Good morning. Welcome to the Vermont House Human Services Committee. Today is Thursday, March 24th. And this morning we are going to start our, we're going to have an introduction to S74, which is miscellaneous amendments to patient choice at end of life. And as a way of beginning we're going to have a walkthrough so that we know what's in the bill. And then we're going to have former representative Sandy Haas talk about the history and talk about where we've begun and all of that because I thought it was important that we have a context. And this builds on on some builds on on some level, but we heard last week from the Vermont Ethics Network in terms of decision making at end of life and care and respecting people's wishes. Legislative Council. Legislative Council. Thank you. Good morning. Jennifer Harvey from the Office of Legislative Council. I'm not sure if I've testified in person in your committee yet. Oh my God. So I wondered, Madam Chair, if it would make sense, I wasn't able to stay for all of Cindy Brzezi's testimony last week, did she go over the law itself, the patient choice end of life. No, I think it may be helpful to do a bit on that to give context what the I think that that would be excellent. Okay, that would be helpful. Otherwise we don't know what we're amending. Exactly. And it sort of jumps in right in the middle of some of the provisions so it's difficult if you don't know what the framework looks like. Just to orient you in the statutes we are entitled 18 and we are in chapter 13 which is entitled patient choice at end of life. And it sets out there are a number of definitions and but the main part we're going to focus on is the process that out in section 5283. And so this is entitled requirements for prescription and documentation immunity. And so I think Cindy talked to you a little bit maybe about this the concept behind this law which is to allow a patient. To request medication to be self administered for the purposes of hastening their death, and the way the law looks at that whole process kind of through the prescribers lens the physicians lens. So, that's important context just to know when you're looking at it that section 5283 which is amended in the bill says a physician would not be subject to civil or criminal liability, or professional disciplinary action. If the physician prescribes to a patient with a terminal condition, medication to be self administered for the purpose of hastening the patient's death. And the physician affirms by documenting in the patient's medical record that all of the following occur and then it lays out the process but it's really looking at it from the physician affirming that all of these steps have. So first the patient made an oral request to the physician in the physicians physical presence. Look at that in the bill for medication to be self administered for the purpose of hastening the patient's death. So an oral request, and the second one is no fewer than 15 days after the first oral request, the patient made a second oral request to the physician in the physician's physical presence for medication to be self administered for the purpose of facing the patients. So one oral request, at least 15 days later, a second oral request. Number three is that at the time of the second oral request, the physician offered the patient an opportunity to rescind the request. Number four is that the patient made a written request for medication to be self administered for the purpose of hastening the patient's death and that was signed by the patient in the presence of two or more witnesses who were not interested persons and that's a defined term in the statutes, who were at least 18 years of age and who signed and affirmed that the patient appeared to understand the nature of the document and to be free from duress or undo influence at the time the request was signed. So at that point we have an oral request, at least 15 days later we have a second oral request. At that point the physician offered the patient an opportunity to rescind the request take the request back. And in this process as well the patient made a written request for the medication and that was signed in the presence of witnesses. Number five is the physician determined that the patient was suffering a terminal condition and terminal condition is defined as an incurable and irreversible disease, which would within reasonable medical judgment result in depth within six months. I know Cindy mentioned to you about the six months that's what the six months refers to. The physician determined that the patient was suffering from a terminal condition, based on the physician's physical examination of the patient and review of the patient's relevant medical records. The patient was capable was making an informed decision and made a voluntary request for medication to hasten their death and was a Vermont resident. Number six is that the physician must have informed the patient in person, both verbally and in writing of several things the patient's medical diagnosis, the patient's prognosis, including acknowledging that the physician's prediction about the patient's life expectancy was an estimate based on the physician's best medical judgment and is not a guarantee of the actual time remaining in the patient's life, and the patient could live longer than the time predicted. The range of treatment options appropriate for the patient and their diagnosis. If the patient was not enrolled in hospice care, then information about all feasible end of life services, including palliative care, comfort care, hospice care and pain control. The range of possible results, including potential risks associated with taking the medication to be prescribed, and the probable result of taking the medication to be prescribed. The decision requires that the physician have referred the patient to a second physician for medical confirmation of the diagnosis, prognosis and determination that the patient was capable was acting voluntarily and had made an informed decision. So the physician must have either verify that the patient did not have impaired judgment, or refer the patient for an evaluation by a psychiatrist psychologist or clinical social worker licensed to Vermont for confirmation that the patient was capable and did not have impaired judgment. Number nine is applicable the physician consulted with the patient's primary care physician with the patient's consent. The physician informed the patient that the patient may rescind the request at any time and in any manner, and offered the patient an opportunity to rescind after the patient's second oral request. The physician number 11 the physician ensured that all required steps were carried out in accordance with this section and confirmed immediately prior to writing the prescription for medication that the patient was making an informed decision. Number 12, the physician wrote the prescription, no fewer than 48 hours after the last to occur of the following events. The patient's request for medication, the patient's written request for medication, the patient's second oral request, or the physician offering the patient an opportunity to rescind the request. So again in the timeline we have first oral request, at least 15 days later second oral request with an opportunity at that point from the physician to rescind the request, a written request, and then the prescription written not less than 48 hours after the last of those to occur. Number 13, the physician either dispense the medication directly, as long as they were eligible under law so they were licensed to dispense medication in Vermont had a current DEA certificate and comply with applicable administrative rules. So if the patient's written consent contacted a pharmacist and informed the pharmacist the prescription and delivered the written prescription personally or by mail or fax to the pharmacist who dispense the medication to the patient, the physician or an expressly identified agent the patient. Number 13, the physician recorded and filed all of following in the patient's medical record, the date, time and wording of all oral requests to the patient for the medication to hasten their death, all written requests by the patient for medication to hasten their death. The physician's diagnosis prognosis and basis for the determination that the patient was capable was acting voluntarily and had made an informed decision. The physician's attestation that the patient was enrolled in hospice care at the time of the oral and written requests, or that the physician informed the patient of all feasible end of life services. The physician's verification that the patient either did not have impaired judgment, or that the physician referred the patient for an evaluation and the person conducting the evaluation said the patient did not have impaired judgment. Record of the outcome and determinations made during any evaluation the patient may have received a date, time and wording of the physicians offered the patient to rescind the request for medication at the time of the patient's second oral request. And a note by the physician indicating that all of the requirements for this section were satisfied and describing all of the steps taken to carry out the request, including a notation of the medication prescribed. Number 15 is that after writing the prescription the physician promptly filed a report with the health department documenting completion of all of the requirements under this section. So again the beginning of that section says physician is not subject to civil or criminal liability or professional disciplinary action, if they prescribe the medication to the patient and the physician affirms by documenting in the medical record that all of these things occurred. Subsection B says this section shall not be considered to limit civil or criminal liability for gross negligence, recklessness or intentional misconduct. There are also some other provisions in this chapter about there's no requirement that any health care provider participate in