Assembly Standing Committee on Business and Professions

Good morning, everybody. Welcome to the BNP hearing for January 9. We have one Bill on the agenda, and anybody want to present it? Show hands. No takers? If Mr. Low is in the building, it looks like he's in the building, so I'm confident he will be on his way soon. When he gets here, we'll get started, I guess in the meantime, I could start with some opening remarks. Welcome to this morning's BNP Committee hearing, which is our first regularly scheduled hearing for the year.

We will be considering just one Bill today that is subject to the two year Bill deadline. I would like to welcome the new Members of the Committee and thank them in advance for their prompt and reliable attendance. At least some of them this morning and throughout the coming year. In particular, I want to welcome the new Members, Assembly Members Carrillo, Low, Pellerin, Sanchez, Soria and Zbur to the Committee. And welcome to all the returning Members as well.

For today's hearing, we will be allowing primary witnesses here in the room today to speak for up to two minutes each, with up to two primary witnesses per side. Any additional witnesses will be limited to name position on the Bill and the organization they represent, if any. For those wishing to provide further comments, we are accepting written testimony through the position letter portal on the Committee's website, and with that, we will take a brief recess. zero, excuse me, we have a quorum. With that, we'll begin today's hearing with the presentation of Assembly Bill 1570 by Assembly Member Low. Assembly Member Low. Ready when you are.

Mr. Chair and Committee Members, thank you very much for allowing me to present this sole Bill Today. As I understand it, on Assembly Bill 1570, which I know is very exciting for so many who see the vision and clarity on this proposed legislation. This is not a new concept. Access to eye care, especially in rural California, has been a critical problem, made worse by the fact that it takes a long period of time to find a practitioner who takes medical.

When optometrists provide 81% of eye care provided by medical, that is important in terms of the access to care. In 2022, a similar version of this Bill passed this legislative body, but was vetoed by the Governor. Since the veto, my staff has met with the governor's staff as long as the respective boards and opposition to address their concerns.

The Bill presented today is the conclusion of that of addressing the hours of conversations and the concerns as we have went through as we had a chance to take a look in the review of the public testimony in opposition based on the concerns from previous hearings, we took the following amendments in which was addressed in the previous Committee hearings. Number one, prohibit certified optometrists from performing advanced procedures on patients under the years of 18 years of age.

Number two, require the training procedures on simulated eyes be equivalent of entire procedure. This is the exact language, the exact language as requested by the opposition. Number three, replace the minimum of one corneal cross linking training procedure with a minimum of 10 cross linking training procedures. This is the exact number that opposition requested and proposed. Number four requires at least 40% of the required training procedures on live human patients. This amendment, along with others, makes this Bill very similar to that of other residency programs.

No other profession has a requirement like this with respect to the renewal license and certification. 18 other states allow optometrists to use lasers. 18 other states already allow for these types of procedures to address the issue of lumps and bumps to be removed. Six other states currently allow for optometrists to do this procedure as well. This Bill requires the 32 hours courses coursework to also be taken, which will also require an independent national exam to occur. There's conversation about that.

We don't want subpar training as presented in the Bill. No Member of the Legislature would want to be associated with any type of legislation that would potentially harm individuals. And as I understand with the Committee analysis and support from the chair as well, I also don't believe that the chair would also lend his name and the hard work of Committee staff and policy work in addressing this issue without making sure they are the safeguards and protecting patient care.

So you'll hear a lot of conversations from opposition about lack of training. But specifically, we point blank looked at opposition testimony and in conversations and addressed that in this Bill. But the goalpost keeps moving time and time again. This is about helping to ensure that we increase access, maintaining the type of education and requirements to making sure that we have the adequate training. In that regard, I respectfully ask for. I vote and have other witnesses here to also testify in support. I respectfully ask for an aye vote.

Thank you, Assembly Member witnesses, please proceed.

Morning, Mr. Chairman. Members of the Committee, Terry Mchale with. Aaron Reed and associates representing the California Optometric Association. First of all, is there a need for the Bill? Certainly there's a need. The Governor is adding 750,000 new people to Medi-cal this year. Optometry takes 81% of the Medical in the State of California. Is there a need? There are 8000 optometrists who are throughout.

The State of California dealing with frontline health care for Californians. There are 2000 ophthalmologists, many of them specialists, half of them over the age of 50. There's an absolute need for the Bill. Are optometrists capable of doing everything that is in this Bill? This is not the first time this Bill has been heard.

Earlier Committee hearings the California Academy of Ophthalmology put in writing that absolutely everything that is in this Bill, optometrists in California are capable of doing. The question becomes the educational component. As a comparison, we are no longer in the vanguard in California on any of these. 18 other states allow the lumps and bumps.

