Senate Standing Committee on Business, Professions and Economic Development

Mr. Grazer, can you hear me?

I sure can.

Cool. Thank you. Okay, next.

Good morning, everybody. Welcome to this morning's Sunset Review oversight hearing, which is being held jointly by the Assembly Business and Professions Committee and the Senate Committee on Business, Professions and Economic Development. I'm Mark Berman. I'm the Chair on the Assembly side.

I was in a good mood until my chief consultant just reminded me that we're doing this again in 8 days at 9:30am also after the weekend. And so I'm no longer in a good mood. Thank you for that, Robby. This is the third in a series of sunset hearings held by the committees.

And I would like to thank Chair Ashby for her partnership in this process. And I know she'll be joining us in a minute. Today we'll be hearing from five entities responsible for overseeing the regulation of licensed professionals in California.

The Board of Behavioral Sciences, the Board of Psychology, the Physician Assistant Board, the Podiatric Medical Board, and the California Massage Therapy Council. For each portion of today's hearing, we will begin by hearing from representatives of the entity and of review. Next, we will open the discussion up for questions or comments from Committee Members.

Finally, we will invite other interested stakeholders here in the room to provide public comment. As a reminder, speakers will be limited to a maximum of two minutes per organization. And additional speakers making substantially similar comments are encouraged to simply provide their name and state their alignment with prior testimony.

As I mentioned, we've got a lot to get through before Assembly session starts at 1pm we have a busy schedule this morning and the Assembly has session at 1pm so we'll be moving through the agenda as quickly and efficiently as possible to ensure we can have a thorough discussion of each item before we begin.

Nope, not going to do that. So the first board is the Board of Behavioral Sciences. We'll begin with representatives of the Board of Behavioral Sciences. Testifying today is Steve Sodergren, Executive officer Marlon McManus, assistant Executive officer Rosanne Hemps, Legislative Manager, and Chris Jones, Board Chair. And we're ready when you are. Thanks so much for being here.

It Good morning, Chairperson Ashby and Chairperson Berman and Members of the Committee. My name is Chris Jones and I have the privilege of serving as President of the California Board of Behavioral Sciences.

On behalf of the board, I appreciate the opportunity to speak with you today about our recent accomplishments, the challenges we are tackling, and the priorities shaping the board's continued work. The board regulates four critical mental health professions, licensed marriage and family therapists, licensed clinical social workers, licensed professional clinical counselors, and licensed educational psychologists.

Over the last four years, the board's licensing population has grown by approximately 25%. Our primary mission is to protect consumers, uphold ethical and competent practice, and respond to emerging trends in mental health.

As the demand for behavioral health services continues to grow, we're committed to to ensuring that our regulations and policies allow Californians to access the highest quality mental health services. Workforce development is a top priority of the board.

California faces an ongoing shortage of mental health professionals, particularly in rural areas, due to provider retirements, recruitment challenges, and clinician burnout. In response, the board is focused on addressing barriers and in the licensure pathway, streamlining licensing processes and expanding supervision options.

In 2024, the board conducted a licensure pathway survey that collected direct feedback from registrants and licensees about the challenges they face, including financial burdens, supervision availability, and exam related obstacles. The information has directed our work of refining licensing requirements, adjusting supervision regulations to allow greater flexibility, and working to remove other hurdles that delay entry into the profession.

To further support workforce expansion, we are evaluating the adoption of the AMFTRB National Exam for LMFT licensure. Aligning California with national standards can improve license portability, reduce costs for multi state licensure, and increase professional opportunities while maintaining high competency standards. Another major area of focus has been telehealth and online therapy.

The rise of virtual mental health services has transformed this field, presenting both opportunities and challenges. To ensure that telehealth remains safe, effective, and ethical, the board has conducted multiple surveys to assess its impact. These surveys gathered valuable insights from licensees and registrants about supervision challenges, informed consent practices, and emergency planning.

Based on this data, we developed best practice guidelines for telehealth providers, tele supervisors, and consumers. We also created a public outreach document to help consumers understand the different mental health professions the board regulates. In addition, we work to strengthen telehealth training requirements.

As of July 2023, all applicants and licensees are required to complete a minimum of three hours of coursework in telehealth law and ethics, ensuring that they are equipped to navigate the complexities of online services. One of the board's key priorities has been expanding outreach and education.

To better support applicants, we published three new handbooks outlining the pathways to licensure. These handbooks provide a clear overview of the process as well as practical tips to help applicants avoid common pitfalls. Recognizing the importance of direct communication, the board has also significantly increased its social media presence.

Since 2020, we have significantly enhanced our social media presence, allowing the board to engage more effectively and efficiently with its registrants and licensees. Through initiatives such as hosting live events and actively responding to inquiries on social media platforms, we have strengthened communication and outreach.

These efforts have been well received, as evidenced by our Facebook following growing from approximately 5,000 in 2020 to over 32,000 today. In addition, we partnered with the Department of Consumer Affairs, Office of Public affairs to develop 10 instructional videos that guide applicants through key aspects of the licensure process, including degree requirements, supervision requirements, and examination preparation.

In addition to these efforts, the Board has prioritized modernizing our licensing and application process to improve efficiency. To keep pace with the increased increased workload demands, we collaborated with the Department of Consumer Affairs organizational improvement to identify opportunities for improvement for 75 of the board's processes.

We have restructured our licensing units, added new management and evaluator positions, and streamlined our supervision documentation evaluation processes. We are also finalizing the implementation of an online registration application system which will further enhance accessibility and reduce turnaround times for applicants and renewals.

While we are proud of the progress that we've made, we recognize that there's still work to be done. The behavioral health landscape is evolving rapidly and the board is preparing for the for the future by focusing on several key issues.

Strengthening telehealth and online therapy regulations will remain a priority as we continue to monitor new developments and refine consumer protections. We will also be evaluating the role of artificial intelligence and mental health practice to ensure that emerging technologies are used responsibly.

Additionally, we are committed to strengthening education and supervision requirements while addressing ongoing workforce shortages to ensure that Californians have access to high quality mental health services. As California's mental health needs continue to grow, the board remains dedicated to consumer protection, improving licensing efficiency, strengthening workforce development, and addressing emergencies and challenges in telehealth and artificial intelligence.

Thank you for the opportunity to share our progress with you today. We look forward to continued collaboration with the Legislature, stakeholders and the public to advance behavioral health services across the state.

With me I have Steve Sodergren, our Executive Officer of the board Marlon McManus, the assistant Executive Officer of the Board, and Rosanne. Thank you for your time and commitment to California's behavioral health systems. We welcome any questions that you may have.

Great. Thank you very much. And Mr. Sodergren, are you mainly here for questions or do you have any prepared remarks?

Just here for questions.

Great. Thanks so much. Want to bring it back to colleagues for any questions or comments that folks, please. Senator.

Thank you for appearing before us this morning.

One of my questions you had mentioned about the telecommunication telehealth and my, one of my concerns, and I'm sure that you can address this, is how do you feel about the communications back and forth between the LCSW as an example, and it being recorded and the later confidentiality issues that may come up because of a recording that may come up in a court of law, may come up in a divorce, may come up in proceedings of some something and but here that's always been a sacred thing between the therapist and the client.

How are we addressing that when it comes to the. The telecommunication part of it all?

No, the confident electronic confidentiality of records. That is something that we will be looking at and delving more deep in, deeper into in the coming years and coming months, actually, since it's so applicable right now, right now they do have to.

All our licensees have to hold to a standard of electronic communication and privacy for those such as HIPAA laws and such. So it's really going to take us evaluating those to make sure that they do ensure that confidentiality is maintained. And it's not only just with telehealth, especially with AI, that is a concern too.

Yeah. And If I may, Mr.

Chair, that, you know, I'm pointing this out because the number of people now teenagers that are encouraged to see a therapist, even physicians are encouraged to see physicians because of their stress, you know, we just went through it with the pandemic and here, you know, the number of hours nurses and people in the health field, they're just so stressed at home and then, you know, where can they go?

The priest. But they also turn to their professional therapist and that confidentiality is so important. And I just want to make sure that the board is right on top of that, that both the client and the professional feels that it is not going to be violated. Yeah.

One of the things that the main, since we are going to have these discussions to get out in front of that, what we have done is we created those materials for licensees to kind of explain to them the importance of that.

It does highlight in those material and I think it's going to require us in the next, you know, the next year. And so providing more outreach so the licensees understand when they're using these online platforms or performing services through telehealth that it is a key component that they must abide by.

So, but first part is really getting that outreach so that clients understand it too, and also the therapist, but then also working on to seeing if there's any amendments we need to do to our regulations to, you know, kind of bolster that.

Thank you, Mr. Chair. Thank you.

Dr. Jackson.

Thank you very much. Just a few questions in regards to first supervision. I mean, obviously not just in terms of supervision. When we talk about, I think supervision all the way around. I remember in my own MSW program, supervision was 50/50 chance you'd enjoy the process.

And then even on the licensed category in terms of supervision, of course, the actual requirement of finding someone who's certified to provide supervision as well. I mean, you're trying to find unicorns out there in the community. Right.

What are we doing to try to make sure that there's, we're not continuing to face these huge hurdles for the very few people who are willing to even go and go through that arduous process?

Well, we've done a couple of things actually in the last few years. We had AB 1651 pass, which now allows LEPs like myself to provide supervision to other registrants that are providing school based counseling so services for kids who have disabilities who are on IEPs. So that increases the load of people who can provide supervision.

Oh, and additionally, we will be in our workforce development Committee. We are going to actually put out a survey in the next month or so to really kind of see the environment out there.

In addition to that, we're trying to create different incentives for people to supervise, like providing CU opportunities for providing supervision and things like that.

And did you want to add.

And part of that survey is going to ask about supervision and the practicum and then supervision as associates to get more information back on that.

And then previously mentioned by Chair Jones, we did in the workforce study survey, that was one of the components we asked about what were the barriers that, what were the barriers to supervision that were being experienced out there. So we do have a good idea. And like you said, we're continually.

Supervision is a key component to the licensure process. So that is one of the things we do focus on and are looking for improvements on that.

My second question is in regards to there's a number of professions who are pushing for compacts to be able to make sure that one state's licensure it can be validated or accepted in another. Can you outline some of the concerns that you may have and ways that we can at least possibly pilot that in California?

Yeah, there are two compacts that the board. One has looked that we've looked at the social work compact, which was in last year's legislation and this year it's the social work compact. Compacts can offer that portability for licensure, which is great for continuation of care and access to services.

But in the, in the counseling compact, we did oppose that bill for there's various reasons that, you know, we are concerned about that. The first of all is we want to make sure that licensees coming in and practicing in California understand the cultural diversity and actually the law and ethics that.

And reporting requirements in California to be able to provide quality care and appropriate care. So that's one of the main concerns. Beyond that, the administrative. The administrative task that would be added to the board could be quite large, especially with the enforcement process. And additionally.

Yeah, So, I mean, it does offer that portability, but the concern of actually, you know, the compacts and administering them might be difficult. The other thing, too, is the actual, the. With the way they are written, we would have to cede some of our regulatory authority, which is of a concern.

And then lastly, the equitable participation in the actual committees. California has some of the highest licensing populations for social workers and for LMFTs, and we would only be allowed one position on the committee on the compact committees. So the equitable representation, we're not sure if it's there.

Can you tell me, with engaging in some type of compact, would that help with our mental health professional shortage?

It would need to be seen. I'm not sure. You would definitely have possibly more data. Definitely, California would be. Would be a big market for people outside of California to come in. So it could actually increase the licensing population. But once again, it's really weighing that on the consumer protection concerns.

Access is definitely something that we're concerned about, but at the same time, consumer protection is paramount for our. At least the board's mandate.

Right. So what I'm hearing you say is that you are obviously concerned. I mean, obviously, depending on what states they may come from and the different legislation, you know, legal authorities that others may have. Certainly I would have that concern as well, but I think I might be even comfortable with some states as well. Right.