providing a lethal dose of medication to a patient. And they cannot be subject to discipline suspension loss of license loss privileges or other penalties for actions taken in good faith reliance on the chapter or refused us to act. There's also language. So that's the main one that we should look at. But and then there are others talking about health care facilities can prohibit physicians from writing patient a prescription if the medication is intended to be used on the facilities premises. Some other provisions, including a reporting requirement. So I wanted to give you that context before we jump into what changes this bill is proposing to make. And then there are questions about what the current law says. Okay, thank you for indulging me in reading that long list. We do have a question. So when once you have the medication and you've gone through this whole process. Is there any time limit on that. If you have to rescind it or it doesn't you can have it all and you can have it right so you get the patient gets that goes through the whole process and gets the are you talking about how soon they have to fill the prescription or how soon they have to take the medication. Yes, how soon they have to know there's actually no requirement that they ever take the medication. There are requirements that the health department adopt rules providing for the safe disposal of unused medications recognizing that these are intentionally lethal medications. Okay, okay. No, in fact, I think you'll see, I think the health department report which they put out every two years, because you required that says that there are some number of patients who have did not use the medication some of them died from their underlying conditions, or other other reasons. Carl. Thank you. Do we know how many people have made use of this mechanism. We do. Let me just call up that report. And as you pull it up, I, the health department has asked to testify and, you know, or has agreed to testify about their report, which has all of those details. I think we just send this current one to, I think it's on your website somewhere but I'm going to send it to Julie, she can post it if people are interested in looking at that today. But yes, what can I tell you. The most part I think these are. Oh no this is the full time so since there have since the beginning of this law since logic effect in 2013, there have been 116 events, which I believe is which people were prescribed the medication. And it talks about the different underlying diagnoses. So, of those 77% were due to cancer 11% were due to ALS 5% to neurodegenerative neurodegenerative conditions and 7% to other events. Thank you. And there's some additional information. And they're about back into to you say 2013 2013. Yeah, it seems a shorter time. In that time, only 116 people. I believe that time reading this report there are 29 over the last two years. I do think that David Englander from the health department will be able to go into more detail. And no, no, no, this is important. I just wanted you to know that if there were things that legislative council didn't have a type of her. And then one of the people who I've already reached out to testify. Maybe can talk about what's happening nationally so that we know in context with that. Okay, so now we will turn it to the bill. S 74 is an act relating to modifications to patient for months patient choice at end of life laws. And the first thing it does is makes this add some new definitions and these definitions are added because they, these terms get used as we go into further into the bill so as a definition of health care services which is important because the next definition telemedicine it talks about health care services, health care services and this is our fairly standard definition means services for the diagnosis prevention treatment cure or relief of a health condition, illness, injury or disease. And telemedicine is the delivery of health care services such as diagnosis consultation or treatment through the use of live interactive audio and video over a secure connection that complies with the requirements of HIPAA the health information community and accountability act of 1996. So you I think you've heard some on the floor already this year and maybe talked in this community some about telemedicine and telehealth medicine is is one type of telehealth and it involves the that live audio video like zoom now we're all much more familiar with what live audio video communication looks like. But typically for telemedicine has to be through a HIPAA compliant connection. So to provide privacy. Section two makes changes to that long section we went through on the requirements for prescription and documentation. So this, and in the first instance. This would add to the requirements first and second for around the oral request for medication that the patient have made the oral request to the physician, either in the physicians physical presence and this would add or by telemedicine that live interactive audio video the physician determines the use of telemedicine to be clinically appropriate. So the first two provisions here are adding telemedicine as an as an alternative to request in the physicians physical presence. Further down in subdivision five, the physician determined that the patient and in subdivision a was suffering a terminal condition based on the physicians and this would take out the language requiring a physical examination of the patient. We'll be based on the physicians review of the patient's relevant medical records and a physicians physical examination of the patient. And then it keeps in was capable was making an informed decision subdivision D is just making a change for use non gendered language so it made a voluntary request for medications in case and that the patients own that and was a Vermont resident. In subdivision six. This is again adding a reference to telemedicine being to be an appropriate option here where the physician is informing the patient of certain information. This could be by telemedicine in addition to being in person. And 12 would eliminate the 48 hour waiting period after the last to occur of the specified events. The change in subdivision a is again to use non gendered language and the change at the end of subdivision be is changing an or to an and I see this as a non substantive technical fix it really doesn't make sense, or as much sense to say something after the last of the following events a B or C. It makes more sense to say last of the following events a B and C, but from a practical standpoint I don't think it has a change in meaning. In subdivision 13. We're again making a change to non gendered language, which is just something we're trying to do throughout the statutes when, when gendered language appears so this would say that the physician dispense the medication directly, provided at the time the physician dispense the medication that position was licensed, etc. Subdivision 14 is also a change to non gendered language. Subdivision 14 refer to the patient's own. Same in subdivision 14 be and he on page four. So the substantive changes then in this section would be to allow for the physician to work with the patient through telemedicine, rather than infert requiring everything to be done in person, and eliminating that 48 hour waiting period for the last to occur of those listed events. Section three would add a provision to the existing section on limitations on actions, where it says that nobody is under a duty to participate in providing a legal dose of medication and that a healthcare facility or provider shall not be a physician nurse pharmacist or other person to any penalty for actions taken in good faith reliance on the provisions of the chapter or it's usually to act. This would add a new subsection C saying that no physician nurse pharmacist or other person licensed certified or otherwise authorized by law to deliver healthcare services in this state shall be subject to civil or criminal liability or civil disciplinary action for acting in good faith compliance with the provisions of this chapter. There had been some concern as I understand it expressed particularly by pharmacists about their potential for liability. And this is taking a broader view the language in the current statute looks mostly at the liability of the physician so this is adding for other healthcare providers as well. And, and then it remembers the existing for reletters the existing subsection C to be subsection D, and finally section for effective date the act would take effect on passage. Thank you. In terms of the content. Right now do we have any questions for legislative council. Appreciate it. I just just trying to find what I absolutely and it was on page to the way down. Physicians based on the positions. And that's crossed out review with the patients for all the medical records and physicians. What I understand is the major change areas it's not prescribing position that is a testing to this person's issues, life threatening issues. Well, they are still a testing to the, that the person is based is suffering a terminal condition but it may be based on another position physical examination of the patient. They're their own physical examination the patient this would allow it to be another position. Ask a question about that. Yeah, go right ahead. I just want to hear testimony about it. Sorry. I'm sorry I just was thinking like, is that because we have some positions who do not wish to participate in this practice. Not the testimony that I heard in the Senate and, you know, you'll hear testimony as well it sounded it had more to do with the patient's ability to travel to where the position was, when the one the patient may be in an advanced state of disease. Thank you. Thank you. And committee this really is this is this is day one. This is a complicated and complex. Representative McFawn, do you have a question for legislative council. Yes, yes, Madam Speaker. Not now speaking not yet. Just promoted you. The, the, that that piece that number five, one page two. Does does does an individual always have to have a physician's physical examination. So the determination that the patient was suffering at terminal condition must be based on a physician's physical examination of the patient and not a fellow health. Sorry. And that, that examination can't be done over telehealth right. Right so the physical somebody must have some a physician must have performed a physical examination in order to determine that the patient is suffering a terminal, or to diagnose the terminal condition. The prescribing physician may have may base in part their determination that the patient is suffering a terminal condition on the other patients, other physicians physical examination that they must also have reviewed the patient's relevant medical records. Okay. Thank you. Former representative sandy house. How was your internet connection. So far so good.  