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Senate Agriculture
Jan. 24, 2023
Sen Caldwell: I’m going to call this meeting to order. Chair sees a quorum. Before we start, we kind of had a mess up at our last meeting, and all of the Ag-related lobbyists and supporters of the different industries were standing outside, and they didn’t get to come in and introduce themselves. And so Stanley, we’ll start with you. Back to back, if you would tell us who you are and who you represent, please.
[inaudible introductions]
Sen Caldwell: And we spoke before in our organizational meeting, and I told people that Ag had a variety of industries that we represent. It’s not just row crop. So anyway, I’m glad to have you all here. Sorry, we missed an opportunity to meet you before. Today is a little unusual. Senator Hill does not want to present his bill today. But we do have people from out of state, from Ohio and Texas, that had made arrangements to come into testify against the bill. We’re going to hear the testimony. We’re not going to take a vote. I was going to ask him how many geese he killed. He showed up. I told him I was going to put him on a record of playing instead of working, but anyway, welcome, sir.
[inaudible from audience]
Sen Caldwell: Yes, sir. But again, we’re going to hear the testimony, and if you all have any questions, please ask. We’re not going to take a vote today, which is a little out of the ordinary, but the fact that they had spent the money and airfares and time and effort to get here, I felt it was only fair to allow them to speak. So if you want to pull another chair, do you want to sit at the end, or it doesn’t matter?
Jenkins: I thought the comments. I want to open comment. I’m Dr. Paul Jenkins. I’m a veterinaria.
Sen Caldwell: Dr. Jenkins, if you would come to the end of the table, turn your mic on, introduce yourself for the record. We are recording and live streaming. So we don’t want to hide anything from anyone, but again, it’s a little unusual to the fact that we’re not presenting the bill, but again, we do want to hear testimony. So Doctor Jenkins, if you’d state your name for the record, you’re going to be recognized.
Jenkins: Yes, sir. Dr. Paul Jenkins. I’m a veterinarian in Vilonia. I grew up here in Arkansas. I went to LSU. Please don’t hold it against me. I practiced down there a couple of years and then came back to central Arkansas to practice. I’ve been there since 2004. I want to very much thank the committee for hearing us today, especially in our special circumstances with having the opportunity to have two experts scheduled to come in. And so like Rodney said, I’m here on behalf of the Arkansas Veterinary Medical Association and do legislative lobbying with them. We are against Senate Bill 5 because it strips the required veterinary-client-patient relationship from telemedicine, and I’ll refer to that as a VCPR probably as we discuss. What we are not against is telemedicine, and all of us use telemedicine in various ways, but we are against that VCPR being stripped from it. We feel like it’s a threat to proper animal care in Arkansas and that animals may not get urgent or timely care with some type of in-person visit. We’ve been told that it could be a money grab for veterinarians or another way for veterinarians to charge a fee, but we know that 60 to 80 percent of the time that a telemedicine consult occurs or is performed, that an in-office or on-farm visit actually comes out of that, so there ends up needing to be some type of physical exam or interaction with that animal.
Jenkins: As it’s written, any fees that are collected on a telemedicine consult could go out of state and not benefit our state tax base. I’ll give you two examples. One is, let’s speak theoretically for a second, there are companies out there that are corporate, that have already formed, and, say, someone has a small animal. That company may have a veterinarian employed in another state but be licensed in Arkansas but be located in that other state, and that company employs the veterinarian, owns the telemedicine platform, if you will, that probably would come in the form of an app, and they own the pharmacy. And so their goal is to sell a product and continue to sell that product, none of which would benefit our state. Another example in large animal medicine, you might theoretically have a veterinarian in Nebraska, licensed in Arkansas, doing telemedicine consultations on a group of food-producing animals here in the state and never have had to lay eyes on them.
Jenkins: And furthermore, if this goes through, if I were a young veterinarian looking to come to this state to set up a practice, it is going to deter me with having this competition already going on. It could create pill mills for chronically affected animals that really need follow-up care and are not getting it but are just continuing to be sold those prescriptions from the company as indicated earlier. We feel like it could increase the possibility of controlled substances being overprescribed and then ultimately abused in the human world. It could further add antibiotic resistance if antibiotics were prescribed and they really weren’t needed. Once again, that is the power of the physical exam on being able to determine, and with some diagnostics as well, whether that antibiotic even needed to be prescribed. Veterinary medicine is unique, different to human medicine, in that our patients are nonverbal communicators. And we base what we do off of a history but more importantly the physical exam and diagnostics if they are needed.