So is there a way to engage in our own type of compact that outlines the maybe certain states that we would be comfortable with, given their seamlessness in terms of what they go through and through their licensure and other things? Is that something to be considered?

I mean, anything's up for consideration, but we do actually offer a portability that we put in place about four years. Well, it's 2025 right now, about five years ago, which actually offers a more expedited licensure process for licensees from out of state, what they have to do.

If they've been licensed in another state for more than two years out of the last five, they can actually apply for licensure without taking the clinical exam, because mostly we recognize the other clinical exams that are out there, but they have to take the law and ethics exam and pass that, and also take courses in cultural competency and law and ethics.

So that's the component that's missing from the compacts currently, is that on some of the compacts, it doesn't require a law and ethics exam to be passed or that we can offer a law and ethics exam and then additional coursework, too, in the cultural competencies, which is kind of what you're talking about there.

We haven't seen that language in the compact language, but since we did the pathway to licensure, we've had about approximately 5,000 licensees apply through that pathway. So it has added at least 5,000 licensees to provide access.

So I think. And lastly, obviously, getting mental health professionals on our school campuses are extremely, extremely important at this time. I'm concerned about the additional hoops that you have to go through to be able to be a licensed social worker on school campuses. Can have you looked at those additional. How much. How important those additional requirements are?

To be. So with the regulations, you can get what's called a pupil personnel services credential through social work to. To work in schools in addition to having. Then you don't necessarily need to have a license, and that would be probably the most expedited way to do that.

But in addition, with the repeal of AB 3632, like 10 or 12 years ago, the mental health responsibility has been placed back on schools. So a lot of schools, instead of what we were doing before, was having community mental health centers providing services specifically to kids who are in special education.

And now the state has pulled that back and it's. That responsibility lies within the schools.

And so what they've done is almost a lot of schools have kind of created a model similar to what we had with AB 3632 and created like, a clinic on campus so that they can see the continuum of students, general education, those who are at risk, and then kids that are in special education.

And in the regulations, it says that people who are qualified to do that are either pupil personnel services credentialed, or likely or likewise licensed. So someone with a. With a clinical social work license could. Apply to be a clinician within a school if there are openings without any barriers.

Are there any additional streamlining that we can do that you think would be worth looking at.

The. I don't know if there would be anything additional. One of the ways that schools can. Can provide a tremendous amount of services. The same model that that community mental health uses is, is by employing associates. Right. So we have. So we can apply and employ a number of associates.

Then we just have to have the licensed people to supervise them. Which again was one of the reasons that we pushed AB 1651 to get LEPs on board. We haven't been able to supervise the. Other licensees ever until 2020. So those efforts have been in place.

And then there's a number of different, you know, programs that schools engage in, whether it's through nonprofit organizations or whatever, to bring in mental health supports.

Okay, thank you very much, Mr. Chair.

Dr. Jackson. Yes, please go ahead. Senator Archuleta.

Yes, this pertains to our military. I'm the Chair of the Military and Veterans Committee and I'm very concerned about our military that transfer from one base to another.

And when they come into California with a married spouse who may have been a social worker, LCSW something in the medical field at all, and this business friendly attitude we should have for them, welcoming them into California and expediting their license.

Would you walk me through what we would do if that was there at the board and what would we do with this married spouse to one of our military personnel?

Yeah, we already have the military personnel and spouse personnel expedited licensure. Actual. We review their application as fast as possible. So those are in place. We don't receive too many, but we definitely work with them to get them licensed as soon as possible. So there's various military expedite processes in place currently. Yeah.

And the reason I say that because if there's break in employment when they transfer from mid New York or wherever they're stationed, and then there's that long break waiting for their license and waiting for a provisional license, whatever it might be that could be detrimental to their finances after the move and everything else.

That's why I bring it up.

Oh, definitely. And I know we've worked with a couple actually to try to figure out the best way to get them into this system as possible, licensed as soon as possible, whether it's with the registration, which is a kind of supervised. Supervised licensee or as a licensee. So we've.

We definitely pull those out of our applications and work on those quickly.

Good. Well, thank you for honoring their service of the spouse. We appreciate it. Chair. Thank you.

Thank you, Senator. Any Additional questions or comments from Committee Members before I take it to the Vice Chair, Please Assembley Member Nguyen, Caloza please excuse me.

That's okay. I forgive you. It's early Monday morning. Appreciate you. Thank you for your presentation. I want to just ask a little bit about, since you brought up telehealth, can you talk to us a little bit about Headspace health and what happened there, especially with some of their layoffs?

I asked that because that would be super helpful in just understanding what's happening in this space. I know there's a lot of interest in expanding the telehealth space. So it would be really helpful to hear about what's happened previously in particular with this company.

And the headspace issue I think you were talking about is that automatically there was licensees that were. They woke up one day and Headspace had locked off their, you know, ability to actually practice. And so that was definitely. That raised eyebrows on the continuity of care and the problems that that can actually look at.

I mean, that can happen. What we've done, as we were mentioning before, we did an online only, we called it online therapy only survey back in 2021, and we received 1,700 responses. 77% of those responses said they had worked or contracted with an online therapy platform.

And 40% actually claimed that they were saying that it was their primary form of practice. So it is definitely something to be concerned about. What are. One of our big concern is that our licensees in California are practicing with clients in California.

And to maintain that part of the, to maintain that, we, we definitely have to let the licensees really understand that they need to practice with California clients. If they're going outside the jurisdictions, they have to understand the, the requirements of that jurisdiction.

18% of those, the survey said that they were not matched with clients in California, but there was a way for them to refer those clients to appropriate actual licensee in another jurisdiction. The other thing that we're concerned about is the privacy policies, like you said mentioned earlier.

And 56% shared that the privacy policy and data sharing practices were implemented with the companies. And so that was, you know, half is questionable. So it's something else we need to look into.

The thing that what we're currently doing right now is really, we put out those education education pamphlets for licensees to understand that it's really, it's their legal obligation to make sure when they're working with a client, they're working with them appropriately, they have the appropriate consent requirements in there.

They understand that there's a safety plan in place that they're able to understand where the client is actually receiving the services. There's a lot that needs to be looked at still.

Do you feel like the board has the appropriate tools in place to be able to help regulate the space for telehealth or what can we, as a Committee do to work with all of you?

We're definitely looking at, you know, what we have to do with the companies itself. If there's anything that, you know, regulatory we could look at, but that's not necessarily in our mandate, but it's something that we are definitely, you know, at least staff level, talking about and seeing how we can actually work with that.

Is there a way we can either, if not regulate, definitely reach out to these companies and. And make sure that they are, you know, have the necessary understanding of California laws to be able to implement their. Their platform appropriately in California?

Okay, thank you. Yeah. It's an issue that I would love to follow up with you on directly.

I know there's obviously a growing number of companies who are entering the telehealth space, and so we want to make sure to work with you thoughtfully and making sure that people don't wake up essentially unemployed the next day, which is what happened here.

Unemployed. But then the other for our. For consumer protection is definitely that part too, is the continuity of care. Big concern.

Thank you, Assemblymember Coloza. My apologies again. Any additional questions or comments before I turn it over to Chair Ashby? Go ahead. Chair. Vice Chair.

It's okay. Assembly Member Coloza. He mixed me up with Assemblymember Flora. So it's just. We'll get our Chair some more coffee, you know. Okay. Well, first of all, I just want to thank Dr. Jackson for his line of questioning. And at the root of that, obviously just trying to get more professionals in this industry across the State of California.

I just want to reiterate my strong support of the existing Pathways program. I feel it's far superior because we don't lose the control that's necessary to really keep the practices in line with California law that we've worked so hard to put together. And I think that's an incredibly important piece.

But so too is the balance of finding ways to grow the field, because we know, as you've heard up here, and people are.

Are seeking help in all kinds of ways, from the apps like Headspace to needing school assistance and trying to grow social workers, too, into those roles and create other avenues that are a little bit more expeditious. So I appreciate all of that. Really important.

I know we have a very lofty agenda and the Chairman and myself are hell bent to get through it as quickly as possible. So I'd love for you to be brief on this one. But I would like to get you to say this during, during this hearing.

Can you just talk a little bit about your enforcement in terms of the temporary practice authority and can you confirm for us how we are tracking the practitioners in other states to make sure they're complying with the current 30 day limitation on serving in California?

If you could just talk a little bit about that and we'll hand it back to the Chairman and thank you for your time.

I'll try to be brief. Temporary practice was something that we put in place last year and it's actually been pretty popular. We've had I think around 500 people apply for that.

And that allows somebody from another state to actually not apply necessarily, but certify with the board that they are going to be practicing with a client for 30 consecutive days. And what that's looking at is to establish the continuity of care. So if somebody's traveling from their state to California, they're able to actually assist them.

We, what we have put in place is an electronic, electronic application that they can actually sign up for and then we have the actual data of when they're going to start the actual, actual client relation within California and then when it ends. So it's pretty new still.

So what we can do, what we, we haven't received any complaints yet, but when we do we definitely have the actual data that we can actually use to pursue any cases like that. And also it's for somebody who is, they're currently in practice with too.

So it's not just I want to practice 30 days in California, it is for a current client.

So thank you.

Thank you, Chair Ashby. So now we're going to turn it over to Members of the public and I know some folks have come in. So just a reminder for folks, this is for the board of Behavioral Sciences. If there are Members of the public who would like to come up to testify.

You have up to two minutes each. And if anyone doesn't look like we have a rush of testimony, so I'll spare that other part. Go ahead.

Hello, my name is Shanti Ezrine. I am with the California Association of Marriage and Family Therapists. We are an Association of over 38,000 marriage and family therapists across the state who are licensed and regulated by the BBS. And we work very closely with the BBS.

The BBS has done a great job in engaging with the different professions and we've always found them to be very responsive to our needs and very strong partners in advancing the MFT profession.

Just in regard to a couple items in the Sunset Report, wanted to share that we are in very strong support of the potential transition to the national exam for MFT licensure in California. So just wanted to express our appreciation to the Board for their continued work in that area.

And then additionally, with the current behavioral health workforce shortage, there is a very big need to get qualified providers through the application process as quickly as possible.

We do believe that the BBS is doing everything they can to expedite the process, yet we like to continue to just advocate for additional resources, additional funding to the Board so that they can continue to enhance that application review process.

And I think all that said, we just really, really greatly appreciate our continued partnership and, you know, the board being responsive to our needs and recommend that they continue in their great work. Thank you.

Great. Thank you very much. Any additional Members of the public seeing? None. Thank you very much. I'm sure we'll have more conversations as the process moves on. Next up, we're going to move on to the Board of Psychology. I believe we have Leah Tate, Board President, Jonathan Burke, Interim Executive Officer, and Sandra Monterubio, Enforcement Manager.

And we're ready when you are.

There should be a little button. Got it. Perfect.

Can you hear me? Perfect. Thank you so much. Good morning, Chair Ashby, Chair Berman and honorable Committee Members. My name is Dr. Lea Tate and I am the current President of the Board of Psychology. With me today is the Board's Executive Officer, John Burke, and the Board's Enforcement Manager, Sandra Monterubio.

Also present are some of the Board's management, including Stephanie Chung and Cynthia Whitney, and the Board of Psychology Vice President, Shacunda Rogers. Since the last sunset review, the Board has accomplished the following. We have changed fees to address a structural imbalance and ensure the financial health and stability of the Board.

We've implemented a statutory change allowing the National Register of Health Services Services psychologists to perform foreign credential evaluation services for applicants trained outside the United States or Canada. We've amended statutes to streamline pathways to licensure. We've sponsored chaptered legislation to delegate authority to the Board's licensure Committee to independently approve exam eligibility and extension requests.

We've performed an internal evaluation of the enforcement processes through the Department of Consumer Affairs Organizational Improvement Office. And this evaluation helped identify process improvements and effective use of resources. Excuse me.

We've amended existing language to define sexual misconduct along with adding and defining sexual behavior to the list of what is considered unprofessional conduct for licensed psychologists and registered psychological associates. The amended changes authorize an administrative law judge to include an order of revocation and proposed decisions.

