Vermont Legislature SmartTranscripts:

[Robin Scheu (Chair)]: Good afternoon. This is the House Appropriations Committee. It is still Tuesday, 12/16/2025. It's 03:00, and we have our last couple of Human Services departments to come and talk to us about the budget adjustment. So first up, we have the Vermont Department of Health, and we have a new commissioner. Welcome. We'll introduce ourselves. We haven't practiced that. We haven't done that yet today. And I'm the finance director as well. So if you two would like to introduce yourselves, then we'll let you know who we all are. So.

[Dr. Rick Hildebrandt (Commissioner, Vermont Department of Health)]: I'm Rick Hildebrandt. I'm the new commissioner at Farmer Macphail.

[Megan Hoch (Finance Director, Vermont Department of Health)]: And I'm Megan Hoch. I'm a

[Megan Hoch (Finance Director, Vermont Department of Health)]: financial director at Farmer Macphail. Great.

[David Yacovone (Member)]: Welcome, I'm David Yacovone from the Lamoille, Washington district. I'm John Kascenska from Burke, and

[John Kascenska (Member)]: I represent 10 towns in the Essex Caledonia district. Thomas Stevens from Waterbury represent the Washington Chittenden District, which is made up of Waterbury, Bolton, Huntington and Fuels Corp.

[Multiple members (diarization mixed)]: I'm Marty Celtis from Caledonia 3, which is Linton, Sutton, New York, Chittenden, Sutton. I forgot something. That's right.

[Robin Scheu (Chair)]: I am Robin Scheu and I'm from Middlebury.

[Multiple members (diarization mixed)]: I'm Wayne Laroche, I represent Highgate, Franklin, Berkshire and Richter. Hi, welcome. I'm Michael Mrowicki and I am from the Southeast Part Of Vermont in Windham County and I represent the Windham 4 District that's Putney in Dallas.

[Eileen “Lynn” Dickinson (Member)]: And I'm Linn Dickinson, I represent Chittenden of St. Louis Town.

[Dr. Rick Hildebrandt (Commissioner, Vermont Department of Health)]: Good to meet you.

[Eileen “Lynn” Dickinson (Member)]: So welcome and take it away. I think we have copies, and you're getting a screen

[Robin Scheu (Chair)]: share, so that's terrific. Right.

[Dr. Rick Hildebrandt (Commissioner, Vermont Department of Health)]: And the meat of this is pretty short, so I figured I'd take this opportunity to tell you a little bit about myself, my background, and some priorities that we have in the health department that might be helpful. Other legislators have had that helpful in the past. So my name is Rick Hildebrand. I am an internal medicine trained hospitalist, so a doctor that treats patients in the hospital sick enough to go past the ER, but not quite so sick in the ICU. And that's sort of where my folks typically land. I've been in Rutland for almost fourteen years now, following my residency training over at Dartmouth. And when I started in hospital medicine, I thought I was going be a clinician at a community hospital my whole life. When I was doing my training at Dartmouth, I liked the Vermont side of that equation more than the Hampshire side. I remember That's beautiful.

[Multiple members (diarization mixed)]: Yeah.

[Dr. Rick Hildebrandt (Commissioner, Vermont Department of Health)]: And I knew I wanted to do community medicine, so I ended up at the largest community hospital in Vermont. Anyway, when I started, there was a couple of things that became immediately apparent to me. One is that I can't fix the problems of my patients within the four walls of the hospital. The problems are too big, and they're beyond the care that I can deliver there. And that led me to reach out to the community partners that I had around me, to the FQHC, to the VNAs, to the nursing facilities, and an organization that ended up becoming something called the Rutland Community Collaborative to try and improve care, reduce readmission rates, which is something that we care a lot about in hospital medicine, and reduce admissions to the hospital in its totality. And it was great work, was really engaging. We did a lot of work and we made a difference in that community in those measures. But even with that work and with a lot of stakeholders, the problems were still there. And it really was more about social drivers of health in many regards than it was about any medical problem that we were treating. Lack of access to finances or transportation, nutritious foods, exercise, you name it, the problems were significant. Substance use disorder, mental health disorders were paramount. My wife is a LICSW, she's a social worker. She works down at a therapeutic farm work program down in South Sudbury. Anyway, so that led me to pursue some other endeavors outside of the hospital, some boards and commissions. I was on the board of one of the DAs. I joined the board of medical practice six years ago. I served as their chair for four years and tried to sort of get involved more in population health and things that are really more outside of what I was doing in my day to day, which at the time was something called being a chief medical information officer. I found myself in hospital leadership over the course of my career. I was a hospital executive for a while. But I cared for sort of the interface between IT and medicine, which is an interesting space, but not really my passion. Anyway, I was very involved in the COVID response at the hospital as a COVID czar, and I ended up chairing the infection control committee. And I had said to myself for some time, if and when Mark decides to retire, I might throw my hat in

[Multiple members (diarization mixed)]: the ring.