So I was asked to kind of put all of this in a historical context. So that's what I'm going to do. This legislature has worked for years to empower patients to get the care they choose. Long ago, Vermont clarified that patients have the right to refuse creating even when doctors don't agree with them. In the 1980s, legislation facilitated what were called living wills and durable powers of attorney for healthcare. As a practicing lawyer, I helped many clients who wanted to finalize their choice of refusing to be hooked up to machines, just to stay alive. Now, first year on this committee, we continued that work. Our advanced directive bill in 2005 became a model for the country. I believe you heard a lot about that last week from Cindy. That legislation makes it clear that medical providers must follow the wishes of a patient, or his or her designated agent. Later, Vermont implemented an online registry for advanced records, assuring that those documents could actually be located and used no matter where one ends up receiving treatment. Then this committee focused on palliative care. This was a field so new that many Vermont practitioners had not even studied it in medical school. In this work, we passed the first continuing medical education mandate in the state. It took us two terms to get that passed, because there was so much opposition from the medical community. Now doctors must spend one hour every two years hearing about palliative care and pain management. In 2013, we took up and passed patient choice in the blood, which is codified in Chapter 113 that Jen just talked to you about. That bill was intended to give patients one more tool to assure that they, not the medical establishment, can make decisions regarding their own treatment.  The only questions are when and with how much suffering.  When we drafted the law in 2013, we chose to model it on a law that had been used in Oregon since the late 1990s, and in the state of Washington since 2009. Both followed a very careful procedure to provide that one final tool to a dying patient whose suffering feels too great to bear. In negotiations with the Senate, we found that not everyone supported that very careful procedure. As a result, we passed a compromise bill that forced us to reconsider that process at a later date. In 2015, we took up Chapter 113 again and voted to keep in that careful procedure, keep it in place. Technically that was accomplished by removing the sunset. Our 2015 amendments also required that the Department of Health review the physician reports filed under the law and report to the legislature regularly on the use of Chapter 113. So you've heard of you've heard about current law in detail from Jen, I will just go through it a little bit, a little bit more briefly. It continues the multi step process that was first adopted in Oregon in 1998. It permits a qualified patient to request a legal medication that has to be self administered. And that medication can be described only if the patient is a Vermont resident. The terminal diagnosis is given a six month or less prognosis that is six months expected life expectancy, and that that is confirmed by at least two doctors and to be a qualified patient, you have to be able to make a health care judge, health care decisions, not have impaired judgment, make an informed decision after being informed of the diagnosis, the prognosis, the range of treatment options, the range of comfort care options, the, the risks of the legal legal medication and the probable results. And as Jen laid out for you it has to be requested three times orally and both orally and in writing. And there's that 48 hour waiting period between the last request and the actual writing of the prescription. Participation participation under this law is voluntary. It's voluntary to patients, and it's voluntary to providers. It creates a very narrow path for a dying patient who seeks medication to hasten their death. If that narrow path is followed, both the doctor and family members are protected from criminal liability, what we call in the law as safe haven safe harbor excuse me. In advances in pain and symptom management. We heard that there are always a few patients whose end of life suffering cannot be relieved. Chapter 13 will pass to assist those patients. And I think what you've heard about as 74 is that it proposes a few modest changes to that very careful procedure. And you will hear from other witnesses how that how that would play out now, but we've had in place this this multi step process for many years now. And, and people who have worked with it have proposed those changes and having read the bill I support those changes. Thank you. I'm going to move on to former representative house. And former representative house was. I think that committee member who for each of these sequential steps from position, continuing ads to advance directives. reporting the first initially on the House floor and then the amendment. So she really knows it this way. And I thought it was important that we hear the history going back to what she talked about, which was a long time ago in terms of thinking about palliative care and end of life and how we can enable Vermonters to approach end of life in a way that works for them. Questions or comments or discussion? Yeah, I just, it's so, hi, Sandy. I just find it so interesting what you said about palliative care and how the physicians were so against it from the Vermont. I just, and now it's the thing to do and people really are physicians encourage the consideration of palliative care. So very, very interesting history. Well, it was a little pet peeve of mine that radiologists said, well, I don't need to know about this. And my feeling was, you know, if I'm behind you in the groceries floor line and I say, Dr. Jones, you're a doctor. Have you heard of palliative care? I didn't want the answer to be no, even though the radiologist was unlikely to ever use it in any way. I thought at least they ought to know what the word means. And I think I'll stop there, but I could go on about what I consider the arrogance of doctors. What, the arrogance? The arrogance of doctors. Who we all love and adore. I think somebody said that all surgeons are really psychopaths. Sandy, during the testimony that was given when this law was first enacted, I know there was a lot of pushback by the disability community as it relates to maybe, I guess what I would call a substituted decision making. And so how, and maybe this is a question for much counsel. So if a person has been determined incompetent by the court to make decisions on their own behalf related to healthcare and they have a guardian, whether it be a public guardian or a private guardian, this seems to speak to the individual. And I just want to confirm for my own mind, because this happened before my time, that that means the individual, not the person acting on that person's behalf if there is a guardian. That is correct. This law does not allow substituted judgment. Thank you. Carl. Justin, maybe you can answer this, Sandy for what I've counseled, but again, going back to paragraph five on page two, this change about the positions can be another position, not the prescribing position. How does that marry up with the fact that there have to be two independent diagnoses by two different positions? Does that mean there'd be two positions that were not the prescribing position or not? I understand somewhere in it says there have to be two diagnoses independently. As I read that language, and I will defer to others on the intention there, I believe that at least one position has to do a physical exam, but there would still be a requirement that another position look at that at all of the records. Look at the results, not necessarily performed. My name is Anne. Okay. Now perform a physical exam in person. Thank you. So legislative counsel, maybe another way to ask that question, how many different physicians does a person who is considering this need to connect with? At minimum two. Okay. So at least two, there could be three or more. There could be one physician who would perform the physical examination, a second who is the subscriber, and a third who is doing the medical confirmation, or it could be within those two providers, but never less than two. Okay. Tapper. Thanks Madam Chair. On page three, we've taken out Sandy at the 48 hours. Madam Chair, are we going to get, is there a reason why the 48 hours was taken out? I will, if she wants, I will let Representative, former President Cross respond. We will be taking lots of testimony. We will be taking testimony from the supporters of the bill in terms of why and what was needed. What is the problem that this removal is trying to address? And we will be hearing from individuals who did not support the law in the beginning and who do not continue to support the law. And so we will be doing, so I don't know, I guess I'm saying I don't know if Representative Haas can answer that, or if legislative counsel, if that's a fair question for legislative counsel, or we should wait. So I will just jump in and say that you will be