for it. Well, thank you for taking some time on your last day of your conference. I know that in my national conferences, the last day I'm thinking, this better be good. And I got the roller bag ready to go and back to wherever we're from. I will tell you, by trade, I'm an emergency doctor. And this is a wonderful opportunity to cross specialties in terms of speaking together with you. Now, the intent of my talk is to talk a little bit about Utah state legislation, and then to go to a federal perspective. Now, the reason I wanted to talk about Utah legislation is this. This is a unique year in 2022, and much of the legislation that we faced here in the great state of Utah are going to be similar issues that you're going to face in whatever state or territory in which you find yourself. And it will be different, but there will be some similarities. And so you'll see some topics today that we'll go over on a state basis that may be relevant not only to you as a citizen, as a physician or provider, and also to your, just of interest to you both in a state and national basis. So, as a background, I spent most of my career working for HCA, which is a big for-profit hospital corporation in the United States. Ran the emergency department there. And then I took a few years and worked with the previous administration as a regional director for the U.S. Department of Health and Human Services. So, my region was a six-state area, and I got a chance to oversee things like the CDC, the FDA, NIH, HRSA, SAMHSA, the Indian Health Service, and other organizations, and had a chance to work very closely with them, and been recently working at the University of Utah, where I'm the vice president over health policy. And the other part of my background is I served two terms in the Utah State Senate, also while I was practicing. So, I have a different perspective on things. Now, as many of your legislators will tell you, there's only two things, really, that legislators will do, either in the assembly or when they're in session. And what are those? They're going to figure out ways to spend the taxpayer dollar, and they're going to pass a bunch of irritating bills. And either way, those are the two things that they accomplish. So, let me tell you on this last session here in Utah, two of the things that we were interested in. One was, we were able to get $2 million in ongoing funding for the Rocky Mountain Center for Occupational and Environmental Health, which helped fund at Weber State University and the University of Utah, programs for OCMED training, research, and then working with our workers' compensation group here in this state, which is basically the insurer, the payer for industrial injuries, and work on ways to prevent injury, to enhance the workplace safety, and also to make it more accessible and keep up the quality, which basically are really the things we look for, isn't that right? To keep our access up, our quality up, and our costs as reasonable as we can make them in our profession. So, that was one of the great things we were able to accomplish, and that will be a boon to not only the training, but the research, and working with the community in terms of collaboration and going forward. The other thing we did was, the University of Utah was able to get, since it's a state-affiliated institution, now some of you are academicians and you may work in your local states, and one of the things you have to do if you intend to embark on a big project is to get legislative approval to do so. So, in this last session, we got $400 million in revenue bonds approved to do what? To create a new hospital on the west side of the Salt Lake County, Salt Lake Valley, in an underserved area. And this area, let me just give you an example, it's growing like a lot of areas in the state of Utah are growing, and yet it has a higher density of diversity. And this is where, during the pandemic, which is, by the way, as you know, is still ongoing, unfortunately, where a lot of our essential workers lived. And we often found them living in circumstances like you all know, multi-generational houses, maybe not a lot of bathrooms for, quote, isolation and separation during the pandemic, especially important in the pre-vaccine era. And these were the people that showed up every day physically at work. They didn't have the luxury like some of us to do some telehealth or maybe virtual work. These were there every day and night in their jobs and going forward. Well, what we noticed is sometimes in our ICUs, we would have not only people from the West Valley come up to be hospitalized, but we would have two or three members of the same family in our ICUs because they had no access to healthcare and they couldn't get their isolation treatment otherwise. So in any case, this is an area that's underserved, and so we were able to work together with the legislature and come up with some money to put up a new hospital there that will have both outpatient and inpatient facilities. And the life expectancy, if you go one zip code over that direction, is 10 years less than it is on the east side of this valley, which is unconscionable, but it's true. And you can say for whatever reasons, access, diversity, difference in quality of care, but the fact is, is it just wasn't available. So that's some of the things that we saw, and that was one of the appropriations or revenues things that we were able to accomplish in the legislature. And so when you talk to your legislators, that's one of the big things that they will do is they'll figure out ways to hopefully wisely and smartly spend your taxpayer dollar. So our thought is, and think about this, for those of you who are climate conscious, the people in West Valley, we had 15,000 annual ER visits coming from the west side clear across, which isn't an easy thing to do. You have to almost pack a lunch to get up to the inconvenient place on the hill. Great views, hard access. That's where the cancer center is. That's where the trauma center is. And all of the big specialty services are up there. And then there's Intermountain, which is on the other side. So the people would come, 15,000 emergency department visits. And you think, well, that's not a lot, but that amounted to almost three quarters of a million outpatient visits annually. And for those of you who, again, are climate conscious, 12 million miles in commuting distance. So you can figure out the metric tons of CO2 that that produced and how that will save them by putting a hospital right in their neighborhood complete with surgery, OB, pediatrics, mental health services. Maybe