[Dr. Rick Hildebrandt (Commissioner, Vermont Department of Health)]: And after many months of interviews, I found myself at the health department. It's been a wild ride since I've been here. And I'll tell you, there's some things that are very clear. It's an amazing group of people that work at the health department. They're incredibly intelligent and care a whole heck of a lot about Vermonters and the health of this state. That came through in bounds, it was frankly shocking to me how excellent the people were that I was working with. And I'm still learning a whole lot, and I have a lot of questions and not a whole lot of answers, unfortunately. But I know I've got the right team around. So as a reminder, this is our vision and our mission and the values for the health department. So our vision is that all people and communities in Vermont have equitable opportunities to achieve the highest level of health and well-being. Our mission is to promote the physical, mental and social well-being of people in Vermont by advancing equity, protecting against disease and injury, preparing for health emergencies, and then our values include equity, collaboration, inclusion, our main stakeholder. So sometimes it's challenging to explain exactly what the health department does or what public health actually even is. And we've used this framework of detect, connect, prevent, respond, which can be a useful framework to help understand what public health means on a broader level. As an example, relatively recently, we detected a number of cases of pertussis, which is also called whooping cough, in a school in Washington County. We responded by providing the school community with resources on how to protect themselves and their families, alerted the health care providers in the area to help prevent the spread and ensure that people had access to vaccination, which is something that can be vaccinated against if they were under vaccinated or unvaccinated. Our work goes much far beyond infectious diseases. We have worked with school liaisons. We work with our local health offices to improve school health. We collaborate with partners in maternal health. We connect with Vermonters with cooling sites during hot seasons. We help with health related behaviors, we help with smoking cessation, manage pain and other long term health problems. There's so many tendrils that the health department has in so many areas. And it's taken me, frankly, a bit of time to get my arms around everything that we do. This is our organizational structure, which I have referenced as many times just to remind myself of all these little chiplets and where they go, so we call them. Chiplets. Yeah. The Department of Health has about 600 positions, depending on how many open we have at any given time. And we have a central office and 12 district offices. It ranges from very, very concrete clinical work, like the Office of the Chief Medical Examiner to much more or home nursing visits and laboratory testing and other things that are very concrete and clinical, to areas that are much less clinical, like community based work on disease prevention, health promotion, environmental health, looking at water quality, air quality, and food safety. And we have experts in all of these areas that know far more than I do. And if there is a specific question that anyone ever has in an area, I will not hesitate to call on them to give you the actual answer. I'm happy to be a pretty face and talk about it, but really, you wanna talk to the experts a lot. So it's an interesting time I found myself in public health. And to be fair, this was intentional. Part of the reason I am here is because I felt appalling. There is an attack on public health across the country. And it's very clear to me that one of my main directives is to preserve the trust in public health. We are lucky in Vermont. There's a high degree of respect with the health department. That is not true across the country. And I've talked to some of my colleagues across the country, and they did not get out of COVID unscathed. There is a ton of turmoil nationally. There's a lot of uncertainty. And that seems to be amplifying every week. We need to be the rock that people can rely on. We need to preserve that trust that people have in public health. Because without that, it's very, very challenging to do this work. The good news is we have a lot of trusted names and faces. We are in local communities. People are embedded in the hospitals, in their health systems, and they are known entities, they're helpful in many, many regards. So it's really a strength that we have. There are, however, a number of issues that we are likely to encounter over the course of the year. There's a lot of false claims and falsehoods that we've heard on the national level that has led to uncertainty at the CDC and other historically trusted institutions. I have been working with our team at BDH to ensure that both in the press and in other areas, are reaching Vermonters to ensure that they have the accurate information that they need, that they know who to connect with. The drum I have been continually beating is to please talk to your trusted health care providers rather than listening to news articles about health and health related information. We've been working with a large number of stakeholders across state government to ensure people have access to care and immunizations, through the Department of Vermont Health Access, OPR, Department of Financial Regulation, Health, and so many more. And we are working with a bipartisan group of legislators to ensure that we have access to vaccines within our state, and that regardless of what changes that happen at the national level, people remain informed and have access to the right vaccines that they need.

[Wayne Laroche (Member)]: Yeah. But yes.

[Multiple members (diarization mixed)]: Of course. Thanks for coming. That's okay. I think Vermont has done pretty well with vaccination rates. Mhmm. But for instance, I think South Carolina right now is seeing a measles outbreak, and there was one in Texas. Where are we at with the levels we need to maintain herd immunization? Yeah,

[Dr. Rick Hildebrandt (Commissioner, Vermont Department of Health)]: for measles specifically? Well, in general, I mean. Yeah, and it depends on the specific disease, right? So depending on how contagious an illness is, the percentage of people that need to be vaccinated to maintain herd immunity is different. Measles is the hardest one because it is so contagious that if you don't have vaccination rates in the high 90s, you can lose herd immunity. Other illnesses are less contagious, so you can still get herd immunity with lower levels of immunity. Whooping cough, we talked about before, you may see a small dust up, small number of cases, but it's not going to spread in a broader context because we have a high vaccination rate that's above that threshold. So it really is dependent on the specific disease that you're looking at. All that said, we are keeping a very close eye on vaccination rates because we are concerned that we might be seeing some slipping in things like COVID and flu vaccines. And that's just a marker of, hey, where are we with vaccinations in general? Something we keep a very close eye on and make sure that if there's changes, we can provide information to people as they need it, connect them to the

[Multiple members (diarization mixed)]: right resources that they they need. K? Thanks. You got it?

[Dr. Rick Hildebrandt (Commissioner, Vermont Department of Health)]: As it as it pertains to the immunization work, we are just to be clear, we're not looking for funding. This isn't a funding issue. We just wanna make sure people have access to the right information. So we're gonna be proposing some legislation just to ensure that that remains the case. So another obviously big topic, if you haven't heard this already, I'm sure you will, is around substance use disorder. It's clearly a big priority of mine and the Department of Health. We do a number of things in substance use disorder, including prevention, treatment, and recovery. Recovery is the area that I've probably spent the most of my time in the recent months. This is a landscape that's continually changing. For many years, for at least ten years, we've been focusing mostly on opiates. And opiates remains the number one problem with substance use disorder. But that landscape is evolving. We're seeing more and more stimulant use across our state. Stimulants are a different game. Of the stimulants, meth is the worst, the worst drug that probably mankind has ever made. And my colleagues across the country who have populations where meth use is much higher, the stories they tell me are harrowing. I mean, these people can become quite violent and aggressive with this medication. It's very hard to treat. Recovery is measured in many, many I mean, it's measured in years for opiates, but it's even longer for methamphetamines. It's not at a very high rate in Vermont right now, but it is on the rise, and we are seeing more cocaine and polysubstance use as well. The treatments are different. There's not MAT or MOUD for stimulants. So this is going to be an ever evolving field and something that I need to be on top of with my team for sure. And it's, again, just something that you all need to be aware of and how that's changing.

[Stephanie Barrett (Financial Director, Department of Vermont Health Access)]: One more question, I think.

[Multiple members (diarization mixed)]: Yes, of course.

[Wayne Laroche (Member)]: In the past, I've been critical that back in the sixties, we had a tremendous don't smoke campaign. And I've been critical that I don't see the same kind of campaign coming out of the health department. I see more other kind of messages. When I asked that question before, they said, well, you're just not looking in the right place. You're too old. That's really right. But I don't think that was a good reply, because I think everybody should be seeing that message. So you're absolutely right. And there's, I think, two

[Dr. Rick Hildebrandt (Commissioner, Vermont Department of Health)]: things in there. One, we need to be better about communicating the work that we're doing. That came to me pretty clear. We're doing a lot of work in substance use disorder. Just today, we're opening or not. The Valley Vista is opening a facility, a 30 bed facility, which there was people who were not aware of the work that had gone into this that should have been aware because, frankly, we haven't done a good enough job communicating So the number one, yes, you're right. You as legislators should absolutely know what we're doing, okay, in substance use disorder and prevention. And B, you're right, prevention is far more effective than, well, I don't know it's more effective, it's more important than treatment. We want to try and prevent this illness from happening to begin with. Prevention is an incredibly important piece of work that we do. And I do want to connect with you all more about what we are doing in prevention and how we can show the data and the outcomes related to that.

[Multiple members (diarization mixed)]: Right.