hearing my understanding from following this in the Senate is that this is exactly one of the areas where the, what is it now, nine-year experience in working with this law as written, you will hear from people who have used it who will say that they are suggesting this change and why. So I'm going to defer to the people who have been working with the law. That's what I use to do and what you do now is we take laws and we see how they're working and we make adjustments to make them work better. So we'll hear from somebody then, right Madam Chair? Yes, and that's everyone, you know, I think this is an introduction. How's that? And I think, you know, my understanding broadly is that this was to remove unnecessary barriers for those individuals who wanted and continued to want to exercise their options under this law. And we will hear, we will hear from those and we will hear. We have an email out to Mary Honsburg Beardsworth as to when she is available or whether someone else in her stead, as she has reached out and we have reached out to her and she is someone who represents a constituency that has many concerns about this, about the existing law and the change. Thank you, Madam Chair. Sandy, it was nice seeing you. Wonderful presentation. I have to leave. I'm sorry. Please take care of yourself, Topper. Other questions right now for Legislative Council in terms of the content or Sandy in terms of the experience and history and what were some of the, or other things as relates to how we got to where we are today. So folks, this is, so let me lay out some ideas that I had in terms of who we hear from. I think it's, and look, before I do that, who do people want to hear from?  Well, I think we probably should hear from the Medical Society and maybe some physicians who have actually participated. Right, actual doctors, yeah. I'm sorry, I can't hear. I was agreeing with your actual physicians who have actually participated. And people. And people, family members who have been impacted. Yeah, okay. The leader of the nomination of the church, I don't know what one of would be, just to hear with a perspective from the religious community. Maybe more than one. Okay. We'll figure out how to do that. And we have the health department. I just want to circle back to Carl in terms of figuring out which are the, the religious community is very wide. And I want to say probably the religious community being very wide has very different perspectives on this. And I might suggest to each and every one of you who has a connection and for whom their religious community is part and parcel and important to them that they check with them. And we will, I believe that Mary Han Spirgworth represents a non, non, she's not necessarily connected to a particular denomination, but I think she represents and her views are, are rooted in a religious context. I'll change it. I'd like to hear from her. Oh, absolutely. Absolutely. And so we've got family members, some sort of connection to the religious community, the health department. What? Drinking. That's challenging. It is. It's very challenging where, you know, whether it's, you know, from the state, probably just going over legalities. Okay. Which I don't question. Okay. So since we're being in this way, I don't know where we have ledge counseling, but on every other bill that has legal questions, we've had people from, you know, the Donovan's officer or whatever. Journey general. Okay. You know, so I mean, it's not a question of that. It's just, that's what we do. Okay. Yeah. We don't get to pick and choose when we're going to do it. Okay. I am, and now I'm turning. Yes, Carl. Could we hear from some family members that may have had people. Good idea. Yes. And I know there are, I know that there are several who have experienced this recently who would like to testify or who were, were offering if this is not too hard for them to testify. I also have been thinking about there is a, there's an organization in Vermont for people that they have questions. And as there is a national organization. So to have representatives from both of those groups. And do you want us to hear from the disability community again around this? Let me check in. Okay. Folks. I know that the primary and big issue was around substituted decision-making. And emotional pressure. Yeah. Or family members or other people who are guardians of an individual with a disability making the decision for them that it's time, you know, for, for their life to be over. And I think that that was, that was a quite a large concern back in 2013. It hasn't proven to be the case. And by not enabling substituted decision-making, even if you are a guardian, I think that elate a lot of people's concerns. So I will check in Madam Chair. Okay. I do want to put our witness on the spot. Sandy has, if you remember what, if you can, what some of the issues, if there were additional issues or concerns. Well, there was, and how, and how, let me say, and then how we, how we tried to, how the law tried to address them. I think the, there were, there were concerns about family pressure. And, and that was one of the reasons that we were so careful to follow the, it must be the individual deciding, it must be the individual self-administering the drug. We, there, you know, the, the witnesses have to be people who are, who are not interested in the estate of the, of the, of the ill person. One of the reasons that we followed Oregon so closely was that Oregon had a track record that, that revealed that many of those fears had not been realized in all of that time. All of the, all of the concerns that we heard in 2013 had been raised in the 1990s in Oregon and, and they had been reporting right along and had found no evidence that any of those things happened. And I was just, I had, it's, I'm glad that you found the 2022 report from the health department because they don't have it on their website. And I was intrigued to see that of the 29 people who, who, who quote, used the law clause quotes in two years, only 17 of them actually used the prescription. So, so I think, I think on one level the numbers by themselves reassure us that, that this is not being used. Thank you. I hate to be so ignorant on this, but I don't recall in the initial bill what the situation was with life insurance. In other words, if somebody chooses to take their own life and they would not be eligible or their estate would not be eligible to receive the benefits. Is that true or not true? I don't know the law. Yeah, what's in the law? Yes. So in the law in ATVSA 58287 it specifies that a person and their beneficiaries shall not be denied benefits under a life insurance policy or actions taken in before this is checked. So I'm surprised that life insurance industry didn't protest more when it's low. Anyway, just following up on that. It's a good question. Yeah, that's a good question. I think we need to hear from the insurance industry if these changes, I don't know, reading it, I don't know what these changes would do to make it, let's say easier to or affect the possibility of insurance or not, but it might be useful to hear from the insurance representative. Okay, life insurance. Just a thought. We're asking for a suggestion. No, I appreciate that and we can figure out, I mean, what the response is and yeah. Yeah, thank you, Madam Chair. I think a question that came to my mind and hearing that not all individuals who are prescribed these medications ultimately take them is maybe hearing from a pharmacist or somebody like that. But my question is sort of what is the follow up in these cases of like proper disposal or retrieval of those medications after they're prescribed if somebody's not going to use them. Also if we could hear from one of those people who decided not to take the medicine, they might be interested. Well, they still died. They still died. Yeah, they still died. I mean, they're they either died. Oh, I think that's the main reason they didn't take it.  They chose to die naturally rather than take it or maybe something happened before they took it. Of course, we also know even if somebody has been diagnosed with a terminal illness, it doesn't always mean it is terminal. But usually, as I agree. Committee, my sort of thought about this is that this is still, I mean, well, this is Thursday, but we're not going to take any more testimony this week on it. Julie, how are we working on next week? All of the witnesses for next Thursday. Okay, so their witnesses for next Thursday and they have been confirmed. And whether or not we have another day or a short thing is up in the air. And then we will direct more, more concentrated time on it the week after. So that's that's why I want to know what people's opinions and thoughts were. So I think I think that gives us I hope this gives us all a good beginning and to begin to think about this and who we want to hear from and know that it is one of the Senate bills that we have. We have two Senate bills right now and we'll be getting a few more. And my plan committee is to have to have a walkthrough of what those Senate bills are. So then we can figure out what we do next. So with that, Representative Haas, thank you very much for joining us today and for helping set the stage. Good day. Bye. Committee, it is earlier than I wasn't sure I wanted to leave sufficient time for this because it's it this can be a hard discussion or a hard issue. But now that we have some time, rather than coming up after the whatever we're doing judicial retention, how I believe that Representative Whitman has shared an amendment with you on on our bill. And so if you could present that first straw poll. Yeah, so I'm sure. Yeah, I forgot my straw. We'll find one. Okay. Thank you. So yeah, glad to hear back from quite a few of you that you had the chance to look at this last night, sent an email after a lot of close collaboration with the Department of Vermont Health Access and going back and forth and checking with a lot of interested people based on this floor amendment, which is essentially