we can prevent somebody from getting as far along in their diabetes. Work with them. Now the other thing is it will bring 2,000 jobs to that area. And as you know, hospitals are frequently, especially those of you who have rural connections, frequently the biggest employer in that area. And so it's going to bring 2,000 new jobs. It will help the local industries in the construction. And the other thing we'll do is we will partner with a lot of the industries which are on the west side of Salt Lake County. And that's frankly where our industry is, right? It's a real dichotomy in terms of residences are on the east side, the schools are on the east side, and our industry and manufacturing is on the west side. So we'll have a chance to work with our med and industrial partners. And so they've been very enthusiastic partners. Well, that's just to give you an idea. So that's one part of your legislative session will be spent in doing what? Well, they're going to be figuring out how to spend your money. Now the state of Utah spent this year a record $25 billion in its annual budget. So you can think if you're in California, that's much higher. But if you're, say, in Iowa, it might be about the same or even possibly less. Now $25 billion, when you think of that in the $1.7 trillion in the Build Back Better America, or the ARPA, multi-trillion dollars. And by the way, Lieutenant Colonel, your national debt is going up every day under the current administration. So just be aware that you're having quite a bit of national debt increase. And so these are some of the challenges we have. But so Utah had a $25 billion budget record. And part of that budget came from what? Well, if you think about it, a lot of that came from federal stimulus funds in response to the COVID pandemic that we are going through, ARPA, and all of the other funds that came during the war. Now depending on what state you're in, most of your state budget comes from what? Well, it comes from personal state income. It comes from your income tax that you pay the state. And it will also come from sales taxes and corporate taxes. Now some states are fortunate enough like, say, the great state of Texas or Nevada not to have state tax because they get revenues from their other businesses. But Utah has a state tax, which is actually fairly robust state tax and federal tax. And so that gave us as legislators even more impetus to do this wisely in terms of that. So that explained a little bit about some of the interests we had in this last legislation that might be germane to you. Now, a couple bills that I just wanted to go over. And this may or may not be applicable to what's going on in your states. For example, HB 127, medical practice amendments, and a similar bill dealt with abortion. And in the state of Utah, if you intend to have an elective abortion, you have a certain period of waiting time. It's about 72 hours where the woman has to go in and wait before she has the abortion. She also has to, under state statute, see a video that describes the procedure, possible complications. And it describes in detail the embryogenesis of the fetus during this time. And so you actually see the fetus grow and you hear the heartbeat. It's for, there's no question, this is informed consent in the state of Utah, which is a red state and an anti-abortion state, let's be clear. And so one of the bills was directed to make that an even more onerous process for the woman to do. She would, for example, be mandated to listen to the fetal heart rate live prior to the actual procedure. And if the physician who happened to do this failed to demonstrate and document this, he or she would be guilty of unprofessional conduct and a $50,000 per case violation, or fine for that violation. So that was some of the issues. This is, and when you hear about possible Roe v. Wade this year, you ain't seen nothing yet. We had demonstration in state capitol yesterday, and you will see this across the country as this becomes more politicized. And if you wonder about judicial activisms, well, this will be a very interesting timeline and episode for us. So in Utah, which is a red state, there were transgender, opposition to transgender, in fact, the very last bill. So the legislature gavels down at midnight on Friday, and at 1130 p.m., before they gavel down, and they had lots of bills, over a thousand bills were proposed this last session, 500 were finally passed. In the last 30 minutes, an amendment was passed to HB 11, which was to prohibit female transgender participation in high school sports. And it made it all the way through the House and Senate. So just be aware that transgender, abortion, other bills like that may face your individual legislators, and that might be coming up in your own states. HB 116 was medical billing. Well, for those of you who are in your own businesses, what this did was arbitrarily state that if you didn't generate your bill, submit it to the insurer or to the patient within 90 days of the visit, for whatever reason, the bill was gone. In other words, you couldn't charge the patient for that. Well, as an ER doc, I found that a little unsettling because sometimes we don't even know the name of the patient, and then even if we do, we have to get the name right, the address right, if they happen to speak the same language as our coders and the people who check the patient in. And so this was a really troublesome bill. We were able to stop that just so we could make that a little more reasonable in terms of what would allow. So be aware, too, that the billing and the cost of medicine are clearly in Congress and your state legislators' minds as they look to your practice. And they will scrutinize your facility charges, your professional fees, and in this case, also the delivery of the invoice or the bill to either the payer or to your patient. HB 224, they say, well, what does that have to do with me? What's this? Scope of practice. Now what you may see in your own legislatures or assemblies is what? Scope of practice bills. As physicians, you're basically, we're told to do what? Practice at the top of our license, to have more people come in and see us quicker in a more timely fashion with good quality and lower costs. Not big, that's a pretty big, pretty big expectations of which we all strive every day to do. And especially with preventative medicine, we want to embark on things that will really help our patients. So what this bill did was actually expanded the scope of practice for optometrists in the state. Now, you think of ophthalmologists, they do like us, they went through