[Dr. Rick Hildebrandt (Commissioner, Vermont Department of Health)]: Go on to access. So this is the last area that is something that is important to me because of my background, but it's also important to public health. We have been talking about health care transformation as long as I have been in the state, and those of you who have been in the state longer, I'm sure, have been talking about it for ten years before I was here. We have an opportunity now to look at how we are delivering health care across the state. However, I want to make sure that we maintain access to care regardless of what work we're doing. Obstetric care is incredibly important in every community in Vermont, and we need to make sure that we don't have people with excessive drive times who can receive the care, both prenatal and postnatal care that they need, regardless of the finances. And I want to try and help in whatever way I can. Health department wants to help. This is not something we own in isolation. This is something that is shared by many state agencies. But if there's ways in which we can help with either data or other ways, we want to do that. Transportation is incredibly important. As we talk about regionalization of health care services, to do that effectively, we need to have good electronic systems of information sharing. We need to have great transportation. We don't have either of those right now. Transportation is primarily delivered by the EMS system, something that we have a piece of within the Department of Health. I've talked with our EMS services division, and they're very interested in being part of the solution here. There's barriers that we have to talk about in terms of funding and some regulatory changes we might need to make, but I think there's an opportunity in the transportation route. And then reproductive health care is another real concern that I have. We want to ensure that we have access to these critical services, regardless of any federal changes that come down the pike. This is a really, really complex space. And there are a lot of people that are involved in this work that probably can give you more information than I can. Just know it's really important to stick the landing. We can't, while we're going through transformation, end up having gaps in coverage, because that's where people get hurt.

[Stephanie Barrett (Financial Director, Department of Vermont Health Access)]: So if have a question, I'm

[Multiple members (diarization mixed)]: going to interrupt you guys. Go ahead. Thanks for being here today.

[Dr. Rick Hildebrandt (Commissioner, Vermont Department of Health)]: Absolutely. Good to meet you. So I just

[John Kascenska (Member)]: had a recent conversation with our local EMS service for rescue. Caledonia is in the St. Johnsbury area there. We're just kind of talking about some of the things coming up for them. Just like our hospitals are having difficulty with balancing their budgets with reimbursement rates, so are the EMS folks here. You know, again, it's all about the demographics, you know, to some larger degree here. I know there's this regionalization conversation planning going on here with that. And I'd just like to hear a

[Dr. Rick Hildebrandt (Commissioner, Vermont Department of Health)]: little bit more about your,

[John Kascenska (Member)]: I know you're just into the seat here of things, but what your thoughts are about the regionalization of being a service, how that might play out, especially in our more rural areas. We have a lot of territory to cover. Some of our services are covering nine to 11 towns. Right. And

[Dr. Rick Hildebrandt (Commissioner, Vermont Department of Health)]: I think if you talk to the EMS services, they'll tell you they're strapped. The system that they've had that has worked effectively for some period of time, to some extent, is really almost at a tipping point of not working very well. They only get I don't know if you know this or others don't, they only get paid if they transport someone to the hospital. That is the only source of revenue for most CMSs. That's a problem. Because we ask them to do a lot more than that and we want them to do more than that. The concept of community paramedicine I think is an opportunity not only for revenue but also for decreasing healthcare costs by avoiding some transports to the ED and other things of that nature. The transportation itself, that should be reimbursed. And we need to figure some of those things out. This isn't something that the state should be funding. It's something we need to figure out with our insurance partners around payment for. But they need an infusion of capital through services other than what they've been doing in my assessment to continue this system because it's really tendering on the brink. There is a structural issue. And I think many of our EMS folks will tell you that there's a lot of independent systems that have been designed effectively to provide emergency care and transport people to the hospital. When we're talking about care delivery or transportation, there needs to be a superordinate sort of way to organize that. I don't know what that looks like. I know that the folks who are in the EMS can probably give me the answers of what that looks like, but we should engage in the conversation about, hey, how can we restructure the EMS system to better serve the needs of our monitors? And these are gonna be hard conversations because Yeah, they for sure,

[John Kascenska (Member)]: if they come to a position, a transfer that takes them out of their community here. Sometimes transfers are quite lengthy. And if they're going to Dartmouth and St. John's, bring it back. It's a chunk of time.

[Dr. Rick Hildebrandt (Commissioner, Vermont Department of Health)]: And what is frustrating to me is there's a there's a lot, you know, down in Rutland. Regional will take someone to Dartmouth and then have an empty bus come back to Rutland when there was a person that needed to go from Dartmouth, you know, one town over, and we're we're not coordinated. Right? So we need to have that information system to allow for coordination of some of those services, not so much wasteful time. So it'd be great to hear more about this, that kind

[John Kascenska (Member)]: of Absolutely. This coming year would be great.

[Robin Scheu (Chair)]: Wayne has a question.

[Wayne Laroche (Member)]: So we've been aware that some of our emergency rooms have been really overcrowded. If they have to transfer the report to a hospital, does that contribute in any way to that overcrowding?

[Dr. Rick Hildebrandt (Commissioner, Vermont Department of Health)]: Crowding is an interesting problem that my lens is that of the person who's admitting to the hospital, not of the guy who's caring for them in the ER. But many of my patients were bored in an ER overnight. It's a really complicated problem. There's not one thing about it. Transportation is a piece of it. So if you don't have the ability to transport a patient who needs to go to a different facility, they could end up staying in your bed for longer than one would need. The other problem, though, is around non medical care, non hospital level of care. So a lot of times when you look at crowding, the actual problem is more around capacity within the inpatient unit, which has to do with capacity in the subacute units. So sometimes it's a really complicated problem around borders in the ER, if you will, which is what they're termed. Communication is a piece of that, but it's a really complicated

[Wayne Laroche (Member)]: And I thought maybe just a small piece, but I was wondering if someone was being transported and had to be dealt with at the hospital that didn't actually need to Correct.

[Dr. Rick Hildebrandt (Commissioner, Vermont Department of Health)]: Correct. So community paramedicine, the idea that we can treat someone urgent care is another option, where people go to an urgent care center as opposed to an ER. Well, what if we can treat someone in their home with a paramedic rather than having to send them anywhere and having them still get paid to do that? Because currently if they do that, they're not getting paid. So you're absolutely right.

[Multiple members (diarization mixed)]: That is the benefits. Maybe

[Wayne Laroche (Member)]: a small part of the problem, but it could be But

[Robin Scheu (Chair)]: lots of little things make a big difference. Exactly. They really can. Thanks.

[Dr. Rick Hildebrandt (Commissioner, Vermont Department of Health)]: All right. So again, the last piece that I was going to touch on was reproductive health care. Important, it's protected by our constitution. Decisions around reproductive health care should always be made between patients and their providers. And our BAA asks to change some funding streams to ensure we continue to have access to these critical services, again, regardless of what happens on a national level.