We've implemented an inactive status for registered psychological associates who have experienced disruption in supervision and or care that does not count towards their time limit in holding the registration. We've implemented a retired status which allowed the Board to issue a license and retired status to a psychologist who holds a current active or inactive license in good standing.

And we've amended regulatory language to implement the continuing professional development, or CPD requirements. The CPD model consists of 15 continuing professional development activities grouped under four different categories. This change did not affect the required 36 hours required for renewal. This change includes a requirement that four hours be devoted to cultural diversity and social justice. We've also identified newer issues that are being addressed during the sunset review process.

To include establish a psychotherapist client privilege exception for Board investigations Amend current language related to the requirement of a foreign master's degree and the advancement to candidacy to alleviate uncertainties for licensing staff and applicants Change the statute for psychological testing technicians to add a fee to change supervisor and add continuing professional development requirements and coursework requirements such as human sexuality, child, elder and dependent adult abuse assessment and reporting Suicide risk assessment and intervention and foreign degree equivalency for research psychoanalysts and increase the type of degree which qualify for psychological testing technicians.

We thank you for your time and consideration today and to the Committee staff in helping us focus the information provided during this process and is necessary for your deliberations. We're happy to answer any questions you may have regarding this brief overview or other issues of concern to the Committee.

We hope that you will continue to support us in our efforts to effectively and efficiently protect consumers of psychological services in California. Thank you so much.

Great. Thank you very much. And other folks are here just for questions. Great. Open up to colleagues. Dr. Jackson.

Thank you very much, Mr. Chair. My, my only concern is on issue number 11 when it comes to the psychotherapist client privilege exception. Obviously in many of our professions in the behavioral sciences, confidentiality protection of their records is really one of the core components of what we do. Or clients might not want to get the services that they need.

Obviously you're making the argument that, number one, under a very rare circumstances in which access to the client's records would be helpful, especially when it's not because of the professional involved, but then the client involved in other matters and that, I mean, obviously it's costly through the current process to be able to seek court approval, but it's the same process that professionals have to go through as well.

Right. In terms of making sure that the courts are the ultimate arbiter of those matters. Can you explain why? I mean, to me this is a very big ask why we should be considering considering this. I mean, isn't it worth going through that extra process to ensure that patients confidentiality is protected?

That's a great question and I'm happy to answer that. Currently the records that we receive are kept confidential under evidence code 1040 and government code 7923.600. We do not release that information to the public. When we send cases to our experts to review, we send that through a box.

They have to have a passcode to retrieve that information. And if a case does warrant formal discipline and is sent to the Attorney General's Office for prosecution, the Attorney General's Office will redact files and issue a protective order for those files. Clients names are not used, not even their initials. Everything is redacted.

Correct. But that doesn't get to the point of clients maintaining their own power. Right. I mean, so in terms of the issues of self determination, which is a core principle in most of ours, I'm not sure if it is for psychology, but it certainly is for social workers that what you're asking for is a violation of self determination.

So the cases that. And again, this was brought up at our 2018 child custody stakeholder meeting and we were receiving complaints alleging bias. We weren't able to get all of the records in order to determine whether or not there was a departure from the standard of care. What we were receiving was a 730 evaluation.

But if a complainant is alleging bias, we're going to want to look at test data notes to determine was one parent interviewed by the psychologist more than the other? Was there truly bias? And without all of the records, we truly wouldn't know that and would have to close a case. Insufficient evidence.

But child custody are not the only cases that are a concern for the board. There's also sexual misconduct cases. So when a consumer files a complaint and alleges they've had an inappropriate relationship with their psychologist, going to want to look at certain parts of those records as well.

We're going to want to look at the case notes, how often were the individuals meeting, where were they meeting, the frequency of those meetings. So in order for us to make those determinations, we are at times going to need additional records. Otherwise, our only option is to close a case. Insufficient evidence.

And I think that we could all agree that when a psychologist engages in sexual misconduct with a patient, that is one of the most egregious violations that they could commit.

Yeah. That doesn't get to my argument though. I mean, I understand that there's still a process that already exists to be able to get those records. So it's not that you don't have the opportunity to get those records. You are asking us to bypass the legal process in which to be able to get those records. Am I correct?

You are correct. In order for us to try to get additional records, we would have to go through subpoena enforcement, which can take over a year and it costs anywhere from 15 to $30,000 for that process.

Right, so you're saying that even. So you're saying that a patient's right to their own secure of their own records and their own self determination is not worth the extra money that has to be spent and the time that has to be spent to be able to access that. I mean, that's, that's basically what you're asking us to weigh, right?

I. We're asking that you consider another option, especially since the medical board has had the patient privilege language since 1980.

Okay. Okay, thank you for that. I mean, at this time. I mean, I would be opposed to such a change like this until we can say that, you know, I don't. I just have concerns about this issue. But thank you so much for your answers.

Thank you. Dr. Jackson, any additional questions or comments from Members of the Committee? Chair Ashby

Thank you for being here and for your great work on behalf of the state. Some tough questions facing your board this go around, but we'll work our way through them.

So I asked this question of the behavioral science folks as well, but can you please just briefly again, because we have a big agenda, explain how enforcement works in terms of the temporary practice authority for your board as well.

We have similar legislation which allows for temporary practice for 30 days. We don't really. It's not defined really more than that. So it can be, we take it to be 30 non consecutive days with one hour constituting a day, if that's all you do.

We don't have any kind of tracking mechanism or anything like the Board of Papal Sciences laid out, although that's something I'm sure we'll. We'll be very interested in looking into and exploring because at the moment there isn't really an enforcement mechanism for that.

So, Dr. Burke, then, is this realistic and feasible or are we. Have we created a situation here where we may just not know that folks are providing services and care without being licensed? You have some. Does the board have concerns about that?

Yes, the board would be deeply concerned about that. We haven't received a tremendous amount of indications that that is happening in terms of complaints or consumer harm, but it is a possibility.

Okay. All right. That would be something we'll need to look at then in this process as well, Chairman.

Thank you. Chair. A couple of questions and concerns that I had have been raised and I think that'll generate a lot more discussion over the coming months. One issue that I just want to dive a little deeper into is workforce needs.

And a 2023 behavioral health workforce needs study by the Steinberg Institute determined that California needs to add more than 16,000 psychologists by 2030 to meet demand, which is approximately a doubling of the number of licensed psychologists in California. Can you dive a little deeper into your efforts to streamline licensure?

And I'm also curious if attrition amongst psychological associates is an issue or if most associates do go on to become fully licensed psychologists.

Thank you. So a number of ways that we have tried to streamline the process, we went through the pathways to licensure. So that was where we reviewed all of our statutes and Regulations to clarify and simplify the language regarding requirements to make the language more user friendly for both applicants and staff.

We also, one of the best ways is to make sure that our licensing processing timeframes internally are as good as they can be. And so to do that we have utilized temporary help. We have retired annuitants that help with application review and processing.

We've also made other changes like enabled the California Psychology, Law and Ethics exam request and the retake request applications to be online and you can pay the fee online as well just to make that quicker. We also send out courtesy emails with any deficiencies that have been identified when the initial application comes in.

So we can inform the applicant as soon as possible that, zero, you know, you, you didn't submit your transcript or the supervision agreement needs some extra pieces just so we can do that.

That's sort of a primary way where we can help I think, address the workforce need is there are so many really issues outside of the board's control that do sadly impact the cost and length of time of the education required to become a psychologist.

The psychological associate portion, we did see some attrition From, I think 2017-18 to 2020-21 where the numbers were going down of the number of registered psychological associates. Not sure why that is.

Since then the numbers have increased year over year and we currently have 1853, I believe was the last time I checked, which is the highest number that we have had since 2015-16. So I think that number is moving in the right direction as we see it. One change we did make was we allow for registered psychological Associate. You have 72 months to complete that.

One thing we've done is they are allowed to go on inactive status because of course these people are often in their 20s, 30s, because we were getting extension requests, quite a few of them for things like pregnancy, having to leave the workforce, a sick parent.

So, and there's no, you know, of course we were granting those, but there's no need now. All they need to do is go inactive and that stops the clock and then they can reactivate when life circumstances and other things allow.

Thank you, great. Thank you very much. And yeah, definitely encourage you to keep on looking at, you know, what are some things that we can make it do that we can do to make it easier for folks and sort of meet the needs, the real life experiences that people are going through as they try to seek licensure.

Any additional questions, comments from colleagues? Seeing none. I'm going to open it up to Members of the public. If Members of the public have any public comment? You have two minutes each.

Good morning, Chair Members. Tyler Rinde. On behalf of the California Psychological Association, we are pleased to see the recommendation to continue the statutory authority of the Board of Psychology. We appreciate the significant work of the Board to reduce license processing timeframes in the past few years and the overall partnership with the Board of Psychology.

We'd like to thank the Committee and the Board for considering our proposal. Issue number eight on page 24, to expand the eligible bachelor's degrees to register as a psychological testing technician to include neuroscience, cognitive science and behavioral science. These are degrees closely related to psychology, which is the current standard as a registered psychological testing technician.

The Board approved or supported. Sorry. The Board of Psychology approved our proposal at their February meeting. Testing technicians were established through. In 2022, through SB 1428 by Senator Archuleta to expand access to needed psychological testing services used to diagnose conditions such as Alzheimer's and autism.

Testing technicians administer and score psychological or administer psychological tests under the supervision of a licensed psychologist. However, since the Bill took effect in 2024, only 75 people have registered as a testing technician. Increasing the eligibility will expand access to care, reduce the wait times, which range right now from three to six months. Thank you to the Committee for considering our request.

Thank you very much.

Kind of short. Thank you. Good morning, Chair Ashby, Chair Berman and honorable Committee Members. I'm Dr. Elizabeth Winkelman. On behalf of the California Psychological Association, we have significant concerns with issue number 11 of the Sunset review background paper where the Board of Psychology proposes an exception to the psychotherapist patient privilege and would allow the Board to access confidential records in complaint investigations without patient consent.

I want to thank Assemblymember Jackson for his insightful comments and questions on this issue. The vast majority of Board investigations are initiated by patients complaining about their own services that they receive from a psychologist.

As far as we know, there have been only four cases in the last four years where the Board closed a case because the patient declined to release their records. So we view this proposal as unnecessary.

Also, in cases involving third party complaints where a patient does not consent to the release of records, as discussed, current law already allows the Board of Psychology to obtain records through a subpoena and a civil court order ensuring judicial review to determine if the needs of the investigation outweigh patient privacy considerations.

The Board has stated that this process is difficult and costly. We believe the process is difficult by design and that the standard for obtaining patient records should not be lowered. For example, if a patient who has experienced domestic violence and is satisfied with their own treatment, does not want to release their records.

The abusive partner should not be able to force the patient's records to be released by filing a complaint, nor should the patient have to hire an attorney to defend against the board attempting to access their records. For these reasons, we respectfully request that the Legislature reject this proposal and maintain the current confidentiality standards for psychotherapy records. Thank you.

Thank you very much.

Hello. My name is Shanti Ezrine. I'm with the California Association of Marriage and Family Therapists. While our license and associate marriage and family therapists are regulated under the Board of Behavioral Sciences, we would like to echo the concerns you just heard from the California Psychological Association on the proposed exception to the psychotherapist patient privilege.

The proposal circumvents legally protected consumer privacy and sets a dangerous precedent with the other regulatory boards. We appreciate and thank Assemblymember Jackson for your comments earlier and respectfully ask that the proposal not move forward. Forward. Thank you. Thank you very much.

Seeing no additional questions. Thank you very much. I'm sure we'll have robust discussion over the next couple of months as we move through the sunset process. Appreciate it. Next we're going to move to the physician Assistant board. Board President Vasco Dion, KID Executive Officer Rosana Khan and Assistant Executive Officer Christy Voon are here today to testify.

Ready when you are.