medical school, then they did a residency program, and maybe they even did fellowships. And you all treated eye injuries or you've had eye issues yourself. You know exactly how important vision is and how precise this needs to be done. Well, the optometrists are creating a optometry school here in Utah, four-year school, and they'll use laser. They'll train their kids in how to use lasers and then do procedures on the eye. Let's say for maybe glaucoma or relief of like a capsulotomy or something like that. Well, they were going to expand the practice by a number of procedures. And this was opposed by the ophthalmologists saying, you know, the eye is not exactly a place where you can have maybe okay care. This is really so precise that you need to have expert care by residency fellowship-trained people. This bill ultimately passed, and so we were able to stop that. But it will continue to come up because as more and more people want to have that opportunity to practice, whether they're mid-level practitioners, whether they're people from other areas, maybe they enter into compacts. But just be aware that scope of practice will be something that you might see in your own legislatures. Now I'll just stop here for a second. One thing I've noticed is that when you look at the GOP and the Democrats, one of the things I've noticed in the legislature is that the Democrats have often had a, for example, under the Affordable Care Act, health care as a right and have more universal coverage so that patients, when they're sick or injured, can go to an emergency room, go to a clinic, and have care. It seems like a reasonable idea, right? You know, you're sick or injured, you ought to get care. And it ought to be a fundamental right here in the United States, here in the great, you know, the most wealthy country in the world with the best medical care, we ought to have. But you all know our costs, and I won't go into that. You know the disparity of our costs and our outcomes. Well, the Republican Party has often had the opinion of health care is more of a privilege and you pay for what you get, and that there should be more competition, and hence the scope of practice is more competition, right? Get the same health care. And so that was one of the things I noted philosophically, emerging both at the congressional level, but also at the state level. So just be aware of that, that there will be politicization of the scope of practice as we go forward. Now, some positive bills. I just want to point out SB63. This was a bill that basically said, if you happen to have a miscarriage or a stillborn, this bill will grant you a couple days off work to recuperate. Well, you know as well as I know, three days on anything for someone who's gone through a horrible thing like a miscarriage or a stillborn. But for some reason here in Utah, we never made that provision among our payers to grant a woman this time to start the healing process, both emotionally, physically, in their lives. And so this bill actually gave about three days off for them to start. And I thought it was a humane, smart way to go, and it passed unanimously through both houses and was signed by the governor. Healthcare Worker Protection Acts. Now, this is something that we started several years ago. Now, as an ER doc, I've monitored the original bill, which would give first responders and ER nurses and docs protections within their facility against assault. In other words, if you went and punched a nurse in the ER, you went to a class A misdemeanor, for example, from an ordinary punch. It's kind of like punching a policeman. Got some pushback, but we were able to pass that. It worked so well as a deterrent, not to increase crime or, you know, the criminal records of people or make it harder for them to seek care, but it did protect our nursing staff and our doctors. Well, it was so successful that this was expanded to clinics here in the state of Utah and all of our hospital care workers. Now, how many of you have noticed within your inpatient and outpatient hospitals during their facilities, burnout and people who just work force issues? In other words, the nurses are saying, enough, two years is enough of this. I'm out of here. I'm going to go work somewhere where the, or they go to, they become travelers and they'll travel at multiples of their salary to go elsewhere. So we were, this, this really was a very big morale burst due to our clinical care workers and saying, we value you enough that we want to protect you. And believe me, the, a lot of the people, and now I'm, I wore my mask, so you know where I politically have fallen that in that particular idea. But if you force me to wear a mask or you've refused to say, give me ivermectin or something like that, or you won't let me visit my husband or spouse in our ICU. And they became very threatening. And we had some injuries at the, at the university and other healthcare facilities within the state. So this expanded that we think it will have the same event, same effect. It will be a deterrent to misbehavior against healthcare workers and protect you all and your staff from, from basically assault under a lot of these circumstances. HB 63, well, basically this said, employers, you can't force your employees to be vaccinated. So it's a very, it was public health, right? The vaccine versus individual rights. How dare you tell me that I have to be vaccinated to work here? It's my right to choose, right? It's my body. I get to choose whether I get this vaccine. And by the way, you know, does this thing really work or could it cause all sorts of problems? Well, you've heard all the literature on that. Well, we amended that bill so that healthcare facilities could at least be excluded because after all CMS did what they said, if you want to receive Medicare and Medicaid funding, you have to do what you have to have vaccines, right? And if you don't, you don't get the funding. Well, you know, as well as I do inpatient outpatient clinics without Medicare and Medicaid support, it's a death knell for your group. So we're able to exclude them, but we also got it to exclude those groups which would interact with healthcare facilities in sort of a nexus pattern. In other words, if you work for say a laundry service or for a food service, maybe for a plumbing service that came up and had to go to your clinic to work there, and yet they wanted you to be vaccinated, you can be vaccinated because you had that interaction with a business that required that. And so we had to amend that. And as I told the lieutenant colonel here, my son is an Alchemed