medical researcher. I read, asked questions, talked to other women, and returned to my doctor ready to advocate for myself. Only then was I prescribed an estrogen patch which dramatically improved my symptoms and restored my quality of life to the best of its ability. That delay in recognition and treatment prolonged my suffering unnecessarily. But no one should have to become their own medical expert to navigate a universal life stage. What stays with me most is this, in doctor's offices with specialists and even in the ER during triage, I was really I was routinely asked if I might be pregnant, but nobody asked if I might be in perimenopause or menopause. Pregnancy is routinely considered in care. Menopause, which affects half the population, remains largely invisible. Every day approximately six thousand women in The US enter menopause, yet too few clinicians feel adequately prepared to care for menopausal patients. When they are not prepared, symptoms are often misattributed, minimized, or dismissed. Menopause affects far more than hot flashes. It can affect mental health, sleep, oral health, bone health, cardiovascular health, skin, and eye health, and problems and probably others that are not even documented. Yet, too many patients are left to connect the dots on their own. As a black woman, this is personal. Black and Hispanic women often experience more severe symptoms and longer duration and gaps in care deepen disparities. HB 5,389 offers a practical solution, a statewide provider toolkit to improve menopause care across the healthcare workforce. And when paired with SB353, which addresses workplace accommodation, this creates a coordinated approach. When menopause is not recognized or treated appropriately, people may also struggle to access the support they need at work. Better provider education equals earlier recognition, more appropriate treatment, and less dismissal. I have a teenage daughter. I want her generation to enter midlife knowing their healthcare system will be prepared, not confused and responsive and not dismissive. Thank you, Representative Bell Kieten sorry, Representative Kai Belton for champion menopause equity in Connecticut. I respectfully urge you to pass HB 5,389. Thank you for the opportunity to testify and share my personal story.

[Sen. Saud Anwar]: Thank you so much, miss Pitter for your testimony. And, I I see, in the back, you have menopause equity for all. Is that an organization or it's just a statement? It is

[Tricia Pitter]: a statement by me. I feel menopause equity should be a right. It's something that we deserve. I felt like I needed to, make a statement. Right? Menopause equity for all.

[Sen. Saud Anwar]: You you're you're a very powerful advocate. Your testimony was very powerful. And within the time and the visuals are within the time. I love it. It's it's very, very helpful. I know, representative Belton has a comment for you or question.

[Rep. Kai Belton]: I want to thank you for your testimony, Tricia. And we we've heard a few times today how women go in for you know, go to their healthcare provider and they're dismissed. So I really appreciate you telling your story. And I wanted to know if you could possibly send me that background because in every meeting I'm in, I would look for it to be back there.

[Tricia Pitter]: Absolutely. Tony. Thank you all. Thank you, committee.

[Sen. Saud Anwar]: Thank you. Seeing no other comments or questions, thank you again. And we'll move to the next person on our list, which is, I wanna make sure, Jade, Thomas. Welcome. Thank you for being here in person, and thank you for spending your morning and afternoon with us.

[Jay Thomas]: Senator Anwar, representative McCarthy Vehi, and distinguished members of the public health committee. My name is Jay Thomas, and I work as a community engagement and public policy specialist at the YWCA Hartford region, a nonprofit which has served the greater Hartford region for more than a hundred and fifty eight years. The organization provides critical programs to the surrounding community, including emergency shelter and affordable housing, career training, and youth leadership excuse me, youth leadership development. In addition to operating early learning centers and before and after school care for students in grades K through five across Central Connecticut. I am offering testimony in support of h b five three eight nine, an act concerning a provider toolkit for the diagnosis and treatment of menopause, perimenopause, and postmenopause. The YWCA Hartford region stands in strong support of h p five three eight nine. This bill would require the development and distribution of a statewide provider toolkit to help health care professionals better diagnose and treat menopause, perimenopause, and postmenopause. The toolkit would provide practical evidence based and culturally culturally appropriate guidance for providers across multiple fields, including primary care, obstetrics, gynecology, psychiatry, and others. With a goal of better equipping providers to reduce misdiagnosis, dismissal, and unnecessary emergency room visits. For too long, menopause has been under recognized in health care settings. Many patients experience years of symptoms before receiving accurate information, diagnosis, or treatment. A statewide provider toolkit would help close these gaps by providing health care professionals with current clinical guidance and continuing education resources. In a 2023 study of obstetrics and gynecology resident programs directors, ninety percent responded that residents should have access to a standard menopause curriculum. Despite broad support, only a third reported that their programs offered one. A concerning discovery given that knowledge practice deficits leave health care providers unprepared to adequately address and treat menopause concerns. Addressing the ongoing menopause and training education gap is a matter of equity. First, the lack of awareness creates disparities in care for a significant part of the population. This discrepancy threatens the quality of life of our mothers, sisters, and friends. Second, menopausal transition, including frequency and severity of symptoms, can differ across races. With studies showing that black women tend to experience transition earlier than other races. For example, it is reported that anywhere between seventy five to eighty five percent of women experience hot flashes during menopause. However, researchers excuse me. However, researchers have discovered that black women are more likely to experience intense and more frequent hot flashes. They were also less likely to receive treatment for vasomotor symptoms, like hot flashes and night sweats. Ensuring that providers receive comprehensive, equity informed education will help reduce delayed diagnosis, improve access to treatment, and ensure that all patients, regardless of race, language, income, or geography, receive evidence based compassionate menopause care.

[Committee Clerk/Timer]: You may, Ms. Thomas, but your time has expired. Thank

[Rep. Kai Belton]: you. Thank you.

[Jay Thomas]: I would just like to acknowledge that several states have proposed laws establishing continuing medical education or supporting training to ensure healthcare providers have the necessary menopause related education. I would like to thank Representative Kai Belton for championing menopause equity in Connecticut and for advancing a thoughtful, forward looking public health approach. I appreciate the opportunity to offer testimony. I respectfully urge the committee to pass HB five three eight nine favorably, and I'd be happy to answer any questions.

[Sen. Saud Anwar]: Thank you so much for your testimony. Would you be able to share what other states have done? You touched on it towards the end.

[Jay Thomas]: Yes. Absolutely. So California, Maine, there's a longer list, however, of states. Let me see if I can pull this. California, New Jersey, Illinois, Arizona, Maine, Texas are some of the states that have introduced legislation aimed at either supporting continuing medical education or some type of additional training or education like a toolkit that I'm aware of.

[Sen. Saud Anwar]: Okay. So so there there have been toolkits in other states as well?

[Laurie Gaglione]: Yes.

[Jay Thomas]: I'd be happy to provide more information on specific states. I'd be able to follow-up with the committee. I just don't wanna misspeak and share which state specifically Sure. Have proposed a toolkit.

[Sen. Saud Anwar]: Okay. But but I I just wanted to thank you for your advocacy work and and for being here in person as well. I just wanna make sure if anybody has any question or comments. And I wanna confirm nobody on Zoom has it either. Seeing none, thank you so much for your testimony. We appreciate you being here and and your work.

[Jay Thomas]: Thank you.

[Sen. Saud Anwar]: With that, let me see. The next person on our list is Sean Gramelli is not here. And Brian Donahue is not here. And Elise Cortoy. You're on. Welcome.

[Tricia Cunningham]: Hello.

[Sen. Saud Anwar]: Hi.

[Dr. Elise Courtois]: Good afternoon, Senator Edward, representative McCarthy Vehiem, Senator Summers, representative, Cletridis Detria, and distinguished members of the public health committee. My name is, Elise Courtois. I'm an assistant professor and director of a single cell biology lab at the Jackson Lab in Farmington. I'm also the very proud director of, ENDORISE, which is Connecticut Endometriosis Research, Innovation, Support, and Education Initiative. So on behalf of myself and the EndoRISE codirector, doctor Daniel Luciano from Yukon Health, I'd like to express our sincere appreciation for the opportunity to testify in support to house bill five three two two, an act concerning an endometriosis working group regarding endometriosis. So it is very fitting that this bill is being heard, now in March, which is endometriosis awareness month, A time that is dedicated to shine light on a disease that affects one in ten female born individuals. And yet it has been historically, under recognized and underfunded. This week also marks an important milestone for Connecticut. Just on Monday, we joined the Connecticut Endometriosis Working Group to celebrate the first distribution of samples from the state endometriosis data and biorepository to a therapeutic partner. And this milestone represents the realization of a legislature original vision, creating a program that accelerates the discovery of new diagnostics and treatment for this disease. Since its its launch, the biorepository has already collected more than 5,000 biospecimens for participants across 58 towns in Connecticut. And those samples are linked to clinical data and being used now to support research. And the endometriosis working group played a central role in shape shaping this progress. It championed the original policy recommendation that led to the creation of this endometriosis data and biorepository program. But legislation established the most comprehensive state led endometriosis initiative in the country and really positioned Connecticut as a national leader in women's health innovation. So most importantly, end of the endometriosis working group has continued to serve as a critical forum that brings together policy makers with clinicians, researchers, patients, advocates to ensure that we bring legislative initiative and we can translate them into real progress for research, awareness, treatment, but also education. So house bill five three two two is therefore not symbolic. It really ensures that this collaborative infrastructure continues to function and evolve. And to be effective, we recommend that the formally established endometriosis working group maintains a broad and representative membership, including legislators, state agencies, physician, hospital and community health centers, researchers, biorepository leaders, and therapeutic developers, as well as patient advocates and representative of a historically undeserved population. Maintaining this coordinated structure is essential to preserve the stakeholder engagement and to guide future policies and priorities. And we'll ensure the continued progress in, taking care of endometriosis across the state. And this is an exciting moment for Connecticut, for the more than eighty thousand residents in our state that live with this chronic inflammatory and very debilitating disease. For decades, research in endometriosis has been limited with insufficient funding and lack of prioritization. And I think, professor, I'm

[Committee Clerk/Timer]: sorry. But your time has expired.

[Diane Santos]: Thank you.

[Dr. Elise Courtois]: I will just finish with this unique sentence.

[Sen. Saud Anwar]: Yes. Please go ahead and complete what you're saying.

[Dr. Elise Courtois]: The legislature will protect and strengthen the infrastructure that has already begun to transform how endometriosis is addressed in Connecticut and in the country. And Connecticut will continue to serve as a national model for this policy for a disease that has been historically neglected and women's health in general. Thank you so much for your support.

[Sen. Saud Anwar]: Thank you for your testimony. Thank you for the work that you do. I just wanna make sure representative Gilchrist has a comment or a question. Didn't wanna put you on a spot, but go ahead.

[Rep. Jillian Gilchrest]: Thanking doctor Courtois for being here and for her participation and, work in the endometriosis field. Thank you so much. Thank you, mister chair.

[Sen. Saud Anwar]: Thank you. Doctor Courtois, I just wanted to clarify, with the work that you guys have initiated, and and there was some seed money from the state and our our hope has been that we'll be able to get some NIH grants. What is the status that status at the national level for NIH grants around some of these areas or any area right now?

[Dr. Elise Courtois]: So as we know, endometriosis is not a strong priority for the research at the NIH level. But things are turning, so we are getting more and more requests for biospecimens from the biorepository to be part of grant application and proposals. So we really hope that this will lead to some NIH and Department of Defense funding for supporting the research on endometriosis. And I would have to say that we are a unique partner in those applications because of this biorepository.

[Sen. Saud Anwar]: Good. Okay. Thank you for your good work. I see no other questions or comments. We appreciate you being here, and and we'll reach out again later if you have a question. Thank you. Next person on our list is number 30. I just wanna make sure you're not here. Tricia Cunningham, and you're not. And next 31 is Fiona Fareen. Miss Fareen, welcome. You're on. Fiona? Sometimes our audio doesn't work out. Can you hear me?

[Fiona Cullinan Fereen]: Can you hear me?

[Committee Staff (Zoom/Tech)]: Go ahead.

[Fiona Cullinan Fereen]: Can you hear me now? Alright. Hold

[Sen. Saud Anwar]: on one second.

[Fiona Cullinan Fereen]: Alright. Just took me a minute to connect. Good afternoon, chairpersons and members of the public health committee. As you know, my name is Fiona Cullinan Fereen, and I'm one of the founders of ForCameron, an organization we began after losing our son and brother Cameron to a fentanyl poisoning when he unknowingly took a counterfeit pill. I'm here in strong support of s p three sixty five. Through our experience with Cameron, we learned how difficult it can be for people in crisis to access health or substance use disorder in our hospital emergency departments. Too often, patients are told they do not meet admission criteria and are discharged with nothing more than a list of phone number and resources. This leaves people without guidance at the moment they need support the most. Raised senate bill three sixty five addresses this gap. It requires hospitals to provide buprenorphine even if patients do not meet admission criteria. It supplies naloxone at discharge and makes direct referrals to local treatment programs. Providing this medication reveals the severe symptoms of withdrawal without a patient's often experience extreme illness and return to using opioids, not for recreation, but out of urgent need to relieve suffering. Perhaps if Cameron had had access when his cravings returned that weekend, he would not have felt he needed to seek what he thought was a prescribed OxyContin, and it was actually a counterfeit pill. I'm dedicating my testimony to Nathan Jacquette and Mark Andrew Collins. Both sought help at emergency departments when they tried to address the disease consuming them. Their pleas and the pleas of their parents were met with a system that simply sent them back through a revolving door. The parents have bravely testified here many times. Nathan Stapp testified in support of this measure in 2022, and you heard from Mark Andrew Collins' mother just a few moments ago. Bridges are a crucial part of our infrastructure. This bridge, SB three sixty five, closes a deadly gap. Strengthening this emergency and follow-up care pathway saves lives and provides families with real and practical support. I want to say because I come before you so often, I appreciate the work that each of you do and that you care about the lives and the well-being of Connecticut residents. It's always an honor to testify before you, and I know that working together, we could save more lives who died needlessly. Thank you.

[Sen. Saud Anwar]: Thank you, Fiona. You're welcome. Like I was saying earlier to Diane, and you you're my hero too because you you stand up for Cameron and you stand up for everybody else, and then you relive the pain just to make sure that no other mother or other family members have to deal with this. So I I wanna thank you for this. And did I hear you correctly that it had this bill passed some time ago, this would have helped Cameron?

[Fiona Cullinan Fereen]: If it had been passed, Cameron died in 2018, senator. So I don't want to misrepresent that. But if this bill had been in place in 2018, it absolutely would have helped Cameron because he encountered sort of an anxiety mental health crisis on the weekend he died. And, if he had been able to access his medication, I have no doubt that's what he would have done. He was very actively involved in therapy and in working to achieve recovery. And instead, what he did is he took, what he thought was an OxyContin from somebody he knew. He did not know it was not a prescribed OxyContin. And he called his therapist and left a message that he was relapsing and that, he would need to speak with her first thing Monday morning, but Monday morning didn't come from Cameron. So I think these measures that are in this bill would save lives in real time.

[Sen. Saud Anwar]: Thank you. Thank you so much for your testimony, and thank you for the work you do. As soon as the questions or comments, we'll move to the next person. I wanna make sure, Monica Shoham. Welcome. Thank you for being with us all day.

[Rep. Nicole Klarides-Ditria]: Can you hear me?

[Monica Shoham]: I submitted longer testimony online. This is trying to fit this all in under three minutes really hard. So, this distinguished chairpersons and members of public health committee, my name is Monica Shoham, and I'm a resident of Wethersfield, Wethersfield, Connecticut. I'm testifying in support of bill 5,389. I'm 51 years old and I have been in perimenopause for several years. Exactly how long, I cannot say because I did not recognize my symptoms for what they were. Not no one told me they could be related to perimenopause, not even my doctor. Looking back, my symptoms clearly align with what many women experience. Yet the only things my OB GYN asked about were hot flashes, night sweats, and irregular periods. For many of us, their are it is far more complex. My first symptoms was depression, something I had never experienced before. Nothing in my life had changed. I had a good job and a healthy family, but suddenly, I felt persistently sad and disconnected. When I asked for help, I was offered antidepressants. Then came severe brain fog, crushing fatigue, and worsening sleep. I began waking at 3AM almost every night with intense anxiety and a sense of impending doom. My memory and focus decline. I would forget grouseers in my trunk until they spoiled. Those were frightening signs that something was wrong. At age 49, I was diagnosed with osteoporosis after an early bone scan. Many women cannot access the screening until age 50 or later. Yet we know bone loss can begin after age 40 as estrogen declines. Too often we diagnose osteoporosis only after a fracture when prevention opportunities have already been missed. I also experienced painful mouth sores that were resolved only after starting hormone replacement therapy. A connection no provider had made. I did it myself. These experiences are not rare. They are under recognized, including long term health risks, which are significant. I am sharing my story because I, like many women, feel deeply failed by the current system by providers and insurance companies. More than half of The US population is female. Every single woman who lives long enough will go through perimenopause, menopause and postmenopause. Each year, nearly two million women in The United States enter menopause. Thousand of them are here in Connecticut. Working, caregiving, leading businesses, supporting families and contributing to our economy. Yet many are doing so while exhausted, anxious, sleep deprived, medically under underserved. While midlife women's health suffers, workplace productivity declines, healthcare costs rise, families feel the impact, preventable conditions go untreated. Women in their forties, fifties, sixties and beyond are at the height of their professional and personal contributions. We deserve a healthcare system that recognizes our biology, listens to our symptoms and acts early enough to protect our long term health. Right now, two minutes of us are being left to figure this out alone. Thank you.