10 other states allow these specific lasers. And they allow these to be done. With two weekend courses, 16 hours on the lumps and bumps, 16 hours on the lasers. In terms of the corneal cross linking in the Bill, this is done in the office.

Last week in the first Committee hearing, we had just one live patient. Because it's such a procedure that can be done in the office, they asked for 10. We gave them 10. In terms of the training. Also, just to back up, this particular Legislature has, over the last 20 years, expanded the scope of practice for optometry in several ways.

And in every time of the expansion of that scope, it has been opposed by the Academy of Ophthalmology and has. Been opposed by the California Medical Association, which is one of the reasons, 120 years ago, California made sure it was specifically understood that these are two very distinct professions.

And what we are talking about, ladies and gentlemen, are very qualified doctors. These optometrists are the best in their class in college. They struggle to get into optometry school. They have four years of optometric education following.

And I'm going to ask you to wrap up.

Yes, sir.

So everything in this Bill, we're willing to talk about the educational components. As the author said, we went through all of the Committee hearings, looked at what they asked for in education. We gave it to them. We ask for an aye vote.

Thank you.

Mr. Chairman, Members of the Committee, I'm an optometrist and my name is Dr. Jeffrey Garcia. Today I'm here representing myself and not any organization or board. My comments today are on behalf of the 2 million medical patients in my region. These patients have been going underserved for the length of my service in optometry, 30 years and has not improved. You see, this is an access to care Bill, and I feel deeply concerned about this, and that's why I'm here today.

I own three practices in the Central Valley, in Lemorre, Corcoran, and Visilia. These are farm communities, much like communities that you may come from areas where option for healthcare is minimal, option for ophthalmology care is even more minimal. So quick access to ophthalmology care in my region, especially, is terrible.

In the counties of Kern, Tularian, Kings and Fresno, my region, there are two, and I repeat, there are two ophthalmology practices that accept Medi-Cal that's a crisis, and that has been the same crisis for the past 30 years. It has not changed, it has not improved, and there's no indication that it's going to get any better with more Medi-Cal patients coming on board. And frankly, if you're ophthalmologist practicing in the Central Valley. So for my patients, it's an hour drive from Lemorre Corcoran to Fresno.

It's an hour and a half drive to Bakersfield. This is not right. And many of our patients go without care because of the length of time it takes to get the care. It takes several months in many cases, and a lot of our patients, frankly, just forego the treatment because it's just no longer an option for them to get the care. We are their only care. Optometrists in the Central Valley and in California are in practically every community. You don't see that with ophthalmologists.

Ophthalmologists are centered in larger cities like Fresno and Bakersfield, and yet they still don't take Medi Cal. I, like the majority of my optometry colleagues, choose to accept Medi Cal, even though the reimbursements are not good, and it's challenging to practice that way. We do it because we believe it's our duty and obligation to care for all in our community. These are our friends, our neighbors, and they're not just patients. These are people that we know. We live next door to them, we shop with them, they live amongst us, and we just want to take better care of them.

And if you could wrap up, that'd be great. Thanks.

And I treat profound, sight threatening conditions in my practice every day. I treat glaucoma injuries, foreign bodies. We treat those every week, every day. So practicing to these additional scopes are not going to be challenging for us because we already do them. And frankly, these are routine types of procedures. They are not emergency procedures, and we are very well skilled and prepared to handle them.

Thank you very much. Thank you. We'll turn it over to witnesses in opposition. Similar, with witnesses in support. Two witnesses, two ish minutes each. We're dragging. We'll be fair. Thank you

Good morning, Mr. Chair and Members. My name is George Soares with the California Medical Association. CMA is respectfully in opposition to this legislation. We want to thank the author and sponsor for the ongoing conversations, but at this time we remain opposed to AB 1570. This Bill allows optometrists to perform certain surgeries and laser procedures in and around the eye after the optometrist has performed a given number of procedures.

Obviously, the eye is one of the body's most important and most fragile organs and requires the highest degree of training for a practitioner who is using scalpels and lasers to treat conditions. We do not believe this Bill contains sufficient training requirements that meet the level of safety needed.

At the heart of our opposition is the understanding that gaining proficiency in surgery and laser procedures on the eye require a multiyear hands on residency training program that allows the resident experience in both specific procedures, but also general proficiency and surgery. We believe that optometrists should go through the same rigors of residency as a physician before performing this type of surgery.

This Bill contains the same framework of AB 2236 which was vetoed by the Governor in 2022, and we were expecting a new proposal from the sponsors. Rather than tweaking AB 2236. And despite other arguments, there is no guarantee that this Bill would improve access. For those reasons, we are respectfully asking for a no vote. Thank you, and I'm happy to answer any questions at the appropriate time.