doctor who graduated from Walter Reed. And so he faced the challenge of how to keep, and by the way, for those of you who are interested, his group happens to be providing some of the munitions which are going over to Ukraine. So he has the obligation to help make sure the workforce, the vital essential workforce in the US Army is able to provide those supplies to go forward. And so that's one of his jobs is to supervise a number of areas. And he's been to Dugway, by the way, to supervise that. Physician workforce amendments. What this did basically was increase residency funding for, well, for residents. And so a lot of times you'll have a DO or an MD student apply for residency and not match because there just aren't enough residency slots to do so. And so these kids will basically be, well, I graduated, now what? And so this will help expand the number of residency slots. And for areas that are important. And so your state and your nation can decide, well, we need more family doctors, for example. We need more OB-GYNs in this area. And we'll help them. So we were able to get some increased residency funding at state and actually funded from the state. And also a forensic psychiatry fellowship that will help just under the mental health issues that we're facing. The CANDOR Act. I'll just talk briefly. I hope none of you ever get sued. I have once in my life, and it was an awful experience. I kept the record because it was so traumatic for me personally. And it was dropped early on in the pre-lit thing. But just the very act of being sued was really distressful. And what the Medical CANDOR Act is, is very simply this. Because a lot of times, when we're as doctors, we'll have an adverse event occur. Doesn't matter what. Let's say, for example, oh, here's one. You never want to be the OB on my, when I was on the ER. I called up an OB one night saying, I did a CT scan on your patient with belly pain. And who's post-op. And by the way, there's a sponge in the belly. And so, you know, he came in and we got the case done. But the point being is, that partnership and communication. We're human. We do the very best job we can. But what I was taught when I was younger, at your age, and able to interact on a daily and nightly basis with patients is, that if an adverse event happened, we kind of clammed up and just said, let's look at our records, make sure they're okay. What the CANDOR Act will simply do, and this has been passed a number of other states, will allow confidential, protected discussions between you and the party that was injured. And his or her family. And allow you to say, look, this is what we think happened. This is how it happened. Because you answer those four questions that the patients always ask, right? What happened to me? Why did it happen to me? What are you going to do about it? And how are you going to prevent this from happening to other patients down the road? Well, you can do that. And it's protected. And if your hospital risk manager is there, and their attorney agrees, you can say, look, we'll cover your lost wages, we'll cover the cost of your medical care, and on. And actually even offer settlement agreements. What they found in other states, and we did here in the state of Utah, is, one, is it increased the patient and doctor interactions, and decreased the number of really expensive lawsuits. And yet patients still got good care. And what you got rid of a lot was the anger and the general damages, the pain and suffering damages, that were so important. So that was why medical candor was. Something to think about. But for your sake, I hope you never go through that. But having done that one time, I thought, oh, my goodness, this is really. And for all the cases, I remember the codes and all the trauma, that one kind of sticks out there still. Medical panel governmental immunity. This is a very basic one. For those of you who serve on a disability determination panel, for your state, this we, what we did is extended the immunity, so that you could serve without worrying about, it's almost like DNO kind of insurance, so that you're covered, so that when you make a determination, they're unhappy. If a suit is brought, you're protected. And so you can put that at least worry, and so you can make more objective decisions on that. So the point of this is, different bills, but they might apply to you in your different circumstances, and they might not, but just some examples of here in the state of Utah. So any particular questions so far? I have a question. On HB344, does the parties meet ahead of time to discuss if it was truly a mishap? Because patient perceptions might not be actual or fact. And in the positions where you're not trained legally, if you say things, you're already One thing I was taught early on is, you know, if you have something bad happen. Let's say, you know how you do a, you sort of refer to, after a code or some event, you'll sit down with the team and you'll talk together about what went on. It's sort of a debriefing episode. Well, I was also taught that, you know, if you have something and say, Dr. Johnson, I had a patient that this happened to, and what do you think? And I've often found that just having that frank discussion, or maybe you're the nurse with whom you worked. So we did this. What do you think? Did we do all right? But just get that opinion. And a lot of times they'll say, you know, Brian, you really, you probably should have done this. And as a result, you'll get that initial hint. And you can sit down with your hospital risk manager. I hope you don't get to know them very well. But once in a while you do, and it helps you to deal with them. And so I think early on you can get a hint of something. And if it's adverse, it doesn't mean that it's malpractice. It just means that something didn't happen the way it was supposed to happen. And something, a simple thing like maybe an accidental perforation in a procedure, say in a colonoscopy, or maybe, you know, a post-op wound infection. And it's not necessarily that you did a bad job. Or perhaps, you know, but it's just something like that. The fact is, is it does improve the communication. It's protected. And the nice thing, and the trial attorney said what? That it is, that they still have the right to sue if that is so. By the, does that help? Okay. And I'll be happy to talk with you offline. And by the way, I do, I did something politically incorrect. And so let me just clarify something. When I, the mid-level provider is an antiquated phrase. It probably affects, it probably refers to my, I don't know, what do you