Hello, everyone. Thank you so much for joining us today for the State Advocacy in Action session during DO Day. Our focus will be on confronting scope battles and the evolving additional licensure pathways that impact osteopathic medicine and patient care. I'll also share insights into the AOA's state advocacy strategy and the work our team is doing to support physicians and our state and specialty affiliates in these efforts. I'm honored to be joined by Dr. Shannon Scott-Dito, a member of the AOA Board of Trustees and who previously served as the chair of BFHP and is also past president of the Arizona Osteopathic Medical Association. And she will provide a deeper dive into the commission on additional licensing models and the trends emerging in her state. And at this time, neither one of us have any disclosures to report. So I have listed three key objectives, and those include understanding state-level legislative trends, discussing the impact of additional licensure models on physician practice and patient care, as well as identifying key advocacy strategies for engaging with legislators. So hello and welcome. Thank you so much for joining us in our session today. My name is Brie Schmidt, and I'm the Associate Director of State Government Affairs at the AOA. I oversee advocacy efforts across all 50 states. Our team tracks legislation. We create and support advocacy campaigns and collaborate with affiliates to address pressing health care policy issues affecting the osteopathic profession and our physicians. So today, I'll go through an array of different things, including some foundational aspects of legislation at the state level. I'll go through our 2025 state priorities, some key trends, and how we're addressing challenges, as we had talked about scope creep, some licensing reforms, and artificial intelligence. And so what is the significance of state legislation in health care? So we know each state is a patchwork of regulations, and no state is similar. So if you look at telemedicine and accessibility, some states continue their emergency COVID-19 waivers. Some have made those permanent. Some have allowed out-of-state physicians to provide telemedicine services. If you look at Medicaid and their expansion decisions, some states have approved, and others haven't, and going into vaccine mandates and varied rules. And so I wanted to just give you a little bit of understanding on kind of the legislative process at the state level. I'm not going to spend too much time on it, but there's an idea. A bill is drafted and introduced into the chamber, and the chamber is either the House or the Senate. And when it is in the chamber, it can have hearings, and it can have hearings at the committee level. And if the committee has no changes, they then can pass it to the floor for the entire Senate or House to vote on. And if nothing is wrong with the bill, it then gets sent to the opposite chamber, and it goes through that exact same process. And so if both the Senate and the House agree on a bill, it gets sent to the governor. And a vetoed bill, so the governor, say, likes it, then they sign it into law. And if a vetoed bill by the governor, it goes back to whoever introduced it, and the bill moves to the second chamber for its reconsideration. And if it doesn't, the bill dies. And so that is just a little bit of background on legislation at the state level. And so going into our legislative priorities, our state advocacy strategy is guided by the Council on State Health Affairs. They are one of the many, they are one of many bureau councils and committees at the AOA, and they set our priorities and positions. And of course, those are always based around our House of Delegates, which happens in July. And so as you'll see on the screen, we have eight overarching 2025 state priorities. And they stay fairly flexible and are called our overarching buckets because we want to make sure, and as I said, at the state level, it's a patchwork. So we want to make sure we can comment on them and that we have policy that supports that. And so some of those priorities include scope of practice and new licensure types, osteopathic equivalency and recognition, truth in advertising, public health, physician workforce, telemedicine, prescription drug misuse, abuse, and diversion. And the newest one added in 2025, and I'll go into a much deeper dive into it, is artificial intelligence. And so we keep these priorities broad because state level legislation varies, and we really need that flexibility to respond effectively and to be able to assist our state affiliates. And as you'll see, the current priority boxes on the screen as well, these are very high priorities on our list, which is fighting that non-physician scope, supporting osteopathic equivalency and recognition. And we'll talk a little bit more as well about this when it comes to osteopathic equivalency with boards and for medical board mergers. And so year after year, we are now seeing board merger bills, but also non-physician providers pushing for more authority. And these efforts are becoming more aggressive. They are not only asking for less education and more responsibility, they're asking for independent practice we're seeing as well. And so we work really hard to help educate legislators about the training differences and advocate for that physician-led care model. And I will continue to reiterate today, we really want to make sure we're supporting our state affiliates so that they have all of the necessary tools they need to work towards either supporting or opposing bills that affect the osteopathic profession. So as I was saying, the Council on State Health Affairs guides our policy priorities every year, and we get that from the policy compendium, which you'll see on the screen here, is this vast array of policies that the AOA has passed and continues to use in our advocacy actions. And so you can go onto our website and track the resolution from now till I think like 2016, 2015 