Thank you.

Next witness, Mr. Chairman, Members Joe Lang, representing the California Academy of Eye Physicians and Surgeons. With me is Dr. Mark Mannis, Department chair at UC Davis, training residents in eye surgery. I'd like to just address a couple of key points that were mentioned by the supporters of the Bill, and then I'll let Dr. Manus talk about what really is a key issue here, which is what we're talking about, is surgical complications.

So we have, as the sponsors indicated, been involved in discussions with the optometrists over their scope of practice for 20 years. In the last five years, we have actually cooperated and coordinating with them in the expansions of optometric scope that were mentioned earlier. We didn't oppose them. We actually worked with them in a collaborative manner, and those bills were signed by the Governor.

What you have in front of you now, though, is sort of what we would say is the most important of bills dealing with scope of practice, and that is eye surgery, whether it's a laser surgery or a scalpel surgery. We have, over the last several years, had very detailed discussions. We were having those discussions, as it's referred to, the numbers of training provisions in the Bill. We were having those discussions in a good faith attempt to reach a comprehensive training program.

Unfortunately, we didn't reach that agreement. What they've chosen to do, however, is take some of the numbers that were discussed in those discussions, in those good faith discussions, and say that it's what we asked for. What we've always asked for is a comprehensive training program. What this Bill doesn't do is address probably the most key element when you're talking about performing surgeries, and that is learning and experiencing what to do when complications arise. Surgical complications do happen. They do occur.

And if you don't have experience and have training in those complications in real time, you won't know what to do when those complications occur. This Bill still does not address that issue. It's flawed in that regard because it doesn't provide enough training procedures to assure that you will actually experience a complication in your training.

And just as a time check, y'all have two minutes? Yes.

Now, Dr. Mannis, I think we'll hear is just to talk about a couple of complications because it truly is what we're talking about here.

Great. You've got two minutes, Doctor. Thank you.

Good morning. As Joe mentioned, I'm the chair of the Department of Ophthalmology at UC Davis. I've been training residents in surgery for 43 years here in Sacramento. I believe that this Bill reflects considerable misunderstanding of how surgical expertise is gained, which is acquired as a conglomerate of understanding the general field of ophthalmic surgery and the management of complications. This Bill portrays these surgeries as minor.

I would posit that there is no minor surgical procedure, and certainly the lid procedures and the laser procedures looked at in this Bill can have significant complications, including glaucoma, retinal detachment, a variety of infections. I do cross linking every week in my practice, and I have seen terrible complications, including corneal infections and perforations and loss of the eye. So the notion that these are minor procedures is fallacious.

Quite frankly, optometric training, even with basic instruction in the mechanics of a procedure, really does not provide the practitioner with the broad ability to obtain surgical judgment as to when to do a procedure and how to manage the complications of those procedures. No one in this room, no one at your desk or at this desk, including our optometry colleagues and our optometric lobbyists, would submit to a procedure done by someone with inadequate surgical training.

And I would posit that the Bill, as it's written, simply does not provide the expertise that is required for any surgical procedure, be it deemed major or a minor.

That is a great note to end on. Thank you, Doctor. Now let's open it up to any additional witnesses. Why don't we start with additional witnesses in support of the Bill. Please provide your name, organization you're with, if any, and position on the Bill.

I'm Dr. David Redmond, practice in Mountain View. Support the Bill. Thank you.

Ronald, can you hear me? Thank you. Ronald Seeger, private practice optometrist, also in Mountain View. Thank you. Support.

Thank you.

John Roston, I'm in practice in Dixon. And I'm in support of the Bill.

Thank you.

Good morning, Mr. Chair Members. Sara Noceto, on behalf of VSP vision. Here in support, thank you.

Hi, I'm Nicole Moes, private practice optometrist. In support of the Bill.

Thank you.

My name is Zara Jamshed. Hello. My name is Zara Jamshed, and I'm a pre optometry student and I'm in support of the Bill.

Thank you.

Hi, I'm Spencer Fairgrave. I'm a private practice optometrist, and I'm in support of the Bill.

Thank you.

Hi, I'm Tom Fleischman, retired optometrist. I'm here in support of the Bill.

Thank you very much. Any additional witnesses in opposition to the Bill, please come on up. Provide your name, organization you're with, if any, in position on the Bill.

Kim Stone, Atone Advocacy on behalf of the California Orthopedic Association in respectful opposition. Thank you.

Thank you.

Thank you, Mr. Chair. And Members, Don Shinsky, on behalf of the California Society of Dermatology and Dermatologic Surgery, also the California Society of Plastic Surgeons in opposition.