to offer alternative policy moves around prior authorization. I won't completely rehash it. I think a lot of people here know that we gave an initial proposal. The potential costs associated with that were higher than we had anticipated. And but in the efforts to continue on a path forward to address barriers to treatment for people seeking medication assisted treatment. There were a lot of proposals put forth to the committee and a lot of considerations about what potential opportunities for changes there could be to prior authorization that would potentially make it easier for providers and patients to get the treatment that they needed. So basically the path that we're taking within this floor amendment is to task the department with sort of a deep research of all of the available in the feasibility, the logistics, the potential costs of all of these potential changes to prior authorization. And then for them to propose these to the relevant boards that are currently tasked with reviewing decisions related to prior authorization, that's the drug utilization review board and the clinical utilization review board. And then they will provide recommendations after considering those that research, which will then be presented to us. So I'll kind of walk through the amendment right now. This is good practice for me this afternoon spent a lot of time writing this and now a walk through but so let's see I'm looking at the calendar but it would be page one of the amendments that I emailed everybody yesterday. The new section three of the bill essentially codifies the existing practice which does exempt one medication within the classes of methadone, buprenorphine, and naltrexone from prior authorization. But it's just specifying that it goes through the drug utilization review board. So essentially this was current practice but it was not in statute so we're codifying this current practice. That's yeah so this would be like a it's read a section three because it's within the bill as a whole. Section four is the report which states that on or before December 1st of this year, DEVA will research the following and we included specifying and consultation with individuals representing diverse professional perspectives. One of the reasons that we're here is that we heard diverse professional perspectives on whether prior authorization is good the way it is or it needs to be changed in order to delete barriers to treatment. And we'll submit its findings to the DURB and the CURB for their review consideration and recommendations. And what we've ended up including for their research and following recommendations is quantity limits and preferred medications for buprenorphine, the feasibility and cost of adding monogrupernorphine products as preferred medications as well as the current process for verifying adverse effects to monogrupernorphine. Three is how other states Medicaid programs address prior authorization for MAT including the 60-day deferral period that we've seen in Oregon. The appropriateness and feasibility of removing annual renewal of prior authorization as well as the appropriateness of creating parity between hub and spoke providers with regard to MAT quantity limits. This says quality limits. So that's a Scribner's error, I guess. The person who wrote your report needs to. Then creating the consideration of creating an automatic emergency 72-hour pharmacy override by default. So basically what this following section says is that the DURB and the CURB will include this review as an agenda item at their meetings related to prior authorization. Basically so that this is giving notice for public comment, essentially what this section says. And then honor before January 15th, the department shall submit a written report that basically contains that initial research that they gave to the DURB and CURB as well as the DURB and CURB's recommendations. So that'll be coming to us for consideration of potential further action. Seven is the reports. Again, these are the reports that were with sunset. Now we're looking to renew them and we've also bolstered them. What was being sunset? I'm sorry. So remember when I would kind of read from that table that says like there have been 3,000 prior authorizations and 95% have been approved. So those reports started in 2019 and they basically timed out after three years. So we're renewing those reports as well as asking for additional data just so that it leads less up to interpretation. Maybe a lot of the questions that we were asking the department could potentially be answered ahead of time through this report. And so what the report will include is which medications required prior authorization, the reason for initiating prior authorization that would be a new point. Like why was this medication? Why did we have prior authorization now and not for the other 10,000 times this prescription was prescribed? And then how many prior authorization requests the department received and of these how many were approved and denied? That was already included but we also want to include the reason for approval or denial as an additional data point. The average and longest length of time the department took to process a prior authorization that was already there and how many prior authorization appeals the department received and of these how many were approved and denied and the reason for approval or denial? This is a new piece within the statute. Our understanding is that the department already was presenting this data. So and that's that. So yes I just wanted to mention to folks that I know we had talked about the corrections thing yesterday and I did reach out meaning folks who transition from correctional on MAT and then move to the community and have to sort of immediately switch over if they're able to get immediate access as it is. And so the chair of the joint so I sent a note to the chair of the Joint Justice Committee to see if she would take that up during the off session and she responded that we will take that up during the off session. So we'll take additional testimony on that issue and you know potentially bring back some recommendations for consideration next year. And the Joint Justice Committee. I told her I'd wait for her thing to print out but it wasn't didn't print and it wasn't in the queue whatever she was looking for. Oh okay. Just for folks the Justice Oversight is one of the summer or interim joint committees and it has members the the chair or designee from institutions from human services from judiciary and I don't know that's it and in both the senate and the house and I'm the rep for human services in the house. So before we thank you for that update before we vote on your amendment Topper had and he's he had he had to go away but his his request and he has he he has sort of emailed that he's okay was that we needed to know the amendment what our amendment was before we voted on for we took a straw poll on accepting the Appropriations Committee amendment which is what started this whole thing because they they they they struck everything about pre-authorization. So let's first do a straw poll on the Appropriations Committee amendment to our bill all those who are in favor of the Appropriations Committee amendment please raise your hand. Okay so if it's something wants to zero sorry oh sorry those opposed. Just wanted to vote so I know she had to run but okay so it is a straw poll it is a straw poll so you can um I could text her she's yeah okay you can you can text her to tell her to come back I don't know where she went but she was talking about it on top of top of this too and so I so what we will Topper gave his approval in in an email that the amendment was okay with him but when he gets back I will which amendment one the appropriations no he gave his approval of of the second amendment not the first um he did not give his approval but we didn't ask that specific question of him so I will um when he gets back we will circle back to him. As of now I have eight one two two absences right now you have eight one two and it may that may change and it being a straw poll sometimes a straw vote sometimes by the end of the session these straw votes happen on the floor of the house with someone going from either the committee they huddle in the corner in the corner on that kind of thing so we're not really diverting too much from process and so now I enter a straw poll on accepting the amendment as proposed by Representative Whitman and all those opposed so that is um nine zero two until we hear from other people so thank you very much I don't think we'll have a reason to come back we'll we'll have the opportunity to um come back today I think we have a day on the floor I'm going to text you I mean we do have a bill on the floor so sometimes there may be an amendment or something so think about potentially being here at nine o'clock tomorrow morning if not on Friday 15 minutes after we get off the floor and I will I will confirm that text and email to everyone about Friday okay as far as committee right as far as whether whether well committee right well given where we are and everything I think we will need to check in at least for you know 45 minutes and whether that is first thing in the morning in case there's an amendment to the bill or something like that or whether it is when we get off the floor and when I look at when I look at the calendar the only what we have for first reading on Friday is the capital bill and um then everything else looks like it will be third reading so um if we do if we so I meant so if we don't come first thing in the morning we'll do a quick at the end you know because I don't we won't be we won't be till four o'clock on the floor on Friday so we can point out we don't have any witnesses tomorrow and we don't we don't have any this is just to um to check in um and uh that so um with that uh we have a few minutes before we are going on the floor so this ends our