Jenkins: And lastly, I would make you aware there are four instances where federal law is going to supersede state law regarding the VCPR, and the first one is where a VFD is written, and that’s called a veterinary feed directive. So if an animal producer has a group of, say, cows we’ve identified an infection in, I can write a prescription – it’s a federal document – and have a feed mill add X antibiotic into the feed to help benefit or treat that condition. The next one is where a thoroughbred racehorse is being treated. That is created by the Horseracing Integrity and Safety Authority. The next one, thirdly, would be if drugs are being used extra-labeling. So maybe the condition that you’re treating is not what that drug is intended for, but you can use it extra-labeling to treat if so necessary. And then the last one would be if biologics are being used. For example, in Arkansas, poultry is big. If we’ve identified in a flock a unique infection in that group of birds, we can have a vaccine made. You’re usually working with an outside company that is specific to that flock, and it’ll only be used in that flock. So I appreciate y’all listening to me. I’ll take any questions that you might have.
Sen Caldwell: All right, committee. Anyone have a question? Okay. Dr. Jenkins, thank you.
Jenkins: Thank you.
Sen Caldwell: Dr., if you would turn your mic on and introduce yourself, and you’re recognized.
Teller : Howdy. I’m Dr. Lori Teller, and I am the president of the American Veterinary Medical Association, and I am also a clinical associate Professor of telehealth at Texas A&M. For 28 years, I did work in private practice providing veterinary care for companion animals before being recruited by Texas A&M to specifically develop the telemedicine program there as well as to teach students in their primary care rotation, which is in the last year of veterinary school when they’re in their clinics. Texas A&M is the only veterinary school to currently have a full-time position dedicated to this role.
Teller : So first, I want you to understand the difference between telehealth and telemedicine because we do this in veterinary medicine. It’s a little bit different than human medicine. Telehealth is the overarching term that encompasses all use of technology to remotely gather and deliver health information, advice, education, and care. And tele-triage, so determining if something is an emergency, is also considered a part of telehealth. Telemedicine is a subset of telehealth that refers solely to the provision of healthcare services through the use of telecommunications technology, and telemedicine involves the use of electronic communications and software to provide clinical services to patients without an in-person visit. So in veterinary telemedicine, we do require an established veterinarian-client-patient relationship. So just to kind of summarize all that, all telemedicine is telehealth, but not all telehealth is telemedicine.
Teller : So there is an incredible amount of care that can be provided via telehealth outside of an existing VCPR. This includes tele-triage, so determining if something is an emergency and the animal needs to be seen immediately or if it’s something that can wait till you can be in contact with your own veterinarian. So there’s also tele-advice. An example of that would be somebody is a first-time puppy owner, and they just need to learn how to house-train their puppy. You don’t have to have an established VCPR. You can do that through a telehealth platform with your veterinarian, whatever it may be. There are other things that should only be done within a VCPR that would be making an actual diagnosis or a differential diagnosis for a pet, making a prognosis, or determining specific recommendations to treat a patient.
Teller : Ongoing research has continued to show that antibiotics are more frequently prescribed via telemedicine visits than in in-person visits. And with the increasing concerns around resistance to antibiotics, it is that much more important that a VCPR be established with an in-person exam to lessen the incidences of these occurrences. And those of you that may be in food animal are aware that the FDA is pulling any remaining antibiotics off of the shelf at food supply, feed stores, things like that. So the only way any large animal producer is going to have access to these medications is through an established VCPR.
Teller : Great care is also required when comparing the practice of veterinary telemedicine to human telemedicine. This includes not only how care is provided, but also how drugs themselves are regulated. Physicians have great latitude to use medications in an off-label manner. However, the FDA has very specific regulations for veterinarians to prescribe drugs in a manner for which they are not labeled. And I’m married to a physician. My father is a physician. So I really have a good understanding of the differences and similarities between the two, and there’s some pretty significant differences between what my husband and my father can do versus what I can do as far as providing medical care.