[Multiple members (diarization mixed)]: I'm going to turn it over to Megan to David. Yeah.

[Megan Hoch (Finance Director, Vermont Department of Health)]: So our twenty sixth budget adjustment is rather brief. If you're looking at the AHS ups and downs, I believe it's on page nine. But these are really our two items of substance here. The first in our admin and support appropriation, we just have a transfer from the agency central office for that agency of digital services service level agreement.

[Robin Scheu (Chair)]: That neutral to the agency, but another one that they moved out.

[Megan Hoch (Finance Director, Vermont Department of Health)]: Yeah, So moving from AHS to us. And then what the commissioner was just speaking of, in our public health appropriation, we are asking for a swap of what was funded with investment global commitment dollars to be funded by General Fund for a grant to Planned Parenthood of Northern New England for family planning services. And those are funds that I think Secretary Samuelson mentioned in her testimony. But because of the passage of HR1, those costs, there's a pause on Medicaid funding to Planned Parenthood. So we are asking to allow that, to have this swap in funding source so that grant can continue and we can continue serving those patients. That is big.

[Stephanie Barrett (Financial Director, Department of Vermont Health Access)]: Yes, I

[Robin Scheu (Chair)]: see a short and sweet one. You

[Multiple members (diarization mixed)]: may not be the right person, but if you could help me, I had a constituent ask me how much primary care Planned Parenthood provides. I've been trying to find it without much luck. Last year, I thought I recalled the testimony that it was rather significant. Anyways. You think, is there someone at your shop who would know that or?

[Megan Hoch (Finance Director, Vermont Department of Health)]: We could definitely follow-up and we might have to reach out to other areas of

[Stephanie Barrett (Financial Director, Department of Vermont Health Access)]: the agency as well, we're

[Megan Hoch (Finance Director, Vermont Department of Health)]: not the only ones who provide funding, but it looks, we've got an, they serve about 16,000 Vermonters, but I'm not sure what of that is primary care versus

[Multiple members (diarization mixed)]: you can get someone

[Dr. Rick Hildebrandt (Commissioner, Vermont Department of Health)]: to define primary care for me, then we can give you an answer because I'll tell you Well, have different codes, right?

[Robin Scheu (Chair)]: I think they have that information or somebody in the room here may have information and can get it to us. It's a high amount.

[Multiple members (diarization mixed)]: That's what we were told. A

[Dr. Rick Hildebrandt (Commissioner, Vermont Department of Health)]: lot of OB care in general, a lot of OB GYN to provide primary care to a large percentage of folks. A chunk of what is being delivered there is huge.

[Multiple members (diarization mixed)]: Thank you for any help. You might be able to give me a knife. Thank you.

[Robin Scheu (Chair)]: So that's your presentation. Very nice. Great. Well, we really appreciate it. Very informative. Coming in, nice to meet you. Welcome.

[Multiple members (diarization mixed)]: Thank you.

[Eileen “Lynn” Dickinson (Member)]: Where did you start?

[Dr. Rick Hildebrandt (Commissioner, Vermont Department of Health)]: This is about two months ago. Is the beginning.

[Robin Scheu (Chair)]: Okay, you're almost

[Multiple members (diarization mixed)]: Thank you very much.

[Robin Scheu (Chair)]: Anyway, thank you. We'll be seeing you again in Budget and we'll look forward to that presentation too. This is a great start.

[Multiple members (diarization mixed)]: Thank you.

[Robin Scheu (Chair)]: Appreciate it. One more committee for today and that is DEVA, Department of Rehabilitation and And I did see Stephanie, so I know she's around. She's here too. She's here too, good.

[Multiple members (diarization mixed)]: Hi Stephanie, how are you? Hey Denise, how are you? Good to see

[Robin Scheu (Chair)]: It's like your last time seeing Stephanie was video unless we get her back before her next I'll let her tell you. Okay. Changes

[Stephanie Barrett (Financial Director, Department of Vermont Health Access)]: in this community too.

[Multiple members (diarization mixed)]: So

[Robin Scheu (Chair)]: if you want to introduce yourselves for the record and

[Eileen “Lynn” Dickinson (Member)]: then we'll open it.

[Dr. Rick Hildebrandt (Commissioner, Vermont Department of Health)]: I am Sean Groves. I'm the Commissioner for the Department of Vermont Health Access.

[Stephanie Barrett (Financial Director, Department of Vermont Health Access)]: I'm Stephanie Barrett. I'm the Financial Director for the Department of Vermont Health Access. Until end January. Until the January, when I'm retiring from the city, but not from work. I'm going to go work for the Tanner brand up for the last working years of my career.

[Multiple members (diarization mixed)]: I'll be lucky to have you.

[Stephanie Barrett (Financial Director, Department of Vermont Health Access)]: How would you like us to start? We have a PowerPoint that is the high level summary of our ups and downs.

[Robin Scheu (Chair)]: Yeah, well, don't we go through this? We have an hour. Let's see the Dave, is that you?

[Multiple members (diarization mixed)]: I think I do. Do, yeah.

[Robin Scheu (Chair)]: Whatever you had last year, I You

[Stephanie Barrett (Financial Director, Department of Vermont Health Access)]: still have it.

[Multiple members (diarization mixed)]: Why don't we go through

[Robin Scheu (Chair)]: this and then we'll talk about what are the details of what your ads are in here as well?

[Stephanie Barrett (Financial Director, Department of Vermont Health Access)]: So the details are in a summarized fashion in this and then the very granular line item details are in the ups and downs and we can switch to that at any time.

[Robin Scheu (Chair)]: Okay, let's start with the overview part.