[Sen. Saud Anwar]: Thank you for your testimony. Yes. You did it. And you did it within the three minutes, but very powerful testimony, I must say. And then

[Monica Shoham]: Thank you.

[Sen. Saud Anwar]: I was

[Monica Shoham]: feeling emotion a little bit by feeling.

[Sen. Saud Anwar]: No. It's it's it's it's very important because, you know, your testimonies help us have the authenticity to fight for your bill, the issue that's gonna be relevant to you. And then that's that's why you're physically coming here or virtually coming here and sharing your perspective is important for everybody to hear. Not only the ones who are in this committee, but people who are listening outside of this committee, they would recognize. And I'm sure today we have some bills. There will be a lot of clinicians who are seeing because of some of the other bills. They will recognize the value of, perhaps, as a medical profession doing better. And then this is, your your words, your experience, your sharing, your perspective is very helpful. I know my my, co chair had to step out and she specifically asked me to please thank her for a very powerful testimony. Do do you have a comment? Yes. Representative Belton has a question for you.

[Rep. Kai Belton]: I don't have a question. I do have a comment. I I wanna say thank you for being here today and sharing your testimony. I think that is incredibly important. One of the things that, you know, I've been talking about with women across the state is the fact that for so long, no one was talking about this. No one was talking about it. And we were all just suffering, mother suffering. My grandmother was suffering. And finally, people are talking about it, and we want to see things change for us, and we have the power to do it. So thank you for coming here and sharing your story. We appreciate it.

[Monica Shoham]: Yes. Thank you so much. I really appreciate you saying this. This is very important for me. That's why I wanted to be here in person as my previous speakers. I agree with all of them. We feel not heard, you know, it's, it's unheard of that you go to your doctor and they think you're crazy and and they don't believe you. So it's just it's it's been a long road and I'm sure there is a lot of women that are still struggling in silence. So thank you so much. I really appreciate this.

[Sen. Saud Anwar]: Thank you. Thank you.

[Laurie Gaglione]: Yes,

[Sen. Saud Anwar]: sir. Alright. Next is, Michael Biondi. Doctor Biondi, you're on.

[Dr. Michael Biondi]: Terrific. Can you hear me?

[Sen. Saud Anwar]: Very well.

[Dr. Michael Biondi]: Very good. Thank you so much for this opportunity. My name again is Michael Biondi. I'm a physician radiologist and current president of the Radiology Society of Connecticut. I'm not gonna rehash, the our concerns we have with, Bill fifty forty five because I believe my two colleagues were on earlier and did a fantastic job. I will answer your question, senator, as regards to private equity. I think the damage for radiology is probably done at this point. I think they're done with us as a group. But that doesn't mean some of the other areas of medicine aren't at risk. The, you know, the dentist, the dermatologists, the pulmonologists, the, any other group. And I think, you know, seeing what happened with us, that hopefully that something can be done for them because we definitely don't wanna go through this through the whole medical field. In any case, if you have any questions for me, for the society, for Linda, for my colleagues, reach out at any point. We'd be happy to answer them. Thank you.

[Sen. Saud Anwar]: Thank you. I I think with the the governor's bill, there there are a number of components, but I I think the the existing CON program and the current recommendations, they are pretty much the same as before. So, what what you but the radiologist perspective is do not touch it.

[Dr. Michael Biondi]: That would be it. Yes. And then to keep with the changes that are there to keep the open and open dialogue so that people could come in and give testimony and see what's going on.

[Sen. Saud Anwar]: Yeah. This this is very helpful. And I I think for the private practices, it has actually changed the the the actual suggested thing, but that's that's what some of the clinicians are coming and speaking about their part, which may not necessarily impact the radiologist as much except that sometimes a small radiology practice, which there aren't any anymore. So they're not impacted. Yeah. I I think this is the challenge with the because of technology and the needs for the technology, you you are you don't have a choice but to be in larger groups and in the lifestyle component of being available twenty four seven. So

[Dr. Michael Biondi]: Couldn't agree more.

[Sen. Saud Anwar]: Yeah. Well, thank you for your testimony. We appreciate you not spending the entire three minutes.

[Dr. Michael Biondi]: Have a good night. I appreciate it. Thank you very much.

[Sen. Saud Anwar]: Thank you. The next person on our list is Daniel Fitzmaurice. Welcome. How how are you? Great.

[Daniel Fitzmaurice]: How are you all?

[Sen. Saud Anwar]: Excellent. Welcome.

[Daniel Fitzmaurice]: My name is Daniel Fitzmooris. I'm the director of advocacy at United Way of Connecticut. Thanks for the opportunity to testify in support of Senate Bill three sixty four and at concerning extreme weather protocols. Two one one Connecticut has been a vital public private partnership with the state of Connecticut and United Way since 1976. Today, fifty years later, we leverage state of the art technology that exceeds industry standards and are recognized as one of the most robust two-one-one contact centers in the nation. Two-one-one is available by phone or online at 211ct.org. It's confidential, free, and available twenty fourseven, three sixty five days a year, and in 180 languages. When you call two-one-one, a trained contact center specialist listens and connects you to resources and benefits that match your needs. They also offer empathetic, comprehensive guidance to navigate the urgent, complex challenges you're facing, even beyond what your initial request was. One of our distinct services is the two-one-one housing crisis hotline. This is Connecticut's coordinated access point for people who need emergency shelter. During extreme weather, this system expands to become the frontline response operation. We coordinate with the state emergency operations center, municipalities, and community organizations to maintain real time listings of cooling and warming centers. During severe cold weather protocol specifically, we go a little bit further, assessing vulnerability, arranging transportation, and taking whatever additional steps are necessary to make sure everyone who calls 211 gets safely inside. And the activation trigger for the supreme the extreme cold weather protocol is one or more days or nights with temperatures or wind chill in the single digits. The data that I provided in my written testimony explains why this matters. Since 2015, Connecticut has activated severe weather protocols 55 times, for a total of two fifty nine days. Our team has handled nearly 23,000 calls during those activations. Activation days and call volume have remained significantly higher in recent years. Extreme weather is happening more frequently and lasting longer, And stable housing options are growing more and more scarce. Our response systems right now reflect that reality. That's why we support Senate Bill three sixty four's goal to improve safety, strengthen coordination, and reduce confusion. But please know that extreme weather activation triggers a resource intensive response. This bill must be paired with adequate, sustained investment to fully deliver on its intent. United Way and two one one Connecticut stand ready to continue and always serving as Connecticut's central hub for information and coordination during extreme weather. We urge you to support the bill and the resources needed to implement it. Thank you.

[Sen. Saud Anwar]: Thank you so much for your testimony and and the work that you're doing. Can I clarify some things? Yes. On a regular day, what happens to people who are home and secure for two one one at 05:15PM?

[Daniel Fitzmaurice]: So specifically, if they're calling 211 for the housing crisis hotline at an ordinary day

[Sen. Saud Anwar]: Yes.

[Daniel Fitzmaurice]: It's not a severe cold weather activation. Correct. They're connected with our contact center specialists who arrange for they assess them based on what their needs are, but it's going towards the coordinated access network for emergency shelter.

[Sen. Saud Anwar]: So even after 05:00, there is a pathway for people to do because my understanding is after 05:00, there's no particular action can be taken on a regular day, not, not on an extreme pro extreme weather protocol day.

[Daniel Fitzmaurice]: Yeah. Our hours are are we are not twenty four seven on the housing crisis hotline anymore. It goes until six. Sorry. I don't need to pick on your nuance, but Monday through Friday.

[Sen. Saud Anwar]: It's a 06:00. So Yeah. Then. So good. I'm I'm a few minutes short. So so 06:15. What would happen at 06:15 then?

[Daniel Fitzmaurice]: At that, they can still talk to a contact center specialist in our information referral hotline, but they're not able to organize an appointment at the can.

[Sen. Saud Anwar]: Right. Okay. And and then if there is a a protocol initiated, what happens then?

[Daniel Fitzmaurice]: So then we have a dedicated team that actually handles the response time on the phone, because it's an emergency. So we have dedicated staff that are responding to cold weather activation specifically. So again, assessing them for what their needs are, arranging the transportation to a warming center if needed, or some kind of emergency response. And we do that, of course, in coordination with the municipalities and the local providers in the core data access network too.

[Sen. Saud Anwar]: So, do you have numbers for the days when the protocol is initiated? What happens and how many phone calls we get?

[Daniel Fitzmaurice]: Yeah, sure. I mean, I have, I put it together in a consolidated way, but I can get you the details on, you know, here's the typical day and how many calls we get, but, you know, to to date, it's this year was more than about 7,000 calls.

[Sen. Saud Anwar]: But that evening and that night, how many calls are you guys getting? So, so let's say

[Daniel Fitzmaurice]: During cold weather activation, it's twenty four hours until at least the activation ends, which is determined by the protocol.

[Sen. Saud Anwar]: So in one day, how many calls approximately?

[Daniel Fitzmaurice]: I don't have it in front of me, but it's it's a lot of calls.

[Sen. Jeff Gordon, MD]: It's a

[Sen. Saud Anwar]: lot of

[Daniel Fitzmaurice]: To get again, this year, we've done sixty three days, 7,000 calls.

[Sen. Saud Anwar]: Yeah. So so and and the the the the timeliness of the decision is critical and and and you're nodding your head. So just for the people who are not if you wanna say yes, you're you can.

[Daniel Fitzmaurice]: Yes. Absolutely.

[Sen. Saud Anwar]: That's critical. Good. And then, and the reason is when you say yes to the computer and everybody gets to see you and the people, and what that does is that allows you to get the resources, but you have a whole machinery in place. This machinery, when it was created many, many years ago, was the best in the country. And everybody used our formula to say, this is what Connecticut gets it, and they're doing a good job. But then and I I use this example that we made the best car, and then we did not put well, nowadays, it lacks electric car. We never charged it. And then say the car doesn't run. He said, well, you're not charging the car. So everybody else has made the car seeing our car, or they charge it, and they're using it and it's working. But we'd refuse to charge it, and then you say our car doesn't drive. And they said, let's get another car, figure this out. And that's part of the frustration at times for people who have followed this issue for quite some time is that we created a system, then we it and the system doesn't work, and the needs of the people are increasing. And those are not because of two one one. You are actually part of the the pathway for emergent solution, not a permanent solution. But collectively what we have done is we have not been able to address the needs for a long time. So the challenge has exploded. It's out of control. And for state policies, federal policies, society policies, and and social issues that you're dealing with is a combination of a perfect storm. And then we are really not dealing with that. And as a result, you are in the midst of that, storm. And then when things don't work out, we say, okay, two one one, we're gonna blame you. But but the two one one is not getting the resources at the timely fashion and not not have the personnel. But even if you pick up the phone, you don't have a solution on the other side. So we again say two one one, it's your fault. You can't get me the home. So I empathize with your stresses and the challenges that you your your entire agency has to deal with. But I know that you are also recognizing the symptom of the larger problem. And and and there should be an opportunity to share collectively broader policy makers that this is out of control calls. We have never seen this. We have a disaster that's going on, and we need to intervene far more than what we are doing right now. So I I wanted to share some of these thoughts and then and first, appreciate you coming here. Appreciate the work you guys are doing, but also, highlight the fact that you need timely information so that we can be better prepared and and and not do this after the fact.

[Daniel Fitzmaurice]: That's right, Senator Anwar. And if I might just again, I said it in the testimony, but just so folks know, the standing protocol right now is one or more days of temperatures or wind chill in the single digits or lower. So that's nine degrees, which is very cold. So as you consider the public health aspect of this policy, the question that we can't even answer, and I don't think a lot of our partners and municipalities and community homelessness providers can answer is to what extent the body can handle nine degrees of temperature for multiple days. That's the point at which we have additional resources and capacities to help people. And I think that's really where, if that was adjusted, we would need additional resources to handle that. But that leads to assume we would also save lives.

[Sen. Saud Anwar]: I I just wanna highlight one issue that people may not recognize, but many people who understand this issue speak about this. I came across somebody who was, homeless and then, and it was not a fault of theirs. It was just their landlord said, you cannot live here anymore. And they could not find a place. When they were homeless, they were in the winter month. There's so much pain from the cold that the person had no option but to take a substance to survive. Now the person is addicted to that substance because that was the only way to survive because there's no place. Now he cannot find a place because he's addicted, and there's no system in place to be able to have them go through detox while he's tried it. And and so he's a friend of mine now because I've invested enough time and then spent some time. As a as a cochair of the public health committee, I cannot find detox Mhmm. And treatment for this person despite making phone calls. And then and and he has to move from one part of the city to another part of the city right five minute, ten minutes from here. So it's a it's a pretty significant failure that we have collectively created. So thank you for listening. Thank you. Yes. My co chair has a question or comment. Absolutely.

[Rep. Cristin McCarthy Vahey]: Thank you, mister chair, and thank you so much, Daniel for being here. And I'm sorry that I did not get to hear all of your testimony, which I will listen to later and I will certainly read your online testimony. I I feel like I need to do this with our planning and development committee chairs who are also members of this committee. But this is, you know, a trick question. We would you agree that we would have a lot less issues related to homelessness if we built more housing?

[Daniel Fitzmaurice]: Yes.

[Rep. Cristin McCarthy Vahey]: Thank you. I appreciate that. That was really for to support the efforts that are happening in other committees. And and also just to add that this issue is certainly across many committees, and it's a multisystemic issue that we need to address on many levels. So, I appreciate you focusing on this particular aspect of it from the health perspective. Thank you for being here today.

[Daniel Fitzmaurice]: And just to add to that, I was surprised looking at the data we put together in the testimony. Folks have been talking about the winter the harsh winter we had in 2015, which we did. And we did have 40 activation days in 2015, but only 3,000 calls. This year, we've had significantly more activation days, but also more than double those calls, which does suggest, again, a correlation between the availability of places to be inside during that time frame. Because this year's cold weather, I think, was quite similar to 2015.

[Rep. Cristin McCarthy Vahey]: Thank you for adding that piece important piece of data.

[Sen. Saud Anwar]: Representative Kevros de Groot.

[Rep. Eleni Kavros DeGraw]: Thank you so much. And thank you for being here, Daniel. We appreciate it. Certainly, I we recently a bunch of us toured 211, and we were incredibly impressed by the call system and how the calls are handled. But, obviously, it's a lot harder when you have more calls. To your point about nine degrees and how you can be outside, and perhaps this is actually something that the good doctor, senator could comment on. My understanding is at 46 degrees, you could, if it's raining, you can actually get hypothermia, which certainly begs the question of why we've kept it so low other than perhaps funding. But in a situation like yesterday, for instance, my understanding is we only had sort of a partial, you know, situation. We knew there was ice coming. I I don't know how the rest of the state was, but in the Hartford Metro Area, there were inches of ice on the ground. This morning when I drove in, I saw, various unhoused people walking around and and, you know, it was incredibly slick on on surfaces. So to yes to the point of yesterday, did you at what point did did was two one one notified that there was a partial cold weather? And what is a part what is a partial cold weather situation?

[Daniel Fitzmaurice]: Yeah. I don't know the exact time that that activation occurred. It did occur, and I have the data on that as my colleagues have alluded to. It was pretty late in the evening, which does make it difficult, as a lot of folks have mentioned, even for us to deploy the necessary staff to do the appropriate surge on the phones and also the organizing of everything else on the ground. That said, you know, it is difficult to, our staff, for example, look ahead at the weather to see when we're getting into single digits with windchill so they could begin to be ready as possible. But until the activation occurs, there are no resources available to do additional, actual additional staffing on any of that.

[Rep. Eleni Kavros DeGraw]: Okay. I thank you so much. Thank you, mister chair.

[Sen. Saud Anwar]: Thank you. Thank you for your testimony and the work you do. Say hello to all the people who answer phone calls. I had a chance to meet them, many of them, so I appreciated them.