Good morning. Good morning, Honorable Chair Ashby, Honorable Chair Berman, and Members of the Senate and Assembly Committees. Thank you for the opportunity to present our Sunset Review Report today. My name is Dr. Vasco Deon Kidd, and I'm a licensed board member currently serving as President of the Physician Assistant Board of California.

I have served on the board since 2021. With me today is Executive Officer Rozana Khan and Kristy Voong, Assistant Executive Officer. We also have Jasmine Dhillon, who's our Legislative and Regulatory Affairs Specialist. California is home to the second largest PA population in the nation.

According to recent PA licensing data, there are now 18,200 PAs in the State of California, reflecting a 22% increase from our last Sunset Review, and we think that's fantastic. Additionally, the number of PA education programs in California has grown from 16 to 20 accredited programs over the last five years, representing a 25% increase.

There are also four applicant PA programs currently awaiting national accreditation in the queue. If all existing PA programs in California remain operational, more than 1,000 PA graduates will enter the workforce annually. This is of critical importance, as PAs are highly skilled and exceptionally qualified healthcare professionals who improve access to care and enhance care delivery.

According to the U.S. News and World Report, the PA profession was named the number two best healthcare job and the number three best STEM job in its 2025 rankings. As a reminder, PAs practice in all medical and surgical specialties. The Physician Assistant Board remains steadfast in its mission to protect and serve consumers through licensing, education, and objective enforcement of the physician assistant laws and regulation. We take enforcement action against licensees who violate our Practice Act.

It should be noted that in September 2020, the board took full responsibility for enforcement, including complaint processing and disciplinary actions, which were previously managed by the Medical Board of California under a shared service agreement. The board is composed of five licensed members, four public members, and an ex officio member from the Medical Board of California.

Since our last Sunset Review, 7 new board members have been appointed to report place 7 outgoing members. We currently have one vacancy for a public member. We are supported by 11 talented and dedicated board staff members led by our outstanding Executive Officer who assist the board in fulfilling its consumer protection mandate.

Members of the board and board staff actively engage with licensees, PA students, and prospective applicants at public events and speaking engagements. Regarding regulatory activity, the board approved the regulatory implementation package for Senate Bill 697, which went into effect on October 1, 2024, four years after the law's enactment. Senate Bill 697 modernized the PA Practice Act.

Not changed the scope of practice, but modernized the PA Practice Act by removing outdated administrative requirements that hindered PA practice. In regards to the budget, the board remains financially stable, but facing rising costs for licensing, relicensing, and enforcement without additional revenue. With no fee adjustments over the last two decades, action is needed to sustain its enforcement responsibilities.

For example, enforcement activities account for on average of 53 and a half percent of the board's annual budget. To address this, the board seeks to adjust statutory fee caps, allowing greater flexibility to raise fees as necessary. Additionally, the board is developing a regulatory package to increase the initial licensing fee from 200 to the statutory cap of 250 to help offset expenditures. These adjustments are intended to be reasonable and aligned with those comparable to regulatory boards.

Finally, in response to LA fires, on January 29, 2025, the Governor issued an executive order which postponed for one year the license renewal fees for DCA licensees experiencing or expiring between January 1, 2025 and June 30, 2025 for those within impacted zip codes. Currently, eight licensees have deferred their renewal fee for one year.

Fees for duplicate or replacement license and wall certificates have been waived. In addition, DCA provided the board with a list of affected licensees and the staff member has contacted them to inform them of the Governor's order, which is also posted on the board's website. This concludes my report, and we are open to questions. Thank you so much for your time.

Great. Thank you very much. Opening up to, does anybody else want to make opening comments?

Just here for questions.

Thank you very much. Open up to colleagues for any questions or comments. Senator Archuleta.

Yes, I've got to make some comments. Probably very little question. But I'd like to praise the physician assistants that often give the patient the time and care and the sensitivity that the doctor doesn't have the time to do because he's got patient after patient.

And of course, with the fact that we had the pandemic, and those of us who served in our positions as Senators and Assembly Members that were here during the pandemic realized that the number of cases that were coming in and out of hospitals, deaths and tragedies to families, and went on and on. And time and time again I heard about the physician assistant holding hands, staying with the patient, meeting with the families, things that obviously the doctors couldn't do.

And so I wanted to praise that. And when you tell me your numbers have increased, I can see that wanting in that profession to raise to that next level is so important. But can you walk me through, say the last five years or 10 years maybe, how that position has enhanced itself in the eyes of the medical field? With responsibilities and so on.

Yeah. So we have some evolving responsibilities of physician assistants. Senate Bill 697 really helped to create the flexibility that the physician and PA team needed, which was allowing really kind of the scope of practice or really the supervision to be determined at the practice level. This, the PA profession continues to grow by leaps and bounds.

I want to articulate everything that you just said or underscore everything that you said. The PA profession continues to improve access to care, improve continuity of care, and healthcare delivery. We see PAs in demand across the state and across the country.

Just to put this in context, for 40 seats in a PA program, there's anywhere between 1500 to 3500 applicants for 40 seats in any given PA program. We continue to have huge demand. Now, whether or not that's sustainable, given some of the undergraduate concerns in terms of enrollment.

But PA profession continues to rank in the number one and number two best slot usually year over year. And it's certainly something that folks are very much interested in. We do get a lot of requests from applicants and from prospective applicants to learn a little bit more about the PA profession.

We're also seeing PAs are, as I mentioned earlier, are in every aspect of healthcare. They're in leadership, they're at the clinical level, they're in education, and PAs are here to stay. The State of California, as I mentioned earlier, is a second populous state for the number of PAs that we have practicing here.

But certainly we're always looking for opportunity to expand the work that PAS do each and every day in meeting the needs of the consumer. And so we're grateful for the profession and for everything, again, that you've underscored. It continues to be a profession of choice for many folks entering the healthcare industry field.

Very good. And thank you. Thank them all. Thank you.

Thank you, Senator. Assembly Member Macedo.

Thank you, Mr. Chair. I want to echo what my colleague said. I come from a very rural community that PAs are truly the backbone of us having access. And so that's where my kind of line of questioning is going to be is what, you know, plans or what do you see as an opportunity for that space to grow in the Central Valley or encouraging PAS to practice in the Central Valley, because we do have doctors that are completely overwhelmed and there's a lack of access issue that we're struggling with in a healthcare desert.

Absolutely. Thank you for the question. I think one of the opportunities is to look at increasing ratios, to really think about ways we can adjust the physician to PA ratio. Right now it's 1 to 4. It's been 1 to 4 since 2008. And if you look at other states, 22 states have no physician to PA ratio. And the states that do enforce PA to physician ratio, 45% of those states have adjusted their ratio higher over the last seven years. So certainly they're looking at ways to increase access to care.

One of those is to either get rid of the ratio or to increase the number of PAs that a physician can adequately and competently supervise concurrently. So I do think there's opportunity. Central Valley, there's only one PA program out there, which is A.T. Still University. Cal State University, Monterey Bay recently closed this door, unfortunately, which limits the number of PAs that will be going out into the workforce.

So I think one of the ways to really help to enhance primary care, to bolster primary care is to figure out barriers within the regulations that hinder the PA and physician team from increasing access to patients. And I think ratios are one of the low hanging fruit opportunities that I think we, along with the Committee, can really, I think, help to address.

So in your professional opinion, what would that ratio look like if we did increase that number?

Great question, which is a million dollar question. I want to be very careful about the sensitivities around that. But AB 1070 passed that increased the ratio from 1 to 8, but only for home health. California is the only state that has done that. When ratios have increased, generally they've increased across the board.

So when you look at ratios in general, they really affect prescribers and those who provide direct patient care. AB 1070, which passed in 2023, does not impact PAs that provide direct patient care or prescribe medications. And so that's challenging because 95% of all PAs across the country prescribe medications.

So one of the ways that we would think to maybe a numerical value would be 1:8, because there's already precedents for that. And I think a 1 to 8 would, that goes across and standardized across the state, I think would be advantageous to improving opportunity and enhancing care delivery.

Awesome. Thank you so much.

Okay. Assembly Member Ahrens, do you have a question as well?

My mic fell off. Thank you. Thank you so much for being here today. My question was regarding the emerging technologies such as AI and where you see the impacts of the industry going? I represent Silicon Valley, and there's been a lot of concerns about how quickly this technology is going to change our lives in the next few decades and was wondering if the board is prepared to address the impacts on patients and the community and the industry as a whole.

Absolutely. And thank you for the question. Artificial intelligence is being adopted in certain areas within healthcare. It's being used for predictive analytics, for responding to patients, for medical decision making. The board has not received a single complaint or concern regarding a licensee and inappropriate use of AI or any other technology. It's always related to direct patient care.

However, the board is watching and seeing the adoption around AI. There is really no universal consensus on how AI should be used within the state, much less the country. I think there's some ethicality issues associated with the use of AI that is still being fleshed out, but certainly the board is very keen and aware of the use of AI and we will be monitoring our licensees for any concerns related to that.

Thank you, Madam Chair.

I have to get your name right. Ahrens. Is that right? You say it to me.

I'm new, so Ahrens. Like I'm running your errands.

I wish. Okay. Thank you for being here. And thanks for giving me some grace on pronunciation of the Assembly Member names. Any other questions? Your name I know, Senator Niello.

Or Niello. Thank you, Madam Chair.

No, it's Niello.

In the mother country, it is mispronounced. I have always believed that the ratio of PAs to physicians restricts access to care, and I think it's a huge deal. I favored more of an expansion back in 2008 when I was in the Assembly, and I continue to believe that.

And given the prescription of their practice, frankly, I'm not sure that any ratio is justified. And access to care should be our driving motivation, subject to a quality of care, of course. But with the education of PAs, the prescription of their practice, I would be in favor of eliminating the ratio entirely.

I would as well.

I got you to step out. Good for you.

Thank you, Senator Niello. Chair Ashby. Any... Sorry. Any other colleagues? Nope. Chair Ashby.

All right. Okay. So first of all, on your presentation today. Great job. I had a list of questions, as did the Chairman. And if you could see our notes, you'd see they are precisely checked off as you went through your list. You did a great job. I do have one remaining question. It's really just an expansion. You touched on this. There's a pretty obvious need for a fee increase on your board.

And you talked about going from 200 to 250 and waiting till now to do so. And you did a good job of laying out why that needs to happen. But the piece I'd like you to just touch on is what have you done to talk to your stakeholders about letting them know that that's coming? What feedback do you have from your members? Is this gonna take them by surprise? Do they know? What are their expectations?

I'm gonna go ahead and hand that over to Executive Officer Rozana Khan.

Good morning. As far as the fee increase, we are currently in the process. We have a packet out, regulatory packet to for a 45 day comment to increase the initial licensing fee from 200 to 250. As far as just raising the caps for all fees that have reached their statutory caps, we've had stakeholder engagements, we have board meetings regarding it. So we have not received any kind of, you know, negative comments or feedback. Again, this will be... Sorry. Yes, it's going to be increased. Increment. I can't even say the word...

Incremental.

Sorry. Yes, incremental increases. Again, it's going to go through a whole regulatory process with comments and stakeholder engagement.

Okay, perfect. We're all struggling with our words this morning. It is ever the Monday up here. Okay, well, thank you very much. I hand it back to you, Chairman.

Thank you, Chair Ashby. Just one last question. Around practice agreement, around practice agreements, is the board tracking other states' efforts to expand access to care by removing requirements for written practice agreement? And if so, has the board formed any conclusions or recommendations or thoughts?

Great question. So the board has not deliberated on the removal of practice agreements. It is a topic that certainly I can bring up in our next meeting. We are tracking what other states are doing. I keep apprised of that along with other board members.

Montana and New Hampshire no longer require a practice agreement or some sort of supervisory agreement after 8,000 hours of clinical practice. Wyoming, North Dakota do not require a practice agreement for a supervision or collaboration with the physician. So there's this movement across states to eliminate barriers that impede access to care. And so certainly it's something that we in California are monitoring, but we have not formally had any discussions or deliberations on that topic as of yet.