Teller : Veterinary medicine is often compared to human pediatrics, as Doctor Jenkins said, because neither animals nor infants can speak. And so you think that there are all these telemedicine people out there, saying, “Get online with my baby,” right, “Help me.” However, when you actually read the guidelines from the American Academy of Pediatrics’ telemedicine guidelines that were also adopted by the American Telemedicine Association, they very clearly state that telemedicine services should not, and that is bolded in the guidelines, should not be provided to children under two years of age, except when the provider has a previously established in-person relationship with the patient or when the patient-centered medical home has referred them for a subspecialty consult.
Teller : So a patient-centered medical home is where a patient gets primary healthcare services. It also creates and maintains the provider-patient relationship, or what we would have as a VCPR, and coordinates and integrates care with specialists or other care providers needed by the patients. So that way, your primary doctor or veterinarian is coordinating any care that you may need with others, and you’re not fragmenting what that care looks like. This is very different than direct-to-consumer telemedicine, where prescribing is done outside the traditional doctor-patient relationship. And with direct-to-consumer telemedicine, there’s an increased risk for inappropriate prescribing in drug interactions, and the main goal is to sell product, not to determine what is the best possible treatment for the patient.
Teller : On the human healthcare side, the FDA has recently taken an increasing number of enforcement actions against DTC or direct-to-consumer telemedicine companies. These actions have ranged from warning letters to criminal indictments. This is all within the past four years. This reiterates the fact that the FDA has broad regulatory and enforcement authority over a telemedicine-related activities. And so if Arkansas allows for the creation of an electronic VCPR which conflicts with the federal VCPR, veterinarians will be at risk of violating federal prescribing laws. And as the amount of research has grown on the human side, it’s actually become increasingly clear that human medicine is moving towards a hybrid model where patients are encouraged to have an in-person visit with a physician then use telemedicine as appropriate for follow-up visits, management of chronic conditions, consults with specialists, as coordinated by your doctor or veterinarian, and tele-triage when needed. This is very similar to the position that the American Veterinary Medical Association supports for the provision of veterinary care for our patients.
Teller : And I just want to say, because I know Arkansas is mostly a rural state, as is a significant portion of Texas, so a significant portion of my clinical duties at Texas A&M includes decreasing the barriers to veterinary care that may exist for our clients in rural areas or with limited funds. So telehealth is huge. It can be used to help provide care to some of these patients, but I have yet to see one patient that I could have helped with telemedicine alone. Each patient has required an initial in-person visit to address acute medical issues as well as determine the next best steps to provide appropriate care. The in-person visit also allows the veterinarian the opportunity to determine how well an owner can recognize and interpret the animal’s clinical signs and minimizes the risk for a misdiagnosis. Also, the same population of people that has trouble accessing veterinary care frequently also has challenges with broadband access and with digital literacy.
Teller : So telemedicine is a tremendous – and I do this; I live and breathe this – adjunct to enhance veterinary care for our patients when it is used within an established in-person VCPR, but it’s really not necessarily the wisest investment for someone who has limited funds. Even the access to veterinary care coalition states that managing veterinary cases with incremental care, so step by step based on their funds, requires frequent communication with animal owners and regular reevaluation through in-person clinical exams. Telemedicine visits in between these exams can help ensure client compliance with the veterinarian’s recommendations and troubleshoot minor problems before they become more complicated and expensive to manage.
Teller : So in summary, telehealth can be helpful to all animal owners, who need general advice or tele-triage services. And in veterinary medicine, neither of those require an established VCPR. For more specific care, telemedicine is best utilized following an in-person examination of the patient and establishment of the VCPR. And I’ll entertain any questions.
Sen Caldwell: Senator Dees, you’re recognized.
Sen Dees: Thank you, Mr. Chair. Thank you, Dr. Teller just for coming today. You said you were brought in to A&M, specifically this area. This seems to me a relatively new development in the medical space as technology advances. Can you give us a little bit of background of how long have we been doing this?
Teller : Sure.