[Daniel Fitzmaurice]: I certainly will. Thanks Yeah.

[Sen. Saud Anwar]: Thank you. Alright. Next person on the list is Linda Sprague Martinez. Welcome. You're on.

[Dr. Linda Sprague Martinez]: Good afternoon, senator Anwar, representative McCarthy Vehi, and esteemed members of the public health committee. My name is Linda Sprague Martinez. I'm a professor in the Departments of Medicine and Public Health Sciences at UConn Health, and I direct the UConn Health Disparities Institute. I'm here today to provide testimony regarding House Bill 5,389, an act concerning a provider toolkit for the diagnosis treatment diagnosis and treatment of menopause, perimenopause, and post menopause. The Health Disparities Institute was established in 2011, and we have a legislative mandate to enhance research and the delivery of care to minoritized and medically underserved populations across Connecticut. Community engagement and partnership are critical to our work, and it is through community engagement that we identified menopause and menopause equity specifically as a community priority one year ago. One point eight million women in The United States enter menopause each year. And as we heard, it comes with a series of symptoms. And it's also important to take into account that it's shaped by social, cultural, and environmental factors. Despite everything we know, menopause remains rarely discussed, which further contributes to misinformation, stigma, and barriers to care. Over the last year, the Health Disparities Institute, under the leadership of Tricia Pitter, has established the Menopause Equity Collective. We've partnered with them to launch a menopause equity initiative and engaged hundreds of individuals across the State in community led health education and promotion events focused on menopause equity. Through extensive community engagement, with our partners across Connecticut, we've identified urgent concerns regarding a lack of accessible, culturally responsive, and linguistically appropriate information about menopause. Consistent with national research that's been conducted nationally, women in Connecticut report limited access to accurate information, which reinforces a culture of silence. Silence, stigma, and isolation are well documented in the menopause literature. Ageism and gender bias contribute to cultural norms, which devalue women as they age, framing menopause as a marker of diminished worth. This lack of information, coupled with already existing racial healthcare inequities, further marginalized women of color. House Bill 5,389 addresses a clear and urgent need by supporting the development of a provider toolkit for the diagnosis of treatment of menopause, perimenopause, and postmenopause. There are documented gaps in provider training. We've heard some of them alluded to earlier today. A study of the 2023 study, for example, of obstetrics and gynecology residency program directors, where over 90% reported that there was a need for a standard strongly agreeing of the need for a standardized menopause curriculum. Thirty one percent reported having a menopause curriculum of the '99, and only twenty nine percent reported that trainees have access to menopause clinics or even to work with women who are experiencing menopause. All, well, 84% agreed that there was a need for more curricular resources overall. In addition, there were reports from providers overall reporting with fewer than seven percent of reporting and feeling adequately trained to have conversations around menopause. And recently, because we did an assessment recently in an effort as we were developing CME trainings for oral health providers, we learned that sixty six percent had no training in menopause and forty seven percent reported not screening for menopause despite the fact that research indicates menopause is associated with dry mouth changes to taste and tooth sensitivity, tooth decay, and tooth loss.

[Committee Clerk/Timer]: Excuse me, miss Martinez, but your time has expired. Thank you.

[Dr. Linda Sprague Martinez]: Okay. Thank you.

[Sen. Saud Anwar]: Actually, if you have a couple of sentences, please go ahead.

[Dr. Linda Sprague Martinez]: Yeah. I just wanted to make the important point that there is evidence that's out there that reports that providers are very open to additional training and resources regarding menopause. There are studies that report that self paced modules, podcast based learning are all acceptable among providers. And we've also found through our efforts in Connecticut, when we invite providers to our events, they come. And we heard earlier California is a state where they've incentivized providers using CME trainings, free CMEs. And so, there are ways when we include providers in the development of trainings and materials that they do participate. We're able to create resources for them that don't cause additional burden given that fact that providers are already, burdened. Their time is already burdened. So I can stop there. I've also provided written testimony.

[Sen. Saud Anwar]: Thank you so much for your testimony. So so, can I ask, have you guys changed your curriculum for the training for residency or even for medical students and the residents around this?

[Dr. Linda Sprague Martinez]: Yeah. So we've been doing men work around menopause education that's focused more broadly on communities. We've that's focused on communities and community residents for in particular because that's where we heard the initial need. Recently, we've just completed the assessment of oral health providers because that was an area where we saw unheard of need. And so we met with them first, and then developed the CME training for them. So, we are we haven't yet developed for for residents. So

[Sen. Saud Anwar]: Thank you. Your written testimony is very helpful. We appreciate your your work. And and, I I think, representative Belton has a question or comment for you.

[Rep. Kai Belton]: Hi, Linda. Thank you for being here today. I wanted to ask a question about what other states have done as far as the toolkit. Do you know of any other states who have the the toolkit or anything close to it?

[Dr. Linda Sprague Martinez]: Yeah. There are states, and we we can provide this in writing because we did, an analysis that was led by, Malia, who's gonna testify later today. But we did an analysis of all the legislation that's been introduced across the country, and educational initiatives were the most common type of, the most common type of legislation that's been introduced in other states. And so there are examples, of resources and toolkits that, she she we can provide you a written summary because we have

[Adelita Orefice]: that. So

[Rep. Kai Belton]: Thank you.

[Sen. Saud Anwar]: Yeah. Yeah. My my co chair, representative, Kristen McCarthy, Velez a quest.

[Rep. Cristin McCarthy Vahey]: Thank you. Thank you, senator. And, thank you so much for being here with us for your testimony. And as, senator Ammar said, your written testimony, which has some really great visuals for anyone following along at home with a lot of helpful and important information. As someone who knows very little about menopause, I wondered if you could actually talk about the connection between oral health and menopause. We have, as you know, a bill on the agenda today also about our dental care. But can you just talk a little bit more about that connection, why it's important for dental providers to be informed and what kind of impacts there are for women who are going through menopause?

[Dr. Linda Sprague Martinez]: Certainly, although I'll say that I'm not a, I'm not a dentist, I'm a social scientist. And so, but I can tell you that the literature indicates that dry mouth is associated with menopause and drops in estrogen, as well as changes in taste, tooth sensitivity, as well as tooth decay and tooth loss. And there have been some studies that have found that as many as thirty percent of women have lost a tooth during menopause. And so, there's definitely implications when estrogen levels drop that there are implications for oral health. But I will let the dentists and OB GYNs talk specifically about some of that.

[Rep. Cristin McCarthy Vahey]: I just wanna say thank you. And I think that for you and for everyone who's testified today, as all of us know as humans, it's really validating to be heard and understood, to be seen, and to know that half of

[Sen. Saud Anwar]: the

[Rep. Cristin McCarthy Vahey]: population is going through this experience if they're fortunate to live long enough to do so. And that you and I, again, can't thank Rip Belton enough for her leadership are bringing this forward to us, an issue that we really haven't talked about in this committee and certainly many people haven't. So I just allow my thanks to you and to others who testified before you, who I wasn't able to thank. Just echo forth.

[Dr. Linda Sprague Martinez]: Yeah. Well, we are we are very grateful to Representative Belton for bringing this forward. And just to echo your point about, there's such a desire to be heard around this topic. We hosted an event in March. We had over 300 women come out for the event to talk about menopause and menopause symptoms. And the more events that we host across the state, the more women that come out and they repeatedly tell us they're not getting the information they need from their providers and they're not getting it early enough.

[Sen. Saud Anwar]: Thank you. Do you think it's possible to have a video recording of a CME program that can be shared with clinicians across and then they could get their CME credits?

[Jay Thomas]: I do think

[Dr. Linda Sprague Martinez]: it is. Yeah. There's a I read a really interesting study that looked at self paced training for, physicians and, podcasts as well. There was one. So there are definitely ways to get, the CME training to physicians in a way that, and providers, different provider groups in a way that would work for them, that was tailored for their specialty. I think it's a question of anytime you do we do a lot of toolkit development. And one of the most important things is really working with the end users, to make sure that you're developing something that works for them and piloting it. But also, in this case, we wanna make sure that what we're hearing from Connecticut residents, they also have access to that information because that's so important as well. So

[Sen. Saud Anwar]: Thank you. Thank you. We will con oh, representative, Kevin Stickeroff has a question.

[Rep. Eleni Kavros DeGraw]: I was just wondering because we're talking about the fact that women are going to their providers, and they're not getting the information that they need necessarily from their providers. Or maybe they have a provider that, you know, they're interested in hormone replacement therapy, and that provider is not interested in in prescribing it. Just because we do have you and and and you have expertise in this, is there something that you would suggest in terms of, like, what the the patients should be saying to those providers to try to have a better interaction? I mean, I I as a Gen X woman who has been in menopause for two years,

[Fiona Cullinan Fereen]: I I see. I'm sorry.

[Rep. Eleni Kavros DeGraw]: The majority the majority of my information is doctor Mary Claire Haver and other doctors who are on TikTok or Instagram. I think they're calling them doctor influencers at this point. But if it weren't if it were not for them, I don't think I would have sought out that hormone replacement therapy. And it's incredibly frustrating because, well, thankfully I didn't have the dental issues. I could give you a whole laundry list of what losing estrogen has done to our bodies. So I guess if you have any suggestions at all for how to approach physicians, specifically, that would be really useful to us.

[Dr. Linda Sprague Martinez]: Yeah, no, definitely. And you bring up a really important point because you have to think for years, physicians were trained that estrogen was hormone replacement wasn't a good thing, right? Because some of the earlier research that has since been invalidated and only recently are we starting to see changes in packaging where disclaimers are being removed. But that's all upstate information that not everyone is getting and not everyone is having access to immediately. And some, we find that some physicians aren't even aware of that. But probably the most important thing when you're talking to the physician is to remember that you are the expert in your own lived experience. You know your body best. And if you're not being heard by that physician, it's okay, one, to fire them, and to find a new one or to continue to bring things to them. If you feel like I've done studies, similarly around black barriers to cancer care in clinical trials. And one of the things that we hear consistently is that, I've spent so much time, I've invested so much time in educating this physician on working with me as a woman of color. And I don't want to just get a new physician to have to start all over. And so sometimes people are not willing to fire their physician, but it's okay, to bring information to them as well, and continue to have conversations with them. But I have to say it's it is exhausting and takes a toll on the body when you're having to consistently fight for adequate care because there's not enough information and research out there.

[Rep. Eleni Kavros DeGraw]: And I would just add to that, the fact that, you know, I remember watching a doctor who said, you know, there were literally hundreds of ways that the loss of estrogen and our other hormones affects our body, that I think the most common thing that comes up with other women is when you say, oh, I didn't realize this was a symptom of menopause. And then you share it with them and they say, oh my god. I've been having that for a year. I've been having that for two years. I mean, the itchy ears thing alone and the fact that we're getting tips again from the Internet about how to put Flonase on a Q tip to put in our ears so they're not itchy. I mean, this is the level of ridiculousness, and no offense to our our men in the room, but honest to God, if if this were the same situation, I do believe that with men, this would have already been resolved many years ago because the amount of research that has not gone into this, and again, I'm repeating what I have heard from other female physicians who are saying this, It just has been incredibly frustrating, but I also am so proud of us as Gen X women that we are making this better for the next generation because I certainly don't want millennials, Gen Z, etcetera, to have to go through what our mothers and grandmothers have now had to go through and what we almost had to go through if this HRT hadn't, you know, and other things. And not everyone's a candidate. I understand that. But there there is a lot of possibility out there for us finally to not have to just suffer because we're of a certain age. And I'm loving this of a certain age, if I'm being honest. So anyway, thank you so much, Doctor.

[Dr. Gail D’Onofrio]: Settlek. Yeah.

[Dr. Linda Sprague Martinez]: You're welcome. Thank you. Thank you so much. I think, you know, it's funny. We learn about pregnancy in fifth grade, right? We get like health curriculum. We're told the way ahead of time, all the things we need to bring into it because they finally are figuring out what our symptoms are that, I mean, we should be talking about menopause so much earlier. It's than we are. So thank you so much to the committee.

[Sen. Saud Anwar]: Thank you. Thank you for your testimony, and we will move to the next person on our list, which is Sarah Fox. She's virtual online. Sarah well, Fox, you're on. Welcome.

[Committee Staff (Zoom/Tech)]: Good afternoon, members of the public health committee. My name is Sarah Fox. I am CEO of the Connecticut Coalition to End Homelessness, and we lead the statewide effort to prevent and solve homelessness through the Connecticut Canada and Homelessness Campaign. We work closely with providers, state agencies, municipalities, and frontline staff and people experiencing homelessness every day. Before I speak about the raise bill, I just wanna address what is currently happening across the state. You know, the winter response has required constant coordination across agencies and municipalities. United Way of Connecticut and providers, state agencies, people have extended our hours. We've opened doors. We've transported residents to safety and made placements under enormous pressure. I am very grateful for that partnership and the seriousness seriousness which everyone has approached these life safety stakes. The severe cold weather protocol has been effective for an active for forty seven days this winter through activations and weather driven surge response. And for you and for many of you, you come to this work not only as legislators, but as physicians and nurses. You know what it looks like when a clinical course is predictable and when a a system still intervenes too late. And that's why I'm here today in strong support of this bill. Raise bill SB 36 three sixty four, in support of an extreme weather protocol. I wanna share some of what outreach teams are reporting, because I think it's the clearest indicator of how serious this has become. They describe lying laying blankets over people sleeping directly on frozen ground, Trying to slow heat loss because there's nowhere else for people to go. They have provided care to people with icicles forming on their clothing and bodies after nights outside in the snow and sleet. In the summer months, they have watched people deteriorate in extreme heat when dehydration and heat illness progress quickly without shade, water, transportation, or indoor cooling. These are our neighbors, sons and brothers, sisters and mothers, fathers and grandparents. For someone who is on shelter, weather is not a backdrop. It is exposure. It can cause hypothermia, frostbite, decompensation of heart, lung disease, infection risk, falls, and sometimes death. In extreme heat, exposure becomes dehydration, heat stroke, rapid organ stress, especially for older adults and medically frail people. When someone cannot get indoors, weather becomes a preventable medical emergency. We do have a statewide protocol. And as Daniel said before me, it is in the single digits for multiple days. I will also say that I'm grateful to the administration for enacting it oftentimes this winter at higher levels. We need a predictable ongoing protocol that accounts for extreme weather, whether it is extreme cold, whether it is extreme heat or severe cold or severe weather so that every single one of our neighbors can come indoors, can be protected, and can not have these life saving, not have these critical issues and this exposure at this scale. As more and more of our neighbors fall into homelessness, we need a response and we need to be well situated on the ground with the capacity necessary to handle this level at scale.

[Committee Clerk/Timer]: Excuse me, miss Fox, but your time has expired. Thank you.

[Committee Staff (Zoom/Tech)]: Well, thank you very much for having me. I have examples, national examples that I'm more than happy to share, and I've also included the severe cold weather protocol in my testimony.

[Sen. Saud Anwar]: Thank you. Thank you, miss Fox, for your testimony. Sarah, could you share about some of the examples that you may have and that that would be done? And then if you can share with us what other states are doing, as well around this.

[Committee Staff (Zoom/Tech)]: Well, first say, you know, last winter, there's a story that just stays with me. It was a man who received care through Hartford HealthCare, and he had been out for quite some while. He did not and he he tried to come inside. They identified him, and he had frostbite all over his body. He ended up having to have limbs removed and to have extensive care provided by the state at a high level of cost. And there were few places where he could go after after having his limbs removed, and and they didn't know where to discharge him to because he would have been back out in the cold. Those are the stories that we hear. We're hearing that from from medical providers. You know, if you if you speak to a health care van that is going around our streets, they're seeing people in critical situations because they cannot come into safety. To answer your other question, senator, just give me a second, and I will share some national examples. There are there are a few things that set national examples apart. And so what they are is, you know, there is a public health emergency response framework that exists. There is a predictable sustained infrastructure, that is enacted. And so some of these includes New York City's activates cold blue when temperatures are forecasted to reach 32 degrees Fahrenheit or below, and that includes wind chill, and it expands shelter access while intensifying street outreach. So people are brought inside before conditions become life threatening. Multnomah County in Oregon activates severe weather temperatures at 25 degrees Fahrenheit or below, 32 degrees Fahrenheit with rain, snow, and high winds, recognizing that precipitation and wind sharply increase hypothermia risk. Philadelphia activates code blue during life threatening winter conditions and increases street street outreach operations and emergency shelter capacity during those periods. And other jurisdictions across the country have heat related protocols where they are resourced to ensure that people can come into cooling centers that and to save spaces and to shelter during extreme heat as well. So they are not just looking at at at a cold weather response.