Thank you.

Hello. David Bolog, on behalf of San Fernando Valley alliance, take a stand. Santa's law fax, law, truce, justice, law firm per group and freedom angels, all in opposition of section 5D, only of this Bill. We have no position on any other. Parts of this Bill. Thank you.

Thank you. Any additional witnesses in support or opposition to the Bill? Seeing none. Going to bring it back to colleagues for questions or comments. Dr. Jackson?

Thank you very much, Mr. Chair. I think just a few questions, because I want to just make sure that we're getting things right, because obviously there's been a lot of numbers and a lot of data, old and new, floating around. And so I think the important part is what will do the most good and what will do the least harm while trying to do the most good. And so what I'm hearing is that other states are already doing this. Is that correct?

Now, if other states are doing so, has there been any red flags in terms of the other states that have done so, and if there are red flags, what are they?

Okay. Thank you. Some of them in Jackson, I guess I'd answer the question in two ways. One, there are some states that allow for some combination of the procedures that are involved. They tend to be small states, smaller populations. And the reality is there is no data collection. There is no data requirement in those states. As a result, we have no data to work from.

But none of the states provide for the comprehensive number of surgeries, both lasers and scalpels and corneal cross linking, that are involved in this Bill, other than the State of Oklahoma. So, unfortunately, there just isn't any data and not any real way to collect that data, because in most case, the states operate in a complaint driven system, not in a result driven system, so there just isn't any data.

Dr. Jackson, Terry Mchale. Two things in response. One, it is absolutely true that the 18 other states and the 10 other. States laser, do not require the comprehensive. Education that we're requiring in this Bill. In terms of are there other states where we can have data?

In 2022, Colorado became the 18th state to allow it. And when they ran this Bill, they called the optometric boards of the other states to see if there had been. Any concerns or complaints, and the answer was no.

I also want to say that what this Bill does is that we're very careful that there will be data collection. Inherent in this Bill is that we must report to our California Board of Optometry what we are doing and if any problems arise so it can be revisited. But there is data. There have not been complaints. Those other states have seen in excess of 100,000 other patients without a problem.

Thank you. Now, when we talk about. I might have a few more, Mr. Chair, I'm just letting you know now, we talked about the 10 procedures to be able to get certification. Is this in line or less than what other states are requiring?

The 10 procedures came. I want to first of all say. That at no time has optometry ever suggested that any of these procedures that are on this Bill should be taken lightly, or that any patient should expect that the care they're going to receive from an optometry will be anything less for these particular procedures than they would receive from an ophthalmologist. In terms of the corneal cross linking.

When we had this in testimony in the last Committee last year that went the Bill that went to the Governor. We said one procedure because it's the dropping of.... And they came back and asked for 10.

Hold on. So we're not concerned about the back and forth. What I'm asking is there is certain amount of practice of procedures that other states also require. Is that correct? There are. And what is their highest number of procedures that they're required?

I'm sorry. That's a great question. Only Mississippi requires live patients in order to be certified. The other states allow you to work. On simulis and on pig eyes and those kinds of things and rely on the fact that the education you receive as an optometrist is enough that you don't need the live patients. California, this particular Bill requires live patients. And that's in excess of other states.

Okay. And when we talk about the certification process, who certifies that they have been certified?

Yeah, great question. So if we can back up just for a second.

I don't know if we have enough time to back up real quick. Don't back up too far. Yeah. Be careful now.

As Springsteen says, one step forward, two steps back. I'll come right back. The suggestion from the opposition is that this Bill is identical or barely tweaked with what went to the Governor and. Is now being suggested today. There is a significant and profound difference in this Bill, Dr. Jackson, that separates it from what we had previously.

40% of all of the live patients must be done in a cohort system. Now, cohort was their word, but ostensibly. What cohort is is almost a residency. For optometrists to be able to do these procedures. The cohort system requires that five optometrists work together, and each of them are required to do a live patient all the way through from the day of examination to the day of conclusion. But all of those individuals within the cohort must participate in the treatment and.

The understanding of all of those patients. So let's jump back so that multiplier takes it far beyond. It is overseen by a special educator qualified in these procedures. So the schools must agree to it. The special educator, who's likely an ophthalmologist, must agree to it. If the optometric student is not qualified after all this, the legislation says you. Don't pass them, and then they must pass a national examination.

And so after they pass the national examination, they're certified. Right. And so are we saying, and this is for both pro and con here, is that if they pass the national examination, are we saying that we can safely be assured that they have been properly trained to do the procedure if they pass the national examination?

Dr. Jackson, I think the answer to that is the way the Bill is established, the national exam occurs before the human patient training. You have to complete that national exam, which does not include hands on performance of surgeries in order to be certified. The training with the human patients occurs after you've passed the exam.