Great. Thank you very much. With that we'll open up to members of the public. If you have any questions... Excuse me. For any comments. As a reminder, this is for the Physician Assistant Board, and you have two minutes per person. And if anybody has said anything that was already on your mind, just feel free to align your comments with whoever said that earlier. Go ahead.

Good morning, Chair and Members. Good to see everyone today. We have a concern just with issue number three in the report as it relates to practice agreements and ratios. It's important to preserve an explicit physician to physician assistant ratio in state law to ensure the practice agreement exists between patients and PAs.

On the note of ratios, it's important guaranteeing safe and efficient delivery of care regardless of the setting. Certainly happy to have a conversation around this and appreciate the comments today as well. Practice agreements are also important in defining medical services that are performed by a PA to ensure proper supervision and responsibilities between both professionals.

This also optimizes patient care and collaboration between the care team. We want to thank the stakeholders on this issue and their early engagement. We look forward to working with the committees and everyone involved. And I apologize for not saying my name at the beginning. George Soares of the California Medical Association. Thank you.

Thank you.

Chairs and Committee Members, thank you for this hearing. Thank you for this opportunity. My name is Jeremy Meis. I'm the President of the California Academy of PAs, also a practicing PA here in Sacramento. I'm the Associate Medical Director for Primary Care at WellSpace Health, a local federally qualified health center serving underserved patients. I do adult primary care and also medication assisted treatment for opiate use disorder.

So I first want to thank the PAB's President and Executive Officer for working so collaboratively with us on the regulations mentioned and enthusiastically support extending the PAB. Against the urgent backdrop of our current Code Blue emergency, where by some estimates half the state does not have access to medical care, something we've all addressed already today at this hearing, I want to thank the committees for raising issue number three, which asks those three questions.

And so that I don't go over time, CAPA's incoming President right behind me will briefly answer these questions. So the first question does the current scheme requiring we have a piece of paper memorializing what it is that we can and cannot do and imposing a one size fits all cap, no matter the experience or inexperience of the PA and the physician limiting the ratio, does it add any actual value to patient care? Respectfully, no, they don't.

In fact, not only do they do they not add value, but both of these top down, one size fits all restraints on physicians and PAs being able to allocate limited resources in real time to meet the overwhelming and ever changing needs of your constituents get in the way and impede patient care at a time when we need to be eliminating barriers to patient care, which is why both were waived during the COVID pandemic, which is exactly why states all over the country facing similar unmet needs are moving to eliminate and reform these laws.

So when it comes to so called practice agreements, as the background paper alludes to, such a piece of paper is entirely redundant both of the employee employer relationship, the legal requirements that PAs be supervised, and practice to the standard of care. Which is why seven states in recent years have deleted it for experienced PAs, which is why there's 22 states across the nation now that have no ratio requirements whatsoever.

If you wrap up, that'd be great.

Right. Just want to thank you again, and I'll turn it over to CAPA's incoming President. Thank you.

Thank you.

Hi, good to see you this morning. My name is Sonny Cline, and I've been in medical practice for 25 years. Work here in Sacramento, California, and I work in a combination of primary care medicine and psychiatry, behavioral health. And I can tell you there's a huge need in behavioral health.

And so one of the things I would like to address is this item number three and address some of your questions. And I've been to some of these more rural counties, and I can tell you for sure, one of the things, one of the mistakes I think we make a lot of times is thinking we can make a policy that fits for everything.

And being in California, one of the largest states in the country, we've got to believe that this one size fits all does not work. I've been to these small towns, I've done a lot of medical talks, Eureka, let's go down this Tulare. I mean all these little small towns, one size fits all policy does not work, right?

And so the fact that we have these limits on ratios and this practice agreement issue, I've got 25 years of experience and this is limiting me from walking into your county and saying, I can help you right now. And I want to. I work with children, I work with adults.

And I can tell you right now, nobody wants their 12 year old who's depressed, waiting for four months and may be suicidal to see somebody. That's not okay. And at the end of the day, that's what this is really about, right? Is getting people seen giving people care that need care. Right? And so really, if you look at item three, we're not talking about getting rid of ratios and all this kind of stuff altogether, and no price agreement altogether.

We're really asking you leave this up to the physician, the doctor in charge, who's the typically the medical director, what have you for them to decide on the ground if they need this, how much they need this, and what they need. That's simply it. That's all we're asking for, for these people on the ground in these small towns to to make the decision, bottom line. And that makes sense to me. I think it makes sense to you. Thank you.

Thank you very much.

Good morning. I appreciate your time in discussing these issues for the PAs across the state. My name is Jaye Andaya, and I have been a practicing PA in the State of California for the last 18 years. More recently in an adult urgent care for the past six, providing care for many different communities, privately insured, uninsured and even the unhoused.

As a newer resident to San Joaquin County, I was personally faced with a challenge of accessing and obtaining a new primary care physician after a serious health event in early 2024. Barriers such as a ratio limitation in our practice settings have essentially forced me to establish with a new primary care provider well over an hour away from my new home. Furthermore, that primary care provider that was able to take on my case thankfully just happened to be a PA.

It is through my extensive work experience in multiple clinical and in hospital settings, as well as my personal experience as a patient now that I can confirm updating these ratios and practice agreement requirements for PAs would positively impact medical practices statewide and allow increased access to much needed primary care services. Thank you.

Thank you.

Good morning, and thank you, Committees, for raising issue number three. I am Nancy Hamler, and I stand before you not only as an emergency medicine PA but as a witness to the daily struggles faced by our community due to outdated practice agreements and restrictive ratios.

I'm also a full time PA educator, deeply invested in the future of our profession. For years I've worked on the front lines of emergency care, both in busy emergency departments and now with Sac Metro Fire District Community Health Unit. I've seen firsthand how archaic regulations create barriers to care.

I see patients who call 911 for non-emergent issues, a refill they cannot get, a chronic condition that's flaring up, a simple infection that's spiraling out of control because they cannot get access to timely care and follow up. These are not frequent fliers seeking attention.

These are individuals that are trapped by the system that prioritize bureaucracy over patient well being. And these regulations also impact my students, the next generation of PAs serving our communities. They limit their abilities to fully utilize their training and hinder their employment opportunities. As PAs, as already was mentioned, we are subjected to a standard of care that has the same backstops as our physician colleagues. We're governed by similar employer requirements and limitations.

I must emphasize that the current bureaucratic requirements for ratio limitations and estate mandated practice agreements are a redundant and unnecessary hurdle that, frankly, some employers just don't want to deal with. Some employers will preferentially hire other health care professionals given that they have fewer regulatory hurdles. I'm sorry.

In fact, several of the PA students that I prepare to alleviate health care shortages in California have already expressed their intent to leave California to go to more non-restrictive states. This is our chance to abandon archaic practices and create a better future for our communities. By mirroring the progressive reforms adopted by other states, we can immediately expand access to crucial medical services. Thank you for your time.

Thank you very much.

Good morning. My name is Emily Thatcher, and I am a physician assistant here in Sacramento. I'm also an educator, and I want to just speak from the heart with the experience that I've had. I'm actually a newer resident to California, and I've been practicing as a PA in another state.

So I have the experience of going from a less restrictive state to a more restrictive state, which has been very eye opening as a fairly newer PA. I work in emergency medicine as well. When I moved from North Carolina here, I had a very collaborative relationship with my supervising physician, which I enjoy.

And that's why I became a PA is to work in a team. And the ratios varied on our relationship and what the physician felt he could handle and supervise. And it was a wonderful working relationship. And then moving here, that changed. And then it's mandated by a piece of paper, not necessarily relationship and the capacity of what the physician can supervise. And so as I thought I was moving to California to a more progressive state, it's been a little bit disappointing to move backwards in this regard.

And I'm hoping that we can catch up with other states that have successfully changed this without any increased malpractice or anything else like that. You know, there's not many categories that we're at the same as Texas, but we are the same as Texas.

We have the same practice agreements right now, which is to me, as someone providing medical care, very, very disturbing to me. And I think that we can do better providing more care. I'm excited to be a part of this and be part of this decision. I'm happy to speak with anyone as well. Thank you very much for your time.

Thank you very much. Appreciate it. Seeing no additional Members of the public who want to speak to this issue. Thank you very much for the presentation, the robust discussion, and I'm sure we'll have more conversations over the coming months.

Thank you.

Thanks so much. Next up, we're going to move to the Podiatric Medical Board. Executive Officer Brian Naslund, Board Member Dr. Carolyn McAloon, and Vice President Dr. Devon Glazer, as well as Enforcement Coordinator Bethany DeAngelis are here to testify.

And if you just hit the little mic button right in front of you. There you go.

Fantastic, thank you. I'm Dr. Carolyn McAloon. I'm the outgoing President of the Podiatric Medical Board of California. Joining us on the phone is our Vice President, Dr. Devon Glazer. With us today in person is our Executive Officer Brian Naslund and our enforcement coordinator, Bethany DeAngelis.

On behalf of all of our stakeholders and all of us at the Podiatric Medical Board of California, it's my pleasure to present our highlights and accomplishments since our last sunset review in 2020. Our board works closely with all the stakeholders of the podiatric medical profession in California, which is—has—resulted in improved efficiencies and the following accomplishments.

We eliminated outdated burdensome license renewal requirements. AB 826 was sponsored by the Podiatric Medical Board and updated the licensure renewal requirements for doctors of podiatric medicine. Now, as the same with our MD and DO colleagues, the requirements are: completing our 50 hours of continuing medical education, remaining free from disciplinary actions, and paying our licensing fees.

Additional legislative accomplishments include updates to DPM MD partnership agreements in AB 834, modernizing the limited radiographic permits for those who work in our clinics and offices, in AB 1704, and clarification of the ability of doctors of podiatric medicine to provide vaccines, which was so important during the COVID pandemic. And that was AB 526.

The Podiatric Medical Board of California continues to improve timelines for the processing of applications, renewal, and other licensing matters, through the automated Breeze System, with reported high satisfaction from licensees and stakeholders.

Additionally, the Board has increased training opportunities for doctors of podiatric medicine, by reviewing and approving an additional three-year Podiatric Medicine and Surgery Residency Program in our state. All of us at PNBC are dedicated to our mission to protect the consumers of California.

In service of our mission, we have added six new podiatric experts and consultants to our available pool, to assist the Board with the initial review of complaints through the disciplinary process.

The Board continues to monitor our enforcement costs and works closely with the DCA Budget Liaisons and Department of Finance to increase—excuse me—to address increases in these costs.

The Podiatric Medical Board of California continued to increase our outreach efforts through communications that are shared through our website, our social media accounts, annual newsletters, and ever-increasing listserv, as well as through the California Podiatric Medical Association. In alignment with Governor Newsom's Executive Order N 1622, the Board, Executive Officer, and Staff have been working with the DEI team at DCA Solid Planning Unit.

Surveys were sent, feedback was received, and the goals of DEI were discussed at a board meeting and added to our current strategic plan that runs 2023 to 2027. The Board will be voting on these updates at our next board meeting later this week.

Since our last sunset report, PNBC has continued to comply with the changes of the Bagley-Keene Act, including a hybrid board meeting where attendees in both Northern and Southern California actively participated. This hybrid meeting allowed us to conduct the business of the Board at a significant financial savings.

PNBC has worked diligently to provide detailed information and data, as to our activities and accomplishments, since our last sunset review in 2020. I would—wanted—to give the majority of our time to any questions that you may have. Thank you for your time and consideration.

Thank you very much. And your colleagues are here to answer questions, I take it? Or any intro statements?

Nope, to assist with answering questions that you may have for us.

Great. Opening up to colleagues for any questions or comments. Senator, please.

Thank you, Mr. Chair. One of my questions is in athletics, pertaining to physical therapy and that sort of thing, because we're finding more and more injuries because of the intensity of college athletics as well as high school. Are we reaching over into that field more than ever or how have you—because it's such a need for it?