[Sen. Saud Anwar]: Thank you. This is very helpful. I wanted to just also ask you. I know cost remains a big issue in this winter. I hope this winter is an anomaly because if if we're gonna have a winter like this every year, maybe we all need to have another state. But if if if we were to look at this strategy, do you think there could be efficiency that can be created even in communication systems outside of the one part is the decision making. So let's keep that on the side for the time because we've already addressed that. How can the communication systems be more efficient across the entire state and then work with a CAN system so that if the decision is made, you just press a button and with the 2026, we should be able to get everybody on the same page right away?

[Committee Staff (Zoom/Tech)]: Well, first, and and that's a really good question. And I think when you get to cost, there are costs associated with really having a system in place to protect people. It is there, but there are also costs, Senator, of homelessness. So for the individual I described earlier, the amount of cost to to to rehabilitate him was exponential within the health care setting. And we know, you know, an emergency room I mean, you all know all too well the cost associated with health care and providing health services for people who are coming into emergency rooms, who are outside. So I won't belabor that. But in regards to, in regards to ways to make this better, elevating the temperatures so that right now, honestly, it is you know, you'll have the severe cold weather protocol called. You've heard from all of my partners and colleagues about the challenges of, you know, the mobilization. You will have it called, and then and people are brought inside. They're brought into hotels. And then then they have to go back outside. They have to go back outside on days like today in Connecticut, where there is snow and ice and you have people often frail, often who have been exposed to the elements for a long time who are, being exposed. So making sure that we have a humane response means that that we're really analyzing those those triggers, and we are moving from the very low triggers to, a higher threshold, which would allow us to have more time to get everything situated, because it's it's, you know, it people would be able to come inside during that those activation periods. And beyond that, it's really about having public facing triggers. And we do have that, but strengthening those, making sure that because we have a longer duration of time, we can more clearly outline these for, every every single partner, including people currently experiencing homelessness who are waiting to find out what's gonna happen. I will say just within the last couple of days, the CLIP program that we work with, which is the Consumer Leadership Improvement Program, they have been sharing about their concerns, and they're hearing from people in their communities that are frightened for their life because they're outside in this temperature. And so I think it's really about looking and doing this work through the Interagency Council on Homelessness, partnering with all of the state agencies who are dedicated to this, who we appreciate, and coming up with clear strategies that can really turn this around and turn this into a clear lead, protocol, sustained infrastructure for the state that is life saving and strong and sustained in a way that that upholds providers.

[Sen. Saud Anwar]: Thank you so much, representative Christian McCarthy, but he has a question.

[Rep. Cristin McCarthy Vahey]: Thank you, mister co chair. And, Sarah, thank you so much for your work, for your testimony. And, actually, my question is a follow-up to what you just said. If you were to kind of design the perfect room of who would be sitting around the table to have this conversation, to kind of hammer out the details on how this would work and how we would implement things differently here. Who would be sitting around that table with you to have this conversation?

[Committee Staff (Zoom/Tech)]: Well, I mean, I will say, and with great appreciation, the people who are doing this work, including the Department of Emergencies, I'm gonna say it wrong, DESP and department of emergency management, United Way of Connecticut, department of housing, DMIS, the governor's office, OPM, and and all of our relevant other state agencies, including DSS, our health care providers, our municipal leaders. This must be informed by the people who are currently experiencing homelessness and their voices to ensure that we are meeting the system level gaps. This is most appropriate through the inter agency council on homelessness that was codified and has been enacted and, you know, and we are meeting. And, but it needs to be something that isn't delayed that we can bring forward in a short period of time, because this is, you know, for every day that we delay, people, people die. And it's it's not just the cold, it is the heat and it is when severe weather hits. And so it needs to be responsive and it needs to be timely and actionable.

[Rep. Cristin McCarthy Vahey]: Thank you. So I hear United Way, Department of Housing, Governor OPM, DMIS, DESP, DSS, health care providers, municipal leaders, and the interagency council on homelessness.

[Committee Staff (Zoom/Tech)]: I mean, I'd add first responders, faith communities. I mean, I could go on and on, but it it's really the people who are working with the unsheltered outside and making sure that we have the tightest response, a disaster response to the experience of unsheltered homelessness.

[Rep. Cristin McCarthy Vahey]: Okay. Well, I look forward Sarah to ongoing conversations on this to just think through and work on the practicalities of how we can make this work more smoothly so, basically, people are safe, sheltered, and stay alive. Thank you.

[Sen. Saud Anwar]: Thank you, Sarah. I think represent Christian McCarthy way, and I won't take it personally that we are not involved in the party and the table.

[Wayne Pesce]: But

[Committee Staff (Zoom/Tech)]: Oh, you know what? So that is just I do mean

[Dr. Boris Goldman]: to I

[Sen. Saud Anwar]: was joking. Do

[Committee Staff (Zoom/Tech)]: No. But I actually did. So that was just I do meeting to include, like, the committees of cognizance in the legislature. When I think about the work that we need to do to prevent and solve homelessness, it takes your voices and leadership. And obviously, we so appreciate your leadership every single day in

[Erica Ruggavain Byrne]: the work that we're doing.

[Sen. Saud Anwar]: Speaking of leadership, Representative Kevvitz deGraw.

[Rep. Eleni Kavros DeGraw]: Thank you so much, senator. Mister chair, I Sarah, you mentioned more than once. It's good to see you. You mentioned more than once heat. And we talk a lot about the cold, and we've talked a lot about cold weather today. Are you aware when you're talking about other places that have different, cold weather structure, do they has anyone put in, any sort of heat recommendations? Because, you know, they always say the heat the heat will get you first. And we, you know, have seen some incredibly hot summers. I think the past four or five have been the hottest on record, breaking the record every single year. So my my question is, are there other states that perhaps are putting those resources in or at least have some guidelines for what we should be doing around the heat?

[Committee Staff (Zoom/Tech)]: I mean, so Arizona, Phoenix, but they're mostly places that have warm climates that are not dealing with sort of, like, the, you know, the shift of all four seasons. And so I don't think that we shouldn't act because other states don't have a really humane framework. I'd also say that other states have a similar protocols to us, but it's incumbent that our state really drives and we can lead across the nation a response that encompasses because what we're seeing on the other end of that and what providers are telling us, is really about, you know, how many people are impacted during the heat, how how oftentimes heat related exposure is so much worse and it's sort of, it's a silent killer. And it's not something that we often talk about, but it's something that we are recognizing more and more, which is why this year, you know, we didn't just say we were grateful for the resources we received last year, and have been annualized in the budget, for cold weather. But providers really have been saying, in a really profound way, like, no, we have to ensure that we're addressing heat related exposure as well. And we must, we must come up with policies to protect people. So I can, I will, provide you with the strategies that Greater Hartford has been deploying, and they've really come up with a wonderful framework through Journey Home? And, you know, it would be a great step forward for our state to be able to think in this other way, which is really recognizing extreme weather, and for us to be resourced appropriately for it.

[Rep. Eleni Kavros DeGraw]: Thank you. I really appreciate that answer, and I'm looking forward to seeing that information. Thank you, mister Sher.

[Sen. Saud Anwar]: Thank you. Seeing no other questions or comments, thank you, Sarah, for everything that you're doing. We move to the next person on our list, which is Kate Hickey, who is not here or on oh, you're here. We're looking for you remotely, but you're I'm glad you're here in person. Welcome. I'm glad you decided to come here, and thank you for being with us all day.

[Rep. Cristin McCarthy Vahey]: Hello. Sorry.

[Dr. Ayanna Liles]: I'm in between patients, so I apologize for the running around. Good sorry. I'm getting myself all settled.

[Sen. Saud Anwar]: Doctor Lettice, did there was some somebody else there? Oh, sorry. Just wait for a second when we'll you're next still.

[Committee Staff (Zoom/Tech)]: Hey. Good afternoon, members of the public health committee. My name is Kate Hickey. I'm from Old Lyme, and I'm an MSW student at the Yukon School of Social Work. I'm here today to testify in support of h b fifty three eighty nine, an act concerning a provider toolkit for the diagnosis and treatment of menopause, perimenopause, and postmenopause. This bill will develop a statewide menopause screening and treatment pathway toolkit that will focus on on when and how to screen, symptom assessment, evidence based treatment options, guidance on knowing when to refer to a specialist, and the creation of free and optional training modules they'll be eligible for continuing education credits. Menopause is a universal and natural stage of life that affects more than five hundred thousand women ages 45 to 64 in Connecticut. However, there's a significant lack of equitable evidence based and accessible menopause care. Because of the lack of research, education, and stigma associated with menopause, I myself was unaware of what menopause was and the impact it can have on an individual's life. Many women who are experiencing associated symptoms may not even know that their symptoms are related to menopause and are consequently being left untreated. In Connecticut, approximately seventy to eighty percent are experiencing menopause symptoms, but only one in four women are receiving treatment. Not only does this have a drastic impact on the health of the individual but on society at large. Research shows that women with untreated symptoms have a 121% higher health care utilization and experience 57% more days loss of productivity, which results in an additional $2,100 per woman per year in health care and absenteeism costs. These costs contribute to an increased use of emergency services, higher health care spending, reduced workforce participation, and economic stability, and winding widening inequities for underserved populations with limited access to care. For women that are seeking care, many health care providers are not trained to recognize menopausal symptoms and counsel patients on treatment options because of limited training curricula. In Connecticut, less than seven percent of primary care providers reported that they felt that they felt adequately trained in menopause care. Evidently, there's a significant gap in education and care for menopause related care. This is why I'm asking you to support and pass the bill that will help thousands of women receive the care they need. Thank you for your time and consideration.

[Sen. Saud Anwar]: Thank you, Kate, for your testimony. You did very well. Is this the first time you're testifying?

[Committee Staff (Zoom/Tech)]: This morning was. The second time.

[Sen. Saud Anwar]: Second time. Well, it was very good. Looks like you're a pro. You just did it within time. Your message was great. You'll be doing wonderful.

[Committee Staff (Zoom/Tech)]: Thank you.

[Sen. Saud Anwar]: We need social workers. Thank you. Thank you. Alright. We have representative Belton has a question for you. Don't go away.

[Rep. Kai Belton]: No question. Just a comment. I wanna say thank you so much for your testimony, and happy social work month.

[Sen. Saud Anwar]: Thank you. You're good. Alright. Doctor Liana Liles, you're on now. Thank you for your patience with us. Welcome.

[Dr. Ayanna Liles]: I am so sorry about that earlier, y'all. That happens when you multitask way too much. Good afternoon. My name is doctor Ayanna Lyles. And to senator Anmar, representative McCarthy Veggie and distinguished members of the joint public health committee, I'm a board certified OB GYN physician in Connecticut for the last eleven years and the vice chair for the Connecticut section of ACOG, which represents a 68 OB GYN physicians and partners in women's health answering the call of our profession in our state. I also take care of patients with endometriosis, perimenopause, menopause, and feel very comfortable in that space. Thank you for the opportunity to submit the testimony on behalf of the Connecticut ACOG section in support of HB five three two two with some general comments for HB five three eight nine. I did submit testimony for both of those bills. But to start with HB five three two two, we we applaud the committee for valuing this underrepresented community and the challenges they face in diagnosis and treatment. I have several patients with endo, some of whom have complained of years of symptoms and experienced delays in their diagnosis. ACOG recently released new clinical guidance on the diagnosis of endo that is intended to reduce delay in diagnosis and improve treatment for patients. Endometriosis is a chronic inflammatory condition that causes significant impacts on a person's life. ACOG's new guidance provides detailed recommendations on the use of clinical findings and imaging tests to get early, treatment options and diagnoses, and it is essential for us to understand the burden of disease in our state and improve timely access to care. However, we want to ensure that the correct individuals with expertise in this area are providing this information. And as such, CT ACOG respectfully requests that one of the members appointed to this committee be an OB GYN and a member of ACOG. With regards to HB five three eight nine, ACOG's clinical expertise and guidance covers all stages of the patient's health, including menopause, perimenopause, and postmenopausal care. The resources are in the written testimony for review. And suffice it to say, we strive to equip clinicians with expert reviewed clinical guidance and practice management tools to address the concerns they have during their transition. I know that I frequently use it on a daily basis to ensure that I'm providing the most update counseling and options. It feels like menopause care is having a renaissance as more people are being advocated for, diagnosed, and treated. So, I applaud the members of this committee for advocating for this underserved community. At the same time, I also believe that creating medical resources should rest with experts and should not be influenced by the legislative process. The patient physician relationship is essential to the provision of safe patient centered care and protected from government involvement. The creation of state mandated materials interferes with this relationships and sometimes can proceed, prevent physicians from proceeding with patient centered care that is nuanced. ACOG welcomes the opportunity to to partner with members of this committee to identify gaps and access to menopause related care and determine legislative fixes. Overall, we seek to partner in the work of this committee and appreciate all the efforts to center evidence based medicine, protect the patient physician relationship, and provide critical resources to our patients.

[Dr. Kirsten Ek]: Thank you, man. Hey.

[Sen. Saud Anwar]: Thank you so much for your testimony. You're on time with on message. I appreciate you. Can I ask you for a favor? Would you be able to do a CME lecture for us that we can put online for any of the places that would be willing?

[Dr. Ayanna Liles]: Regarding CME for what? I I won't agree unless

[Sen. Saud Anwar]: I meant a lecture a lecture on menopause. Well, so the clinicians would be able to learn about it and be better prepared.

[Dr. Ayanna Liles]: I can do it. I I also as you can see, I'm really busy. So I I would be happy to find a board certified ACOG, someone who's evidence based because I agree. I think the more knowledge everyone is aware of menopause, the better that we can serve that that group of individuals who have unfortunately been neglected for decades. So, if you are all willing, I'm happy to help set that up either with me or whomever. There's several people in the state who are what we call NAMS certified, meaning they've gone through the menopause certification, and they are passionate. I'm passionate about everything as you guys have all learned over the years, but finding someone who's extremely dedicated in this space is something I'd be happy to coordinate.

[Sen. Saud Anwar]: Perfect. We we wanna thank you for your testimony. Thank you for your time, and thank you for the work that you do.

[Rep. Nicole Klarides-Ditria]: Thank you.

[Sen. Saud Anwar]: Alright. That brings us to the next person on the list. I wanna make sure you are not in the room here, Quinn Meehan. No. You're not. Alright. That brings us to online medicine. Madison, Ms. Spremuli, you're on.

[Madison Spremuli]: Thank you. Good afternoon, members of the public health committee. My name is Madison Spremuli and I am the organizer for the CT Zero Waste Coalition. I'm here to testify today in support of Senate bill three eighty two, an act concerning edible food recovery. The CT Zero Waste Coalition brings together various environmental nonprofit organizations across the state, including food recovery organizations, all with a combined goal to advocate for waste reduction. We believe that this proposed bill provides a solution to two pressing issues our state is facing feeding our hungry residents and diverting organic material from landfills and incineration. It is alarming that we throw away nearly 40% of our food supply while approximately one in seven Connecticut residents face hunger. I will speak primarily for the rest of my time on the economic and environmental burden of wasted food. Nearly a third of our state's municipal solid waste is organic matter, which is heavy and expensive to dispose of. Currently retail food establishments and municipalities incur high costs by sending food waste to landfills hundreds of miles away in Pennsylvania and Ohio. And disposal costs are only rise as aging incinerators in our state close and landfills reach capacity. Not only that, but food decomposing in landfills is a major contributor to methane emissions. To put it in perspective, Connecticut sends nearly half of its waste to landfills out of state. We do have one proposed change to this bill regarding the definition of food distribution organization. The current definition in the bill is limited only to nonprofit organizations. However, there are other organizations without nonprofit status that contribute greatly to food recovery in our state. Instead, we urge the committee to adopt the broader definition of food relief organization established in public act number 22 dash 28. This definition includes community based organizations, mutual aid networks, as well as nonprofits. So to conclude, we ask the committee to please pass Senate Bill three eighty two and act concerning edible food recovery. Thank you for your time.

[Sen. Saud Anwar]: Thank you for your testimony. Do you have a written testimony as well, Madison?

[Madison Spremuli]: I do. I did submit it.

[Sen. Saud Anwar]: Perfect. Perfect. Thank you. We'll make sure that we look at your specific recommendations. We wanna thank you for being with us. We appreciate you and the work that you're doing. With that, we're gonna move to the next person on our list, which is I don't know. I don't see him. Doctor John Wysock. Yo. There you are. You've been here all day with us. Thank you. Thank you.