[Stephanie Barrett (Financial Director, Department of Vermont Health Access)]: So we'll go through the Diva admin budget, which is very different than the Diva program budget in scale and what it pays for. The admin keeps the lights on, pays the people, pays the contracts, and program is primarily all the services that we pay providers for. Most of that money flows through the MMIS system with our fiscal agent. And then, we have a few one time requests in the BAA for general fund funding. And then we thought we'd just update you on a few of the one time items that you appropriated last year and what the status of those are. So, in the DIVA admin budget, there's no real adjustment to the staffing at all. We do have many contracts that are held by DIVA, and several of those have adjustments mid year, amendments that have come up since the budget was passed, etcetera. We have a couple of small adjustments to a couple of contracts that support our Chief Medical Officer. We have a person that's been on contract for several years, and then we have another person, another, physician that focuses on mental health. And that's what that $39,000 gross adjustment is. This is probably the right time to remember that in Medicaid, which is the majority of DIVA, things are both in a gross dollar amount. And then we also note the general fund amount because Medicaid is a matched program, where it's state and federal dollars together. So, the gross dollar is the total cost. And then the general fund is the general fund portion of that, the state fund portion of that. So where your tightness and rub is on the general fund and state funding. And then we also have amendments that have, happened in our game well contract, which is a major big contract that runs the whole Medicaid program in terms of the claims processing, and the payments out, not just for DIVA, but from the other parts of state government that, have payments flowing through that system and out to the providers. That in total is just a smidge under $2,000,000, In terms of the state match, it's about 10% of that. Just the majority of this is a developmental development and, implementation funding. So the majority of this cost is on the ad hoc, what we call DDI, and that gets a 10% match under our agreements with the federal government. So any questions on the DIVA held contracts part of our picture? Also in our budget, in our operating budget are contracts that aren't held by Diva, they're held by ADS, they're technology contracts, but we are the payer of those contracts at the moment. And so we get the invoices sent to us and, we pay them. And there are some adjustments to those Viva Health contracts. The biggest one is in our, what's called MDWAS, our Medicaid Data Warehouse and Analytics Solution. I don't know if folks remember, but three, four years ago, you provided one time funding to develop this system, and it is turning on. It's been going through testing as we speak. And as we head into January, we move to another phase of this, which is the maintenance and operations phase. So the one time money was for the development of the system, and now we have to maintain and operate the system. And that comes with a price tag that is now coming into our budget mid year. So you'll see this again when you see the 2027 budget in front of you for the full year as well. So that's the single biggest admin adjustment in our budget. And then, also over in ADS, they have a smaller Gainwell contract, but they also pay for the licenses for Oracle that supports the Vermont Health Connect and those licenses are going up and there's been a small adjustment to the gain well contract in ADS. So that's the final adjustment in our contract, world. And then, in terms of regular operating expenses, the primary adjustment here is with the return to office, what we call RTO, the three day standard back in the office. Diva is one of the entities that's moving to lease space, in February, timeframe. And so those leases have now been executed. They are now going to be paid for out of our budget. And so this is the partial year Cost of the leases for diva,

[Robin Scheu (Chair)]: annual, it's around 360,000.

[Stephanie Barrett (Financial Director, Department of Vermont Health Access)]: I think it's 400 something annualized, because this is a seven month. It's not a full amount. The $2.52 is the total amount. We match this at the admin match that we can, because we are a mix of all sorts of types of matching percentages in Diva.

[Robin Scheu (Chair)]: I was looking just at the general fund, not the

[Stephanie Barrett (Financial Director, Department of Vermont Health Access)]: whole thing.

[Robin Scheu (Chair)]: The whole thing sounds like it's close to 1,000,000.

[Stephanie Barrett (Financial Director, Department of Vermont Health Access)]: The Diva portion is 400 and something. I can get you the annualized number. You will see that in the '27 budget. And then just as you just heard from the health department, there's a couple other adjustments, a net neutral agency wide adjustment related to the, service level agreements for the agency of digital services. That's, you see that as an up in our budget, but it's not enough in total. And then also with Planned Parenthood in New England, we're doing the same because of the restriction, the one year restriction of funding for Planned Parenthood in the HR1 bill, swapping out, the funding source. So we're keeping the budget bowl for what is in our budget for Planned Parenthood, but we are substituting the federal share that was embedded in our budget for general fund for the for the budget adjustment. So it reflects a full year cost of doing that because HR one was passed in early July. And you'll see this in our program budget as well. So, before we move to our program budget, does anyone have any questions on our admin budget?

[Multiple members (diarization mixed)]: So,

[Robin Scheu (Chair)]: when

[Stephanie Barrett (Financial Director, Department of Vermont Health Access)]: you're looking at the ups and downs, the event program budgets across three appropriations, one is very large, the global commitments appropriation. What this presentation will do is walk you through all the pieces together, but we can stop at any time if you want to break down into anything more granular. But, and we understand from folks that have been before you earlier today that you probably have some questions on our consensus update, which is the process by which the Medicaid program budget in DIVA is updated year to year. And that's with staff from DIVA, staff from the central office, staff from joint fiscal, and staff from finance and management, come together and look at the data midway through the year, update the estimates for caseload and the estimate of cost per case. And so this is a substantial $33,000,000 up in terms of a percentage. It's not very substantial, but it's a substantial chunk of funding up across all our caseload and utilization needs based on how, because last year when we built the budget, we were building it at this time. Folks, I don't know if Dave, Representative Yacovone or folks look at the dashboard that we put out monthly. But as we went through the end of the year, you could see that we were, when we were closing out '25, that there was a gap growing. We were able to close that gap with help. And then, and then this is updating with new information on what actual costs were through the first quarter of the year, what we're seeing for trends. And so that's what's driving these numbers. And the caseload continues to go down, but the cost per case is staying up. So that's telling us that the more expensive folks are the ones that are staying on the program as the caseload comes down. And we just can't we didn't quite get it right last year. We didn't quite get it right coming into building the budget, you know, in terms of where that trend of cost per case is up. Some of the things that are driving that are pharmacy costs, because our our net pharmacy cost is coming up. Our rebates are a little bit lower as a percentage, and it's a very large chunk of our costs. So that's what we're seeing. We're not actuaries. We're not going in and building a big model of every life in the system. We are looking basically at average cost by Medicaid eligibility group at points in time and saying, is it holding steady to what we thought it was going to be? And while the caseload, we get pretty spot on, we can see it continue to go down. It's actually that cost per case that comes up. We see a little bit of that in some places, but it's on average across, it's just a higher cost per case, which tells us that it's the we do have as the folks that are coming off. In terms of total coming down, what is the health status, the utilization of those remaining people are at the higher end. And we're not capturing that every time we come in to build that consensus. We do, you know, we add an acuity factor. It just hasn't been sufficient to capture where we end up when you six months and then twelve months further down the road in terms of the cost of covering the folks that are enrolled in Medicaid and paid for by DIVA. I did understand that the committee had a specific question about demographics, And we're going to take a look at that because actually two years ago, we started collecting demographic, like for every of our, each one of our Medicaid eligibility groups, we have caseload information every month. And we started collecting starting in January 2024. That's the distribution of age and every single one of those Medicaid eligibility groups to see if it was going to change over time. And now we're almost two years into that. So we can actually do some analysis and see if, you know, if the average or the median age has come up, if the distribution of age in any Medicaid category is coming up and that might be a little bit, illuminating to the pressure that we're seeing on the cost per case.

[Robin Scheu (Chair)]: That's great. And I think we'd

[Megan Hoch (Finance Director, Vermont Department of Health)]: be very interested in seeing that when you have it.