even, you can see kind of what we've done. And it just serves as a comprehensive research and resource tool for tracking the status of past resolutions from the AOA, which will allow you to kind of conveniently check progress of the resolutions, utilizing various search criteria. You can check it out based on the year, the resolution number, actions taken, and current status. So I want to go into a little bit more information on what it looks like to submit a resolution for the House of Delegates and what that policy development looks like. So as I was just mentioning, is there already existing AOA policy? And as the diagram on the screen will show you, if there is, then current AOA policies are sunset reviewed every five years. And if there isn't one, then either a bureau, council, or committee, or affiliate organizations are able to submit resolutions to the AOA House of Delegates. That happens every July. And those resolutions then that are submitted are reviewed by the Board of Trustees and our reference committees. And folks are able to submit testimony. And then the reference committees make those recommendations to the House of Delegates. It is then brought to the whole House of Delegates floor and it is voted on. So if it's not adopted, the resolution is either fully outright rejected, or it is referred back to the author for revisions. If it is adopted, the policy is added to that compendium that I was mentioning on the previous slide. And then it is reviewed every five years, similar to if we already have policy. And all policies are reviewed or updated by the AOA's bureau, council, or committees. And the sunset review is an evaluation of the need for its continued existence. Some years we reaffirm some of those policies, other years we edit them because we know how ever evolving the healthcare landscape is. And so we want to make sure that we're staying abreast of all of that new information, technology, etc. when it comes to our policies. So I had told you I was going to go into a little bit more about our new 2025 priority, artificial intelligence, which was to support awareness and appropriate use of AI with the physician retaining ultimate responsibility for clinical decision-making and patient care. And during the 2024 House of Delegates, a new resolution was passed, H.429, Artificial Intelligence and Healthcare Report and Action Plan. And also in 2024, when we really started to see states take on artificial intelligence at the legislative, at the state legislative level. It had kind of been in talks for quite a while, but we saw an FSMB policy, we saw the North Carolina Medical Board, as well as a few bills I'm going to go into a little bit more. But the FSMB AI guidelines came out in April last year, and it really emphasizes the responsible and ethical integration of AI into clinical practice while ensuring patient safety and professional accountability. It also, AI has the potential to improve diagnosis, treatment, documentation, and efficiency, but it requires clear governance and oversight in mitigating risks. And the guidelines also included really specific focus areas such as education, human accountability, informed consent, data privacy, liability, expert collaboration, and ethical governance. So it goes very deep into it, but they were one of the first to really put out clear and thorough guidelines. And then last year we saw North Carolina's Medical Board post a physician statement on AI and telemedicine, which was the first we saw specific to telemedicine. But it emphasized that telemedicine must meet the same standards of care as in-person medical practice, and that physicians must retain ultimate responsibility for the patient care when using AI. It also underscored that AI tools should support and not replace clinical decision making, and that licensees must understand AI's limitations, including the potential biases. Additionally, medical records, patient confidentiality, and the continuity of care must be maintained when utilizing AI. And the last one was also very interesting is, and AI-assisted diagnosis must be evidence-based and meet established medical standards. And so this was the first Medical Board to kind of come out and really discuss AI and the potential it could have, but also some of the limitations specifically within artificial, or specifically within telemedicine. Georgia last year had HB887, which it did not pass, but it prohibited the use of AI in making sole decisions regarding insurance coverage, healthcare, and public assistance. It required human oversight and review of any AI-influenced decisions. And so going into a little bit more on these three specifically, they really laid the groundwork for a lot of legislation coming up this session in 2025. But California actually passed SB1120, or the Physician Makes Decisions Act. And this was really considered a gold star standard when it came to AI and healthcare legislation. So it ensures that health insurance coverage denials cannot be made solely by AI algorithms. It also must involve human oversight. And the California Department of Managed Healthcare is responsible for enforcement, auditing the denials, and imposing fines for violations, with strict guidelines for coverage decisions. And this is where it was very surprising for the passage, and that it included this, because those strict guidelines said that they had to figure out deadlines for insurance decisions, five business days for standard cases, 72 hours for urgent, and 30 days for retrospective reviews. And so because of that, it drew national attention. Guidelines were incredible to people to use and introduce legislation, but because California was able to pass it, it drew such national attention. And currently, 19 states are considering similar legislation. And at the federal level, policymakers have also started using that to explore potential models in the future. And a little bit more information on AI and healthcare. I'm going to show you quite a few maps