[Dr. John Wysocki]: Yeah. Thank you, doctor senator Anwar, rep McCarthy Vehi, and distinguished committee members. Thanks for having me today. My name is doctor John Wysocki. I'm a board certified gastroenterologist with Connecticut GI. We care for tens of thousands of patients all around the state of Connecticut. We are an independent physician practice, And, normally, my partner, doctor Joe Cap, has been here the past few years, presenting testimony on behalf of similar bills, that we've talked about today. He sends his regrets that he cannot be here today. But I'm here today to talk about House Bill 5,398 in opposition to that bill. This is a bill that would make it harder for independent practices like ours to continue providing care outside the hospital, health system, or insurance company setting. This bill assumes private equity partnerships, harm care, and increased costs. Data would suggest otherwise. Research does show that hospital driven consolidation, not private equity, is leading to higher health care costs. Health care organization called Avalir analyzed some Medicare data back from 2019 to 2022 across five different medical subspecialties, including GI. According to that study, a staggering 82% of physicians in those fields are now affiliated with hospitals or corporate entities, like Optum, but just 6% of those are independent and affiliated with private equity backed, MSOs. So private equity does support independent practices and is not necessarily the driver of consolidations. You know, hospitals and payers, buying medical practices are. Avalir also found in that same study that previously unaffiliated physicians, when they joined a hospital system annual Medicare spending per beneficiary actually increased by over $1,300 When that when a similar unaffiliated physician would join a private equity backed management service organization, they found that Medicare spending per beneficiary per year actually went down by $963 A new peer reviewed study in July of this past year show that hospital outpatient departments are reimbursed at dramatically higher rates than that we see in independent physician offices and ambulatory surgical centers across these medical specialties, including GI, upwards of 860% more for Medicare and over 1300% more for commercial insurers. This has real world impacts for patients and our health care system. Take, for example, what I do. I do colonoscopies quite often as people's introduction to the GI community age 45. It's the only cancer screening test that both can detect and prevent cancer. According to a study from 2023, a colonoscopy in the hospital setting could be as much as 65% more than an independent independent surgery center like where I do many of my procedures. And I may be the same physician doing that exact same procedure in a hospital in that ASC. But we need to make sure that Connecticut doesn't make it harder for us to expand care in order to offer affordable care to our patients. Our MSO partnership provides capital and operational expertise that allows us to expand high quality affordable care and adopt advanced technologies. Through national data that we have from nearly 3,000,000 patients, we look to implement care management programs across a variety of diseases, including fatty liver disease, inflammatory bowel disease, obesity, and this helps to improve outcomes and reduce ER visits. The part of our

[Committee Clerk/Timer]: Please, miss Doctor. Wysocki, but your time has expired. Thank you.

[Dr. John Wysocki]: Thank you. It's one last closing. Yeah. Please. But I urge the committee to try to tailor policy solutions to address these specific failures, we face in Connecticut like the Prospect Medical Bankruptcy without undermining independent practices ability to grow and be competitive and allow access for high quality affordable care throughout the community. So again, please oppose house bill 5,398. Thank you for your time.

[Sen. Saud Anwar]: Thank you. Thank you. This is very helpful. I think the the data that you're, sharing helps us recognize that sometimes we are worrying more than what the reality is. And the the real challenge is that what prospect did has raised our awareness, and that's where the area of opportunity has been. But I guess there is a little bit of a concern at the national level more so that there are things happening that are concerning in the private practice arena and that brought some of these conversations over here. Absolutely. So anything else that that you do do you think that the MSO agreements can sometimes restrict access?

[Dr. John Wysocki]: I think probably the opposite. So I think there's, you know, not only with technologies, but new ways of doing thinking, sharing how practices are able to survive and thrive, you know, in in today's health care universe is is good to hear because everybody does things a little differently around the country. And when you have that shared expertise that you can get from other practices that are doing things a little differently, possibly better than you can do, may open up opportunities for you to make sure that you can offer care to people in a variety of ways, whether it's after hours or unique APP opportunities in the office, having more flexibility with how you see patients, how you can do bypass colonoscopies, but there are, I think, a lot of solutions that exist that you may or may not be aware of that allow you to enhance your practice, offer more care because we are facing that that disparity between providers and and the demand of society and what our what our patients need. So we have to find new and inventive ways. I think being nimble, allowing for competition, good competition, I think competition is a good thing Yeah. To help push us ahead because we have to be much more creative with our solutions as opposed to the the the the age old techniques that we've been using in the past to try to treat our patient populations and AI technology, the list goes on and on, things that we can implement to help make sure we're offering the best care for the most amount of people at an affordable price. So I think it's a good thing to continue to push the envelope and, you know, having the support of MSOs and other organizations around the country, and a lot of these are independent, is is essential to make sure that we we can all move this this ball forward because it's not just a hospital issue. It's not just an academic center issue. It's not just a private practice issue. We all need to be involved in various facets. So this will help to ensure the health and vitality. It's a it's one of the components that's just as essential as hospitals are. Insurance companies play a role, but they're important to bring to the table as well. So I think there's all these things are important, but independent practice must be, must be recognized and understood and make sure that it doesn't get it doesn't get squashed.

[Sen. Saud Anwar]: Another stereotype we have on the outpatient side is that the Medicaid patients are getting restricted by private equity. Is is there any evidence of that?

[Dr. John Wysocki]: No. I mean, we have there's no restrictions that I've seen in my practice or that I've heard about people. You know, regardless of insurance, it's a nice thing. You just we need to see patients. So we have openings for every patient. Whenever I get asked a question, for example, are you seeing new patients? The answer is always, of course. So we're like, I've never closed a book. I never heard of anybody closing a book as a result of anything before any MSO affiliation or after one. I've never been told how to practice medicine nor have I think my colleagues been told the same thing. So it's I've I've noticed absolutely no change after being involved with any type of MSO organization. Good. Well, we wanna thank you for being with us, throughout

[Sen. Saud Anwar]: the day and then experiencing this part of the world as well.

[Dr. John Wysocki]: Democracy at its finest. I

[Sen. Saud Anwar]: appreciate the education. Thank you. How many patients will be upset at us today with the public health committee?

[Dr. John Wysocki]: A few.

[Sen. Saud Anwar]: Okay. Well, we appreciate them and appreciate you. Thank you so much. Oh, we did we have a question. Sorry. Representative Kristen McCartin. Sorry.

[Rep. Cristin McCarthy Vahey]: Thank you. No. More just to comment and to point out to, my colleagues. First, thank you for serving the people of Fairfield and Bridgeport who I represent.

[Dr. John Wysocki]: Thank you.

[Rep. Cristin McCarthy Vahey]: I also, wanna say thank you for including in your testimony, your the background and the references that you made today. So when I clicked on and saw the 69 pages, it was helpful to see that there is that background, which is great. So thank you for that. Sure. Thank you for spending time with us today.

[Dr. John Wysocki]: I appreciate it. Thank you.

[Sen. Saud Anwar]: Thank you. With that, we will move to the next person on our list, which is doctor Kirsten Ek. Good afternoon. Patients with us. Welcome. Thank you. Good

[Dr. Kirsten Ek]: afternoon. Dear esteemed members of the public health committee and chairs, My name is Kirsten Eck. I'm a board certified internal medicine physician. I take care of hospitalized patients. And in part of my role, I work with medical residents to connect with community partners who do street outreach medicine for our unhoused persons. I have an interest in teaching climate and health, and I come before you as a member of the steering committee for the Connecticut Coalition on Climate Action or CCCA. I come today before you to speak on behalf of Senate Bill three sixty four, which grabbed my attention and my heart, and act concerning extreme weather protocols. This bill touched me because I just recently took care of a gentleman, I'll call him mister l, who came to me in septic shock. So he was very, very critically ill. He had been in the cold in the extreme weather event we had a few weeks ago, and he had suffered frostbite to his hands and to his feet. By the time he was found on the streets, the frost the frostbite had progressed to gangrene. So his feet were black. The tissue was dead and necrotic, and infection had gotten into the underlying bone. The problem is that taking care of this gentleman was very hard because he had schizophrenia. And when we had to discuss treatment options with him, it would trigger stress, mental stress for him. He would begin clenching his jaw repeatedly and to the point where he couldn't speak or process what we were saying. It was a very hard thing to watch. He was in a lot of pain. He ended up with amputations, which he perceived as threats to him as a person suffering mental health illness. His presentation was a consequence of him not being able to organize himself enough to seek shelter and not being able to connect with outreach teams in the town where he was from. You know, I support this bill because I feel that it expands access to people like mister L and to so many others that my medical residency with these street outreach teams who really suffer in these extreme weather events. I heard our previous, speakers talk about the thousands and thousands of calls and need for these services and not just in the cold weather, but in the extreme heat that we were sure to see soon enough, even though it feels far away right now. I hope that you will all support Senate Bill three sixty four, expanding coordinated access and setting consistent triggers across the state state that are more health guided. I agree with the previous speakers that nine degrees is too low, and 90 degrees over three days is too high a threshold to trigger these in order to prevent significant morbidity and mortality for our unhoused persons and for other people all around the state with vulnerabilities to these temperatures. Hypothermia can easily set in in the mid thirties temperature range, especially if it's wet or windy. While for patients with medical vulnerabilities, extremes of age, medications that affect how they handle heat, even heat indexes above 90 for a short time can pose deadly hypothermia threat.

[Committee Clerk/Timer]: Excuse me, Doctor. Reich, but you've reached your three minutes. Thank you.

[Sen. Saud Anwar]: Please do continue. I I wanted to hear last

[Dr. Kirsten Ek]: couple of questions. Thank you. I'll just make one more point that I think sticks really with me as well. This is something I anticipate people house people will also come to need. When I review the global heating projections for Connecticut and the what we can expect in terms of extreme weather, extreme heat, unstable cold. We can expect storms that will displace communities on the shoreline, inland flooding, hurricanes. We can expect neighborhoods to be displaced and need shelter or lack grid, lack power. I think the expression is there by the grace of God go I. Any of us may need expanded access, and I anticipate more and more will be required for this state in the coming decades. I salute the members and chairs of this committee and all the partners who spoke before me for this bill. I think it is a worthy one of your time and vote. Thank you.

[Sen. Saud Anwar]: Thank thank you so much, doctor Ek. Thank you for your advocacy and thank you for the work that that you do for the Connecticut Coalition for Climate Action, and this is very much connected to this. And the way things are, unfortunately, we may be seeing such extreme temperatures that would be dangerous for communities. Yes. Your testimony is very powerful, very helpful. Every year every two years, I would see somebody in the ICU who would lose their limbs from being homeless and and being out in the cold. So it's very real. And and while we the the people who die get attention, but the ones who are very sick are also a significant impact on the health care cost of other state, but but the quality of life for them and then the future options. So your point is very powerful. So thank you for your testimony and the work you do.

[Dr. Kirsten Ek]: Thank you.

[Sen. Saud Anwar]: With that, we move to the next person on our list, which is doctor D'Onofrio. Welcome, doctor D'Onofrio, and thank you for the work you do.

[Dr. Gail D’Onofrio]: Thank you. And thank you, senator Ammar and the committee. My name is, Gail Tannofrio, and I am board certified in emergency medicine as well as addiction medicine. I am support in support of, Bill SB three sixty five, and I am going to give my comments. Opiate overdose deaths, while recently declining, continue to be a leading cause of death in people 45, despite the availability of effective medicines. In Connecticut, for 2025, that was approximately $7.75 deaths. Each overdose deaths results in thirty eight years of potential life loss. Emergency department initiated buprenorphine has been shown to be effective. And increasing treatment engagement in multiple trials is cost effective. And yet, even though we know this, adoption has lagged. Despite this knowledge, for over a decade, the removal of regulatory barriers, some regulatory barriers to buprenorphine treatment access, such as the X waiver, and national consensus recommendations from the American College of Emergency Physicians supporting ED provision of medications for opioid use disorder, published in Annals in 2021, there has been minimal improvements in ED provision of buprenorphine across the state of Connecticut. We know that individuals with obese disorder use the ED as their usual source of care, and this visit provides a very reachable moment. We know that specific state level investments, such as those that had happened in California's expansive ED resource and technical assistant known as California Bridge, has paid off, leading to a much increase in number of Buprenar prescriptions from emergency physicians. And that is published in GM UP 2025. While I'm not usually an opponent of legislating medicine, it is the time to change if we're going to change practice. Emergency physicians expect to treat patients with an acute myocardial fraction with aspirin, other medications, and to send these patients expeditiously to the catheterization lab in less than thirty minutes. Overdose has a similar thirty day mortality rate of approaching five percent, and yet emergency physicians do not feel the same degree of necessity to adhere to evidence based practices. Why is opioid use disorder any different, I ask? There is precedent for this legislation. We know that the state of Massachusetts has enacted a similar one requiring that all hospitals and EDs and satellite emergency facilities maintain capacity for providing MOUD. Also, our neighboring state of Rhode Island has a similar, bill included in their levels of care framework. And other states have other substance use disorder statuary protocol requirements. I have spent my life building evidence for ED treatment for substance use disorder, particularly opiate use disorder. I have not been able to change the practice in my own state. Yet California ran with my work. I participated in the Connecticut Opiate Response, which is core initiative advising the state of Connecticut on evidence based spending of the opioid settlement funds. I am working with Connecticut's Department of Mental Health and Addiction Services right now to improve EDMOUD through monies appropriated by that settlement. We have had difficulty getting

[Committee Clerk/Timer]: me, doctor D'Onofrio, but your time has expired. Thank you.

[Sen. Saud Anwar]: Can you complete I I was really interested to hear what what your outcome for your DMIS support has been.

[Dr. Gail D’Onofrio]: Okay. So we've had difficulty getting EDs to accept the funds for hiring health promotion advocates and insisted to assist the clinicians to detect offer and treat, despite the fact that I have offered my services and other e onboarded emergency physicians to help beyond technical assistance. So this is time to act. I suggest that there are a couple of things in the bill that need to be amended, which I would say that treatment should be provided in any office based clinic for buprenorphine and does not have to be a DMIS certified clinic. MOUD should include methadone as well as buprenorphine. And I'll suggest that there should be a warm handoff to the referral sites for continuation of M O O D and not a simple referral with a name on it. I also ask there be some method for monitoring feedback to ensure that the bill is successful and to help EDs progress, and this not just be another piece of paper. Thank you very much for my time.

[Sen. Saud Anwar]: Thank you. This is very, very helpful. Can I ask you a couple of questions?

[Committee Clerk/Timer]: Sure.

[Sen. Saud Anwar]: I think you were working with Carson, and you had your publication at JAMA recently about your work.

[Rep. Nicole Klarides-Ditria]: Yes.

[Sen. Saud Anwar]: What is your bias, a seven day treatment or a thirty day shot or a seven day shot?

[Dr. Gail D’Onofrio]: Oh, Well, that that that work that we published with a bunch of group of people and my cohort with doctor Filene showed that we, in the emergency department, could give a seven day injectable as well as sublingual. And both of those groups were in treatment approximately forty percent at at seven days, and more than that, forty five percent, at thirty days. The the seven day injectable is great in the emergency department because of the way the pharmacology is. It has a gradual uptake in the bloodstream, and that allows us to inject it with people with very low Cal scores, as little as four. Okay, so in the emergency department, while people are there, we could offer that injection and take advantage of the fact that they're right there in the emergency department. In this whole study, of which there were 2,000 patients in 29 sites, we had less than a one percent incidence of precipitated withdrawal. Only five people that got the injectable and half of that. So that's a reason to use the seven day in the emergency department. We could use a thirty day, and we can have that offered as well. But that is a rapid rise, and so there's other things that have to be taken into account. But we should have thirty day available if we want it as well. If people come in and they've been on view before and they're in higher levels of withdrawal, you could inject a thirty day. But the advantage of the seven day is that we can use it in people who are presenting with very low levels of withdrawal and take that opportunity to use it, to do it, and really initiate treatment right then in the ED.

[Sen. Saud Anwar]: Thank you. And and, how fortunate were you to get them hooked with a a outpatient facility?

[Dr. Gail D’Onofrio]: We're very fortunate. We've we had all of our patients. We continue to and, again, I'm I'm speaking on part of myself today, but we've had I've never had any trouble getting anybody to a place. There throughout Connecticut, there are places. People keep saying there aren't, but there are. And we just have to make those connections to get people in that in into that and make that warm handoff happen. And, really, literally, we can give out prescriptions in the ED. There's no reason not to give at least a fourteen day prescription to get someone into, someone's office or in a, opiate treatment program. There really should be no reasons that we can't do that.

[Sen. Saud Anwar]: Your testimony is very helpful. The work that you're doing is very helpful. We are fortunate that we have a number of experts in this room and this room and and yourself here working on on, helping this issue out. And then we are hoping perhaps as a public health committee, we can do something that may, prevent some deaths. Thank you.