Unfortunately, as we've said, there's just not sufficient training here to make sure that in that training that they're getting, that in fact, they experience a complication and know what to do about it in real time if they do.

And what would you consider sufficient?

What we had suggested, Dr. Jackson, is after the Governor's veto, when the identical Bill that was vetoed was introduced last year, we suggested and expected that people would take a step back and say, how do we create a different framework? Rather than talking about specific numbers of procedures that make training sufficient, instead, look at how surgeons are educated and create a framework based on that that is not driven by numbers but driven by competency.

No, I totally agree. But what would you suggest would be proper training?

Well, so if you look at the governor's veto message.

I'm not talking about that. From your professional experiencewhat would you consider appropriate training.

Is that this should be not driven by a specific minimum number, but instead an education process that would be similar to what our residents experience to perform these same surgeries. It could be a year, it could be two. Dr. Mannis here is somebody that oversees one of those programs. He determines how many procedures, patients that should be seen and treated prior to signing off on someone's competency.

What would you consider appropriate training?

Well, once again, for me, it's very difficult to put it down to numbers. That's a very simplistic way of looking at this. Gaining expertise in any surgical procedure is contingent upon the broad understanding of ophthalmic surgery and its indications and complications. And that's what this Bill doesn't address. The accreditation system for residencies and ophthalmology require x number of cases as a minimum exposure to a surgical procedure. But that doesn't necessarily imply competence in that procedure.

Right. I understand what you're saying. Some people might gain competency before others do. They might need more or less. Right. I would probably need more, considering my skill level. But overall, I think my last thing is this. I want to make sure that we're negotiating in good faith. Right. I think as legislators, we expect that if you are in support or in opposition, that there's proper communication, games are not being played. We are getting back to each other in a timely fashion.

We're not trying to run out the clock on stuff. Right. All of those things are important as we do our job. This is a two year Bill. We've had a lot of time to talk. And the only reason why a sufficient amount of time to talk hasn't occurred because people have chosen not to do so from one way or another. I don't know. But I know from my own experience we've had a lot of months.

Alot of months doing stuff. And we could have worked this out in some sufficient way. And so for me, if I am not feeling like we are actually trying to create some win win situations here where we're doing the best for our people, that we're addressing service gaps. Right. But we're making sure that people are properly certified, properly trained to do this. Right. So at this time, I'll vote to move it forward, but I'm not guaranteeing I'm going to vote on it on the floor.

And you know I love you, boo, but at the end of the day, I want to see some good talks, some good workouts here. But what I'm seeing right now is really frustrating to me. And I hope that we can actually get to where we need to be so that we can actually do right by the people who we're trying to serve. Thank you, Mr. Chair.

Thank you, Dr. Jackson. Any additional questions, comments? Dr. Baines and then Assembly Member Zbur and then Assembly Mamber McKenna.

I worked Christmas day. I worked New Year's Eve. I worked Christmas Eve. I worked every single day in my community providing health care, because I care. I care about access to health care, and I also care about my patients having the highest level of quality of health care as well. And I still have a couple of questions remaining. I would like to know how 15,000 hours of an ophthalmologic residency is comparable to 10 cases.

I would also like to know why only 40% of life patients will be used for these procedures. At the end of the day, it's about safety. It's about the 10%, the complications that arise. That I saw ravage my community during COVID You see, in the Central Valley, we have one of the severest lack of access to health care comparable to the rest of the country.

And we saw that by how many people died during COVID because of underlying illnesses, because of lack of access to preventative care. That 10% of complications that everyone keeps talking about in my community in the Central Valley is actually closer to 90% to 100%. I watched it ravage my community. Lastly, I'll also end with this. I don't think California should ever take medical advice from states that have a total ban on access to healthcare for women, including abortion bans. Thank you.

Thank you, Dr. Bains, and thank you for your service to your community. Any answers to any of the comments? Perhaps?

Perhaps in my close, Mr. Chair?

Mr. Chair, just responding. Just to clarify, Dr. Bains, there is a very big distinction between trying to parse minimal number of training procedures that go into proper training versus, as you pointed out, the 15,000 hours that ophthalmology residents experience after graduating from medical school. Now, that allows them to do complicated surgeries like cataracts and retina detachments.

However, those same residents in that 15,000 hours program experience these same surgeries and perform hundreds of these same surgeries that are in this Bill that is only requiring 10 in one case, seven in another. And that's really the distinction here. Can you be assured that in seven cases of a laser that you're actually going to experience a complication and know what to do.

We just honestly think a different approach, making training the priority as opposed to the minimal training, is the right way to achieve the goal.