Sen Dees: Not only on humans, with humans, but also in–
Teller : So veterinarians will tell you they’ve been doing telemedicine since the telephone was invented. But in the more modern terms, telemedicine really started taking off in the veterinary space, seven, eight years ago. On the human side, they’re probably 20 years further down this road. COVID, of course, drove this home. There were clients who couldn’t come in, didn’t want to come in. There were various restrictions, depending on what state you lived in. If you could basically leave your home. So telemedicine and telehealth services really took off. With COVID, we saw the number of veterinary telehealth visits increase from single digits to about 38%. Since various waivers have lifted, people essentially returned to normal lifestyles. We’ve seen telemedicine visits drop back down into the single digit numbers. So it’s going to be a steady state. And a lot that we learned, particularly in veterinary medicine, is that we really do need that in-person exam or visit. In the case of large animal, that may be a farm visit or a barn visit, something like that as well. But it makes a tremendous difference.
Sen Caldwell: Senator Dees, let me make a statement on the human side of it, on some of the technology and everything that has come about. We passed legislation in my first term, which was 10 years ago. So the human side, other than telephone and speaking on phone, as far as telemedicine, as far as diagnosed from remote areas, everything, in Arkansas, basically started about 10 years ago, have remote access. Rural hospitals have access to UAMS and larger facilities. I remember legislation being passed back then to– allow a lot of that, we’ve done, so.
Teller : And so that brings up UAMS would be a patient-centered medical home. So you have this central facility. And doctors, even rural doctors, tend to be on staff, but perhaps some kind of [crosstalk] position.
Sen Caldwell: Basically technology for an MD to be sitting in an x-ray lab at UAMS, looking at something in the McGehee, Arkansas, which is fairly new. Other questions? Dr. Teller, we appreciate you coming in–
Teller : Thank you.
Sen Caldwell: –from Texas and taking your time.
Gingrich: Yes, thank you. Thank you very much for this opportunity.
Sen Caldwell: Dr., your mic is on. If you would state your name for the record, and you’re recognized.
Gingrich: My name is Dr. Fred Gingrich. I’m a cattle veterinarian. And I was in private practice for 21 years in California and Ohio. And in 2017, I became the Executive Director of the American Association of Bovine Practitioners, which is the largest cattle veterinary association in the US. And we have over 5,000 members, primarily in the US and in Canada, but also in about 32 countries internationally. So I really appreciate the opportunity. And my comments are really going to be on how SB5 can impact both cattle producers and cattle veterinarians, because that’s kind of my space. So I’m just going to stick to my species for the most part in my comments, but I appreciate that. AABP, our organization, we develop guidelines and position statements to advocate for our members. And also to provide our members with information and support on a variety of cattle health topics. And these are publicly available on our website. But the one that probably pertains to SB5 is our guideline entitled, Establishing and Maintaining the Veterinarian-Client-Patient Relationship in Bovine Practice. And it states, “Regular site visits are an essential component to providing veterinary oversight. However, this can be supplemented through laboratory data evaluation, records evaluation, telephonic, and electronic communication. The timeliness of these site visits should be determined by the Veterinarian of Record based on the type and size of the operation.”
Gingrich: So cattle veterinarians utilize telehealth and other types of services to supplement the previously established VCPR through electronic means. And as Dr. Teller previously mentioned when you ask the question about how long have we been doing this, we’ve been doing this a long time through records evaluation. We have veterinarians that place computers on feed yards and get the data downloaded to their system every single day. That’s been going on for years and years. And so a lot of our telehealth is on a consultative basis. Looking at the herd is the patient. But we have been doing that for a number of years. What I would like to focus on is some of the risks with allowing the establishment of a VCPR through electronic means. And that’s what I’m here to talk about today. So the first is risks to cattle health. Our patients are both the herd and the individual animal. Treatment for many diseases affecting cattle are administered by farm labor or owners, not by the veterinarian. And they use protocols and training that have been provided by the veterinarian within an existing VCPR. And those protocols are developed. And we consider the needs of the client, the size of the operation, the diseases they may encounter, their facilities, as well as their ability. So those protocols are very tailored to a specific farm operation within that VCPR.