[Committee Clerk/Timer]: Good. Thank you. I appreciate

[Sen. Saud Anwar]: your time. Representative Carpino has a question for you. Yep.

[Kathleen Holt]: Thank you, mister chairman. I just had a clarifying question. Towards the end of your testimony, you said there should be no reason that we can't give a fourteen day prescription. And I appreciate that, but I was happy to hear that. I just wanna confirm. Can you write the script for fourteen days, or can you fill and send somebody home with fourteen days of the appropriate medication because of the difficulties associated with sometimes filling the script depending on the particular patient?

[Dr. Gail D’Onofrio]: Well, that it depends on the hospital and whatever of whether or not we can get these filled. Some some hospitals have, pharmacies right there. And so if someone has Medicaid, for example, they can get it filled for thirty days even. Other times, it's not. That's the advantage of using the injectable, actually, so that there's not so much trouble of getting that initial prescription. But we, where I am, we have capacity to help with this, and at least start it there in the ED so they have to go tomorrow, say, to get the injection. I mean, to get the prescription filled. But that is an advantage of the injectable that you don't have to worry about going. But we found even in in where I am that we we have the ability of people getting those prescriptions.

[Kathleen Holt]: Thank you very much. Thank you, mister chairman.

[Sen. Saud Anwar]: Thank you again for your testimony. Seeing no other questions or comments, we move to the next person on our list. I wanna make sure, Malia Hunt is not there. So you are. I was looking at at you in the computer again. Welcome. So, Jaya, you have to wait for a bit. Go ahead.

[Malia Hunt]: K. Good afternoon. Senator Onward, representative McCarthy Veggie, and distinguished members of the public health committee. I'd like to thank you for your leadership on public health and for holding Can

[Sen. Saud Anwar]: you come closer to the mic and be a little louder? Thank you.

[Malia Hunt]: This better? Okay. I I'd like to thank you all for your leadership on public health, and for holding this hearing today. My name is Malia Hunt. I'm a graduate social work student at UConn, and I'm currently interning at UConn Health Disparities Institute where I'm working on a menopause equity initiative. Today, however, I'm representing myself as a Glastonbury resident in strong support of house bill five three eight nine. Over the past nine months, I've attended numerous community events across Connecticut focused on menopause education and awareness. I have spoken with countless individuals who all say the same things. I didn't know. I wish somebody told me. Most of these community members are already in perimenopause and menopause or I'm sorry. Perimenopause or menopause and uninformed of the changes already taking place within their bodies. In fact, eighty six percent of our community members report knowing little to nothing about menopause. This is concerning because menopause does not result in just discomfort and undesired symptoms like brain fog and hot flashes. The decline in estrogen levels reduces bone density, increases cholesterol, and raises the risk of health conditions such as heart disease, strokes, and osteoporosis. This means that time, attention, and treatment are critical for protecting and maintaining quality of life and prevention of serious conditions or diseases. As much as we might encourage folks to talk to their doctors, health care providers may also be uninformed. Medical programs do not have enough curriculum on menopause. This is why less than seven percent of primary care providers feel prepared to manage menopause. In Connecticut, there are over five hundred thousand women and gender diverse people in the menopausal age range, which is between 45 and 64. But there's only 23 Connecticut practitioners certified by the North American Menopause Society as being menopause competent clinicians. So there are far more individuals in need of menopause related care than there are specialized clinicians available to provide it. Without the support of doctors, menopausal individuals seek help in unregulated markets for management of symptoms, often using compounded hormone therapy that is not FDA approved. This has many risks and places people at harm. This bill is a great opportunity for Connecticut to join and lead the national movement recognizing menopause as a public health issue. 21 out of 50 states have introduced legislation that focuses on improving menopause related education and awareness between 2024 and 2025. I note there were some questions about that, so I'm happy to answer that. With the average life expectancy of women being 80 years old in The United States, women and gender diverse people will spend over a third of their lives in menopause. House Bill 5,389 offers Connecticut a way to ensure our providers feel equipped with the knowledge, tools, and perspectives they need to deliver high quality, inclusive menopause care. No one should have to navigate this transition uninformed, unsupported, or alone. I've submitted a written a written testimony in addition, but I'm happy to answer any questions you might have.

[Sen. Saud Anwar]: Thank you. You're within three minutes. You did great job. Very good communication.

[Dr. Kirsten Ek]: Thank you.

[Sen. Saud Anwar]: I wanted to ask you, what's going on in the other states? What kind of policies?

[Malia Hunt]: Yes. So I've used LegiScan to do a policy scan of other states. I found four categories or focus areas that other states are proposing things for for menopause equity, So the first category is education. I found that 66 of these of these policies were covered by this topic. The next category was coverage, workplace, and direct care. For education, I can tell you that there was seven I'm sorry. There was five proposals that were successful in passing in 2025. Maine created and distributed menopause education materials. Illinois and Pennsylvania passed awareness resolution, so they set, like, a menopause day or week or month to focus specifically on menopause, and usually during those times, there's distribution of materials that kind of highlight what menopause is. In Arkansas, they passed an assessment of menopause health resources and care probably to then develop policy to fulfill certain gaps that they find. And then Washington calls for the state I'm sorry, calls for the senate to improve tools and efforts that will support those in menopause.

[Sen. Saud Anwar]: Thank you. This is very good.

[Committee Clerk/Timer]: Yes.

[Sen. Saud Anwar]: Very, very good. I don't see any questions or comments. Thank you for the good work you're doing.

[Rep. Cristin McCarthy Vahey]: Yes.

[Sen. Saud Anwar]: Thank you. Good luck.

[Malia Hunt]: Thanks for your time.

[Sen. Saud Anwar]: Next is, Jia Dadwal. Jia, welcome. You're on.

[Jaya Dadwal]: Thank you. Good afternoon, Senator Anwar, Representative Vahi, Senator Mark, Senator McCrory, Representative Belton, and distinguished members of the public health committee. Thank you for the opportunity to provide testimony today in support of House Bill 5,322 and House Bill 5,389. My name is Jaya Dadwal, CEO and co founder of women's health company 4Eva, and I also represent today my co founder Emily Deschanes, the company's chief scientific officer. At 4Eva, our work focuses on advancing women's health through research, innovation, and policy engagement. For Eva strongly supports House Bill 5,322, a working group for endometriosis. March is endometriosis awareness month, so it is my pleasure to be speaking with you today about the condition. Endometriosis affects approximately ten to fifteen percent of women of reproductive age. For most women, if we do not have endometriosis ourselves, we know a friend, loved one, or colleague who does. For me, that person is Kanika Madan, a close friend who at the age of 27 has already had three invasive endometriosis surgeries, two of which left her unable to walk for two months post op. Endometriosis is a complex and often debilitating condition. Despite its prevalence and impact, patients wait an average of seven to ten years to receive a diagnosis and these delays are even longer for many women of colour. Women represent fifty percent of the population and 100% of our life force, yet women's health research and policy have historically focused primarily on fertility and breast cancer. Conditions such as endometriosis remain under recognized and underfunded. Establishing a multidisciplinary working group in Connecticut would be an important step to addressing this gap. International models demonstrate how governments can take meaningful action in this space. Australia, my home country, for example, has invested over £37,000,000 in a national endometriosis initiative, including the establishment of specialized endometriosis and pelvic pain clinics and the development of national clinical guidelines to improve diagnosis and treatment. House Bill 5,322 has for EVA's complete support as an initial step in this direction. Yesterday, I testified before the Labour and Public Employees Committee in support of Senate Bill three fifty three, a bill calling for menopause accommodations in the workforce. Today, it is my pleasure to also support House Bill 5,389, legislation directed at providing menopause diagnosis toolkit. Studies show that over ninety percent of medical residents feel inadequately trained to manage menopause related care. Menopause is not only a natural life stage, but also a critical period for long term health. The reduction in estrogen associated with menopause can increase risk of cardiovascular disease, osteoporosis, and bone fractures, as we've heard today.

[Sen. Saud Anwar]: Evidence shows that hormone replacement therapy is most

[Jaya Dadwal]: effective when initiated before the age of 60 and when comprehensive provider toolkit would equip physicians with clear guidance for diagnosing and supporting patients through perimenopause, menopause, and postmenopause, ultimately improving care for millions of women. Together, these bills represent meaningful steps towards improving women's health across the lifespan. By addressing conditions that affect millions of women yet remain underdiagnosed and undertreated, Connecticut has an opportunity to lead in advancing equitable and evidence based healthcare. Thank you for your time and consideration. For Eva, we welcome the opportunity to work with the committee in any capacity and also answer any questions you might have today. Thank you.

[Rep. Cristin McCarthy Vahey]: Thank you so much for your advocacy here. We've been fortunate on this committee to have representative Kennedy and representative Gilchrist leading the way on this conversation related to endometriosis. So we're very grateful to have you here to help support this effort. Seeing no questions or comments, we will go next to Alex Brown, who I believe is here. Welcome. Thank you.

[Alex Brown]: Good afternoon, members of the public health committee. My name is Alex Brown. I am an MSW student at UConn and work in policy and advocacy on human rights issues. I am here today in support of SB364, an act concerning extreme weather and HB5389, which would establish a provider toolkit for menopause diagnosis and treatment. Today, I plan to spend my time talking about HB 5,389. Menopause is a normal stage of life, yet many people still navigate it without clear guidance from health from the health care system. Symptoms such as sleep disruption, hot flashes, brain fog, joint pain, and mood changes can significant can significantly affect daily functioning, mental health, and overall quality of life. Despite this, many patients report that their symptoms are dismissed or not fully addressed in clinical settings. One of the challenges is that many providers do not receive extensive training in menopause care. When clinicians lacked clear resources or guidance, patients are often left searching for answers on their own or navigating symptoms without adequate support. One of the sorry. A provider toolkit offers a practical and accessible way to help address this gap. By giving clinicians clear evidence based guidance that can be used in everyday practice, Connecticut can help ensure that providers across specialties feel more prepared to diagnose menopause, discuss treatment options and support patients through this transition. From a social work and public health perspective, improving menopause education is also about health equity. Access to accurate information, knowledgeable providers, and evidence based treatment can shape whether individuals receive meaningful support or are left navigating significant health challenges on their own. A well designed toolkit can help normalize conversations about menopause in clinical settings and ensure that providers have the tools they need to offer informed and compassionate care. Menopause is something that millions of people experience yet too often it remains overlooked in healthcare conversations. HB 5,389 represents an important step towards improving provider education and strengthening menopause care across Connecticut. Ensuring that providers have the knowledge and tools to support patients during menopause is not just a clinical issue. It is a matter of health equity, dignity, and quality of life. Thank you for your time and consider consideration. I respectfully urge you to support HB5389 and SB364.

[Rep. Cristin McCarthy Vahey]: Thank you so much for being here today with us, and I will add to what rep Belton said earlier as a fellow social worker. It's wonderful to see our social work students and leaders here. So thank you for your

[Sen. Saud Anwar]: Of course.

[Rep. Cristin McCarthy Vahey]: Testimony today.

[Alex Brown]: Thank you.

[Rep. Cristin McCarthy Vahey]: Seeing and hearing no other questions, we will go next to Paul Kidwell, who, as I mentioned to him earlier, seems to somehow always end up at the tail end.

[Paul Kidwell]: But I learn so much every time. So

[Rep. Cristin McCarthy Vahey]: It's great to see you, Paul.

[Paul Kidwell]: I appreciate being with all of you this afternoon. I had actually written this evening, but I gotta scratch it out. So, this afternoon, we've submitted testimony on a number of bills today, but I wanted to take my time on HB five thousand and forty five and five thousand and forty nine and just highlighting some of the key points we make in each of those bills. Related to the CON process, as has been noted, 5,045 proposes a fundamental restructuring of the CON process in our state. We certainly appreciate the intent of the administration to create a process that moves applications more expeditiously. There are a couple of provisions or lack of provisions in the legislation that I'd like to highlight. The first, and as Boyd Jackson from the Office of Health Strategy noted this morning, the bill allows through the process the unilateral imposition of conditions. Currently in today's process, those are negotiated with OHS. And in this new process, those would be sort of take it or leave it conditions. We think the bill also needs to include prohibiting applicants from being mandated to meet requirements or obligations that are not set forth in statute or regulation in order to obtain a CON. We believe that those conditions should also be justified and the duration of any condition should be justified by weighing the burden of the condition against the benefit. There's also some discussion related to the flipping of the hearing requirements. Not every CON application should be subject to a hearing. This change in process will significantly slow down CON approvals and subject the most administerial CON request to an overly administrative process that is not required. There's also a significant shift in that CONs will be determined by a three member panel. We're concerned that the infrequency with which the panel will meet will mean UN applications are delayed and not determined timely. We also believe the legislation requires clarity related to the role of the panel. Will the panel preside over hearings or will they convene to make determinations? If they're not presiding over the hearings, who will be conducting the required hearings? And will the panel be able to meet in between their scheduled quarterly meetings? We certainly appreciate that there's a change in service terminations, where there's a requirement that the Department of Public Health Commissioner would have to approve a plan. What we're concerned about with that is there's no off ramp should the DPH commissioner never approve the plan for the service termination. There needs to be some due process, where, a applicant could appeal, sort of a never ending process with the department. Related to 5,398, certainly, there's been quite a bit of testimony related, to that bill today. You know, as we've noted in the past, we are concerned related to the review of transactions in involving any health care entity, and in including that the office of health care strategy or its successor organization would be able to participate in the AG's process, basically creating a separate CON process through the attorney general's office. What has not been noted today is there's a separate section in the bill at the at the end related to a requirement that the the to include the corresponding actual cost of each related good or service when a hospital files its its price master. I think the bill just generally doesn't recognize how hospitals do this process. We don't do it by service. We do it in the aggregate, and it's a means to understand how we're getting reimbursement in from insurers. And the notion that we would have to do this by service would be extraordinarily, administratively burdensome and expensive. Happy to continue to discuss that provision with the committee, and thank you.

[Adelita Orefice]: Perfect.

[Paul Kidwell]: Alright, Kathleen. I talked right over you. I'm sorry.

[Rep. Cristin McCarthy Vahey]: The voice. The

[Committee Clerk/Timer]: voice Stop that. Thank you.

[Rep. Cristin McCarthy Vahey]: Oh my gosh. It's great to hear Kathleen's laugh. Paul, thank you for your testimony. I your testimony is online. Correct?

[Paul Kidwell]: It is, and it's much more extensive, related to, certainly, the CON bill. We have some very specific provisions. I think just generally, we'd like to engage in the conversation. We we're we are glad that the administration has proposed something with this committee, and, CHA certainly has been talking about the CUN process for some time. We think there are things that should be corrected. We think the intent is to make CUN more efficient and effective, but we think there are some things in here that won't get us to that end. And so we just wanna keep talking about how do we improve it.

[Rep. Cristin McCarthy Vahey]: Thank you. I Senator Amar? No. I I'm I'm good for now. Okay.

[Sen. Saud Anwar]: Thank you for your testimony. And then I I think this is a big shift that's happening from or at the Office of Health Strategies to the Department of Public Health. This would be a good opportunity to revamp some of the things. So agree with you about the the process issues. What like, I was having a conversation initially with Boyd Jackson was that there's a part that is what what conditions, situations should require, that that's a separate conversation. And and the part that I think, many of us may agree with the CHA is the process part, the streamlining part. I think there's an area of opportunity there to make it more efficient but fair at the same time. So everybody has a say, but it needs to be efficient and and there should be pathways and there is more than one pathway depending on which path it would be. And and the area that perhaps I may disagree with CHA is that when somebody's gonna leave a community, I would like to have a c one process there. Not necessarily as robust or challenging, but we need to have a frank conversation of who's leaving and why, and then what's gonna be the negative impact.

[Paul Kidwell]: Yeah. Certainly, I think contemplated in the legislation is that a plan would have to be submitted to the Department of Public Health, and the applicant would have to explain why they were removing the service or ending the service and what would be the steps to remediate any impact for the service. So certainly, senator, happy to continue to talk to you about that because, certainly, those decisions aren't made widely.