Thank you, Mr. Lang, Assembly Member Zbur.

So thank you both for being here. I am a new Member of the Committee and actually had only a few hours of an opportunity to try to get my arms around this yesterday. And so I want to thank both folks from the optometrists and from CMA for spending some time with me. I didn't have all of my questions answered, and I got to say what I have come away with is being very confused about this Bill. On the one hand, I think we have two goals.

One is that we want to make sure that we're making sure that the public is safe and protected, and that that is absolutely, really the highest goal that we have. On the other hand, we also want to make sure that there's healthcare access for every californian. And there are some benefits of this Bill in doing that. I was not able to sort of have follow up discussions with CMA after meeting with the optometrist yesterday.

The questions that I had for them were whether or not what additional kinds of training they would be looking at. Because when I look at the staff report, it looks like the training that was originally asked for by the Bill author was included in the Bill. And the response I'm getting back is that we need a different framework, and I don't understand what that means.

If that means that there are some kinds of surgeries that are too complicated to be included in the Bill, I'd like to know that. And I would hope that you would work with the Bill author to refine the Bill to exclude things that are more complicated. I don't have a good sense of. I know there are some things in the Bill that I'm not concerned about.

I mean, I've had sort of skin tags removed from my eyelid, and that was done by a dermatologist, not an ophthalmologist. And obviously that wasn't viewed as something that was that risky. And I wouldn't think that that's all that risky and that an optometrist could do that. There are other things that I have a lot of heartburn about, though, because I don't know whether or not some of the procedures are very complicated.

And if you actually had a complication, you really need a Doctor present at that time. And I haven't had the ability to understand whether the Bill includes some of those things or not. So where I am today is that, the other thing I want to say is that I take note of the fact that a number of states have approved these kinds of procedures.

But I'm nervous that the states that have approved these procedures tend to be small states that don't have a high degree of commitment to consumer protection. And that makes me very nervous. It makes me very nervous to not have data about what those states are. I think a phone call from Colorado to some states is not adequate data in my mind to understand that everything is good in those states. So I'd like to have more data.

And then I think the other thing is there's some accountability procedures in the Bill. I talked to the chair last night about them that I think are good, that they're there, but they're really not specific. It just requires some reports to go to the board of optometry. I don't think there's any timing. There's no detail. The report could be 20 years from now, according to the Bill when I read it. So I think that area needs to be tightened up.

I am going to support the Bill today, not because I'm comfortable with it. I'm not. I mean, I really feel like I need to learn a lot more about this whole area and what's included and what's not included. But I do think the author is making a good faith attempt to try to work these things out and would encourage him to do that. And I would hope that both sides would continue working together.

But in order to give this Bill an opportunity for that to happen, I intend to follow the chair's recommendation today and vote the Bill out of the Committee.

Thank you, Assembly Member Zbur. Assembly Member Mckinnor.

Good morning. While the author has well intentioned, I really have an opposition to this Bill. When I think about equity, I feel like we're not going to have equity in healthcare eye care with this Bill. We talked a lot about our Medi-Cal patients. We know that the Medi- Cal patients will go and use this procedure with the Bill, and then our Kardashian folks will go get a real surgeon to perform their procedure. And so I feel like this is an equity issue.

And that's why I posed this Bill, because I know for a fact that this will really harm our poor community, and I don't want to see that happen. And so I'm sorry I'll have to oppose this Bill. Thank you.

Thank you, Assembly Member McKinnor. Assembly Member Pellerin, thank you.

And thank you to the author for your work on this Bill, and I know you're trying to do what's best for the State of California. I just wanted to clarify, how many other states have optometrists performing all of the procedures in this Bill? 11. Okay. All right. My understanding is that ophthalmologists complete four years of medical school and three or four years of residency training.

Furthermore, ophthalmologists that do corneal cross linking requested procedure in this Bill do an additional one to two years of fellowship training in cornea diseases and surgery. Am I correct in that assessment? And we're asking. I'd hate to put people who want to do good and help their patients out doing these procedures with just, what did you say? One weekend, 16 hours of training?

That's another state that is allowed. Can I change my answer? It's six other states allow all of these procedures. I was mistaken. Okay.

Thank you for the correction. Yeah. But I'm just curious the amount of training we're saying. Okay, you optometrists can do this procedure with 16 hours of training?

No. Right now, what the procedure is is it has three components to it. The procedure requires you to remove the front part of the front part to breathe the cornea, and that's something that they're allowed to do under current law. Then you put riboflavin drops on the eye, and then you put it under ultraviolet light. You can use riboflavin drops, and you can use light. These are all parts of these procedures you can do under current law.