Gingrich: And attempting to diagnose an animal condition without a previously established VCPR does put that animal at risk of a misdiagnosis. But also since most of the diseases we treat in cattle are contagious pathogens, it puts an entire herd at risk, which we don’t want to see. And so that is one risk to animal health. Another big risk that we are more and more concerned about today is the risk of foreign animal disease introduction, and that devastating effects that would have on our entire national economy. The recent COVID-19 pandemic has taught us about the impacts of the introduction of a novel disease pathogen. Veterinarians who visit farms on a regular basis are the front line of defense against the spread of a foreign animal disease. The big one we’re worried about in cattle is foot and mouth disease. One of the most critical steps in preventing the spread of this highly contagious disease is a quick diagnosis and then implementing stop movement orders working with state and federal animal health officials.
Gingrich: Risk to veterinarians: As my colleagues previously stated, we must follow both state and federal regulations that are different from those from our human counterparts. An important example is how pharmaceuticals are regulated in this country. The regulation of human drugs by the FDA is focused on their label. And human healthcare professionals have broad discretion in how they use those drugs. In contrast, when it comes to veterinary medicine, a special of food animal medicine, the FDA regulates the label and its use by the veterinarians. And also has the authority to define how a VCPR is established for certain uses of human or animal drugs– or animal drugs or human drugs that we use in animals. And the federal government is very strict about how it regulates veterinarian’s drug use, and the reason they do that is because their overarching charge is protecting food safety. And using antimicrobials and other medications in food animals has implications, and that’s why we have these regulations.
Gingrich: Keeping that in mind, veterinarians must often use drugs in ways that differ from their label when treating animals, including cattle. And the reason is because very few FDA drugs have all label indications. And so when we look at cattle, the most common label indications would be pink eye, foot rot, uterus infection, mastitis, and pneumonia. So that’s five diseases. Cattle get more than five diseases. And so if we’re treating something that is not on the label, that’s extra label drug use, and we have to follow those federal regulations. And that is established in what’s called The Animal Medicinal Drug Use Clarification Act. We call it AMDUCA, which was established in 1994. Another regulation that we must follow is treating, which my colleague Dr. Jenkins mentioned was treating animals by in feed use of antimicrobials. That’s a very common thing. And one very specific example I wanted to share with you is a disease that’s very common in the southeast US, and that’s called anaplasmosis. Okay? It’s a vector-borne disease. It’s spread by blood parasites or sharing needles and things like that. It costs the cattle industry about $300 million a year in the U.S.
Gingrich: And in Arkansas, there was a recent study published about beef cattle in Arkansas, the 5th largest ag commodity in the state, where they took blood samples from cattle in Arkansas and found 59% of the cattle in Arkansas were seropositive for anaplasmosis. So that’s more than half the cattle have this disease. How do we treat and control that disease? It’s through in feed use of antimicrobials. There’s not an effective vaccine. There’s not very good control measures. Those animals need to have this treatment to control the spread of the disease within the herd. In order for a veterinarian to do that, they have to follow the federal guidelines for writing a VFD, which requires an in-person visit. And actually that law states that that prescription is valid for six months. Which would infer that that veterinarian needs to visit that farm, at least every six months. And so that’s just a very specific example for the state about how we need to make sure that that is utilized within an established VCPR. And as my colleague also mentioned, the USDA also regulates veterinary biologicals or vaccines, autogenous vaccines, we do make those for cattle as well. Again, that requires that in-person visit. And the timeliness of that visit should be determined by that veterinarian.
Gingrich: And I think another risk that we can talk about when we’re talking about consumers in the public is the producers themselves. How is this a risk to producers? If we look at another study that we recently published in our journal from Mississippi State University, they looked at 14,000 cow-calf producers across the US. And that study revealed that two-thirds of the respondents stated that veterinarians are influential in management decisions for their farm. And that they use a veterinarian for a variety of services. There are certainly areas of the country where veterinarians are in short supply. In Arkansas, 42 such locations were identified by the USDA last year. We only have 22 AABP members in the entire State of Arkansas. So there’s certainly a workforce shortage when we’re talking about cattle veterinarians in this state. Unfortunately, allowing a VCPR to be established, through telemedicine, increases the risk of the shortage situation in our opinion. Why is this?