We are live. All right guys. We're back with another show We got a special show today because we got the zero X team over here Well one member right now the other one member is gonna appear sooner or later. He's running late right now But I will introduce them both regardless So the first one which you see in front of you right now is a mirror. Yes another mirror It's a duplicity over here to a mirrors is spelled with the I I with two E's Some years background is he's a full stack web application and smart contract dev And he has a former fixed income trader at DRW an online poker professional And he studied finance at the University of Illinois and our second guest which is not here yet The other co-founder of zero X is will Warren his background of smart contracts and R&D previously applied physics research and simulations at Los Alamos National Laboratory and Mechanical engineering at UC San Diego, and he's a PhD dropout. So we got some smart individuals on this call And so basically let's kind of like dive into it because I've been following your progression for zero X And it's actually one of my most exciting projects in the space currently For anybody that really doesn't know it Why don't we kind of do like a bird's-eye view in a 401 on the general spoke of what you're trying to build and how That's gonna look like Yeah, sure. Thank you for the intro of your great to be here really excited about what what block eeks is doing So zero X is a protocol for decentralized exchange on the theory and blockchain So the the token ecosystem is very rapidly evolving I think right now they're over 20 different tokens combined market caps probably around two and a half billion dollars and You see more and more popping up every day almost And in order for these tokens to be useful people are gonna need to be able to easily acquire them And then the end goal of these tokens is so that you could actually use them to work with different applications, right? So currently on the theory and blockchain the exchange ecosystem is sort of fragmented They're a handful of different decentralized exchanges They all use different smart contracts, you know, they have different learning curves different levels of optimization and All these different exchanges are sort of taking liquidity away from each other So in our mind There are huge network effects around liquidity when everybody is using the same underlying protocol Everyone is using the same settlement layer the same messaging format You could very easily trade across exchanges So that's kind of the problem. We're trying to attack liquidity problem decentralized exchange So if we're looking at a conspire comparisons right now if we look at I won't name names if we're looking at at a regular exchange at the moment and We're looking at zero X right now. Obviously everybody knows how regular exchange works, right? It's one center Control center you go in based on their rules you go out based on their rules They dictate all the all the rules for in and out. How would zero X look like from me as a user? So for you as a user Well, first of all, I guess I should explain. There's this concept of a relayer on zero X and that's any person or group that wants to host an order book And essentially act as an exchange So all of the orders are stored off chain on zero X and then they're settled on chain So it actually requires someone to you know do this service of hosting an order book So they're they're gonna be different relayers or exchanges popping up all using the same protocol and you would go to a relayer and Essentially just interact with it like a regular exchange You would need access to an Ethereum account somehow Don't either with like metamask or mist or the parody extension and Yeah, you could just trade directly from your own account. You don't need to deposit any money anywhere You're fully in control of your own funds at all times Every time a trade occurs That just happens on the blockchain You never have to trust any third party with your money Now for zero X are you guys implementing a fee at Gateway or right now is it only focus on crypto and tokens? so it's it's focused on tokens and and The way we see it Assets traditional financial assets are going to become tokenized. It's only a matter of time I know they're already a handful of different groups working on tokenizing fiat Yeah, I mean some are already live right and they're just maybe not used that frequently But but I think things like stocks bonds You know that'll all become tokenized at some point also rare scarce digital assets like video game items or You know memes stuff like that all of those can be traded on zero X and obviously at points protocol tokens are sort of our Our main target we really Aimed to to be able to provide liquidity to other decentralized applications. They're building on top of zero X So does this solve the problem? Let's say like for example if we look at South Latin America Or if we look at certain places in Africa or even some places in Asia, they don't really have access to current exchanges Do you even buy cryptocurrency? Does this can this solve that problem for accessibility for the people that don't have it? I would say not really know you still have to go through the traditional on-ramps or off-ramps to cryptocurrencies and That's a harder problem to decentralized But I know their groups working on that as well our main focus is No, once you have cryptocurrency already being able to exchange it with whatever you need to interact with other applications so, you know right now An application built on a theorem might require one token to be able to to be used But in the future as apps get more and more complex You might need ten tokens to interact with an application and that's just a terrible user experience And you need to be able to get those in a seamless way So when I use zero X because I just want to run it through my my mind I'm pretending. I'm using it. So when I use zero X and can we'll be able to use on the phone or is this just on like on on a desktop So it's just an open system of smart contracts. Okay, how you interact with it is No, it's up to you. Okay, so let's say let's say I'm using on my computer and I'm logged in right now In zero X do I get then a personalized zero X address? And is that address hold or how am I interacting with it? so You just have your regular the theorem address, you know might hold either might hold tokens And then you could create an order off chain So you just need to sign it with your private key. It doesn't cost gas or anything And then when someone wants to actually fill an order They take that and they inject it into the smart contract and then the actual transfer of assets will happen Also, if you are a DAP developer You can write solidity code that you know essentially plugged into Zero X for example, you could have a Dow Or like you you vote on which orders to fill or something like that. So if I understand this correctly and Correct me if I'm wrong. So it's almost like you get the marketplace. I Can go use it with my own Ethereum address and I can put up an order of saying I want to sell I don't know Ethereum for X. I'm on a price I put up that sell order on zero X and I still have it in my own personal wallet, right? It's not costing gas and the only time it's actually executed into a smart contract is when someone says yes, I want to buy it Yes, okay So zero X itself for you guys since you guys are creating a token as a utility within it How does what's the function of that in that process? So By the way, we'll we'll just got here if you want to join in to Before I answer this question sure. Yeah You still hear me already. Yeah, you guys are perfect There we go, we got second second founder here You're just asked about the purpose of our token. So there's two purposes So first of all something I haven't explained yet relayers can charge fees for providing a service of hosting an order book and All the fees are denominated in zero X tokens Relayers get to keep 100% of the fees that they charge. It's not like the protocol Extracts any rent or anything, you know, we don't get fees from people using the protocol So that's that's use case one to incentivize relayers to host order books And use case two is for decentralized governance. So sort of as I mentioned earlier I think the ecosystem is sort of fractured right now and it's it's really hard to trade across different exchanges and We aim to solve this problem through decentralized governance if everyone is using compatible versions of smart contracts You could maintain that network effect and have sort of a global liquidity pool But yeah, it requires governance to to make sure that you know Everyone is using the same protocol Otherwise, you know If you launch a new version of the protocol, someone decides to stay on the old one ends up getting fractured and you kind of Just end up in the same place we are today right Actually, I just found this term yesterday. I've been I've been looking at the literature the term academic term for this This network effect that's created when like can competitors are building on top of this the same standard is called They're called complimentary networks. So if there's two different decentralized exchanges They might even be competitors if they're both building on top of the same infrastructure They can provide mutual benefits for each other because there's there's sort of a disability to arbitrage across The different exchanges the different order books and it ends up producing a mutual benefit for both of them So it's actually better to have a competitor if that's if that competitor is using the same standard as you are It's better to have that situation than to not have a competitor at all and then you just single liquidity Interesting. Can we rewind a little bit? I want to dive in a little bit deeper for the host Can we explain that a little bit more detail like you as a relay a relay or in your hosting? How does that look like or how does that look like? Sure, so the protocol is It's completely agnostic to the different strategies that relays might use so since All these orders are