today. And I know it looks like a lot, but because states are such a patchwork of legislation, it is easier to show you kind of what it looks like on a map, because everybody is so different. And I told you 2024 was really the start of when that legislation took off for AI. And 19 states this year are currently considering AI legislation. And what we're really seeing, and what we want to make sure of with the AI legislation, we now have AOA policy, as I said, that was approved in 2024. So we can now use that policy as our basis for commenting on legislation that may affect a position or their practice. And within that AI legislation being filed, we are seeing kind of four main categories. And that is the use of AI and utilization review, transparency and disclosure requirements, AI generated communications, patient interaction, and consumer protection and high risk oversight. So with the use of AI and utilization review, that really encompasses anything related to insurance companies. Most legislation that I'm seeing really says utilization review or denials and insurance coverage, things like that. So that is kind of all in that category. And we weren't sure kind of what the legislation would look like this year, because this is still so new at the state level. We were unsure. But I think these are really great starting points for legislation and healthcare. And one more that I would also, I guess I'll touch on all of it, the transparency and disclosure requirements was really so that people knew or know that AI is being used, either with their insurance company. So if they are waiting for an insurance coverage, or utilization review that they know about it, and that companies are using AI, that they are disclosing that not only within the healthcare space, but within most of the economic space. And number three, that AI generated communication and patient interaction. There's a couple bills specifically stating that if a healthcare provider's office is using AI generated communications, so in instant email responses, or you are chatting with a representative on a website that you know that is an AI computer system utilizing that and you're not talking to a real person. And then number four, that consumer protections and high risk oversight. Those really go into the nitty gritty detail of who is submitting or AI algorithms. Are they looking at are they they also have to be reporting biases that if they're seeing it, how they're fixing it, and making sure that there are protections in place for people who are useful utilizing this. I would also just like to kind of note as well that we are a part of the Joint Osteopathic Organization Leadership or JUUL, which includes OSIMR, AACOM, AOA, COCA, and NVLME. And we have created a working group on AI, and we'll continue to monitor this legislation on AI and healthcare in the JUUL group. So I wanted to give you a little bit of a state update on who is in session, who is not in session, because it does change very quickly. In 2025, all 50 states will hold regular legislative session, and currently 48 are convened. We are seeing key trends that we kind of are seeing every year. One that's a little bit newer in the last couple years is a push for deregulation at the state level, but it's also because we're seeing that at the federal level. Medical board restructuring and consolidation efforts. So I have a whole slide on this one. We are seeing a lot more of that within the last few years. Medical liability reform, tort reform. I went into quite a bit of detail on AI integration in healthcare. Continued non-physician scope expansion, and this includes physician assistants, nurse practitioners, nurse anesthetists, optometrists, podiatrists. So any of those non-physician clinicians are really looking to continually advance their scope expansion. And that is not the extent of them, but that is a large portion of those practitioners. So going back a little bit to the push for deregulation, a number of states have established their own committees that mimic the Department of Government Efficiency, or DOGE, at the national level, as we know it. So for example, I'm going to pick on Arizona a lot today, and I do apologize. They just have some great examples. So in Arizona, for example, the Regulatory Affairs and Government Agency, or RAGE, committee has been established, and it has been supporting a few of the following bills that I'll describe, which is establishing a public member majority on all professional licensing boards, including medical boards, requiring health regulatory boards to close cases within one year of the complaint if they don't involve public health or safety, or the board itself would face administrative closure. Another bill would require all health boards to refer misdemeanor and felony cases to state law enforcement agencies within two days of receiving a complaint. Another one would require health boards to contract with private sector entities for all of their administrative processes within one year. So that was a lot. There are quite a few red flags within some of these bills, and we know that. We have been in constant contact with Arizona in regards to many of these bills and are working with them, with their lobbyists, helping write letters and grassroots alerts. I'll go into a little bit more as to how we can help state affiliates and how we do help them and some potential partnership opportunities, but it's not all bad. We have had some recent wins, and most of our state wins occur or will occur in the next few months as legislatures start to adjourn, but we have had a couple recent wins. Pennsylvania, we've partnered with POMA to support an update to their regulations to make permanent a waiver that was in place following the transition to a single accreditation system under the ACGME to ensure that DOs are able to continue to get licensed in the state without undue burden or delay. In addition, we worked with Washington to successfully oppose naturopathic