Gingrich: Much of the work that we do requires an in-person visit, such as emergency services, reproductive services, extra label drug use, and prescribing medications for use and feed. There is a risk that consultant firms that have access to establishing a VCPR through telemedicine, even out-of-state veterinarians who apply for an Arkansas license. Many of our members have multiple state licenses. If that is allowed, it may put pressure on those local veterinarians where they are no longer available in a community to deliver those critical healthcare needs to the cattle in that community. If a veterinarian can no longer remain economically viable in a community, due to this, then they are not going to be able to provide those services. Allowing the use of telemedicine within a previously established VCPR can help address those workforce challenges. So I think we need to communicate with our members about how they can do this for their clients. But allowing it to be established increases at risk of furthering those workforce challenges that we all are experiencing in rural America right now. In closing, we’re opposed to allowing the establishment of a VCPR through electronic means due to these identified risks. But we’re very supportive of its use to improve our effectiveness at delivering care to cattle in rural communities while protecting animal health, welfare, and productivity. Thank you.
Sen Caldwell: Committee members, questions? From the testimony that we’ve heard from Dr. Gingrich, basically, the opposition comes from allowing telemedicine without previous relationship?
Gingrich: Correct. Yeah, we’re very supportive of– and I think most cattle veterinarians probably utilize telehealth services in some capacity via just a simple phone call, evaluating records, etc. for their clients. That is difficult to do without an existing client, as well as, like I said, it increases these risks, and the veterinarian could be following a state law and unknowingly violating federal law. And I think the other thing, is that when we look at the consequences of violating that federal law, they’re pretty severe. If a veterinarian wrote a VFD for a herd of animals outside of a VCPR, and let’s say it caused a food residue, okay, they detected that antibiotic. The FDA did an investigation, because that was illegal on a federal level, that feed would be declared adulterated, could not be fed. But the animals that received it would also be considered adulterated and could not enter the human food chain. And those situations have happened. And a veterinarian, like I said, unless they were very familiar with the federal law, they could unknowingly make that mistake.
Sen Caldwell: Okay. Senator Davis.
Sen Davis: Thank you, Mr. Chair. I’m curious in the states– I know there’s a handful of other states that are already doing this. So do you have– has it been going on long enough where you guys have any data on if it’s increased shortages or what that looks like for veterinarians who treat cattle?
Gingrich: So when you say there are states that are allowing this, I’m unsure if you mean allowing the establishment of a VCPR through telemedicine, because there’s no states that I’m aware of that allow that.
Sen Davis: Okay. I thought I saw a list yesterday that had some states. So maybe–
Gingrich: Not for veterinary medicine.
Teller : There’s five of them.
Sen Davis: There’s five?
Sen Davis: Okay. I thought I saw a list. I just was like unfamiliar.
Gingrich: Yeah.
Sen Davis: Okay. Is there any data showing that yet? I am interested to know that, if there’s increased–
Sen Davis: Okay. So it’s not been going on long enough? Okay.
Gingrich: And it’s important also to recognize that during the pandemic, the FDA said that they would exhibit or implement regulatory discretion if veterinarians established a VCPR electronically during the pandemic. And then it’s probably been about six weeks ago or so, where they put a notice out to all veterinarians that said they were withdrawing that, and they would begin enforcement of VCPRs established electronically for extra label use or the writing of VFDs.
Sen Davis: Okay.
Sen Caldwell: Would you come to the table please? And let–
Sen Caldwell: That’s fine. Right. Pull your chair. Rodney, would you pull her chair?
Teller : I’m okay. Okay. Two of the five states are considering retracting the electronic VCPR and going back to an in-person exam. That’s currently being reviewed.
Sen Davis: Okay. Okay. Thank you.
Gingrich: And then you had a question about, are the workforce issues worsening? Was that–?
Sen Davis: Yes, because I mean, one of the concerns – I understand what you’re saying – that if there’s already a shortage, will it just make the shortage even greater if people are doing this? And there’s not as much of a demand for the veterinarians that are already here. So states that are doing this already in this way, but I’m understanding maybe it’s not even been going on long enough to tell what the impact of that will be.