want to call it? Maybe my training, or lack thereof. And so if I offended someone by saying mid-level, let me say for the nurse practitioners and physician assistants, please, let me learn from that. And not disrespect the training and the expertise. We have, for example, at the University of Utah, our team in the emergency departments includes physician assistants and nurse practitioners with whom we work closely together on a day-to-day basis. So for those of you, I apologize, I will retract that particular phrase and I will learn from that. So I'll get rid of that particular term in my vocabulary. So if it's okay, I'm going to go ahead to the next line. And so let's just talk briefly about, in our last 20 minutes, the Congressional Administrative Timeline for those of you who follow this. So, of course, you saw the State of the Union on March 1st from President Biden. And also, on April 16th, the Public Health Emergency, which, by the way, has been renewed. And then as you see above, there's the SCOTUS hearing for Justice Brown is now concluded. And what this slide doesn't have is the SCOTUS in October, and whether it's Roe v. Wade or the other big issues that are being decided. So what this didn't do was affect the balance between the conservative and the more liberal justices on the Supreme Court. But you've all heard about the leaked memo on the Roe v. Wade. So it'll be interesting to see how that goes forward. But of note to all of us is the sequesters are still coming this year, and I haven't heard so far. Have any of you heard if there's been a reversal of those? Because so far I haven't heard. And so that is going to affect our bottom line in terms of whether you're an employed physician, a hospital-based physician, or outpatient physician. And then the prevent pandemics. One of the things I've been really interested in to prevent pandemics is something very basic, and that's the chip, repatriating our chip manufacturing. And the other day we have both air and ground ambulances services up at the trauma center. And we said, well, let's get some new ground ambulances. And this guy said, we have the money finally for it, and we can't get them. But they're backlogged for two years because of what? Because of chips. And so what we're seeing is how strategically important this is. And so the PREVENT Act, both to prevent so we don't have the supply chain issues and how it can support vaccine and other development as we go forward. And then drug and device fee negotiations. I got a call recently from Senator Romney, who is from the state of Utah, and they're talking about remanufacturing versus servicing of medical devices and so how to protect those in the FDA. So this is a timeline as we go forward. And so the other thing this doesn't include is what? That little episode that happened in Ukraine and how that's impacting us as a country. And at the gas station or inflation or whatever, how those are tied in together. And then the midterm elections that are coming up. And so let's talk about those as we go forward. So here's some of the priorities. The SCOTUS nomination is completed. And barring Justice Thomas's resignation or changes that way, we'll probably in October see the same makeup in our Supreme Court. The Build Back America, thanks to the great senator from West Virginia, is currently being renegotiated. And so we'll have to see where that goes. But one of the things that the senator is hoping for is to get a 25% corporate tax and a 28% capital gains before he'll budge on that. And then he wants to bring the figure from $1.7 trillion down. So we'll see where that goes. But given that he's flipped on that and that the vice president has to cast a tied vote, we'll see where that Build Back America goes. Because this is really important to the Biden administration as they go into the midterms. That's ignoring the benefits it might have for us as a country. And then bipartisan health bills, we'll see those going forward. We saw the effect of the No Surprises Act, for example, that was more of a bipartisan effect. Government funding, it's going to look different to you guys. We are not going to have the post-COVID funding like we had last year and the stimulus funds that went out. And one of the things that Utah and other states were beneficiaries of is the increased stimulus funds, the increased sales tax and personal income tax revenues to the state. You won't see that. And then the midterm elections that are coming up. So COVID has basically dominated everything that we've done for the past two years. And whether you're whether you are a fan of the Trump administration or not, they were able to come up with the mRNA vaccines and on different platforms, coming up with the concept of vaccines on spec, which I still think was a was a very effective way to come up with something. And the CDC, which I oversaw, was too inconsistent in terms of our recommendations to the country and everything from masking to going forward on some of our public policy. We're going to see health care systems and providers are going to be really affected by these policy changes, both from a monetary standpoint and from a regulatory standpoint. I don't know how many of you have embarked on telehealth as a vital part of your of your programs, but just seeing on the geographic, for example, the the approvals for those and then the extension of the telehealth is going to be a big cost going forward. There'll be more transparency. We saw that and no surprises. Right. You're supposed to come up with a bill from the hospital to the patient right off to give them a fair estimate of their costs. Data interoperability, and we've seen that in value based health care, integrated health care, this data interoperability that is going to be so crucial as we go forward. Now, I don't know how many of you are at a hospital based hospital, and so I apologize for giving a little bit of a biased perspective because I am hospital based, although we support our outpatient hospitals a lot. But the hospital, frankly, has done pretty well as a result of the federal stimulus funds and. The hospitals are going to see that those funds retracted a lot and in a couple of ways, the sequesters are going to hurt because that went through under the pandemic and the FMAP. For example, Utah has a six percent FMAP and the federal matching fund, and that was forgiven by this by the feds. And so the state of Utah got a six percent boost to all of its Medicaid funding at a lower cost to the state. That's a big change accounting for tens of millions of dollars to Utah in terms of the of