scope expansion during a sunset review by the Department of Health, and this was pretty exciting because we had been in partnership with POMA for quite a while. It had originally started out as a legislative bill to expand their scope, and then they put in for a sunset review, and they were asking for prescriptive authority, being able to perform minor in-office surgeries, and so we worked with them. We provided testimony, attended hearings, and at the end of the day, the Department of Health came back with a report and said, you know, we are in agreeance. If you don't need a scope expansion, you haven't been able to show us what additional education and training that provides you this scope expansion, and so we wholeheartedly count that as a win. We worked very hard with the Washington Affiliate, and we'll continue to work with them on scope expansions. So going into one of the resources that folks can use from the AOA, we provide a real-time legislative tracking tool that any member, affiliate, layperson, legislator is able to use, and it is this fancy map, of course, a map grid, and it shows you in real time what bills we are monitoring, what state they're in, our stance, where the bill is at within the legislature, and then it also includes, you can look this up as well on our online version, which state legislative priority the bill falls under, so you'll know why we're tracking that bill, because it does have some purview within our priority buckets. And the most important part of this legislative tracking are those future hearing dates. So at the state level, there are hundreds and hundreds of bills that we monitor on a daily basis. I analyze bills January through the, I guess all year, our main season for state legislative sessions are usually January to May, those are the, when most sessions, when most states are in session. And because of this, and because so many bills are introduced, many actually don't go anywhere. They're filed, but they're never taken up, never in a committee or chamber of any kind. So we really wait until a bill is scheduled for a hearing date. I will reach out to our affiliates or they reach out to me and say, let's get something done on this. Most of the time, as I said, it's on a scope bill of some kind, we're currently working with Arizona and Maryland on scope bills, Arizona, there's a bill for psychologists to test and treat, Maryland, naturopaths want prescriptive authority, so things like that, but we have started working on them because we have a hearing date scheduled. In addition, we really are pushing for the osteopathic equivalency, and I'll go into a little bit more on the board mergers, and we have taken a little bit more of a proactive approach for those. So we don't wait until a hearing date is scheduled for those board mergers, we really try and work behind the scenes with the state to see how we can assist so that maybe some of those don't get hearings, that maybe they don't get heard, because we know how crucial it is to have osteopathic recognition on a medical board, and so I will also go into a little bit more on some of our advocacy strategies, which include grassroots alerts, legislative letters, and also public testimony, and I'll go into that a little bit more. So here on the slide are kind of some of those advocacy strategies I was talking about. When that bill is set for a hearing, we can send a letter and a grassroots alert to legislators. As you'll see, this is that Arizona bill on their lay person medical board, we sent this in February, and we are working with Arizona on this bill. And on the other end, you'll see the Indiana one, which is Huntsville Scope Expansion, that is a grassroots alert, that's kind of what it looks like, and that grassroots alert is sent to physicians, osteopathic physicians within the state, who then can write a letter or use our templates to call their legislators and provide them with either the template letter that we have provided within the grassroots alert, or you're able to give your own personal story or testimony within that and send it to your legislator, and they receive that. And we are realizing, we of course love to send letters to the legislators, but the impact it has to receive a letter from your constituent is above and beyond receiving a letter from the AOA or your medical association, both are very effective, but we see that grassroots alerts really hit it out of the park when you're able to tell your story. You'll hear that when you go to DO Day and you meet with your legislators and they want to know about you and your practice, that makes a difference and that leaves an imprint on the legislator. So we really push for grassroots alerts. And then lastly, I was talking about public testimony. So you can provide expert testimony at legislative hearings, and the AOA works with the state affiliates to craft talking points in regards to that, as I said, last year for the Washington National Cascode Expansion, we were able to provide written testimony for that as well. Sometimes you're able to get up and speak at those, or sometimes you just submit the testimony via their website. And now I'm going to spend quite a bit of time on this slide. So we are seeing a push towards smaller government and deregulation at the federal and the state levels. Merger proposals for state and DO boards include Maine, Nevada, Arizona, and West Virginia this year. So to go into a little bit more detail, so Maine House Bill 805 was just submitted last week. And it is a study on the feasibility of combining the DO and MD medical boards. And we have been working very closely with Maine on this, because it didn't include a lot of information on the feasibility study itself. So we are working with them to hopefully propose amendments to this bill to include other people within the feasibility study group. So we're hoping to have DO recognition on the board. So hopefully the medical board, somebody from the Osteopathic Medical School, and things