Gingrich: Right. And I think if you look at shortage areas, where do we have major shortage areas? It’s where those communities can not economically– there’s not enough work in that community for a veterinarian to make a living. And with the increasing debt that students are facing, etc., our opinion is that allowing the establishment of a VCPR remotely will put even further economic pressure on those communities, and then the only thing the veterinarian is asked to do is get called out for an emergency at 2 o’clock in the morning, and you just can’t have a good life or make a good living doing that. Does that make sense?
Sen Davis: Yes, it does. Thank you.
Sen Caldwell: Senator Love.
Sen Love: Thank you, Mr. Chair. Now, what were the two reasons? What were the two states? And then what were the reasons why they were–?
Teller : Similar concerns to what we had been talking about, a lot related to prescribing antimicrobial resistance. One is Michigan, and the other one is New York, which also has a big rural area as well. So a lot of it is related to the inappropriate prescribing of medications, and it does put pressure, as Dr. Gingrich said, on revenue staying in the state as well.
Sen Love: Following up on the chairman’s comments in regards to the initial visit, but also, you all want to see the reevaluation done annually? Is that what you’re saying?
Gingrich: So as far as the visit goes?
Sen Love: Yes.
Gingrich: So what our guidelines say to the state is that timeliness– we call that timeliness. That’s the language that’s in most state practice acts and federal law. We believe that that is best left to the veterinarian of record. And why is that? I had clients, large dairies, where that visit was every single week. I had small cow-calf operators, where they had 10 mama cows, and we just preg-checked them once a year, and that was plenty of time. Okay? There was nothing to do there every week, right? And so that’s why it’s very difficult to put that in any type of regulation because of those nuances.
Sen Love: Okay. All right. Thank you.
Sen Caldwell: Senator Love, let me give you an example. It happened to me personally back in June. I have 5 horses at my house. Lightning struck and killed two of them. The insurance adjuster wanted a veterinarian to look at them to confirm lightning struck and killed them, and the nearest vet that I had in Wynne was two hours away. But I did have a relationship with a particular vet. In fact, it’s a vet that we’d just bring them to in the past, but we didn’t have the political means or legal means for him to advise me on that, and so that’s why we need telemedicine. Now, the other issue is I had a relationship with him, and that’s what they are pushing for, is to have an in-person relationship at least once. So basically, what this bill wants is an in-state veterinarian wants to establish relationships electronically, but by doing that, you can have vets from Oklahoma, Missouri, New Jersey, Hawaii, Alaska to establish a relationship electronically and do business in Arkansas, and if we do that, then the local vets that we have would have less customer base by doing that, and that’s part of the issue now.
Sen Caldwell: Again, when it comes in with the USDA regulations on medication, you have five states that have done it, and two have rescinded it. So it’s a deeper look at veterinarians on what we’re doing instead of on people on telemedicine. So you’ll have to decide for yourself on that, but there is a need for telemedicine out there. The crux of whether you’re for this bill or against this bill would be whether you would have at least a one-time personal relationship with that vet or whether you’re going to let any vet call you up and say, “Hi. I’m John Q Veterinarian. I’d like to have your business.”
Teller : To further go on your question. So typical standard of care is considered every 12 months. Most states do not define it. California does, for example. Texas does not. And it goes to what Dr. Gingrich said. It’s based on the veterinarian’s judgment. For veterinary feed directives, that’s every 6 months. So you can even go a year. So when it comes to that law, and that’s federal, that’s every 6 months. But otherwise, if I have a diabetic cat, I’m going to want to see that cat more frequently than every year, but that doesn’t mean I have to see it in person every week. I can do in between visits with telemedicine.
Sen Love: Okay. All right. Thank you.
Sen Caldwell: Senator Dees.
Sen Dees: Thank you again. Help me with this one. So farmers in my district have had this sentiment, and how would you respond to these type of comments? “I don’t want people coming out to my farm.” I know, on a lot of issues, they’ve been the third, fourth generation cattle farmers, “I feel like I know the situation. I just need a prescription.” So speed to get a remedy quickly is a concern. And so how would you respond to some of those sentiments that I’m hearing?
Teller : We deal with this all the time.