the income. And then the telehealth is going to evolve and that's going to be a permanent part, just like our virtual meetings are going to be are going to be a big part of our of our going forward. And they'll be interesting to see what the public health leaders and policy this this. I have never seen our CDC, for example, and NIH have so much national attention, but also be so controversial in terms of of the policy that they develop. And then, of course, our midterm and congressional elections are going to have an impact on where we go forward. Now, I'm going to date myself because I remember this guy and I don't know if you if you recall, but I'm just going to give you a perspective for you young folks in the audience. When Bill Clinton started his campaign, he was really one of several Democrats, if you remember this or who was fighting for the Democratic nod. And who had heard of this governor, this obscure governor from the state of Arkansas? And George Bush made a famous declaration. Remember what he said? Read my lips when he talked about taxes. Well, what did he do? He raised taxes. But the other thing was and James Carville is famous for this. He said, it's the economy, stupid. And what was going on during the Bush administration? Inflation, 12 percent inflation. So you look at our inflation, you think, well, you know, it's 8 percent. It's and you see how we're we're we're abiding by that, imagine under 12% inflation. And you saw what happened as a result of that, and Bill Clinton became a two-term president. He had an interesting presidency, but the point of it is, what it was said then is probably gonna affect us as we go forward to the mid-terms. And now Utah is a state that's very red and it's gonna stay. We're not gonna see, for example, Senator Lee lose his job even though he's got a couple primary contenders. He's gonna go forward. And you'll see the House in general, meaning the House of Representatives, from everything we're seeing, will probably lean redder, lean more GOP as a result of the mid-terms. But if you follow the Senate, and let's look where you're from, leaning Democrat, if you're from the great state of Hampshire anybody from New Hampshire here? Well, if you happen to have the last name of Sununu and you ran for the Senate, you'd probably win, and that would flip to the GOP side, but it's probably gonna go Democrat. And we can go down the lines. You see the open seats in North Carolina and Pennsylvania. This last election, basically the phrase was, how many of you from Pennsylvania? Okay, well, basically the last election is whoever gets Pennsylvania gets the election. And lo and behold, Biden flipped Pennsylvania and was able to win the election. And so Pennsylvania's got an open Senate seat, Wisconsin, Arizona, Georgia. This'll be interesting to see in Georgia. Stacey Abrams' run for the governor there in Georgia may affect Senator Warnock's bid there. And do you know who the leading Republican is in Georgia? Any idea? Yeah, Hershel Walker, go figure. I remember him, we used to carry the ball. And he's had a kind of a checkered past. He's got child domestic violence, sorts of allegations, and yet he's leading the Republican PAC. And so it's gonna be a toss-up in Georgia. And so we'll have to see. Nevada, Laxalt is running, and we'll see where that goes. And then you've got Ohio and Florida. They're probably gonna be GOP. So the Senate's gonna be tough. You could end up with the same, basically almost the same makeup. But if the House flips to the GOP, then you're gonna basically have a divided chamber, right? You're gonna have one Democrat and one Republican, which will affect especially the Build Back Better America bill and other expenditures as we go forward. So this is just an idea on the midterms, and just something to watch for. And so I challenge you to look at your own elections and where they're going. So just let's summarize, and then we can get you out of here after a few questions if you're interested. State legislature and Congress are gonna be redder this fall. Just plan on that. There's gonna be, and your state might be immune to that, but as a country, we're gonna see more GOP. And as a result, that's gonna affect your healthcare policy. Everything from your reimbursement to your scope of practice, and to how the funding goes, both in Medicare, Medicaid, and your payer mixes. And then state and congressional budgets are gonna be tighter. There just is. And what Utah has a record is not gonna benefit from the stimulus funds and the federal stimulus funds like we did before. And so there'll be potential cuts. You, for example, might not see an increase in your Medicaid funding, and I don't know how many percent Medicaid you happen to see, but you could now see cuts in your Medicaid funding. You're gonna have the sequester effect through Medicare, and you might see your commercial payers and your industrial payers also cut back their funding. So I'll just give you a general perspective. Be aware of that and be forewarned, and that'll affect our reimbursement accordingly. Well, that's all I have for this presentation. We're at 45 minutes, and I can take a few questions, and then I'm comfortable letting you get out a little early on this last day of your conference. But go ahead, sir. Yeah, it's on. I'm Peter. I'm former Chief Medical Officer of the state of Wisconsin for five years. And by the way, sitting next to me is the Chief, the Surgeon General of the state of California, Dr. Katz. So we've both been in state government and different things. And now I'm the Policy Director of the VA for all the military exposures. I just wanna highlight the fact that there are 15 congressional bills right now looking at the environment in Congress, and 10 of these focus on veterans and or service members in particular. One of these is very likely to pass in some form. It's called the PAC Act. It's huge. It will completely change how we do presumptions and exposures, and we'll create an independent body, sort of like an independent national academies in environmental health medicine. It also is regulating our training. We actually just started doing a training in accreditation certificate for environmental health with American College of Preventative Medicine right now. So there's just a lot going on. We are so busy, and the agenda is so big, but there's a big push to get a lot of good things happening. The other big area is PFAS, where we have a White House liaison, Dr. Tara Vinson, a senior toxicologist, and we have about 15 initiatives and or bills going on with PFAS right now. There's just