[Sen. Saud Anwar]: And and so so I I saw that part. And and and to me, it's good that that that that information will be there. The challenge I have is I'll use a hypothetical example. So let's say Wyndham, health care is being taken away. The women will not be able to get any OB GYN or women's health care issues. While the hospital may put that information to the Department of Public Health, I want the community to be able to come up and say, no. No. No. We need this health. There's gonna be a big vacuum. There'll be a gap created. So it needs to be a public conversation around that so that we can start to see what else can be done by the state. And if the hospital cannot do it, there may be ways around it for some some support systems that could be created. So so that that's where I think there's an area of opportunity when you withdraw support or or service from in the community. We need to have that community be aware of what's going on. And on the the entry point, I think that should be made easier. Exit should be a little difficult, not extremely difficult, but difficult, and the process should be efficient. So that's the the simplistic thing. So I think we will see eye to eye on a number of different aspects for sure. And then would love to coordinate collaboratively with everybody and getting everybody together to make the best decision. Appreciate that. Thank you. Good. Representative Curtis Dietrich.

[Rep. Nicole Klarides-Ditria]: Thank you for being here today. I think there's something in this bill for everybody to hate.

[Paul Kidwell]: Yeah. You

[Rep. Cristin McCarthy Vahey]: know?

[Rep. Nicole Klarides-Ditria]: And they maybe one more than one thing in the bill. I do think everybody is in agreement that we need to streamline whatever process we have because it takes too long, and there's too many, obstacles to go through the COM process. So I'm hoping at the end of the day, we have something that we don't hate. And that's a lot of times what legislation that comes out of here is is a compromise, and we're hopefully, we'll work with CHA to address some of your concerns because I do think that if a hospital isn't making money or they can't get the help with the doctors, they can't keep a service if they can't keep the doctors in. So there's, you know I I think that's that's worth the conversation to try and figure that out as well.

[Paul Kidwell]: Appreciate that. Sometimes these c o one applications are symptoms of other things. Right? And so we certainly try to keep that in mind. And we also now have experience with our ease, you know, ease sort of the the expedited c o m process related to bankruptcy where we know that these processes can be done efficiently with due diligence and sort of done in the best interest of of the state. So we we we know we can do it. And now I think it's applying it to a broader set of c o n circumstances.

[Sen. Saud Anwar]: Thank you. Representative Christian McCarthy, but he has another question.

[Rep. Cristin McCarthy Vahey]: Thank you, senator Ammar. And so to that point, Paul, besides and outside of the expedited process, Would you say that there's been a change and improvement in the time and experience? Like, I think we've heard from OHS that they have, you know, shown us data, but I just from your end

[Paul Kidwell]: Yeah. I think what's from our members objectively, there are certain CONs are moved more quickly than they had been in the past. So I think OHS had been making a concerted effort to try to process those things more quickly. As Boyd described this morning, there are structural things about the COM process that make it burdensome, make it expensive. And if we could, in this legislation, amend those things that are that make the process burdensome and expensive while not foregoing the review that we all think should be done, think we'd be in a better better position. I think the other you know, beyond structure, we've talked about this with this committee. We're concerned about a c o n process that is used to extend other health policy ambitions of whatever administration is in power at the time. That the COM process is not about is not a policy making apparatus. It's a health structure apparatus and what we want health care to look like in Connecticut.

[Rep. Cristin McCarthy Vahey]: So thank you for that answer. And something you said you used the word burdensome, but I think referencing mister Jackson's testimony, there are also statutory timelines that are in place. Right? Like, is that part of what you're

[Paul Kidwell]: talking about? And I and system you're

[Rep. Cristin McCarthy Vahey]: you're I'm just gonna give words to what I see you saying.

[Paul Kidwell]: Yeah. I think that

[Rep. Cristin McCarthy Vahey]: like me to.

[Paul Kidwell]: The the time frames also can be I'll use an example. So I worked at the Center for Medicare Medicaid Services in Medicaid for many years, And there are statutory time frames in the Social Security Act about how states and the CMS interact. But they get they get used to say, let's pause this and ask for more information, and then we'll come back and let's ask for some more information over here just to buy time. And that in so the corollary in Connecticut is that this that the statute can be used to buy more time, buy more time, ask more questions, ask more questions. And all of that means more cost and more delay. It's and to what end at the sort of at the end of the day, are we coming up with the same answer that we would have come up with ninety days prior? And did all that information we provide actually get used in the in the process or not? That's that's very opaque today.

[Rep. Cristin McCarthy Vahey]: Thank you. That's actually it's helpful. I I would say what I'm hearing you say, and you can correct me if I'm wrong, is that there definitely has been improvement, especially in certain areas that there is a need to make changes to the statute so that we can continue to improve and try and get closer to what the expedited process has looked like and continue to review. So you're not saying, you know, and you haven't said consistently over time. We wanna get rid of this process. We just wanna make it work better for everyone and in the end, for the patients who are receiving care.

[Paul Kidwell]: Absolutely. We do we we do not wanna get rid of the process. We think there's room for it, but we think it needs to be improved and unequivocally, it needs to be improved.

[Sen. Saud Anwar]: I can almost promise we'll have a lot more conversations before the end of

[Paul Kidwell]: the session.

[Sen. Saud Anwar]: Yes. We hope so. Yeah. It's it's much needed. Thank you so much. Thank you for being here with us all day.

[Paul Kidwell]: Thank you. Thank you.

[Sen. Saud Anwar]: And that brings us to the next person on the list, number 48, doctor Gigi Maineki. Welcome.

[Dr. Gigi Meineke]: Thank you. Thank you, mister chairman. My name is doctor Gigi Meineke, and I'm speaking in support of House Bill fifty three ninety nine. I have a degree in nursing and dentistry and hold active licenses in both. I'm a faculty member at the Boston University School of Dental Medicine, where I served for nearly a decade as the director of the facial injectables program. For more than fifteen years, I've taught and continue to teach injectables in continuing education programs nationally, as well as dental residency programs, often in conjunction with cadaveric anatomy. I'm a head and neck cadaveric pro sector, and I also serve as expert witness in legal cases exclusively involving facial injectables. In my limited time today, I'd like to highlight a few points that may add additional perspective to our discussion and help clarify some of the concerns that have been raised. Dental education is often misunderstood. Dentists complete four years of doctoral level education after college that includes pharmacology, anesthesia, emergency management, and management of complications. In my own education, I completed the first two years of medical school alongside my medical student colleagues before transitioning fully into my dental training. Many dentists actually hold hospital privileges and routinely treat medically compromised patients. As The US population ages, dental care is provided to individuals with complex medical conditions by all of us and requires a high degree of preparation, which we have. Dentists have used toxins since the late 1980s. For movement disorders of the jaw, tongue, and lips. And this was decades before its first cosmetic FDA approval, and we continue to use it today for these same dystonias and TMJ problems. In a landmark publication in 2010, the National Academies of Sciences, Engineering and Medicine, an independent body that advises Congress on science and health care policy, emphasized that health care professionals should be allowed to practice to the full extent of their education and training. This reflects modern healthcare workforce policy. Patients are best served when trained professionals are allowed to fully utilize the skills they've been educated and licensed to perform. And my last point is this. It's very important to know that consensus literature recommends spacing tox treatments, Botox treatments, at least three months apart to reduce the risk of antibody formation and resistance When cosmetic and therapeutic injections like those used for TMJ are split between practitioners, patients can inadvertently receive staggered dosing that violates this well documented precaution. Dentists are the primary clinicians trained to diagnose and manage disorders of the masticatory system, including TMJ and parafunction, which is why medical practitioners often refer these cases to us. Tox treatment provided by a single trained provider allows for adherence to the official label based dosing intervals and protects patients. Thank you, and I appreciate the opportunity to speak today, and I'll be happy to take any questions.

[Sen. Saud Anwar]: Sure. Thank you for your testimony. Representative Claire, this teacher has a question for you.

[Rep. Nicole Klarides-Ditria]: Thank you, doctor Gigi, for being here today. My first question is, do are doctors qualified to do cosmetic injections on the face?

[Dr. Gigi Meineke]: Dentists. Yes.

[Rep. Nicole Klarides-Ditria]: Dentists. Sorry. Yes.

[Dr. Gigi Meineke]: Dentists the the very education that we received, all of us, is the entire head and neck. And when I train individuals now, what I'm basically doing when I'm training dental practitioners is this is a complete review of something that they probably experienced either with a cadaver or with some sort of modeling or three d modeling of the layering of the facial envelope. So dentists are head and neck experts. So yes, they are eminently qualified to treat the upper third, as well as the lower third. And I would add that the lower third is much more complex than the upper third. So it's strange when, you know, I hear from other states that, you know, they won't allow the upper third, but they'll allow the lower third, which means you have to train, someone immediately in the most difficult area.

[Rep. Nicole Klarides-Ditria]: Thank you for that, answer. And is it isn't it true that now in 2026, dentists go through an extensive training on oral face, head, neck anatomy, and also do cadaver studies, cadaver work on the head?

[Dr. Gigi Meineke]: Most programs, as I mentioned, have, cataract dissections. Either they've been prosected before by someone who has the ability to dissect these just simply because of cost and, time constraints. But just about every program I'm aware of includes cadaveric dissections. So you really get to understand the different layers of the face. And I mean, the other point I would like to make is we are the only profession that I know of that on a daily basis, we're injecting cranial nerves. And that's when you get down to toxins, that's absolutely what we're doing. But a very clear understanding of the three dimensionality of the face is something that is part and parcel to every single dental curriculum that I know of.

[Rep. Nicole Klarides-Ditria]: Thank you. And one of our testifiers, another doctor had mentioned that his concern is that dentists don't have hospital privileges. But I heard you say in your testimony that dentists do have hospital privileges. Is that correct?

[Dr. Gigi Meineke]: Many of them do. I have a colleague here in Maryland who is a general dentist that treats compromised patients, and he has hospital privileges. And this is just in my very small enclave of, people that I know in the community. But he's I know he's not alone. I just happen to know him personally.

[Rep. Nicole Klarides-Ditria]: Okay. Thank you. And my last question I'm sorry, mister chair is there was also some information out there on negative outcomes. And have you heard of any negative outcomes in other states from dentists performing neurotoxins or fillers?

[Dr. Gigi Meineke]: So, as I said in my preamble, I do, expert

[Rep. Tracy Marra]: legal,

[Dr. Gigi Meineke]: work for cases that only involve injectables. And and I have a a small minority that have been dentists and I have the larger, majority of those cases have been medical individuals. The bottom line is, and we all understand this going into this, that, adverse events are something that are just a reality. And understanding what can happen. And, I know that every day, like today, when I was picking up syringes, I'm always thinking about what is exactly underneath my needle because the face is a an amazing network of on and off ramps of vasculature. So I'm always thinking about what could be there. But the bottom line is everyone must be prepared for the eventuality of adverse events because I've been to many medical forums that are solely based in injectables. And the word is, well, if you haven't had an adverse event, you haven't been doing it long enough because everyone gets adverse events. And the bottom line is being prepared for that. And I would say that the cases that I see, the predominance of the cases that I see in the legal realm are people that were not prepared for those eventualities, which is why in my programs, I usually say, if you see me spending time and dwelling on something and you're wondering why is she beating this dead horse, is because I see a signal, that individuals, medical, and, you know, like I said, a minority is dental, but that could also reflect the number of individuals doing these procedures. I I recognize that. But, but everyone should be prepared. And, and, when I when I teach, I make sure that I cover these areas and people are prepared for all eventualities.

[Rep. Nicole Klarides-Ditria]: Thank you, doctor Gigi, for testifying today and giving you giving us a lot of helpful information.

[Dr. Gigi Meineke]: It's my pleasure. And I'm always available, by email. If there are any follow-up questions, I'm happy to do that.

[Sen. Saud Anwar]: Thank you so much for your testimony and answering all of our questions. We don't see any further questions, so thank you again.

[Dr. Gigi Meineke]: Thank you.

[Sen. Saud Anwar]: We'll move to the next person on our list, which is Heather Guidone. Welcome.

[Heather Guidone]: Thank you. Good afternoon, distinguished chairpersons and esteemed members of the committee. I wanna first thank you for your time and the privilege of being heard today, especially during the first week of endometriosis awareness month. My name is Heather Guedon, and I am the program director of the center for endometriosis care, a member of representative Gilchrist's endometriosis legislative working group, and someone who has lived with this disease most of my life. For over three decades, my work has focused on moving endometriosis from the margins into evidence based public health strategies, and I'm grateful for the opportunity to testify today in strong support of Ray's bill five three two two. Endometriosis, if you are not aware, is a systemic inflammatory disease affecting nearly two hundred million women and girls along with unmeasured numbers of gender diverse people worldwide. It costs an estimated $69,000,000,000 in health care expenses and over 119,000,000,000 in lost productivity annually. This disease can erode quality of life, impair daily functioning, derail education and career trajectories, impact family building, and impose lasting consequences. Yet patients still wait as long as a decade or more for diagnosis and will see as many as five physicians on average before their symptoms are finally believed and treated. These delays are not benign and that is exactly why Connecticut's leadership matters. Our Connecticut based working group and the EndoRise biorepository have become the national model, turning long ignored suffering into real change. Maintaining a formal working group is critical to keeping stakeholders involved, including and especially patients and advocates, establishing policy commitments, securing ongoing funding, and continuing our precedent setting progress, not just across the state, but as the template for the nation. Awareness alone is not enough for endometriosis, and sustainable changes require coordinated policy investments and coordinated policy investments and institutional commitments. Supporting this bill is critically important towards continued improvements in diagnosis, proper multidisciplinary treatments, research strides, and increased accurate disease awareness. It sustains our momentum and continues Connecticut's public health leadership on endometriosis and represents true commitment to ensuring fewer people will spend a decade being told their debilitating pain is normal. For all these reasons and more, I implore the committee to move five three two two forward and support the research progress and life changing efforts it represents. Privilege to be heard today, and I'm happy to answer questions or submit more detailed written testimony if needed.

[Sen. Saud Anwar]: Thank you so much for your testimony. I have, representative Gilchrist and then representative Kennedy. Representative Gilchrist, you're on.

[Committee Staff (Zoom/Tech)]: Yes. And I'm sorry.

[Rep. Jillian Gilchrest]: I can't be on camera. I just want to say thank you to you, Heather, for being here today and for all the work you do for those who have endometriosis and everything you've, contributed to the working group so far and what you will contribute in the future. So thank you. Thank you, mister chair.

[Sen. Saud Anwar]: Thank you, representative Kennedy.

[Rep. Kathy Kennedy]: Thank you, mister chairman. And, I too want to thank you, Heather, for bringing this to the forefront. So many times we talk about endometriosis, and we just it was just pushed back and, you know, women continually were always told, you know, oh, it's fine. Take an aspirin. Use a hot, you know, washcloth or whatever. Make yourself. You'll be fine. And so I really appreciate you, and it's significant that we're taking this bill up today when yesterday, we kicked off endometriosis month with a little public hearing, and it was wonderful. I do believe you were there. I just wanna again say thank you so much for keeping this in the forefront. Thank you, mister chairman. Thank you.

[Sen. Saud Anwar]: Thank you. This was all strategically planned by the public health committee. Seeing no other questions or comments, thank you so much, for your testimony. That brings us to doctor Atik Mirza. Doctor Mirza, you're on. Thank you for your patience with us.

[Dr. Atique (Atik) Mirza]: Hello, and no one's thank you for all of you for who are having a such a long day. I heard it started 11:00, and it still has to go long, you know, many hours from here. So, anyway, good afternoon, mister chairman, senator Anwar, representative McCarthy Wayhey, senator Summers, representative Clarida Sutra, and distinguished members of the public health committees. My name is doctor Atik Mirza. I'm a practicing cardiologist and the president of Hartford County Medical Association. Thank you for the opportunity to testify in support of senate bills three sixty four and three sixty five today. First, with respect to senate bill three sixty four, as we know that extreme heat and cold are not only the weather events in our human lives, they are predictable public health emergencies if temperatures go to extreme levels. As physician serving communities across Hartford County, we and our colleagues see the consequences firsthand. Extreme heat contributes to dehydration, heat stroke, worsening existing heart and lung conditions, and kidney injury. Certain medications, including diuretics, beta blockers, also can increase significant vulnerability to those patients who are on these medications. Extreme cold increases the risk of hypothermia, heart attack, stroke, respiratory failure, worsening of the heart failure, falls, and carbon monoxide poisoning. There has been a very robust circulation pub paper published in 2023, which can be submitted as an evidence in case it's needed. Emergency departments across Connecticut routinely see spikes in temperature related illnesses during severe weather events, many of which are preventable. State bill three sixty four recognizes that extreme weather requires coordinated planning, establishing clear statewide protocols to improve communication, early warning systems, outreach to vulnerable residents, and access to warming and cooling centers. As standardized frameworks promotes equity and preparedness across municipalities, evidence based scientific measures will save lives while reducing strain on our health care system. Now turning to south state bill three sixty five, as we know, opioid use disorder remains one of the most urgent public health crisis in Connecticut. As a matter of fact, my last patient I saw today when I was leaving my office, he has three children and he's lost one child to opioid abuse. And he had to adopt his three children, and now he's taking he said I took care of two families. So we have seen some decline in our fatal overdose. Hundreds of residents continue to die each year with fanta fentanyl overdose in a vast majority of cases. Nonfatal overdose remains high and represent critical missed opportunities for many interventions. State bill three sixty five's bridge program model focuses on emergency department as a point of engagement. Initiating medications for opioid use disorders such as buprenorphine at the time of emergency care has been shown to reduce mortality and significantly improve connection to long term treatment. Providing naloxone at discharge keeps patients and families with life saving tools. We believe discussions on implementation should continue in coordination with our emergency physician colleagues and other stakeholders to address clinical workflow.