like that. So we are in constant contact with them to see what comes out of it. The goal of this bill would, the study would have to be completed by next year, and they will provide their recommendations during that time. So we will keep in contact with Maine and work with them and see what comes of that bill. And I jumped ahead of myself just a little bit. So on the screen is another map, you'll see with the dark blue states having states with osteopathic medical boards, there are currently 12 states that have separate medical osteopathic boards. And so as I was saying, there's now four bills, and I just went into Maine. So I'll now go into Nevada, Senate Bill 78, which eliminates the DO and MD boards and creates a new composite Nevada Medical Board. So we have been working with the state affiliate, as well as NVONE, the National Board of Osteopathic Medical Examiners, to draft a letter to the legislators in opposition to this. The Senate bill would make it an even DO and MD seats on the board, so there'd be four seats for each. But as we know, DOs have distinctiveness, and they understand the professional a little bit better than an MD, so we really pushed hard for the separation of an osteopathic medical board for this reason. Going back to Arizona, Arizona Senate Bill 87 seeks to place a public member majority on all licensing boards, raising concerns about non-medical oversight of physician discipline. And this is truly because a public member majority, they don't have the official and experienced knowledge and education that other physicians have on a medical board. So when there is disciplinary action that needs to happen, or there are issues that come to them, it may be difficult for them to provide proper disciplinary requirements because they don't have that knowledge as a physician does. And so we are really pushing and working with the Arizona legislature and our affiliate to stop this bill because of what that may do, and what precedent it may set as well. So West Virginia, last year in 2024, had Senate Bill 714, which would eliminate the osteopathic medical board. We worked very hard with the osteopathic affiliate there, as well as family practitioners and their West Virginia chapter, and we sent letters and grassroots alerts and worked and lobby The state affiliate worked with a lobbyist to stop this bill, but it didn't. But after a lot of time, it did pass both the Senate and the House. So it was sent to the governor, as you saw in my diagram, sent to the governor to either sign into law or to veto, and he did veto it, Senator Jim Justice did, and his reasoning was because the osteopathic profession is distinct and they should be governed by their peers. And so we are very excited about that. We do know that there is currently a bill, West Virginia Senate Bill 557, which is about the current West Virginia allopathic medical board, and it goes into a little bit of detail on their regulations. And we are monitoring it very closely, because potentially, if it is in a committee, that committee has the option to recommend amendments to the bill. And we want to make sure that an amendment doesn't come through that potentially slips in a board merger conversation. So we are once again, partnering with our state affiliate, we're monitoring it very closely. And if you do have any questions about these bills, and kind of how we're working with our state affiliates, please feel free to reach out, I can give you much more information. I'm also just going to provide quickly another resource for affiliates, and it's the scope of practice partnership. This was founded jointly by the AOA and AMA in 2006, to kind of unite the House of Medicine opposition to this non position scope treaty, through legislative, regulatory and judicial advocacy. It currently has 110 members, including 39 osteopathic state affiliates, and is free for all state societies, because specialty and national organizations. Currently, the AOA represents the osteopathic profession on the SOPP committee, and just some resources that are included, which quite a few states have utilized this year are heat maps that shows where non physician providers versus physicians practice educational models and one pagers, so that you can present those to your legislators when they're looking at legislation that may expand scope of practice. Another thing with scope of practice that we are seeing with that scope are nurse practitioners, physician assistants really trying for autonomy and independent practice. So these include a lot of good educational material to give to your legislators. They also include state law charts, Know Your Doctor wheels, which they can take to the legislators that show the different educational training of non-physician providers, as well as last but not least, applications for grant funding to help combat scope treaty. So we've had grants previously awarded to osteopathic affiliates in Pennsylvania and Oklahoma. And these grants can be anything from hiring additional lobbyists for scope treaty, marketing campaigns, targeted ads, etc, etc, that may help fight this scope of practice problem that we're seeing. And with that, I will like to pass it over to Dr. Scott, who will dive deeper into the Commission on Additional Licensing Pathways. Dr. Scott, I'll pass it to you. Hello, it's an honor to be here today to talk about the Commission on Additional Licensing Pathways. We know that there is increasing interest among state policymakers to improve patient access and reduce workforce shortages by changing licensure requirements for physicians who have completed training and are practiced abroad. Approximately one-third of the United States physician workforce is comprised of international medicine graduates, IMGs. IMGs are a critical component of our U.S. healthcare system and help ensure access to care in underserved communities and in practice in many different specialties experiencing shortages, especially in primary care. Some IMGs entering