Gingrich: I think that’s a great question, and I think veterinarians already have done that. As I said, and in my practice, when I started, I drove around all over the place, just treating animals. Okay? And then I decided it’s a lot more efficient for me to teach you how to do the very simple stuff. I listed those five diseases. I didn’t go out and treat pink eye, uterus infection, mastitis, pneumonia. I didn’t do that. That’s what protocols are for, and training, and then the farmers have their prescription. They have inventory, etc., etc. Most of my farms had more medications than I had because they inventoried them to treat their own animals, and then they called me when the animal maybe didn’t respond to the treatment or maybe they had an outbreak, “What’s going on here? I’ve had way too many of these.” That’s where the veterinarian’s role is.
Gingrich: So I agree with you completely. You’re right. Farmers, many of them are capable of treating the most common symptoms that we see in cattle. Okay? And that’s where those protocols and working within that VCPR work great. There’s not enough of us to treat the number of animals we have. I completely agree with you. But you can also look at, where does veterinary oversight play into antimicrobial stewardship? Because what are we doing in food animals that could be impacting human health? That’s a concern for everyone that eats meat and drinks milk. And so what I would say on that is that there is ample evidence that veterinary oversight is a very critical component to ensuring antimicrobial stewardship.
Gingrich: Oftentimes, when I got called out and the person said, “Why didn’t this animal respond to this antibiotic?” It’s because they didn’t have the disease that you thought they did. Okay? And a very specific example of veterinary oversight and relation to antimicrobial stewardship is about 5 years ago when the FDA put in the VFD regulations, which moved all those things under veterinary oversight. You can look at the amount of antibiotics sold in the US declined by about 30%. Okay? And the only difference was veterinary oversight. Healthcare did not suffer for animals. It improved because we figured out how to prevent those diseases outside of using an antimicrobial. So I think your point is great. I agree with you completely, but a veterinarian is still crucial to ensure that the protocols are right, the treatments are done appropriately, following up, making sure we don’t have outbreaks, etc. Does that make sense?
Teller : Which means that the veterinarian goes out to the property once a year and the farmer already has the– they almost always have that medication already. It’s just the veterinarian saying, “Yes, this is the appropriate use for that.” But the FDA is removing them from the shelf, so the farmer is not going to be able to get their prescription without the veterinarian playing a role anyway.
Sen Caldwell: Anyone else? Nope. Okay. Thank you all for coming. I appreciate your time.
Teller : Thank you all.
Teller : Thank you.
Sen Caldwell: Rodney, you have something else you want to say?
Sen Caldwell: Come to the table, please. The mic is on. I’d like you to just introduce yourself.
Baker: I’m Rodney Baker, and I represent the Veterinary Medical Association over here. I just want to let you know that we appreciate the time that you’ve allowed us today. I understand it’s a little different than normal, but I’ll also let you know that these two people who spoke here, or three people, are going to be around for a little while. If you have personal questions or individual questions you’d like to ask, they’ll be here to revisit with you. And just a feeble attempt at a recap, we passed the law 2 years ago for veterinary telemedicine. Rules were promulgated. They were brought in last summer. And at that point, an emotional discussion came up in the committee about the fact that when you did telemedicine for humans, you took out the professional relationship, the preexisting relationship, and it was left in there because it was still in the law for veterinarians, for animal care. There was an emotional discussion in the committee that day about, why are we doing something for animals that we won’t do for people? I think we’ve illustrated here today that there’s a very big– that there is a significant difference between animal care, animal telemedicine, and human telemedicine, and part of that is the food chain. Part of that is the complication of various species. Part of that is the fact that some of these patients can’t come in very regularly. These are all differences that warrant keeping the preexisting relationship between veterinarians and clients. And just as a way of, again, a feeble recap on my part, but we’re going to be around for a while. We’d be glad to try to answer any questions you may have, and we appreciate you allowing us this time today.
Sen Caldwell: Thank you. Before we adjourn committee, we’ve been invited as a committee to come and tour the marijuana growing facility in Pine Bluff and to go out to the Red Oak Steakhouse to eat. We can do that as a committee and take a guest. So if y’all would give me some dates that you might be available to set that up, if you have someone special you want to take to the supposedly best steakhouse in Arkansas, brand new down there, we’ll set that up and make arrangements. Staff was also included in that. So we always take our staff when we go to eat. If you could take time to meet the people that have introduced themselves here, a lot of different industries are represented, especially for the newcomers. With that, we’re adjourned.