completely off-chain The way in which you communicate that to the end user doesn't matter at all It could be over Twitter, Facebook, email, WeChat, whatever. I would say the Easiest and probably initially most common way to host an order book would just be storing these order messages in a database and organizing them and just Presenting to that to the end user in the form of an order book But you could also have different strategies For example, you could have a dark pool offer a shapeshift type service You could use a centralized matching engine These are all things that you could do in Zeroaxe and they all have slight advantages and disadvantages right so One analogy one analogy that could be somewhat Relevant is like Craigslist You know if you know someone on your email contacts that wants to buy your old bike you can send them an email and You know, hopefully they want to buy your bike, but maybe they don't but if you want to broadcast this offer to the entire world of people that are interested in old bikes you go on Craigslist and You post your offer and everyone in the world is interested in old bikes sees that offer and if they are interested they contact you In Zeroaxe just seeing that offer is enough for them to actually execute a trade with you Because of that offer in that packet of data that represents your word It contains all the information needed for the smart contract smart contract to actually carry out a trade between The person that originated the order and the person that decided to take the other side of it so relayers are essentially just Groups that decide to host these websites much like Craigslist and People can post their orders there and they can charge transaction fees to do that to offer that service and You know, it it's from an analogy standpoint This is an okay explanation But like from an end user perspective It might look and feel exactly the same as like using G-DACs or using coloniacs like they don't under They don't necessarily see or care that what's going on under the surface is this protocol You know, yeah, so correct me if I'm wrong, but earlier you said that When when I when I place an order in I still have the tokens in my own personal wallet, correct? Yes, so when my tokens are sold For whatever I'm selling you for and what I receive does that go back into my personal wallet? Yes, okay Yeah, so The way that works is you would provide an allowance For our the 0x smart contracts to access your tokens essentially And it just pulls them out of your account And pulls someone else's tokens into your account when a trade occurs, right? And the reason why you're comfortable providing this Particular smart contract with access to your funds is because the code is completely open source You can look through it. You can audit it, you know exactly what it's So you know that this smart contract is not going to be touching your funds in any way Unless you provide explicit permission by generating an order that is signed with your crypto group, you know, it's signed with your private key So can we do a little bit deeper dive on the tokenization I know you just touched on earlier, but I want to see how it how it fits into the overall ecosystem of 0x So Can we touch on that? Can we actually can you like go through like the birds I view of of how the 0x token will be Facilitated in the whole ecosystem. Oh, yeah, absolutely. Yeah, so I Think the most important part is the governance So we're complete we're we're building this completely Unopinionated piece of public infrastructure that anyone can go and build on top of and if people if we expect people to Build these profitable businesses these decentralized exchanges on top of 0x They need to be able to have a say in how that infrastructure is upgraded over time you know, it wouldn't make any sense for someone to go and build a Profitable business it takes a lot of time and effort. It's expensive It wouldn't make sense for them to commit all of that to building on top of 0x if Some like one single person or group could just go and decide to change the protocol in a way that completely destroys their business or Requires them to completely rebuild So there needs to be a governance process and how all of these different Applications built on top of 0x can, you know Oversee the upgrade process Does that make sense? Yeah, it does. Yeah, and and we have structured So that big players in protocol, you know, big traders Big relays or big dapps that use 0x will end up having a larger say in governance because They probably have more tokens. Yeah, they naturally accumulate tokens over so this is kind of kind of similar to like if you Ran a proof of stake where if you're staking X amount of tokens, you have a little bit more power and say within the network as a node right Yeah, so that that's like a critical piece like I don't think you could really expect to build a future proof System that has a bunch of stuff built on top of it if you weren't able to sort of smoothly transition to Improved versions of the protocol over time. I like it is just like a critical piece of the whole system the second The second use for the token is for incentivizing relayers to host and maintain these off-chain order books and what's really interesting about Token-based business models is that anyone that wants to go and build a decentralized exchange and Therefore increase the utility of 0x protocol and its token can purchase a bunch of tokens and then they can go commit a bunch of time and effort to building a useful application a decentralized exchange on top of 0x and They can directly influence the utility and therefore the value of the token. So they have an information edge Now, I think it's kind of this is like a new concept So like imagine if you were developing an iOS app And you went and bought a bunch of Apple stock before you released your iOS app to the public Probably wouldn't really matter. Okay, like no one really cares about your iOS app You know Apple's worth billy many many billions of dollars It's not you know your iOS app probably isn't very critical to the utility of iOS as a platform but when we're talking about these open protocols that are very tiny and They have tokens and the value of these tokens is directly proportional to the utility of the protocol You have a massive information edge if you decide to go and build on top of that protocol And so that's kind of that's this idea of like bootstrapping a network that like Fred or some talks about this on in his medium articles and it's It's like a really interesting concept that I don't know if I don't know if we've really seen something like this possible before tokens So what's your guys roadmap right now currently? So I know you guys have a launch coming up soon Maybe next half a year or under but what's your general roadmap within next year or so? so There there are a couple tools that we want to build out initially I Guess one of our main areas of focus will be the governance aspect So initially our contracts will be using a time-locked multi-sig which makes it Completely secure even if we wanted to you know attack it But governance is still a big area of research and there a lot of different projects working on it Our focus currently is to launch a functional exchange Protocol at the time that we we launch our token So yeah, we're getting to that point first then focusing on governance some other tools that We're considering building are like a trade explorer for example like the ether scan of 0x They're going to be essentially three different areas of focus For us so user tools developer tools and then R&D Trade Explorer as an example of a user tool is for developer tools We're building a JavaScript library 0x.js Which will make it really easy for people to interact with a protocol without you know having to deal with the smart contracts directly It'll allow people to easily set up relayers we might release pre-configured databases things like that to Make it a lot easier for relays to operate R&D Privacy is something that's really important There are a bunch of optimizations that can be made Especially if orders are private phase two So there's something we don't talk about very much because it it can be distracting from the primary Utility offered by the protocol But phase two is we want to build a fully decentralized Order book so instead of having an order book that's stored in a centralized database and owned by a single entity we want to spread that word book over a peer-to-peer network that's sensor resistant and Anyone that is participating in that network by propagating the order book and hosting will earn a Will earn a steady flow of tokens and that flow is proportional to their contribution to the network But that is like an entirely different Undertaking that will require, you know serious research It sounds ambitious it's almost like you want to piggyback off like tour or something. It's fascinating Yeah, we wanted the central, you know, I don't get rid of all the centralized points of failure So what can you give us a closer estimation on when your launch is? Yeah, so we're gonna be launching early Q4. Okay, right now. You so our smart contracts are Fully functional you can go and interact with them right now on covon Zero X OTC, which is that zero X project comm slash OTC and like it works. It's fully functional We've done a ton of testing We're going through security audits right now and immediately after our contracts are, you know We're positive that they're safe and secure We're gonna deploy them to the a theory and main net and that's gonna happen in a matter of weeks And after we deploy the main net, we're gonna go and use your X protocol to deploy our token Awesome, so we'll wrap it up like we'll wrap it up with that I just first want to thank you guys for coming on on the show Is there any final any last final words you want to tell our audience? Thank you for your attention. Yeah Awesome, so what's the best resource if they want to find out or if you want to follow zero X? What's your website? What's your Twitter? So our website is zero X project comm If you're a developer definitely check out our github Twitter is zero X project and our slack we're very active on our slack Which is zero X project dot slack.com. Awesome. Well, thank you guys Thank you