Fair enough. So, if I understand, how much do foot and ankle surgeons refer to physical therapists? Is that your question? Well, I can speak to my personal experience. I'm very nostalgic this year. It's my 25th year in practice as a Foot and Ankle Surgeon here in California. I send many patients to physical therapy.

They're a great part of the team, as you know, and healthcare is a collaborative team effort. Anyone who can help my patient get back on their feet faster is on my team. So, I refer to physical therapists on the regular, and I know many other podiatrists do as well.

Whether it's after surgery or after injury, physical therapists do provide assistance to our patient care. And so, we are happy to refer to them when appropriate.

And the reason I bring this up is because the relationship with, you know, the pains and this, that and the other, and then it realizes, hey, this, you've got to take this to the next level. You've got to get some X rays, you've got to see a physician, you've got to take it.

Especially with the, with the athletics that are so intense.

Podiatrists, we take x-rays in our office. So, we're physicians and surgeons, we take care of all of that, and then when we need their help, we refer to physical therapists. We're the physician and surgeon.

Good. Thank you.

You bet.

Thank you. Senator, any additional questions or comments?

Chair Ashby.

Thank you so much. I just want to thank you all for being here and for the great work that you're doing out in all of our communities across the state. And your small but mighty team really keeps the ship running, and we're...

They do. Thank you.

We're proud of that effort, from our, from our vantage point here. I'm trying to determine how sustainable status quo is for you.

That is a very important question to us. As you can imagine, that weighs heavy on us as well.

Yeah, well, you do have a small team and a big task. So, you need, at, at a minimum, significant additional revenue, I think, for your licensure program. So, what, what are some of the options that you guys have been looking at? How are you planning to address this? I know you talked it about a little bit.

Maybe you could dive into it for us, what your strategy is, moving forward to sustain.

Your point, your—it's an excellent question. Your point is well taken, and some of the notes that you have noticed already in our report is that we do have a small number of licensees and the fees for the board are—the majority is from licensing fees, and so that the expenses are spread across a small population of people.

We've done—our Executive officer—and he can speak to this portion. Of course, we also want to see what savings we can perform as well. Unfortunately, savings can be painful. As President of the Board, I would certainly have liked to gone to public events to share with Californians the work of their podiatric profession.

We have two schools of podiatric medicine in California. We have many residencies. I would have loved to engage over the—my—time on the board with our schools, with our residencies, but of course, we've had to travel. It's not an expense we can cover because we've had to be mindful about our budget.

We had the hybrid meeting, which was a good use of our budget to minimize travel. And I'm sure our Executive Officer can speak to other administrative ways that we've worked to save money.

Yeah, so PNBC utilizes all available resources for cost savings measures. So, with that being said, we don't frivolously spend money. If you look at our expenditures, we don't frivolously spend money. There's some things that I am not in control of—inflation, staff services, you know, pay raises, investigations, the DAG cost, OAH cost, and then all the pro rata, everything like that.

Let's just wrap it up with inflation. So, I can't really touch all that stuff. What I can touch is how to operate an office, and we do the bare minimum, of what we can, to get by to make it the most efficient office in DCA.

And that's the challenge we have—how many of our costs are fixed, based on being a board of the DCA and the number of our licensees. So, I, I am a licensee myself. I feel the pain. I will also have to pay the fee increase when it comes.

Just to be clear, I clearly do not see frivolous expenditures. I'm just worried about a small budget.

Yes.

All right. Thank you.

Thank you, Chair Ashby. I was—uh, questions along those similar lines, so I'll skip those. A kind of wonky question on the Ancillary Provider Issue that's raised in the background paper—has the Board discussed ways to address issues like the reimbursement disparity between podiatrists and physicians who provide the same services?

Yeah, so this proposal is actually on the agenda for our next board meeting, which is this week. I look forward to those discussions and after which, I'll ask our Executive Officer to send a report back to the Committee after we have those discussions, which I'm looking forward to.

Great. I appreciate that.

Right, this is kind of a new topic that came to us, and I scrambled to get it on our agenda. So, it's kind of like, okay, wait, let's get it on there. Let's have this discussion, and let's, you know, see what the board's ideas are or, you know, if there's—there—may be an action on it.

I don't know. We just haven't had that discussion. So, but we got it on there, so. Because I know it is, it is a pretty good topic.

Yes, I'm looking forward to it.

Great. Well, we look forward to hearing how that conversation goes. I think that's all the questions.

I'll just say, as a, as a longtime soccer player who was born with terrible feet, I'm very grateful to all the podiatrists in California, and especially the ones that I spent a lot of time with growing up. With that, we'll open it up to question—excuse me—to comments from members of the public. You have two minutes each. Come on up.

Good morning, Mr. Chair, Members. Ryan Spencer, on behalf of the California Podiatric Medical Association. First, I'd like to thank the members of the PNBC, their staff, particularly Director Naslund, for their numerous discussions as they work through the Sunset and the Proposed Fee.

Also, a special thank you to Committee staff, notably Vince and Alex, for their updates and incredible work on this report. Now, to be clear, CPMA truly appreciates a critical oversight that PNBC plays in the small, but vital, profession of podiatry and recognizes the fiscal challenges it faces in doing so.

However, we still must regrettably express, express significant concerns with the proposed renewal fee from $1318 to as much as $1950, a near 48% increase.

For many podiatrists, especially in the private practice or just entering the field, this sharp increase would be a serious financial burden, and may deter new providers in practicing in California, at a time when access to care is most important than ever.

While we do appreciate the Board's continued dialogue and fully recognize this decision is not easy for them either, CPMA also can't sit back and pretend such an increase won't have real consequences.

We just need the Committee to recognize this. Now, for the good. We support Issue Number 2, which removed the outdated 10-year Part Three Exam Limitation for out-of-state applicants, and CPMA also looks forward to any discussion around enforcement, timelines, and coordination of shared services.

Most importantly, we want to urge the Committee to give special attention to Issues Number 4, 5, and 6, which deal directly with the practice of podiatric medicine. DPMs may not be physicians by name, but they are by practice.

Their education, surgical training, and clinical work are equivalent to MDs within their defined scope, practicing side by side with other physicians in hospital operating rooms and medical teams across California. Yet, they are too often still treated as lesser than, characterized and treated by some health plans and facilities, as the Chair mentioned, as ancillary providers.

This misclassification is not only inaccurate, it's unjust. It results in unequal reimbursement, professional benefits, and undermines their role in patient care. With the eventual goal of full parity with MDs and DOs, podiatric surgeons must be recognized for what they are—fully trained, highly skilled doctors delivering critical medical and surgical care.

Again, we thank the PNBC for their 10-year engagement. Look forward to continued discussions, but appreciate your thoughtful review on the policies, in light of the fee increase. We urge you to prioritize practice issues in your recommendations. Thank you.

Thank you very much. Seeing no additional members of the public who want to speak. Thank you very much for the presentation today and looking forward to future conversations.

Thank you.

Thank you. The final...

Thank you.

Thank you. Appreciate it. The final item on our agenda today is the California Massage Therapy Council. Here to testify, on behalf of the Council, is Ahmos Netanel, Chief Executive Officer, Mark Dixon, Board Chair, Kristy Underwood, Board Secretary, Andrew Garston, Treasurer, and Alison Siegel, Special Counsel. And we're ready when you are.

Good morning, Chairman Berman, Chairman Ashby, and Members of the Committee. I'm Mark Dixon, Certified Massage Professional Number 13, and I chair the Board of the California Massage Therapy Council. 37 years ago, I left a good career to seek a better one. Completed a thousand-hour massage program and joined the American Massage Therapy Association, or AMTA.

Been a professional member ever since. I have served on the AMTA's California Chapter and National Boards of Directors, as well as on the boards of the other prominent massage industry nonprofits. Now, while I believe AMTA does valuable work, it's important to remember that fewer than 16% of the 50,000 certified massage therapists in California are AMTA Members.

I, and many other AMTA Members, absolutely oppose licensure for massage therapy in California. I believe the Legislature made the right choice when they authorized a certification program for massage professionals, rather than licensure.

The reasons are many, but three of the most fundamental are: first, local government wants an active role in regulating massage therapy. Through MOUs and agreements with local officials, local government's collaboration with CMTC is effective, expeditious, highly educational, and free. CMTC receives no funding from the state or any local jurisdiction.

Second, legislature would be far more expensive for—I'm sorry—licensure would be far more expensive for massage professionals than the current certification model. An independent study, done at the suggestion of former Senate BNP Chair Richard Roth, estimated that licensure would quadruple the fees charged to therapists, from $300 every two years currently, to a minimum of $1,200 every two years.

Third, CMTC is supported not only by California's DA, Sheriffs, and Police Chiefs Associations, but by every major anti-trafficking group. CMTC's collaboration with these various stakeholder groups supports local entities' ability to move much more swiftly than could a licensing board in the battle against exploitation.

CMTC continues to strive to better service applicants, certificate holders and schools, more efficient and cost-effective administration, and additional ways to protect the public.

Specifically, CMTC is pleased to report the following. One, we have rigorously vetted more than 350,000 applications. Two, we've taken more than 13,000 disciplinary actions that would have stagnated with the Licensing Board and upended them financially. Third, we have meticulously implemented fair process and procedure, and fourth, we have, with great pains, protected the public from fraudulent schools.

Five, we have become one of the most transparent nonprofit organizations in the country, receiving the highest possible award—the Platinum Seal from Candid, formerly GuideStar—a status earned by only 00.75% of nonprofits nationwide. Members of the Committee, our team looks forward to your questions. I'll turn it over now to Kristy Underwood.

Good morning, Chair Berman and Chair Ashby. My name is Kristy Underwood, and I'm the Department of Consumer Affairs Appointee for the California Massage Therapy Council. I also happen to be the Executive Officer for the California Board of Barbering and Cosmetology.

It is, in my time serving on the Board of Directors for CMTC, I've come to see the significant difference between CMTC and how Board—like how I spend my, my regular days—um, operates.

As someone who has dedicated over 30 years of my career to consumer protection, I am most impressed by CMTC's ability to take swift and immediate action to protect consumers. I appreciate the opportunity to be here today, and I'll be happy to answer any questions as we go through the hearing. Thank you.

Good morning. I'm Andrew Garston. I am the—I'm on the Board of the California Franchise Association for Massage Envy, and an active member with the National Association. I've been with the Massage envy brand for 21 years.

And the interesting thing about being with Massage Envy, with a thousand locations across the country, and my tenure being as long as anybody that's left in the Massage Envy Network, is that I get to see the national perspective of massage regulation from massage therapists and business owners. And um, it's uh, it's very, it's a difficult industry to regulate.

It's probably—licensing probably works with many professions, because the first criteria is qualification, and it's almost the last criteria.

With massage, because there's so many environmental factors that impact with subterfuge, endangering people with predators, law enforcement, local communities, anti-human trafficking, a licensing board is ill-prepared to deal with all the environment, the community, that goes around a profession like massage. And what we have here with the CMTC is unique.

The people that are on the Board are all here to solve problems, and to make sure that we are serving the public as well as possible, and that the massage therapists that work in our industry are given the best chance to be the professionals that they want to be.

Good morning, Chairman Berman, Chairwoman Ashby, Members of the Committee. My name is Ahmos Netanel, and I'm honored to be here before the Joint Legislative Sunset Committee, representing CMTC. For the past 40 years, I've worked closely with Members of the Senate and Assembly, and their staff, for statewide regulation of massage therapy.

Those efforts resulted in the authorization of CMTC as a statewide oversight body for massage therapists and massage education programs. Today, there are more than 50,000 certified massage professionals in California.

As a private, nonprofit public benefit corporation, CMTC embodies an extraordinary, efficient, and effective public private partnership. CMTC is a self-sufficient entity that has never received any money from the state. We work closely with local governments to advance safe therapeutic massage in our communities.

We are proud of the way CMTC have helped elevate the massage profession and the extraordinary work of certified massage professionals, as independent providers, business owners, and staff in medical facilities and spas. Massage therapy is allowing Californians to live healthier and more fulfilling lives. Our mission is to protect the public.