[Stephanie Barrett (Financial Director, Department of Vermont Health Access)]: Yeah, I was kind of, I was like, that's a good question.

[Multiple members (diarization mixed)]: This is giving a second.

[Stephanie Barrett (Financial Director, Department of Vermont Health Access)]: And you're right on it. So my team is

[Multiple members (diarization mixed)]: going to look at it. That's good.

[Stephanie Barrett (Financial Director, Department of Vermont Health Access)]: But that caseload and utilization, that consensus update, every once in a while it goes in the better direction for us, but for the past few years we've been struggling. It's always, as we've come out of the unwinding of the pandemic, know, we expected the caseload to come down and we expected the cost per case to go up. It's just that the trajectory of that cost per case is sharper than what we expected, but we're not analyze we're not alone. I sit in on the NAMD financial directors, the affinity group calls every so often, and other states are still struggling with it. The same outcome, that there's just more pressure on the cost per case.

[Robin Scheu (Chair)]: Do you

[Stephanie Barrett (Financial Director, Department of Vermont Health Access)]: have a question?

[Wayne Laroche (Member)]: Yes. Those So analyses, you know where within the cost per case the upward pressure is. Specifically in certain areas or across the board and different aspects of cost for care?

[Stephanie Barrett (Financial Director, Department of Vermont Health Access)]: Well, know one is the pharmacy costs are part of it. But every Medicaid eligibility group, we're looking at the average for each group. And so there's not, I mean, sometimes in the age of the blind and disabled children, you can really see that you have an unusual number of very high cost cases, but, with the other Medicaid eligibility groups, it's a wide range of and we're looking at it basically on just an average point in time, point in time.

[Wayne Laroche (Member)]: So if you do an analysis like a graphical analysis of that sort of thing, you get some noise in the system because you can't predict how many blind children may come in. That's probably not

[Stephanie Barrett (Financial Director, Department of Vermont Health Access)]: That's a very small group. What you can't predict is as your caseload is changing downward, if you're working on an average, are you making enough of an adjustment for the lower utilization of folks that are leaving versus the higher utilization of folks that are staying? And we can see it very clearly after the fact, like any

[Wayne Laroche (Member)]: Travel with a trend line, you might be able to get a trend line, but then something's still changing. The trend line may not be predictive.

[Stephanie Barrett (Financial Director, Department of Vermont Health Access)]: And the last time we went through this, about nine, ten years ago, the trend lines were, that's one of the things we looked at initially. Those were the trajectories were flatter.

[Robin Scheu (Chair)]: Dave, sorry.

[Multiple members (diarization mixed)]: Good question. You mentioned caseload increase, that the percent was rather small. When you get a minute, could you let us know what percentage changes? Sure, you. Let no one let us know.

[David Yacovone (Member)]: And does the FFP rate ever change mid year?

[Stephanie Barrett (Financial Director, Department of Vermont Health Access)]: No, gets set every year, and so it changes Federal every fiscal year, yeah.

[David Yacovone (Member)]: Yeah, so that'll be part of the twenty seventh. Yep. We don't know what it is yet for next year. We do. We do.

[Multiple members (diarization mixed)]: Is it good for us or bad?

[Stephanie Barrett (Financial Director, Department of Vermont Health Access)]: Think it went Pardon? I'm looking at, it, I think it's the pressure on the budget coming into '27, significant pressure on the budget. Thank you. Adjustment that's happening mid year is in our applied behavioral analysis benefit, which is mostly treating autism spectrum folks, an adjustment there in making sure that our coding is correct. And this is a downward adjustment. And you'll also see this when you see the twenty seventh budget. That's why it's negative and red. It's actually, correcting the coding so we are properly matching up the policy and the payment here. But the size of this in terms of the benefit would be felt by the providers for this, but that's an internal, policy alignment and making sure that we are, following that. And I just wanted to acknowledge that for the committee. This is familiar. The next one's familiar. Every year, the federal government has an update to what's called the medical economic index. And that is the index that's used to adjust the rates for the FQHCs and the rural health clinics. And so what you're seeing is a partial year adjustment for, those rates going up based on that index. And then you'll see that annualized when you see the '27 budget. And then the other notation here, we've already talked about a little bit, but Planned Parenthood. This is the cost of swapping out for the entire fiscal year, the $1,130,000 of federal funds that the HR1 restriction, for that began in July, so that we maintain the actual same budget for Planned Parenthood of New England. It's just the cost of the general fund, the federal that represents that roughly 58% federal share of match dollars, in Medicaid for the services that Planned Parenthood provides. And then I've provided just a little bit of a note here, and this should also be familiar to most of the committee members that our system keeps up with Medicare in terms of our fee schedules. And so we do that in a budget neutral way, but we want to keep them aligned so they don't get, out of whack. And so that's happening right now as we go along, but those adjustments are designed to be budget neutral for us. But you may some providers may be seeing that as we put out what we call our PBRs and our adjustments for them annually. That happens January and a few

[Multiple members (diarization mixed)]: of them happen in February. So that's

[Stephanie Barrett (Financial Director, Department of Vermont Health Access)]: our that's the summary of our programmatic budget

[Multiple members (diarization mixed)]: for the budget adjustment. Okay.

[Robin Scheu (Chair)]: So

[Stephanie Barrett (Financial Director, Department of Vermont Health Access)]: there are two one time general fund requests for Diva, for BAA. Actually, one of them might not be in the BAA language, it might be in the Big Bill language coming a little bit later. But the first one is an IT project. It's the cloud migration for the Vermont Health Connect. And this is to we have to stay in compliance by staying up to date with vendor hardware. And as part of doing that, we are moving to cloud supported functionality so that we remain Tough like that. Horse almost. That we remain here. That's right. So that we remain in compliance come January and until the VITAS system can come on to line. That's the general fund share of that is $2,700,000 It's activity that's happening now to make sure that we are in compliance and that they're supported for the Vermont Health Connect. So that's the first one time item.

[Wayne Laroche (Member)]: So you're moving it from your own servers, hard drives, whatever, to a cloud based system? Is that what you're doing?

[Stephanie Barrett (Financial Director, Department of Vermont Health Access)]: I'm not the best one for the IT description, but

[Multiple members (diarization mixed)]: Sounds like it. Yes. Is

[Wayne Laroche (Member)]: it merely to comply with the federal data services hub? Or is it also any cost effectiveness to it? Any reduced cost by doing it this way as opposed to having your own hardware and software?

[Stephanie Barrett (Financial Director, Department of Vermont Health Access)]: To the extent there is, it will be embedded in that estimate of general fund in the analysis. Off the top of my head, I don't remember. But we can look and see if there were offsets in the whole analytics of the cost of the project.