Hello everyone, this is Vaishnavi talking from Shankar Medical Academy, I am very sure you are all familiar with the name and the academy Shankar IAS Academy. This Shankar Medical Academy is a unit of Shankar IAS Academy and we have recently started with this venture of teaching for the NEET aspirants and this year 2022, July 17th we had the NEET entrance examination. As we do the extensive analysis of the UPSC preliminary question paper and then give the key for it, similar atoms have been made to give the key for the NEET question paper also and it has been published in the Shankar Medical Academy's website. Today this particular session what we are attempting is to present our findings on how this NEET questions are like a soothing from the Tamil Nadu's state board syllabus. How they have been like covered extensively in the Tamil Nadu's state board syllabus. Already the government has given some details upon the reflection of the questions in the NEET examination from the Tamil Nadu government's state board syllabus and here we are extending our analysis upon it and our team has worked upon the four different sections physics, chemistry, botany and zoology regarding the reflection of the questions from our Tamil Nadu state syllabus. So what I will do here is I will give you some presentation of the analysis what we have done. It is only the numbers what I am going to present to you right now. The details of this presentation how much reflection has happened from each section of the question paper will be given by our faculty team. In the Tamil Nadu state board syllabus, the NEET exam is written in Tamil Nadu students as well as the other standards. Can we perform as well? Can we clear the NEET class when it is completed? All these details are added. So this is why we are conducting this session with a clear light. We have analyzed the NEET question paper this year and the 277 questions from our Tamil Nadu's state board syllabus have been reflected. This session will be given to you. If you are able to write down the 187 questions from the question paper, we will give you the details of it as section wise. When you give the details, you will be able to answer as many questions as you can answer in section A. We have said that section B can be answered clearly. In section A, 123 questions out of 140 can be answered by you. In section B, all the questions can be answered from our Tamil Nadu state board syllabus. This session will be explained to you. In section A, we are not given 17 questions. How can we address them? When we think that we are not able to answer from the compulsory section, we are given the conceptual clarity of 6-7 questions. If there are no examples, we can say that there are only a few things that can be extended. So, what we are going to understand through this video session is that we have studied our state board syllabus and we have explained that the NEET exam can be attended to a good standard. This is about the NEET question paper of 2022. As we all know, this year we had the pattern of having 200 questions as a whole. The question paper was divided as section A and section B for physics, chemistry, botany and zoology. Section A had 35 questions. Section B had 15 questions. All the questions in section A were compulsory, whereas in section B, we had 5 questions like a choice. So, there was a choice in section B. Therefore, overall, there were 20 questions which the students can leave by choice. So, we had 15 questions. 20 questions which the students can leave by choice. So, upon 180, what is the total score the students can get? So, this is the pattern for this year. Now, we are going to reveal some interesting facts about the questions which are reflected from Tamil Nadu state syllabus. Number one, we would like to share with the data that out of the 200 questions, we have had 177 questions which has come from Tamil Nadu state syllabus. Number two, of this 177 questions, we would like to present it in section A and section B. So, section A in put together of all the physics, chemistry, botany, zoology, the total questions will be 140 out of which the reflections are 123. Whereas, in section B, we have total questions of 60 and we had reflections of 54. So, to go in bit detail about this representation in section A and B, let me rewrite the numbers. In section A, how many questions were asked from physics, chemistry, botany, zoology which had a reflection from Tamil Nadu state syllabus, we can say it is 33, 31, 28 and 31. So, how many questions appeared from NCRT? It is 2, 4, 7 and 4. So, here you get this 123 as the total. This is the numbers what we mentioned here as the total reflections and what was not present in the Tamil Nadu state syllabus book was 17. And I am going to go into a bit detail about this point in a few minutes. Let me complete the section B also. Again in section B, physics, chemistry, botany, zoology, how many questions were reflected from Tamil Nadu and how many questions exclusively only from NCRT will give you some numbers physics, chemistry, botany and zoology. So, this makes a total of 54 questions here. Those students need not attend all the 54 questions or 60 questions. This is how the reflections were. And you can see that a minimal number of questions like 6 questions were coming exclusively from NCRT whereas majority of the questions could be attended from the Tamil Nadu state syllabus. So, as of now if you rewrite whatever we have written here in the table, we can mention that out of the total 140 questions which are there in section A, 123 students could write based upon the Tamil Nadu's syllabus and the 40 questions which they have to appear from the section B, all the 40 questions if they are thorough, they will be able to write. We are only saying if they are thorough, they will be able to write because out of the 60 questions you can see 54 questions are having their reflections from the Tamil Nadu state syllabus. So, out of the 60, there is a choice of 20 so they can attempt the list of the 40. So, that is how the presentation has been given here. So, I told you I am going to give you some more additional data on this, the 17 questions which we are saying in section A which has come from NCRT. In this 17 questions we are going to have some questions which we can say there is a conceptual reflection. Out of the 17 questions we are going to say like around 6 questions they have the conceptual base in the Tamil Nadu state syllabus. The meaning of this is the definition could be there, the examples may not be there, the examples might have been presented from NCRT or it could also be something like a question has four options, two options the students will be knowing it and two options the students may not know it. So, these two options how did they know that examples have been given in the Tamil Nadu state syllabus book. So, by making some simple logical assumptions the student will still be able to do this kind of questions which we call as the questions having the conceptual reflection. Say for example I have picked up the question number 83 which has come in chemistry which we want to call only as conceptual reflection because not all the options in this question have the direct presentation in the Tamil Nadu state syllabus, but we have these options two and three say for example we have the match list one with the list two and you can see the drug class on the list one and drug molecule on the list two. In our state syllabus book we have the examples for this morphine and submitted in the Tamil Nadu's syllabus chemistry book. So, a student who can actually find out that analgesic as morphine say for example we are fixing with now two options in the answers. So, the answer should be between A and B. I am a student from the Tamil Nadu state syllabus I have not heard about this Seldane I have not heard about this Salwar, Salwar San but I know about this morphine and submitted in. So, now I have fixed one answer the moment I say that my antacid is submitted in the answer automatically becomes A. I do not have to have the knowledge of the other two options which might come from the other book which is the NCRT book which we are quoting here. So, these kinds of conceptual reflections are going to add questions into the pool of what we already know. So, we can say that instead of this 17 questions we can only say that actually 11 questions have come exclusively from NCRT. So, this is going to add to our numerator here right. So, you can say that out of the 140 questions for sure we can write 129 questions and in the section B all the 40 questions out of the 40 questions you will be able to attend. So, this kind of an analysis we would like to give now with the evidence in the presentation. As I told you we have seen the data and the statistics about the question pattern and the analysis and how our state governments Tamil Nadu's state governments syllabus itself will be enabling the students to write this competitive examination in a very good manner and get into the medical field. So, we should be confidently studying about this examination. There need not be much worries about whether we will be able to compete in such kind of an examination. We are definitely on par with the quality and in the standard to compete with any kind of a CVSE syllabus or any kind of a background which are who are all coming from the other states. So, we wish to present this analysis through the clear cut evidence of having the faculties with the Tamil Nadu syllabus book and they are going to tell you in each and every section in which volume, in which unit number you are going to have the answers for this. Kindly follow the session and then if you have any feedback you can definitely write back to Shankar Medical Academy. Thank you everyone.