the U.S. healthcare system for residency and our fellowship training have already completed post-graduate training and practiced and or practiced medicine in other countries. Despite substantial increases in U.S. medical school enrollment, steady increases in U.S. graduate medical education and reports that more than 99 percent of U.S. MD&DO graduates enter training or full-time practice in the United States, current and projected physician shortages persist. Some of these proposals by our state legislators have bypassed certain requirements including requirements related to the United States post-graduate training that are designed to ensure physicians have acquired the necessary knowledge, skills, ability, and attitudes to provide safe and competent patient care. Now while some have shared characteristics among these proposals, there are also distinctions that may lead to varying outcomes across the states and create some confusion among physicians, regulators, and patients. And in some cases, it is also unclear how medical boards and regulators will operationalize these proposed pathways. So in response, the FSMB, Intel, and ACGME have come together with national organizations representing specialty certification and medical education and are working through a commission on additional licensing pathways. This commission is seeking to develop meaningful recommendations for licensing requirements and pathways for internationally trained physicians and practicing physicians. This advisory commission was formed in December 2023. As a member of this commission representing the AOA and as I mentioned previously, many of the proposals we have reviewed bypass certain requirements including requirements related to United States post-graduate training. Now internationally trained physicians or ITPs as described in some of the state laws enacted to streamline medical licensure are usually referred to as physicians educated and trained abroad who must also be licensed and have practiced medicine in another jurisdiction. We'll review some of these details in just a little bit. Now this cohort of international medicine graduates, so this cohort of IMGs who are now referred to as ITPs represent a relatively small cohort of IMGs, the broader term used to describe physicians who received their medical degree outside the United States. So again, individuals who are ITPs in most legislative descriptions must have previously completed graduate medical education also known as post-graduate medical education or PGT that is substantially similar to that which is recognized in the United States. Taking one step back just a little bit to review the primary pathways by which international medicine graduates or IMGs are eligible for licensure from their states is included here. So the most common pathways for licensure for international medicine graduates involves completion of one to three years depending on the state or territory of U.S.-based graduate medical education that is accredited by ACGME accompanied by certification by ECFMG and successful passage of all three steps of the United States Medical Licensing Examination, USMLE. Now there is a second pathway known as an eminence pathway for prominent mid-career physicians and this has long existed in many states. Typically this pathway does not require ECFMG certification or successful passage of any step of the USMLE and are likely to continue to be an option for highly qualified and fully trained international physicians. These pathways, the eminence pathways are most often used by individuals who have been deemed to have extraordinary abilities including those classified as eminence specialists or university faculty pursuing academic or research activities that typically align with the O-1 or the extraordinary ability visa issued by the United States Health Department. So with respect to additional licensing pathways currently nine states have enacted such legislation as you can see here by this colorful slide while 16 other states have legislation pending. I'd like to share a little bit about the history here in Arizona with these legislative actions. The Arizona legislature has seen multiple proposals introduced by legislators with the support of the Cicero Institute, an Austin, Texas based think tank that have sought to create another additional licensing pathway. So starting in 2022 we saw the first proposal was introduced by the chair of the Senate Health Committee. At that time the Arizona Osteopathic Medical Association, AOMA, we engaged in stakeholder meetings with the sponsor of the proposal to determine if a compromise was possible. Now at this point the proponents of the bill which was the Cicero Institute did not pursue a meaningful dialogue about amending the proposal. The AOMA and other medical professional associations were able to effectively lobby against the bill by highlighting the lack of will from the proponents to amend the proposal to meet Arizona's needs and by highlighting the numerous deficiencies in the bills especially those that linked to deficiencies in patient safety. The bill didn't go to the floor for a vote and the bill was dead. So in 2023 we had a second proposal introduced by both the Senate Health Chairman and the House Health Chairman. Both chairmen of the health committees deferred again to the Cicero Institute for negotiations on language in the bill. Coming off the 2022 debate we expected in Arizona that the think tank would take a more measured or scaled back approach to the bill which was really not the case. The lobbyists supporting the bill avoided compromises again. The sponsors of the bill did not have a medical background and it seemed as if the bill was going to go through for signage but it was not a surprise that given a strong grassroots effort supported by the osteopathic community and other medical professionals that it did not pass again. Fast forward again to 2024 was another round for this legislation which at this time the bill was