We are proud of our record of working closely with local governments and anti-human trafficking groups to fulfill that mission. I'm here to answer your questions. Thank you.

Good morning. My name is Alison Siegel. I am Special Counsel to the California Massage Therapy Council, and I'm here to help answer any questions that you may have. Thank you.

Great. Thank you very much for your presentation. I first want to acknowledge that the Joint Sunset Review of the California Massage Therapy Council was moved up a year earlier than originally planned, and I thank the Council for its work to help us conduct the review on this new timeline.

The reason for this update, this new date, or the date change, was concerns that I, and others, shared, that the Council's practice in 2022 was to get through its Sunset Review, and then immediately engage in questionable actions that I think significantly lacked transparency, once it was no longer under scrutiny.

I've been troubled by some of what we've seen from the Council and its Board of Directors over the past three years, and I look forward to a productive discussion about how to address those issues, beyond the scope of Sunset this year.

And with that, I want to open it up to colleagues for any questions or comments that they have. Senator Archuleta.

Thank you, Mr. Chair. Would you elaborate a little bit between your certification versus licensing and the timeline to be truly that professional that you represent?

Every year, the Chairs of every statewide massage regulatory board meet to share and compare best practices for a couple of days.

I've attended 12 of these annual meetings and every year, my counterparts, which are Chairs of 45 licensing boards, tell me about how long it takes and how many taxpayer dollars their DAs and AGs spend to get offending massage license, pardon me, offending license holders, to stop doing massage.

They tell me about wait times on their phones and emails, and they tell me that they have zero interaction with law enforcement, city councils, spa associations, and their own legislatures. And in every case, they are blown away by the contrast between their system's model and CMTC's. To put it simply, we are the envy of our counterparts nationwide.

And on behalf of my profession and the public it serves, I implore you to continue CMTC beyond this Sunset.

My, my question is, someone applying, starting the profession, from the time they start, the time they get either certified or licensed, what is that time frame with background, education, whatever they may have to do, to finally practice?

When we have a complete application, it's usually fewer than eight days between that complete application and a certificate going out in the mail.

Okay, thank you. Assemplymember Nguyen.

Thank you, Mr. Chair. So just a follow up question to that, if an individual is denied certification, what is the review process or the appeal process?

I'm going to ask our Special Counsel to address that.

Sure. So, if an individual is denied certification, once they've been denied, they can seek review in Superior Court by bringing a petition for Writ of Mandate.

Sorry, one more question. So what would be some of the reasons why you would deny their certification?

Sure. So the Business and Professions Code lays out kind of a laundry list of various reasons for denial. Some of those reasons are things like related criminal convictions, things like sexual assault or rape or things of that nature might be related crimes of violence. But that's really a small percentage of what CMTC does.

The vast majority of action that it takes is based on conduct based violations. And by that, what I mean by that is in their law, they have the ability to take it, to take action if someone engages in unprofessional conduct. And there's another little laundry list of various types of unprofessional conduct.

One thing could be engaging in essentially a sex act while performing massage, either on the premises of a massage establishment or another location, for example, in a hotel. When this organization was initially authorized. Senate Bill 731 had language there that talked about not wanting massage to be used as a subterfuge for prostitution.

And that was in the beginning language. And so there are provisions that allow CMTC to take actions for that type of conduct. It also regularly takes actions for things that are sexual assaults. So if a massage client is sexually assaulted by the certificate holder or applicant, it can take action.

It can also take action for other things that are a little more minor. There are some dressing provisions. So if they're dressing in a way where, where genitals might be exposed, that would be something they could take action on. And again, unprofessional conduct covers a broad area.

So there are, if they're massaging the breasts of a certificate holder, the female breasts of a certificate. I'm sorry, of a client, a certificate holder or an applicant could be denied or disciplined. And those are, that's some of the various reasons that they would take action.

But those would be just a renewal. For a renewal, right?

No, no. The way the law is set up, both denial and discipline, it's exactly the same process, exactly the same reasons. So that's what the law specifies.

And this would be during the time that they're seeking the certification, they complete their education, their schooling and whatnot, right?

No, the conduct could have taken place in the past. So for example, someone might have a conviction for something like rape, and yet they might go get the schooling and then seek certification. And that the fact that they have that conviction is something that the council could use to take denial or disciplinary action.

But if that's, that is if that is a reason why they wouldn't be able to get the licensing or certification. The school should know that and shouldn't allow the individual to go through it because they should let them know. Right. That you have this. So you. Or is that.

And let me be clear, the fact that someone has a criminal conviction does not mean that they will not be certified. CMTC has something called criteria for proof of rehabilitation. And it's a document that goes through all of the different reasons and different things that they look at to see if someone is rehabilitated.

For example, CMTC has certified individuals with prostitution convictions. And one of the very compelling things that they've seen and that we've seen in the denial process, proposed denial process, is a very compelling letter from an individual who was previously a drug addict and basically said, I would do anything for drugs, including prostitution.

This individual had prostitution convictions, but those convictions were not in the last two years. They were, you know, before that. And they had very compelling evidence that they were no longer engaging in that conduct.

So by using its criteria for proof of rehabilitation, the council went through and looked at those factors and determined that this individual was qualified for certification, even though they did have that conviction. So the mere fact of the conviction doesn't mean that they're not qualified.

Give me one second. I'm going to go to Assemblymember Macedo, and then I'll come back to Senator Archuleta.

Hello. So I do have a couple of questions. So just so I'm clear, you guys are a voluntary certification, so you can be a massage therapist in the State of California and not have this certification. So what incentive is there to be certified by your board?

So what the Legislature decided to do is to create an option for people to be certified. As it turned out, most of the cities and counties in California opt into requiring people who want to work at local communities to be certified. That's exactly the reason why CMTC in the past 15 years have processed more than 350,000 applications.

It is something that allow certificate holders to work anywhere in the state. And if you are not certified, you have to obtain individual permit for every city and county where you work. So it's very much in demand.

So the council still believes the voluntary model is the best model to follow for this process?

Absolutely. We believe that local government play a very important role, and local communities just have its say in the way they want to implement those rules in their local communities. And the reality it has worked. It works very well.

Okay, my next question is how has the council addressed issues of human trafficking while also making sure you have legitimate operators that you're not overburdening them. Where have you struck that balance to protect the people that are massage therapists, use massage therapists and things of that nature?

Well, as a person who personally entered the field of Massage 45 years ago, I can definitely relate to that. Because prior to Cmtc, the local regulations were very onerous.

We had to be subjected to VD tests and when I wanted to open my first office, I had to go to conditional use permit that cost tens of thousands of dollars. So we are very familiar with what was on the books before, which were rules and regulations that really treated the massage as adult entertainment.

All of that is gone now. Since CMTC was created in California, massage therapies are treated and considered to be health care providers. Actually during the pandemics, the California Department of Public Health issued a statement that they deem certified massage therapists to be alternative medical providers practitioners. What we do is work very closely with cities.

An example of a city we worked with recently, Santa Rosa, in updating the ordinance in such a way that they don't end up throwing the baby with the bathwater. The because you cannot protect the public by punishing legitimate massage therapists. It goes hand in hand.

So we make sure that the rules and regulations that they put on the books are in compliance with state law that specifically say they cannot treat massage as adult entertainment.

Have you guys engaged with law enforcement or local law enforcement, statewide law enforcement of how you can kind of be the stewards to make sure that the bad actors are kept out?

That's a wonderful question. Thank you for asking. Law enforcement is part of cmtc. The California Police Chief Association has a board Member on CMTC board. CMTC train law enforcement. We have a Director of law enforcement relationship relations. That what he does, he's goes up and down the state and train thousands of law enforcement officers.

Also Deputy Das, sheriffs, FBI agents. So we, we work hand in gloves with law enforcement on a daily basis.

Okay, I do have a question. And just so I'm understanding that you guys have review hearings using hearing officers from massage schools. Correct? Correct.

I'm sorry, let me, let me ask, what is the, can you clarify the question?

So you guys review like if there's an unapproved massage school, you guys review those appeals. Correct.

So the way it works is CMTC does have hearing officers. Those hearing officers do review matters related to denial or discipline of a school. And discipline includes things like revocation of a school approval.

And do you think that that satisfies the due process owed to them?

Absolutely. So as an initial matter, we hear these matters very infrequently. So we currently have a matter that was just heard a week or two ago, but prior to that, the last matter that was heard was heard in 2018 or 2019. So it happens very infrequently.

In terms of the hearing officers, CMTC is able to get very, very highly qualified hearing officers for schools. Part of the reason is because it happens so infrequently. So they come in as CMTC employees, but they come in on an as needed hourly basis.

So, for example, for the recent hearing that we had, the school hearing officers, one of them is a Doctor of osteopathy. She's in charge of an online program.

She's former President of amta, which is the American Massage Therapy Association and ncbtmb, which, I don't want to get it wrong, but it's national certification, I think, Board of Massage and Body Work. I'll take it. Thank you. I'm sorry, I jumbled that one a little bit.

But anyway, these people come, we make sure, first of all, they are highly qualified. It's not just someone we get off the street. So that's one individual. The other individual, we had two more. One was the former Executive Director of the Nevada State Massage Therapy Board, who is also a practicing massage therapist.

And the third is a very highly decorated massage school owner who still teaches massage, owns the school, and also is involved in accreditation of massage schools and that review for the accreditation. So we reach out, we make sure that for these officers, it's important that they not have actual bias.

And one of the things that's defined as actual bias is that they have a pecuniary interest in the issue. They're reviewing for all of these individuals. The one that owns a massage school, she's out of state, she's in Maine.

So we try to get people who are not California massage school owners because they're hearing school issues in California. And while depending on where the school's located, we don't believe it would be an actual matter of bias, we don't want there to be a perception of bias because we understand that's really important as well.

So this individual is out of state. And then we also make sure that there is no relationship or personal relationship between the hearing officers who are hearing the matter and the individuals who are having their matter heard. Because again, that's an area where you might have an idea of an actual bias.

One of the other things that's really important is to make sure that hearing officers are not initial fact finders. They are not the ones who initially investigate or look at a matter and make a recommendation as to what should be done because that can also be perceived or seen as an area where they would be biased.

So the hearing officers are not involved in any of that type of activity. They are segregated. They're under the legal Department. They are not under the departments for schools. Esd, the educational standards Department is the one that brings the letter proposing to take action against the school. The hearing officers are not part of that Department.

And given the fact that CMTC is. It's a virtual environment. Everyone works from their own locations. There's not an office where everyone gets together at the water cooler or anything like that. They're segregated. They have. Their contact is with myself as special counsel and senior staff. Senior staff counsel and some of the paralegals, but that's it.

They do not have contact with the initial people who were the fact finders who would review a school and find the issues that might lead to disciplinary action.

Thank you so much. Thank you, Mr. Chair.

Thank you. Assembly Member Senator Archuleta. Yes. I think we have a common denominator here. We're trying to raise the level of professionalism in your industry and I think that's very important. Now is there anything that you can do or we should do? You know, it'd be nice to drive by and see machad therapy.

And there's a sign in the window, Certified licensed therapist. Wow. Then the community. As a mayor, former mayor of a city, former law enforcement, I would like to take my.

My kids that were playing little league baseball or you know, later on in college to, you know, get a good massage before that game or whatever it might be. And to be able to see something on the window, Licensed certified therapist, I think would make me as a consumer feel better, the community feel better.

Have you thought of something like that? Or is that something that I'm missing and it's in play already or is it not.

So? State law does require certified massage therapists to post in a visible place. Their certification of CMTC to make it visible.

Well, that might be inside. I'm talking on the window. Because again, perception versus fact. Perception is always not as professional as you should be. Not you, not the board, but those bad apples that will open up and stay in business for six months and close the doors and off they go to the next city.

So for the profession, would you recommend that we should implement something like that? That it's got to be posted so the consumer can feel confident they're going to walk in and not find anything that would be ashamed of.