[Committee Clerk/Timer]: Excuse me, doctor Mirza, but your time has expired.

[Dr. Atique (Atik) Mirza]: Alright. So I might on behalf of heart Hartford County Medical Association, I respect respectfully urge you to support these two bills because extreme temperatures can cause fatalities, and opioid abuse and overdose also disrupt families and are very disastrous. Thank you for your consideration.

[Sen. Saud Anwar]: Thank you so much, doctor Mirza, for your testimony, and thank you for the work you're doing. And thank you, Hartford County Medical Association. We are all little tired, so it's not lack of interest, but we just wanna get to the next person online.

[Dr. Atique (Atik) Mirza]: We are available for any answering any questions in case you have. Thank you so much.

[Sen. Saud Anwar]: Thank you. Thank you. With that, the next person on our list is, Jennifer Paradis. Jennifer, welcome. Good to see you.

[Jennifer Paradis]: Hi. Hello. Hi, everybody. I I know it has been an incredibly long day for you all. Thank you so much for your your your service and your work. Cochair senator Anwar, representative McCarthy Vehi, and distinguished members of the public health committee. My name is Jennifer Paradis, and I serve, as the executive director of the Bethel Center in Milford, Connecticut, and I am a resident of Hamden. Thank you for the opportunity to testify in strong support of s b three six four, an act concerning extreme weather protocols. It's critical in moments like this that I also share that I'm a person with lived experience. Those who will be the most impacted by these critical policy changes are people like my parents, Bob and Judy, who spent years and many hot summers and cold winters sleeping in their van in the back of a bowling alley where my dad worked. I ask that when we are voting on policies such as s p three six four that we think about our loved ones and we think about if they were in the position where their lives, their health depended on the extreme weather policy working to be clear, to be consistent, and to be predictable. We are all very far away from that reality today. Our current policies do not match the current problem, and the amount of deaths we've experienced this past year alone is evidence of the extreme weather policy that waits too long. In Connecticut, you know, homelessness has increased 44% since 2021, with unsheltered homelessness rising by 45% in the past year alone. These numbers are even more significant in the Greater New Haven community where we work, where homelessness has increased by over 80%. Extreme weather policies are now an essential part of how we need to respond. Our cold weather program at the extension to our emergency shelter infrastructure. And as and at a time typically, we have capacity for 20 individuals. However, we have seen consistently since the day we opened 40 to 65 folks consistently throughout the season every night. And large weather events bring us over a 100 folks coming to our doors for help. We have struggled to serve so many, but we have also refused to turn anyone away, resulting in the needs of additional overflow sites and a volunteer core of over 80 volunteers helping our staff manage night to night. This is a blessing, but not how we should be operating our emergency response as a state. Life saving care for our most vulnerable, sick, and elderly, and families. Scotch tape and bubblegum does not touch the surface of describing how we are responding to the need today. And yet, we stand these resources up night after night on a moment's notice with a tremendous amount of of statewide miss and lack of information, communication, disjointed coordination, putting overwhelming strains on our already extremely limited resources. Further, our current lack of policy traumatizes staff and guests alike, not knowing how or when or if emergency weather protocols will be enacted. At this point, I think that you all have heard that this the goal of this policy is to create stability, is to create clear, consistent, and predictable policy. It's better for us all and is better for the it is better for the staff, it is better for the guests, and it's better for our communities at large. I wanna close really by just thanking you all for introducing this policy, but also just sharing. I understand that that OPM came out with a a report saying that the expense associated with this policy is about 17,500,000.0 or something something around there. And I've heard before, I heard earlier today, that we really need to be thinking about, this this moment, and our and, through our through our values, and and not just what, our budgets look like. However, emergency response is

[Committee Clerk/Timer]: is Excuse me, miss Peggy, but you have reached your three minutes.

[Jennifer Paradis]: Thank you. I'll close just I'll I'll close very, very quickly, if I may. Emergency response is two prongs. One is the the response through 169 municipalities, and and and two is through the homeless response system. And I do think that if we got creative and we started looking at how, we implement emergency cold weather protocols, particularly through the municipalities, we could, possibly find some cost savings, but I think, better coordination. And and so I would encourage us to to not just look at the whole as it exists today, but also take this time to reflect and make sure that that the policy is is updated to reflect today's needs for the person, but also from an infrastructure perspective that it's reflective of how our communities need to work together regionally. Thank you so much.

[Sen. Saud Anwar]: Thank you, Jen, for your testimony, and thank you for the work you do to raise awareness, but also help the people who are unhoused in our state. I think we do not see any questions, but oh, there is a question. Yes. The representative Kennedy. Sorry.

[Rep. Kathy Kennedy]: Thank you, mister chairman. I know it's been a very long day, and I still have to education committee, but I would be remiss if I didn't acknowledge Jen Perdis. Jen, your work is just incredible. The work that you and your staff do, I've been there so many times. And how many times you've had to stay open, you know, with the cold weather protocols in place and and serving all the people that there. You just do an amazing job, and I just wanted to note that. Thank you, mister chairman.

[Sen. Saud Anwar]: Thank you, representative Kennedy. Jen, you have a lot of fans over here. Keep up the floor.

[Jennifer Paradis]: So much. We do we do that alongside you, representative Kennedy. You are your family. Thank you so much.

[Sen. Saud Anwar]: Thank you. With that, we have the next person who's in person over here, doctor Wong Jason Wong. Thank you for being with us, and then final speaker will be Tricia Cunningham. So, Tricia, hang hang in there for us for a little bit. Thank you so much for being with us all day, and I apologize for the technical difficulty you had. But I'm so thankful that you have helped us out with a number of thoughts on the policy, and then you're gonna speak as well. Thank you.

[Dr. Sujia Jason Wang]: It wasn't a technical it wasn't a technical difficulty. I just submitted too late. But dear honorable members of the public health committee, my name is Sujia Jason Wang. I'm a board certified addiction medicine physician at Hartford Hospital, where I direct our outpatient addiction bridge clinic and serve on the addiction medicine consult service. I'm the president of the Connecticut Society of Addiction Medicine representing physicians, PAs, NPs, and other professionals across our state who specialize in addiction treatment. I'm here representing the views and recommendations of the Connecticut Society of Addiction Medicine. Thank you for the opportunity to testify on s b three sixty five. There remains a profound gap between what we know works for opioid use disorder and what people actually receive in many hospitals and emergency departments. Medications for opioid use disorder, buprenorphine and methadone, reduce mortality by more than fifty percent. They are among the most life saving treatments in modern medicine, yet they remain dramatically underused in emergency settings. In one large national study of more than seventy four thousand ED visits for opioid overdose, Less than one percent of patients were discharged with buprenorphine, and only twenty three percent received a naloxone prescription. Here in Connecticut, our overdose rate is among the highest in the Northeast. For people with unstable opioid use disorder, every visit to a Connecticut emergency department is a critical intervention point, a moment when people are at high risk of death but are also highly reachable. If we fail to start evidence based treatment at that moment, we are missing one of our best opportunities to save lives. We can and must do better. SB three sixty five moves us in the right direction. We strongly support its intent to improve ED care for people with opioid use disorder. However, we recommend several targeted amendments to ensure it reflects best clinical practice. First, methadone should be explicitly included alongside buprenorphine as an appropriate treatment option. Second, if buprenorphine is initiated in the ED, the bill should require a bridging prescription so that the person isn't left without medication prior to reaching follow-up care. Third, if methadone is initiated, patients should receive a direct referral to an opioid treatment program and a documented last dose letter to ensure continuity. Fourth, the definition of acceptable buprenorphine referral destinations should be broadened from narrowly defined treatment programs to include qualified community providers such as bridge clinics such as mine, buprenorphine capable PCPs and psychiatrists. Alternatively, the language of the bill could be revised to use the more broadly accepted and understood ASAM levels of care. Fifth, the bill should ask that hospitals train and support EDs to provide evidence based opioid use disorder care, including providing subspecialty consultant report if support if necessary. Finally, the bill should preserve clinical judgment, making clear that no medication is required when contraindicated and that clinicians retain full professional judgment. I am not only speaking on behalf of the Connecticut Society of Addiction Medicine. I'm speaking on behalf of people who who we've lost after being discharged from hospitals without effective treatment. And And I'm speaking on behalf of the many we can still save if we align hospital practice with established evidence. S p three sixty five represents a meaningful opportunity to reduce overdose deaths in Connecticut. With these amendments, we can encourage hospitals to deliver high quality, high reliability, evidence based care for people with opioid use disorder. Thank you for your leadership and for considering our recommendations. I'd be happy to answer any questions.

[Sen. Saud Anwar]: Thank you so much for your testimony. Thank you for the work you do, and thank you for working with Diane Santos with with Mark and then having her be the keynote speaker in Hartford on this topic.

[Sen. Jeff Gordon, MD]: Yes. So

[Dr. Sujia Jason Wang]: I'd like to extend an open invitation to you all. We we are gonna have our annual Connecticut Society of Addiction Medicine meeting on May 19 at the Bone and Joint Institute at Hartford Hospital. And the keynote theme is going to be closing the gap on hospital based opioid use disorder treatment. Diane Santos will be our keynote speaker, and then we're gonna have six, leaders from Connecticut hospitals discuss how they are working to improve opioid use disorder treatment at their institutions, both successes and the barriers that they faced. So it'll be a very powerful night, and there will be research and free dinner.

[Sen. Saud Anwar]: Would you be able to email that to us, and we can share with the entire committee?

[Dr. Sujia Jason Wang]: And I've got paper invitations as well. You come prepared. It's gonna be really a blockbuster night.

[Sen. Saud Anwar]: Yeah.

[Dr. Sujia Jason Wang]: I think it'll be powerful, and I think it'll help anybody who attends just understand how hard we're working on this and how much more we have to do it.

[Sen. Saud Anwar]: I I I I so much appreciate the the your testimony and and your help. You send me an email, reached out. We had had quite a few conversations, and I'm glad senator Slapp connected us as we worked on this. You one of your recommendation is to have a training program for the ED doctors and staff in the emergency room. We may get a little pushback on that because, at times, if we have programs like this, there's money involved with it, and and that may be part of the challenge. But we'll approach that and see if if there is a way to, educate individuals without having a cost associated with some of that aspect. So that's very helpful.

[Dr. Sujia Jason Wang]: Yeah. I think the the cost does not need to be extraordinary at all. It's not it's it's not incredibly difficult to start buprenorphine. I think there's a it's it's really a matter of of institutional will. Hospitals prioritizing this. It's it's it's you know, as as doctor D'Onofrio mentioned, it's not terribly difficult to start it. There are some tricks of the trade net these days with fentanyl and the pharmacokinetics of that, But really, it's an institutional will. The evidence has existed for many, many, many years. And Connecticut is a little bit behind the eight ball. When I initially got out of practice in New Hampshire, this was ten years ago, and we were experiencing a horrible opioid crisis, we were number two overdose deaths in the nation. And we initiated a buprenorphine induction protocol at our medium sized community hospital, it was not an extraordinary amount of training. And we cut our against medical advice discharge rates in half, We more than doubled our buprenorphine linkage rates to outpatient treatment. We more than doubled our rates of buprenorphine treatment at all. We reduced our readmissions by over a half. So think of the savings as well to the state in addition to the reduction of the amount of suffering that we have in the state. So So it was a real, it was a real benefit. And that was almost 10 ago. So we can do it. It's I don't think it's, I think it really is just moving all these levers in terms of education, support, legislative levers, potentially regulatory levers, as as others in my field have written about. There's many levers that we can do and and activism as well, activism.

[Sen. Saud Anwar]: My colleague, my cochair has a question for you. Yes.

[Rep. Cristin McCarthy Vahey]: Thank you, Sunny. And thank you, doctor Wang, for staying with us today. It was worth it because you have offered some excellent testimony and very substantive recommendations for us as well as proof that this is working in the settings you've experienced. Just a very simple question. I don't have my computer up right now. Is your testimony online or have you submitted written testimony?

[Dr. Sujia Jason Wang]: Yes. And it's a little bit more lengthy, what we submitted online. So, yes, it's up there. Wonderful.

[Rep. Cristin McCarthy Vahey]: And thank you for sharing the information with us about that event. I think it will be really helpful. We're grateful to have you as a resource. Thank you.

[Dr. Sujia Jason Wang]: You're welcome. Thank you for your time.

[Sen. Saud Anwar]: I'm gonna put something on your radar. Majority of the people who are unsheltered now outside are using substances. We cannot get them to get a place, so we'll have a conversation. Maybe there's a project that we can work on to see how we can help them because they cannot get hooked up to a rehab facility, and and there's sort of chicken and egg situation that they get stuck in.

[Dr. Sujia Jason Wang]: It's it's all related. Housing, substance use disorder, and mental health.

[Daniel Fitzmaurice]: Other other issues as well.

[Sen. Saud Anwar]: Thank you so much for your testimony. Thank you. With that, Tricia Cunningham, you're on. Welcome.

[Tricia Cunningham]: Hi. First of all, I want to say thank you and apologies. I didn't get the Zoom link, so here I am. So thanks. I'm sorry to be joining you at the tail end. Good evening, co chairs, senator Anwar and representative McCarthy Veggie and distinguished members of the public health committee. I have paid attention throughout the day on and off, and it's noteworthy how thoughtful this this committee is and loving all the questions and how engaged you all are. My name is Tricia Cunningham, and I serve as executive director of Always Home. Our mission is preventing family homelessness throughout Eastern Connecticut, and I reside in North Stonington. I'm also a fellow, fan club member of Jennifer Paradis. We always home, but we're a member of the Eastern Connecticut coordinated access network, and we serve as a hub for the homelessness response system, and we are in support of SB three six four. And the following testimony I have is is really from the point of view of our can in our region, Eastern Connecticut, and it was written with the help of Jamie Parker, our can manager. This winter, Connecticut activated a severe cold weather protocol for forty six days requiring extended shelter hours, overflow coordination, transportation planning, late night intakes, and street outreach in below freezing conditions. Each activation relied on dedicated staff working around the clock to ensure no one was left outside in dangerous temperatures. For staff, activation meant canceled days off, double shifts, and constant schedule changes. Warming center staff, outreach teams, and hub staff routinely stayed far beyond scheduled hours, often through weekends and without additional pay, putting personal responsibilities aside to keep people safe. For clients, last minute activation notices created confusion and stress. Many were unsure where they would go, how they would get there, or whether space would be available. These uncertainties understandably created, frustration and and erodes trust in in the system, making it harder for our outreach workers to build the relationship needed for housing focused work. When activation stretches across consecutive weeks, strain intensifies across the system. Staff worked tirelessly to secure warm spaces, food, transportation, and basic necessities, tasks complicated by clients' diverse and often complex needs. I've used as you've heard today, medication pickups, medical and housing appointments, trust transportation logistics, and frequent mental health crises fell heavily on a workforce already operating at capacity. SB three sixty four presents an important important opportunity to bring greater structure, predictability, and support to extreme weather response. Clearer protocols and earlier planning will help reduce strain on frontline staff while ensuring that individuals experiencing homelessness receive timely information and consistent access to safety. Our staff are deeply committed to their work and to the people they serve, but they should not have to depend on last minute decisions and extraordinary personal sacrifice to keep people safe. For these reasons, I and many others in our in our region respectfully urge the committee to support SB three sixty four and strengthen Connecticut's ability to respond to extreme weather in a way that protects both the vulnerable residents and the workforce designated to serving them. Thank you for your time and for, and for your team and making sure I have the opportunity to to testify tonight.

[Sen. Saud Anwar]: Thank you. Thank you. You're, like, on the dot. You're, like, probably have a stopwatch working that you used it perfectly and got all the message through. Yes. So with that, I don't see any questions or comments. It's, but your testimony is very valuable to us, and and that is gonna help us make the best decisions. Thank you, and stay well. And you're our last speaker. With that, we will end our public hearing. We stand adjourned. Thank you.