[Wayne Laroche (Member)]: I was curious about all these IT projects, having dealt with them myself in the past, but

[Robin Scheu (Chair)]: I wanted to There is a it's called

[Stephanie Barrett (Financial Director, Department of Vermont Health Access)]: an IT ABC form that lays out, you know, the cost of the new and then any offsetting pieces in it. And so this was what nets the bottom line total of a general fund need.

[Wayne Laroche (Member)]: Sometimes in the long run, you may not come out ahead. So one thing to come out ahead in terms of technology, know, we'll have higher security and everything. Another question is whether or not the licenses and everything that you have actually cost you more money doing it one way than the other.

[Stephanie Barrett (Financial Director, Department of Vermont Health Access)]: I know a large chunk of this IT cost is license

[Robin Scheu (Chair)]: costs. Do we have a choice?

[Multiple members (diarization mixed)]: It sounds like we don't

[Robin Scheu (Chair)]: have a choice.

[Stephanie Barrett (Financial Director, Department of Vermont Health Access)]: Have to stay in compliance.

[Dr. Rick Hildebrandt (Commissioner, Vermont Department of Health)]: But

[Multiple members (diarization mixed)]: I'm concerned about this comment that this is to keep it in compliance until we can move it to the IE and E program.

[Stephanie Barrett (Financial Director, Department of Vermont Health Access)]: Until the VITAS project is able to replace it. So that's the whole movement of the system, the eligibility system.

[Multiple members (diarization mixed)]: We've been

[Stephanie Barrett (Financial Director, Department of Vermont Health Access)]: something ongoing. Will that eligible in the system replace this? Eventually? There

[Wayne Laroche (Member)]: will

[Stephanie Barrett (Financial Director, Department of Vermont Health Access)]: be a new system. The idea is that that system will also be in compliance and we will, think I can describe what the transition of that system is, but there are people that can to you.

[Wayne Laroche (Member)]: It sounds like it's going to maybe migrate back again eventually. Maybe.

[Multiple members (diarization mixed)]: He's been around for a long time. And

[Stephanie Barrett (Financial Director, Department of Vermont Health Access)]: then the last item on here is, we have what's called an alternative payment arrangement with the retreat where we, every year, contract for a certain amount of beds at a certain rate under a certain construct. That base amount of bed days that we buy at a flat rate and, the overage corridors that are in that, contract allow for, when we utilize more beds than the base, us to pay them. There's a corridor where a certain amount of beds are free for us. The structure of that contract changed last year. We got more beds for a lower rate, but we also moved the overage payment sooner and the free beds a little further out. And so we are on track to the state utilizing the bed days and based on what we can see in terms of the match needed, most of them are general fund bed days because when the stays are longer or the stays are forensic, those are paid for with general fund dollars instead of match Medicaid dollars. And so the contract is for the calendar year. That's why you see it in the budget adjustment. Will go through a full reconciliation of the bed days. We have until, you know, we only have two weeks left in the calendar year for the bed days. So we're pretty sure about how many bed days we're using. We have to get through the reconciliation of exactly which payer, the state, is there another payer? Are they general fund? Are they global commitment fund paid days for the run out of the last few months of the year. But we can see already that we are in that category where we'll have under the contract the reconciliation payment. And this is the estimated general fund share of it. It's very similar to what we paid last year. I think it was $11,000,000 last year. So, you actually funded 11,000,000. In the end, we actually paid them 7.9, but we actually used that differential because we had that problem with our rebate refunds. That was the way to solve that. We were seeing that at the end of the year. And so this number is very similar to the actual reconciliation payment that we made. The year before that, it was $12,000,000 that we paid them.

[Robin Scheu (Chair)]: Any questions on that, Dave? A different topic, if I may.

[Multiple members (diarization mixed)]: Does the federal subsidy for healthcare premiums that's being discussed in Congress now. Does that impact in any way what our Vermont subsidy is for healthcare premiums? Is it linked in any way?

[Michaela Strumolo (Deputy Commissioner, Department of Vermont Health Access)]: Yeah, it is. So what you're talking about is the Enhancement. So that came out in the Inflation Reduction Act. And so with those expiring, the subsidies are still there for some individuals. Won't be there for individuals over 400%, but there is still subsidies there. So there's just a lower subsidy amount that

[Multiple members (diarization mixed)]: The Vermont amount will be reduced Well,

[Stephanie Barrett (Financial Director, Department of Vermont Health Access)]: Vermont Premium Assistance Program, which is what I think you're referring to. The cost of that to the state went down with the enhanced. And so when you see the '27 budget, you will see that we estimating, an increased cost of that program, but the structure of the subsidy is not changing. I don't know if, Deputy Commissioner Strommelo is on with us or not. Okay. But, so we still have that Vermont premium assistance subsidy that we expect because less of the cost is being picked up by the enhanced tax credits, more of the costs will fall in the state to maintain that same subsidy level. Not a BAA issue? We're not seeing it as a BAA issue for, because of the timing of that because it's the back half of the year and the timing of when it hits. But you will see there's a small adjustment in that caseload and utilization number for it. But there's a you'll see a more significant one for the full year in 'twenty seven.

[Multiple members (diarization mixed)]: And probably doesn't impact BAA, but we appropriated, I think 10,000,000 last year for the stabilization fund.

[Stephanie Barrett (Financial Director, Department of Vermont Health Access)]: So, actually, on your website, because I got a notice around 01:00 today that it's been posted on the legislative website, because we submitted it yesterday. You did actually ask us for a report on December 15. And here we are. So, the report lists everything, all the applications we've had to date, what we have awarded, what the status is, what's left, what we have not awarded, etcetera. And we are still, today, we got another application in. And so, based on where we are right now, have about 3,300,000 left from actual awards that have been signed. We have far more than that in pending applications. It's only a handful of applications, but the requests are significantly higher than they were earlier in the year. And so that's the status of the provider stabilization general fund one time $10,000,000 currently. And so we are still working through a review of about five current applications.

[Robin Scheu (Chair)]: Okay, so it's been posted, is it? It's probably posted to the legislature's website,

[Multiple members (diarization mixed)]: so I will find it. Okay. You can add a

[Stephanie Barrett (Financial Director, Department of Vermont Health Access)]: copy of mine if you want.

[Robin Scheu (Chair)]: Okay, we can get

[Wayne Laroche (Member)]: it posted.

[Multiple members (diarization mixed)]: Okay.