still supported by the Cicero Institute and had a new support from a sponsor that actually had direct patient care experiences. During this approach the Arizona Osteopathic Medical Association was able to have some serious and direct negotiations with the sponsor. The ultimate product was a Senate bill which was introduced and given the compromises and negotiations that we were afforded the AOMA was able to reach a neutral position on it and it's important to note that we did not support the proposal but and we did not lobby against the proposal we remained in that neutral position. This compromise was really only possible because the sponsor of the bill had direct patient care experience and respect for the elements of added patient safety. The bill went further this time but again it failed in the house. So our summary of the approach from Arizona is really to keep the patient at the center and focused on safety for the patients and ensuring that the licensing pathway has necessary safeguards, the state medical board has the necessary rulemaking authority to administer any program but ultimately in the AOMA's opinion the solution should be focused on GME graduate medical education expansion in the state to find a holistic solution to the physician shortage problem. Thank you so much Dr. Scott for that really insightful Arizona legislation. I know how difficult that can be especially when it is year after year we introduce and not really look for compromise or partners in that area and so next I'm going to do just a little bit of a deep dive. The Federation of State Medical Boards created this really nice graph for us to look at for states that have enacted this IMG legislation that Dr. Scott was talking about and as you'll see on the screen all of the green dots are included in that state's legislation whereas red is not included and as I have said in the past you know AOA keeps our priorities very broad because every state introduces legislation differently they are not ever the same bill usually and so as you'll see Florida they have some SMB rulemaking authority but they also don't have any standard reporting requirements. So as you'll notice all of these legislations do not have standard reporting requirements and so how are we able to track what this looks like long term and you will see that all of them include graduation from medical school and they have to be licensed to practice in the country but as Dr. Scott was talking about they some of them don't have to have postgraduate training completed and so that could be very detrimental to patient care and patient safety and so this kind of is what led into the commission is what Dr. Scott was talking about and some of those recommendations and so I'll pass it over to her to kind of talk about some of those recommendations. Thank you Brie. Now since these nine recommendations have been released it's important to know that there's still work to do so we'll talk a little bit about that at the end for some of the next steps for the commission. But looking at the nine recommendations you can see the first one includes that rulemaking authority should be delegated to the state medical board. Additional licensing pathways will likely incur increased time and resources for the state medical board personnel. State legislatures should also consider additional funding and resources that may be allocated through state appropriations to implement operationalize and evaluate any additional pathway for medical licensure. And looking at the complexity of just number one alone states evaluating how to proceed may even wish to consider first authorizing their state medical boards to establish a smaller pilot program and in some states this is occurring. The second recommendation is the offer of employment prior to application to an additional pathway. The employer should in all cases be an entity with sufficient infrastructure that allows for supportive education and training resources for the ITP as well as supervisory and assessment resources that include but are not limited to peer review. For this reason offers by individual physicians in solo or group practices to serve as employers for ITPs eligible for these pathways are really not advisable as such settings may not have the capacity to provide the supervision. States in consultation with state medical boards should define which medical facilities are able to supervise and assess the ITPs proficiency and capabilities. Now in number three ECFMG certification and graduation from a recognized medical school is important. Traditionally IMGs have been required to obtain ECFMG certification which is a qualification that includes verification of their graduation from a world directory recognized medical school passage of USMLE steps one and two and demonstration of the English language proficiency via the occupational English test of medicine referred to as the OET. Moving to recommendation number four is completion of postgraduate training outside the United States that's substantially similar. Now this is a difficult one as there are no formal accreditation processes for international postgraduate training. Most states that have enacted additional pathway legislation have included a requirement that applications must applicants must have completed postgraduate training that's substantially similar to a residency program accredited by the ACGME in the US. There is significant variability however in the structure and the quality of international PGT and until that formal recognition system or an accreditation system for PGT is created the term substantially similar will need to be further determined by the state medical boards. Number five is license authorization to practice and practice experience. Such legislation typically includes a requirement that the license obtained overseas be considered in good standing and that an attempt to be made by the medical board to verify the physician's disciplinary and criminal background history