You can't do them together under the way that the current law reads. And so that is why we believe the procedure is not a big step away from what optometrists do under current law.

Assemblywoman Peller. And specifically on the 16 hours. That's what's allowed in the other states under Assemblymember Lowe's Bill, it's going to take six months for an optometrist to get certified. They have to do the 32 hours course. They have to do the live patients. And as the opposition has asked for, and we have given them, they wanted a residency style educational program.

We gave them the cohort program that gets away from the numbers and talks more specifically about what happens if there's complications, what happens if there's a need for surgical intervention. I would say this. We believe that the ophthalmologists in the State of California are the best in the world. We have absolute respect for them. We have absolute respect.

When the opposition talks about complicated surgical procedures, what this Bill does is allow them to use the education, the training, and the experience they have to take care of not only those people on Medi Cal, but all individuals. And I would just close by saying this. When it comes to these surgical procedures, the optometrists in the State of California already do the pre op and they do the post op, and they work closely with ophthalmologists throughout the program.

I appreciate, I just. I do have concerns about the different levels of training that we're putting on each profession here. And I myself have been a patient of an ophthalmologist for some eye surgery, and something did go wrong. And I was lucky that this person had the training and skill to deal with an unforeseen circumstance and was able to correct and get the right tool and do the right job correctly. So I appreciate our authors in this attempt to do this Bill, but I'm going to be not voting today. So thank you.

Thank you, Assembly Member Pellerin. Assembly Member Carrillo.

Thank you, Mr. Chair. First, I want to acknowledge that it is human nature to fear change. It is human nature to fear that somebody else wants to. I'm going to use the word intrude into our profession, and I disagree with your assessment of how this Bill would affect our communities, respectfully, because the region that I represent, there is a lack of access.

It is a rural area for about 30 miles of what I represent, and the populated regions are on the edges of the district that I represent. And we have to drive down to La or San Bernardino, Riverside to be able to have access to medical care. I do believe that this will actually improve our communities, my community, because it will provide access to a service that is not provided. In my district, there's only 10 optometrists that accept Medi-Cal zero ophthalmologist. Nobody sees our patients.

So that means that my constituents will have to travel to be able to get that service. And I feel that really, the big elephant in the room is the medical rate. I think that we should be working on increasing that medical rate so that we are able to provide the medical care that we all, California, deserve to have. I had two questions for the opposition and the support Members. Do optometry students have to take the training from now on?

We heard from a student in support of the Bill to me, that would indicate that the optometrist training would now have to include some sort of training that we're talking about here. The other thing is, if optometrists do work for ophthalmologists in assisting them in doing those procedures, if somebody can answer those questions, it'd be great.

I'll go first. Kristine Shultz, representing the California Optometric Association. Yes. These procedures are included in the training that optometrists receive currently in school. And additionally, of course, the Bill includes additional training that requires a 32 hours course, requires testing, National Board testing, and requires 52 procedures on live humans to make sure that they're competent. These procedures are, of course, minimums, not the maximum. So if an optometrist is not competent, the educator can require additional procedures to make sure that optometrist is competent.

And also, the second question that you had was?

If optometrists work on ophthalmologist offices.

Absolutely. There's a lot of optometrists that work in ophthalmology offices. Currently, it's a good percentage of individuals that work in that way.

The author mentioned that the chair would not put his name on something that would not have safeguards and protections. And I would also say the same statement. I wouldn't put my name on something that I would feel that there'd be no safeguards and protections for patients. And again, for me, in the region that I represent, access is a big issue.

And like I said earlier, I think it's the medical rates that we need to be working on to make sure that all Californians are able to have access, because doctors obviously don't want to see patients only for the medical rates, which are just inadequate. That's all I have to say. Thank you, Mr. Chair, for allowing me to make comments.

Thank you, Assembly Member Carrillo. Any additional questions or comments from Members of the. Yes, Assembly Member Lowenthal.

Thank you, Mr. Chair. I want to thank all my colleagues for this really, truly thoughtful discussion. I want to thank the author for bringing this forward and identifying a need in the State of California. And I want to thank Dr. Mannis and the ophthalmologists. I really appreciate the time spent with myself and my colleagues at UC Davis educating us on the process subsequent to that meeting. Actually, I have a daughter who had orbital cellulitis. Really tough case.

And I gained a true appreciation for the work that you and your colleagues do. I want to take this time, Mr. Chair, to underscore the words of my colleague from Moreno Valley and address the elephant in the room, which is the lack of collegiality and the lack of trying to get anything done between these two parties. It's not serving the people of California. It seems like some of these issues can be bridged.

I would like to ask you in front of everybody, would you be willing to continue to sit down and discuss these issues in a productive manner as we move this process along.