a lot going on with those two entities. So I just wanted to mention that. Thank you. Well, I appreciate the information and perspective, and we didn't talk about specific congressional legislation as go forward, and I will tell you whether the VA is a unique organization, and I wish it were apolitical, but it does get affected to a certain extent by the administration, and so hopefully, if you've got some very meaningful bills. You know- I would just say, I'm not gonna go into this policy one way or another, but our current secretary is actually the former chief of staff of the former Obama administration, so he knows how to get things done. So we are, there's a lot of stuff that's happening without legislation, very rapidly, very quickly, on a policy level, because of that experience. Yeah, one of the great things we have at the University of Utah is our faculty and residents train at the VA, which is right across the street from our campus, and so we've had a great opportunity to work with the VA and their physicians, a lot of whom are basically sort of cross-labeled, but it will, going forward, and yes, a lot can be done legislatively, but a lot can be done administratively, as you know, and administrative rule can affect a lot of our practices, both on a state level and a national level. It'd be interesting also, we'll see how the great state of California is impacted as we go forward and affected by the midterms. Any other questions? Yes, sir. And I will thank you ahead of time for your service. Well, thank you, thanks for the talk. Your son actually rotated through my clinic, so I run the Occupational Health Clinic at Hill Air Force Base. Something that maybe you can take, elevate for us, is federal workers' compensation will only allow medical documentation from an MD for workers' compensation claims. Here in the state of Utah, nurse practitioners, PAs are practicing with more autonomy, and it's really delaying a lot of what we care that our patients can get, because the federal workers' comp won't accept those medical documentations from those PAs or nurse practitioners. So we're running into a lot of delays on getting people the care that they need and return to work. Well, that's a very practical suggestion. You've got to change that. Let's say it would increase their access, increase the timeliness of their care, probably lower their costs. Well, naturally, the Republicans will refuse that. Sorry, I'm a GOP, so I can say that. But thank you for that suggestion. And that's actually, that actually, and this might be something that you can do in your own states, and that is that you can find areas like that, approach your legislators, do it during the interim session, whether it's the assembly, or you can do that during a session, and actually either get an administrative rule, or you can actually get some sort of legislation to do a little tweak like that. Something as simple as that should be very actionable. So thank you for bringing that up. I'm gonna give you my card. And by the way, you'll have all my contact number, and so you can give me your hate mail, too, for this. And frankly, I'd appreciate your feedback, because policy is tough, it's political. And so I may present something that is, that you're basically seeing from one point of view, and so it may not be right, but I'll give you at least some perspective from a lot of the people I'm hearing on what to expect going forward, both on a federal level, but on a state level. And it's gonna differ state to state, but a lot of the same issues are gonna be germane. Anything else? Ma'am, why don't you, since we're on, since we're supposed to be doing this virtual, why don't you come on up to the, Lieutenant Colonel, you're welcome to come up, too. And identify yourself. Hi, I'm Ronit Katz. And you are the? I am the physician from the California VA, RISC, and I'm a professor at Stanford and a NASA consultant. Quick question, how are we gonna protect physicians who are doing telemedicine? Not necessarily the federal, because we are so-called protected, but many physicians, due to the pandemic, ended up doing telemedicine, which can be cross-state, and how can we protect physicians who are in private practice? Elaborate a little bit on what you mean by protect. At the beginning of the pandemic, we were told that if you're doing telemedicine, you're protected from malpractice lawsuits. Now, being an official with the AMA, I hear quite a few physicians complaining that they are in private practice, and their malpractice insurance has gone up because they are worried about malpractice issues. Over. I don't have the complete answer to that because interstate and licensure and the compacts that we're doing, and that might have to be that we're going to have to even talk about interstate liability compacts so that a neurologist doing telemedicine out of, say, Stanford, doing that for a rural Utah community, can still practice her or his telemedicine and do that without, and under the same standards of care and be protected. So that's something that we ought to have to look at, but that's a very good observation. And we'll put the chilling effect on our telemedicine because why are you going to do this if you're going to get sued, for goodness sakes? And then, plus somebody from Arkansas that might sue you. So yeah, that is something. That might be actually something for a national talk about if we're going to, and we could even look at an amendment to the Prevents Act because that talks about telemedicine and also talks about how we continue telemedicine going on. Now, the pandemic is going to, we did get an increase since the PHE got sustained. And President Biden, given this Omicron sub-variant blossoming all over, you saw what it did in New York recently, they may push the PHE out a little farther, but that only kicks the can down the road, to quote. And that still means that we may have to get, maybe we'll have to engage our great senators, maybe our VP Kamala Harris engaged a little bit on something like this. So we should have further offline discussion on that. Thank you, especially since in malpractice lawsuits, it's the standard of care in the community. And if you're practicing interstate, there's a problem because it might be that in Arkansas, the standard of care is different than in Palo Alto, California. Over, thank you. Yeah, thank you. That was a very astute comment. I do have a co-pilot with me right now. Sorry about that. Welcome, welcome both of you. So my question was, is during the pandemic, when I've been tracking some of the complaints against providers