and in some instances this is taken on a case-by-case basis because some of the information may be difficult to find but also reiterates the reason why the state medical boards really need the resources and personnel to pursue these pathway obligations and research. Recommendation number six is based on a recommendation for limitation on time out of practice similar to what we experience for physicians in the states already that have been out of practice. Considerations here include for states that have enacted additional licensing pathways they have as you saw by the chart listed varying ranges for the number of years the ITP practice could be considered or required when they are out of practice. So as you can see by the charts some applications are recommending a requirement to five years. States should be cognizant that requiring continuous practice may be difficult for many applicants to manage and or demonstrate especially if they have to navigate the immigration system adjust to displacement or face a number of non-immigration barriers. And number seven number seven is provision provisional licensure and supervised practice prior to full license and seven is actually broken down into a couple subcategories. This includes supervision which is recommended to be within the same specialty and assessment is continued with adequate support by the employer and also that supervision and support for ITPs are crucial to navigate and bridge cultural differences and to enable qualified ITPs to learn practical technical and operational sides of our U.S. health care system. This includes cultural diversity health care system variabilities billing processes use of electric health records such supervision and support are essential for public protection. Recommendation number eight is that state medical boards should retain their authority to assess candidates for full licensure. Such assessments can include step three of the USMLE and passing the employer's assessment program. It's also important that candidates have no disciplinary actions. And finally number nine as we are looking at these different programs and processes is to collect and share data about the process. State medical boards assisted by their partner organizations as may be necessary should collect this information and facilitate the evaluation to see that these pathways are meeting their intended purposes. So what are the next steps for the commission? The advisory commission we are continuing to meet. This will be essential to support any recommendations coming out later in 2025 to address the important areas such as the criteria or assurances that should be required for a physician to transition from that provisional to full and unrestricted licensure. I wanted to highlight a couple of other considerations that have come out during these discussions. First it should be noted that U.S. federal immigration and visa requirements will impact the practical ability of physicians who are not U.S. citizens or permanent U.S. residents to utilize any of these additional licensing pathways. So this could be a complicated step for members going through this process and these steps should be noted. Also for the ubiquity of specialty board certification, this is a key factor in employment, hospital privileging, and insurance panel inclusion decisions. This is important to impact the efficacy of non-traditional licensing pathways. And last but not least, states should therefore also wish to consider other health care workforce levers that could be more effective to increasing access to care in our states. This is a familiar topic to us but is advocating for increased state Medicare and Medicaid funding to expand U.S. graduate medical education programs. Thank you Brie for the opportunity. Thank you so much Dr. Scott for that information and I'll now kind of go into AOA's response to that kind of feedback in a little bit. In that final draft we did notice kind of the language concerning postgraduate training equivalency had been adjusted to acknowledge a lack of standardized global accreditation system for postgraduate training and leaving the determination of that substantially similar to state medical boards with suggested proxies such as the ACGMEI accreditation. We did have some concerns just because if state medical boards aren't receiving additional funding to push these additional licensing models, they may also not have the resources to determine what substantially similar actually means. And so in addition, our response to the draft guidance kind of acknowledges the FSMB's efforts to maintain rigorous standards but we do express the skepticism regarding the additional licensing model emphasizing that we need to prioritize investment in the domestic medical graduates as Dr. Scott was saying. You know we supported several of the recommendations particularly the requirement for the UCFMG certification, structured supervision, and specifically that standardized data collection that we haven't seen in past legislation. However, we also have key areas of divergence that remain including the concern that these pathways be leveraged to create lower cost labor models rather than genuinely addressing workforce shortages and underserved areas. We also recommend more explicit safeguards against predatory employment practices and stronger requirements for board certification within a specific time frame. While the final guidance does incorporate some of these concerns, particularly reinforcing the role of state medical boards in oversight, the ARA's broader apprehensions regarding the long-term implications of additional pathways remain unaddressed. And so that is the end of our presentation. If you have any questions, Dr. Scott and I will gladly take any questions.

osteopathic medicine

scope battles

licensure pathways

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telemedicine

artificial intelligence

healthcare standards

board mergers

internationally trained physicians