Of course. Of course. So we'll be happy to sit down with the Committee and discuss different options. Anything that increase public confidence in professional massage therapists, certified massage therapists, we will.

Fully support because I, I think it's sorely needed. And as the board Members here, Mr. Chair and, and my co Chair, I, I think that would be something that'd be extremely important and I, I think I'm going to look into that and I would appreciate your input.

So we can eliminate the bad apples and bring forward the good apples.

So all of us in the community and also some of the regulations that you'd like to implement that we can in turn make that into a Bill that makes it tougher to open up a practice, as you mentioned, for 40 years, open up a practice that is not going to be part of the Chamber of Commerce, open up a practice that is not going to be looked at as part of the community.

So let's work together in raising that bar.

Looking forward to it, Senator.

Very good. Thank you, Mr. Chair.

Thank you, Senator. Any please. Some Member win.

Thank you, Mr. Chair. So back to the original question. I asked about certification licensure. You'd mentioned that there may be some people who have a criminal record that may or may not, depending on what the situation is. How do we determine, how do we determine if there was any type of biases or not based.

I mean, I guess who overlooks that area? Right.

So who says because of this individual, there may be two individual with the same criminal record, but for whatever reason you gave a pass to this one and not that one and then who oversees that whole entire area to ensure that there's no biases and unequal treatment in providing approval?

Sure. So, so CMTC has a number of different departments that deal with denial and disciplinary matters. There is a supervisor and the supervisor supervises two different departments. It's investigations and what we call brd, which is background review. So essentially if someone has an issue that information comes in various different ways it comes in.

Maybe if they have an application that they're submitting, either a new one or an application for recertification, we get subsequent arrest notices. So that might come in, we might get a report from law enforcement, something might come in through the complaint link.

There's all kinds of avenues and they essentially all come together and they go into, they go to the supervisor for the background review and investigations Department and she reviews one person, she reviews what everything is and she determines if it's something related to a sexual assault that goes to the investigations Department because investigations is dedicated to dealing with sexual assaults.

One of the things that CMDC does is they have a process by which a victim of sexual assault can submit a declaration drafted under penalty of perjury. And CMDC may use that to propose to take action against a certificate holder or an applicant. So if it's a sexual assault, it goes to investigations to get investigated.

And so they work with law enforcement, they work with the victim. They might interview a manager at a massage establishment. They work their cases.

The two that we currently have, and what is always our preference is, and I think has always been what we've had for the investigators are individuals that are former law enforcement who have worked, they call it the sex desk. So they've worked on sexual assaults and sexual crimes. So they are highly trained.

They have a very significant background. These individuals are trained by the attorneys, myself and senior Staff Attorney about CMDC's legal standards. So CMDC's legal standard is a preponderance of the evidence, which is, is it more likely than not?

We kind of talk about it as 51% and they are guided by the procedures that talk about the basis for taking action.

They are guided by the criteria for proof of rehabilitation, which again is a written document that talks about all of the things to take into account like number of convictions, how old the convictions are, likewise number of declarations. For example, sometimes we might get a declaration from one victim, we might get a declaration from multiple victims.

So they look at all of that evidence, they take everything in, they, they reach out to the certificate holder or applicant and they request information from them. So they contact them and then they take all that information in and then they make a recommendation as to what they think should happen.

There are also disciplinary guidelines because we want to ensure that any discipline that is imposed, no matter who it is and when that discipline is imposed is going to be standardized.

So everyone in the same situation is going to be proposed to be having the same type of discipline or denial or revocation or proposed suspension, depending on, you know, whether they're an applicant or certificate holder. So they make that recommendation. That recommendation goes before brd.

And it's a little, I know it's a little confusing sometimes because we refer to BRD as doing two different tasks.

There are some individuals there who are the reviewers of things that are not sexual assaults, but things like criminal convictions or you know, basic conduct based violations or things like they forgot to notify us or fail to notify CMTC about a recent arrest or conviction, things of that nature.

So they're looking at that and then it gets reviewed at what we call a final BRD meeting.

And so the individuals who are involved in reviewing or investigating the matter are not involved in making a decision of whether the individual before them should be either denied, proposed to be denied, or whether they should be proposed to be revoked or have some kind of disciplinary action taken against their certificate. So they make that.

So it's, this is the first level, kind of like the investigators slash reviewers goes to BRD for a final meeting, they make a proposed decision that goes out to the staff counsels and to the attorneys.

The attorneys review at that, at that point, kind of much like, you know, the DA's might review something that comes from law enforcement. And they say, either we think you have sufficient evidence here or we think you don't.

If, if they believe that there isn't, they send it back down and say, you know, go investigate, continue investigation, there's more that's needed here. Or they say, okay, it's free to move forward. In that case, a letter is drafted and sent to the individual. The letter notifies the individual of the proposed decision.

And at this point it's just proposed, it's not final. So the letter goes out and the letter very clearly articulates the legal and factual basis for the proposed action to be taken against the individual. It identifies all the provisions of CMTC's Law and Procedures that are believed to have been violated.

It talks about the evidence and the evidence that supports that and that goes out to the individual. The individual gets that letter. There are specified timelines. They receive the letter, they have the absolute ability to oppose it. And so we're making sure that they're giving notice and opportunity to be heard.

We believe it's very important and there's a timeline on that. Letters are generally sent about 30 days before we schedule a hearing date. In the letter, the individual can oppose it. They are not limited in what they can do in opposition. They can have attorneys and often do.

They can have their attorneys write briefs, which we often see. They can submit whatever evidence they'd like in opposition and they can have a full and complete record. We don't say, you know, like if I'm in court I might have a 15 page page limit. We don't do that.

We sometimes get 50 page briefs from individuals and hundreds of pages of documents in opposition. And then that individual is free to request an oral hearing or a consideration of a written statement. If they do that then they move forward and that oral hearing or consideration of just documents essentially done on the papers happens.

That occurs before dedicated hearing officers. So CMTC has kind of two batches of hearing officers. They have those who specialize in schools and those who hear individual certification matters. All of the individuals that hear the individual certification matters have backgrounds in massage. They've been teachers. They're not, they're generally not just.

So just one question real quick. Sure. You had said that there is one individual that looks at all of these applicants and gets it over to. You mentioned brd. Right. She all.

She, yeah, what she's doing, it's the, the, she's the Director of BRD and investigations and what she's doing is just assigning this gets assigned because it's a sexual assault to investigations or it gets assigned to BRD for review.

Is there a criteria that she takes to say whether or not it gets assigned or not? Because you said she's the one person that signs off on it. Whether she puts it through the review or not or she doesn't.

And let me say she doesn't sign off on it. She's not rendering any kind of assignment, substantive opinion. All she's doing is assigning workload. So she's saying it's a sexual assault. It goes to the investigators. Essentially it's a matter that's, that's not, it goes to the BRD reviewers. So she's not making a judgment call.

So there, there is sometimes for, for things that we call in house clearance, there might be very simple things that we do have two BRD Members that are assigned that review those very simple things. And that is a little kind of offshoot of the process where they review things.

Like for example, people might have a conviction, like one of the recent things. Someone had a conviction because they were trespassing because they were trying to save a tree from being cut down. So I forget the penal code section.

But for those types of matters, the two BRD individuals that hear the matter together is the in house clearance process and they'll decide on those very minor, not related things. Well, that just gets thrown back out. That individual goes forward with certification.

For the other things where there's the potential that there's a substantive issue, it does get assigned by the Director. But the individuals reviewing or investigating are the ones who come up with a recommendation. The recommendation might be, there's nothing here. We don't believe there's been a violation of the law or procedures.

This person can get cleared and then that goes back in front of the BRD final review meeting, where they look at that and say yes or no.

Okay, thank you. Sure.

Assembly Member Recaloza.

Thank you. Chair Berman, thank you to the panelists.

I'm not gonna ask any questions right now other than, obviously there's a lot of interest, you know, in your work in CMTC's stakeholder engagement, which is what I'm really most interested in, especially as it relates to issues around preventing human trafficking, ensuring that consumers are safe, that people who have the license are safe, and how do we really best promote the industry with best practices that I know you are all working on, so I can follow up with you afterward.

I know it's been a long hearing. I just wanted to take a moment of personal privilege to actually welcome a constituent of, of Assembly District 52, Mr. Garston. Nice to see you here and thank you for your work in your industry and look forward to working with you.

And we'll follow up directly to get some of the answers and hopefully work on some of the stakeholder engagement that I mentioned. Thank you.

Thank you, Chair Ashby.

Okay, this has been a bit of a lengthy hearing, so I do have a number of questions for you, too. But I'm going to ask you to be as succinct and brief as possible. And you can, of course, I don't want you to cut yourself short, but let's be. Let's be as brief as possible.

So first of all, thank you for being here today, all of you, and for your work. It is a little bit of a different Committee in terms of the oversight that you have in the voluntary certification. And so you hear some folks trying to really grapple with that.

And I think we all do want to make sure that we're using the board to its best of its ability. So what messaging goes to the students who attend or have completed the education at the programs that the CAMTC has approved?

What kind of communication are you having with those students and how do they know about the hearings that might be available to them or about becoming certified and demonstrate competency amidst questions about their program?

Well, we have ESD Educational Education Standard Division that has monthly school calls, which it's not only open to all the schools, but to the public. Anybody can call in to these monthly calls.

Right. But so when a school is starting to be in trouble, right, Their. Their accreditation or whatever is problematic, what communication do you have with the students at that school to let them know what's happening so that they can continue to pursue your profession at a school that is Accredited or does have a better track record.

So when a school is placed under investigation by Cmtc, that is noted on its website.

And what outreach do you do to the students at that school? Any.

Well, so remember, CMTC certification is voluntary, so it doesn't have the ability or jurisdiction over individuals until they apply for certification. So they are not. Doesn't have the ability to contact students at a school unless they apply for certification.

Right. But if the school has applied for certification and then the school is in trouble, what outreach are you doing to the students?

Again, we have no. CMTC has only jurisdiction over applicants and certificate holders. So we have no way of communicating directly with students at schools because they have not applied with us yet. So we do post it on our website, which is publicly available.

Yeah, it just. I mean, I'm sure you can see the problem there. These students are going to be applying for your program at some point, if they haven't already partially through, but expecting. I went to McGeorge Law School, for example.

If they had lost their accreditation, I would expect somebody to let me know partway through my tuition and experience there so that I could switch to a different school. And I think we, you know, when students head into a school and then that school becomes under question, we ought to do a little bit more for outreach.

But you know what, we'll just, we'll let that sit for a minute.

If I could take a shot at that.

Actually, Mark is okay if I just try and very quickly answer. We do believe that's the school's responsibility. The school has the contact information for all of the individuals. The school is aware of the fact they've been placed under investigation. CMTC does not have that contact information until they have applied for certification.

Okay. Did you want to try to answer that as well?

Just to say thank you for asking. Just to say that we don't know about a student's interest in becoming certified until they apply. We don't have access to them when they're still students or even if they're graduates. They have to approach us and at that point then we consider them for certification.

So if a student applies for your certification having come from a problematic school, what happens then?

They should know because the school is notified when they are students before they graduate. The school is notified that they are under investigation and that they're.

I'm hoping that you're seeing the problem here. Yeah. And your solution. Hold, please. Your solution relies on the school to notify the students that the school is in trouble. If that doesn't happen, then somebody, a Californian here in one of our constituents will have paid to go to a school that is in trouble with you.

And therefore, when they apply for their certification with you because they're trying to do the right thing, that may or may not be held against them. So that's, that's the question I'm seeking for clarity. This is just an informational hearing.

You'll have another chance to maybe circle back on that later and let me know what you think might be a better pathway forward that doesn't rely on a school that's already shown you that they may or may not be a good actor to then go tell their students, which I'm assuming is the basis for their income and revenue, that perhaps they should choose a different institution to pay their, their hard earned dollars to because it might better their chances at a certification later down there.