Yes, Assemblymember Lowenthal.

Yes.

Okay. Thank you, Mr. Chair.

Thank you, Assemblymember Lowenthal. Any additional questions? Comments from colleagues? Assembly Member, would you like to close?

Thank you very much, colleagues. For those of you who have not previously served on BNP Committee, welcome. This is actually all of the other the licensure over the 50 plus odd license categories. This is the issue that you'll be dealing with, which is how to look at the issue of scope of practice, that is, of increasing assets, care, territory, turf battles. And many of us are not trained in this arena.

And that's why we heavily rely on the Department of Consumer affairs, the boards, the incredible dedicated Committee staff, as well as the hard work of the Committee chair to come up with a holistic approach in understanding the wide landscape about what the direction of the State of California should embark on. And we take this very seriously, this work, especially in this Committee.

So I want to again thank the chair and the Committee staff, because this is difficult work in trying to come up with a product that is decipherable and digestible to each and every one of the layman's terms about how does this increase access to care? How does this help support consumer protection? And how do we, from an author perspective, what is the legislative intent? The legislative intent is to work within healthcare practitioners to increase access, to increase patient care, specifically hard to serve areas.

What are some best practices in other states? You heard about it from other states. If there were problems in other states, we refer to this as the sunset process. Other states looking at the regulatory body and saying if there is malpractice and also patient harm, then we need to make necessary legislative changes to increase certification practices or certain license categories should not be able to practice accordingly. That has not come about from the other states specifically.

We would see data from that and we would hear about that, and we would highlight that. And I would not lend my name to this as well. In terms of the legislative approach, we have come up with a product in which we have said to opposition, we know that this is a territory battle for you, that this is a turf battle. What are the type of in good faith efforts to look at data and criteria and addressing these issues?

We incorporated all of the opposition, again, from public testimony in this regard. And as you heard that, there was no specifics. And so from a legislative standpoint, what do we need to do to help ensure that we are working with opposition and good faith?

We have done so. I can provide the receipts over a period of time and exhaustive conversations because I do not want to sit here before you and tell you something to which we did not put the good faith effort in and working with opposition and addressing the real issues at hands. I know that these are very difficult issues to splice out in terms of policy, but from a legislative standpoint, that is the legislative intent.

And I know that this Committee works hard to ensure that we have the consumer protection in place. This is continuation, and I hope that you will continue in holding me accountable, support accountable, and also opposition accountable to say, what does that look like then? If this is the intent, how do we get there and what will you do to help ensure that we are partners in this versus just simply opposition? With that, I respectfully ask for. aye vote.

Thank you, Assembly Member Low. And I want to start by recognizing and thanking the author for his author, for his tenacity and the years of discussions that stakeholders have had on this issue over the years. I think Dr. Jackson mentioned this is a two year Bill. This is really a 10 year Bill that feels like a generational Bill. Every time we have a conversation about it, I learn more.

The debate today represents a fundamental question that the author highlighted and that this Committee is constantly considering, which is, how do we balance our need to increase access to care with the need to protect the health of patients. And I appreciate that there's never an easy answer to this question and appreciate the thoughtfulness that Members of the Committee have shown on this Bill.

And I really think what this hearing did, it was one Bill, but I think it really sent a notice to every colleague, to all of our staffs, to all the lobbyists and the advocates that this is going to be a tough Committee. And you got to know your stuff and you got to reach out to Committee Members ahead of time.

You got to ask them their questions, because Committee Members are reading these bills very carefully and are coming up with long lists of questions and concerns that they have. And I'm excited for that. That's going to push me as a chair as well this year, which is going to be a fun opportunity for purposes of today. I believe the Bill, as amended, makes significant progress in adding safeguards to the Bill while preserving its intent.

With that, I'll be supporting the Bill today, but I do encourage the author to continue working with opposition stakeholders to make sure that any Bill that reaches the governor's desk strikes the best balance possible. And I appreciate a lot of the concerns that were raised by colleagues today. And I'm sure the Bill will continue to evolve as it moves forward. So with that, I'm happy to support the Bill. Madam Secretary, please call a vote, but we need a motion and a second. 1st.

Thank you for reminding me how this works. Got a motion from Assembly Member of Carrillo. Got a second from Assembly Member Nguyen.

On AB 1570 Low the motion is do passed to the Committee on Appropriations. [Roll Call]

That Bill is out. We'll leave the roll open for absent Members. 10 to three. Thank you, everybody. The hearing is not yet adjourned, but for your intents and purposes, it is.

Madam Secretary. Please run through the roll.

AB 1570 Low the motion is do passed to the Committee on Appropriations. [Roll Call]

Thank you. And with that, the hearings adjourned.