for professional issues with different boards across the nation, the rate of complaints against providers during the pandemic has exponentially increased. And for the longest time, the different boards of medicine, their primary objective is obviously to protect the public. And I respect that and I support that. However, I don't think that there's adequate and sufficient consideration for the healthcare providers who are being put into extreme situations, especially considering the pandemic, and they're human beings. They have greater amounts of stress, more error is gonna happen. And unfortunately, we are seeing a much greater rate of complaints and issues and on a broader spectrum being brought to these boards, and there's no protection or rights or judicial process for these providers. And I would really like to see in the future that instead of shifting more and more of this onerous burden on healthcare providers, that we make it more of an equitable field. And I don't know how to change that. I've reached out to different senators, I've reached out to different governors to try to get support. But of course, the pandemic has been extremely burdensome, but I have dealt with that with my APPs, I've dealt with that with my physician companions. And to be quite honest, it's as burdensome, if not more mentally and psychologically distressing as an actual malpractice case. And a lot of our malpractice insurances don't cover or support you during a complaint with the board. And it can take on average three to five years to resolve a board complaint. And oftentimes, a lot of healthcare providers leave medicine after that. First of all, thank you for bringing that important point up and that's something that we... Obviously, it resonates with a lot of people. And that's one of the things we're all subject to because we all like our board certification. And in a way, we are afraid or respectful of our boards. So that's something that our med board I look at, our family, our primary care boards I'd look at going forward. Don't have a short answer on that, but that follows up with the same issue about liability and complaints. And you've seen that too. I had a patient complain on the phone, an elderly patient basically said, I hate this. I can't get my questions answered because I'm not there in the room with the doctor. I don't know how to use my computer. And so those complaints come and not because the doctor didn't care, but we didn't dare bring her in because of her conditions and expose her to the hospital. Expose her to the, well, you know how that is. We have to be careful with that interaction, but thank you for that. We'll take notes and go forward. Thank you, I appreciate it. And if you have any tips of who I could talk to or work with, that would be great too. Cause I've tried really hard. All right, we got a couple of minutes. Dan Curlin. And thank you guys. This is a great opportunity to interact with you. Go ahead. Yeah, Dr. Shiozawa, thank you so much. And I apologize to everybody. I may be the one that keeps us from getting the early time you were trying to give us, but my question is in today's, in our current environment, what can we as practicing physicians, understanding the active duty may be slightly different, but what can we as practicing physicians do to advocate for good policy, good legislation? You know, obviously, you know, being in the state Senate is a great way to do that, but that's something that many of us may never do. What are some things in our current environment, our current situation that we could do? You'd be surprised how often that question is asked because you think, well, how do we impact policy or do we feel helpless and frankly victimized by some bad decision? You know, the people are elected, just aren't, there's nothing special about us or them. You just happen to run for office and be lucky enough to get elected under the circumstances. First is know who you are. You guys, as doctors and providers, have a lot of expertise that most people don't have. And that earns a grudging respect from some or outright respect and should get a lot of respect from your legislators and policy makers. You should, you know what's going on in your respective fields. And so that's the first thing, know who you are and what you can do. But the second thing is know your legislators. Do you know who your house rep is? Do you know who your senator is? And if not, you should. And then the third thing is, if there is something this big, whether it's advocating for liability protection in telehealth or for complaints to your professional society because of just, you're trying to help out, that's something that you can identify. For example, let's say you were my congressman or my senator. I would say, I have to be brash, is I am a voting constituent of yours and I am also an MD or maybe I'm a nurse practitioner, whatever, and just say, this is my concern. And believe it or not, that does help. And so just doing that, and that does help doing that. Now, sometimes you have to get elected. Okay, that helps. I was told to, when I ran, I said, you really want to be effective? Don't be outside the chamber, be inside the chamber. But that's not easy thing to do. But the other thing is, is I did listen. I'm a voting constituent. And so that's one thing to remember. Get to know your legislators, get to know the issues, remember you're a doctor, and that does make a difference because you know what you're doing. And you hope that your legislator has some ethics and concern about public health, right? I mean, after all, that's why they're elected for the public good. Sir, you had a question? I'm sorry, I'm kind of out of time. I want to make a comment on that. Somebody like Lieutenant Colonel could apply for congressional fellowship, and there's also presidential fellowship. We have DOD people working on the Hill and with our agency right now, and are doing projects for the VA. So if you're really interested in that, that's a career-shaping move, and you can get into those fellowships. They're competitive, but not unduly competitive, people get into them. I just want to mention that. Okay, so another resource. All right, you guys, we're almost on time, so we'll end here. And I want to thank you for your attention today. Have a great travel and a great conference. Thanks very much.

Utah legislation

federal perspective

occupational and environmental health programs

underserved area

medical practice amendments

abortion regulations

Congressional Administrative Timeline

healthcare providers

congressional fellowships