[Stephanie Barrett (Financial Director, Department of Vermont Health Access)]: And I don't know if there was anything else the committee wanted to discuss about the rider stabilization. Trends, what are you seeing? So we've had applications from several different types of providers, res care, hospitals, FQHCs, one designated agency, primary care practices. And they're all over the board in terms of their situations. We're treating every type of provider the same way. Primarily, we are utilizing the resource we have of the forensic accountant for the larger organizations, the hospitals, the FQHCs, the designated agency, because they're bigger and more complex. And so you'll see in that report, they've been very small to, more substantial from the accuracy. This is an editorial comment that might not be welcome, but it's not a solution to everything. It's stop gap in nature in some cases, or just a timing bridge. But all different organizations have all different stresses, Some applied, you can see that they're in good shape. They're just test, you know, seeing if qualify. Primarily the bar that we use is whether or not there's real imminent risk and whether or not it's a provider that's very important to Medicaid programs. So, you know, and then we consult with the other departments for res care, VAL, for, you know, the hospitals and the primary care with the health care reform team. You know, if it's a nursing home, we put them down the path of the, because the nursing homes have their own, EFR process, which is a match process if it's if they're there.

[Robin Scheu (Chair)]: We have a lot of stressed out organizations between provider stabilization and then, the nursing home EFRs, which are down

[Stephanie Barrett (Financial Director, Department of Vermont Health Access)]: from last year, but there's still $14,500,000 nothing to sneeze out there. So it's clearly a system that we are propping up that could be healthier. Yeah, and knowing where it's, you know, what the struggle is, what does stabilization look like and mean and what timeframe?

[Wayne Laroche (Member)]: Wayne? So two parts to that, and I'll just go on that one. So prioritization, I mean, you said treat them all the same, but obviously

[Stephanie Barrett (Financial Director, Department of Vermont Health Access)]: We the of providers the same, but we look at every individual application. In the more complex, large organizations, we have this resource through the central office of the forensic accountant who, we send their application and their supporting document there, and they have conversations with them. They look at them. They share their thoughts on the strength of those stabilization plans.

[Wayne Laroche (Member)]: You are trying to get the biggest bang for the buck.

[Stephanie Barrett (Financial Director, Department of Vermont Health Access)]: We're trying to be it's a slightly unusual program of one time money, and we're trying to be as consistent and aligned with the intent of the legislature when you granted this appropriation.

[Wayne Laroche (Member)]: So the five applications that you might look to do, how do those match up with the $3,300,000 remaining? It's going to eat that all up? Is it more than that?

[Stephanie Barrett (Financial Director, Department of Vermont Health Access)]: Oh, it's way more than that. It's like 8 to $10,000,000. So you're not going have

[Wayne Laroche (Member)]: a problem spending all that money?

[Multiple members (diarization mixed)]: No.

[Robin Scheu (Chair)]: The question is that Are there

[Multiple members (diarization mixed)]: critical systems of care providers that from now until the start of it, should we be adjusting the stabilization capacity in the BAA to try to accommodate saving some system critical organizations? We just may not know. But if we do nothing and, you know, the 3,000,000 is gone and there's still some legitimate, wrong word, but legitimate need, what would we do? We wouldn't have an appropriation. Right?

[Stephanie Barrett (Financial Director, Department of Vermont Health Access)]: I know, you actually have to have that conversation too about what does it mean to have a continuing appropriation and your moral hazard and what does the system, different systems, what makes sense? Because this is 100 general funded. We're not drawing any match on it. And so thinking through what that means systematically, I think is something that you want to do.

[Multiple members (diarization mixed)]: I thought buying time while a provider is stabilized to do the analysis of what is the future state going to be.

[Stephanie Barrett (Financial Director, Department of Vermont Health Access)]: But that's provider by provider. You're talking about having something that's always there for every provider. Cause there's always going to be another provider in that situation.

[Multiple members (diarization mixed)]: Yeah, not always. Yeah. I appreciate that.

[Eileen “Lynn” Dickinson (Member)]: Didn't we have this conversation the last couple of years, maybe three years ago for Vermont Veterans Homes. And this was the whole issue, was that we kept getting these huge requests for BAA that were ongoing continuing costs, and it was like you're creating moral hazard by paying it all in the BAA without We don't

[Robin Scheu (Chair)]: want to use the Budget Adjustment Act as the budgeting tool. Right. We want to use it for a tweak. And the veterans' home was, for whatever reason, actually being asked to use it as a And helping we stopped that. I'm not sure that I would say this is the same thing. No, but it could be. I think there's also what these guys and other departments in human services is have to predict, right, and project what you think utilization will be, who you think is going

[Stephanie Barrett (Financial Director, Department of Vermont Health Access)]: to be failing or not. Well, we don't do that. We see applications that come in and we try to apply a consistent for each type of provider approach to them and evaluate them. And as you go through time, you're using down the balance of this appropriation. But as we see right now, most of the applications came in in June and July. It took us a while to get our system of how we did this in, and now we have more applications in as we're spending down this balance. And so that's where you're left is this question of what does it mean for one time appropriation? And what does I don't know what your what the answer is, but this is new money.

[Robin Scheu (Chair)]: This is what's left from what we

[Stephanie Barrett (Financial Director, Department of Vermont Health Access)]: had in the budget last year, what you appropriated last year. Right. Which is what? 10,000,000? 10,000,000.

[Wayne Laroche (Member)]: So you're just running this. Is there an agency or department that's actually trying to do the assessment of whether, you know, what we need out there, what it will take to fix the system? Or are we just plugging a hole?

[Stephanie Barrett (Financial Director, Department of Vermont Health Access)]: I mean, that's collective effort of everyone in terms of what We have our rates that we pay for the services that we provide in Medicaid. Not all the stress that these providers are under are Medicaid driven necessarily, the stress across the board in all types of healthcare providers. So all of those have to be weighed. But I'm coming back to the fact that if you were looking for a ongoing base solution, you might want to look at that differently than one time general fund money.

[Wayne Laroche (Member)]: Right. Because those could range anything from core business practices to

[Stephanie Barrett (Financial Director, Department of Vermont Health Access)]: legitimate real pressure. Or even what is I mean, it's a market. And being in the position of picking winners and losers is not a comfortable position for anyone. We'll go to primary care. Also provided significant one time bridge money for primary care because of the change in the ACO. And we just wanted to let you know the timing of when those payments are scheduled to go out. So, we had $10,800,000 of global commitment funding to, go to primary care into Sash, about 5,000,000 of it is going to Sash, the other 5.8 is going out to the primary care providers. And, those should be going out either in late January or early February. We're working on the Sash grant agreement right now. The Medicare Blueprint one time payments are all keyed up and will go out. And then, you also added general fund funding, dollars 835,000 for the comprehensive payment reform and $3,200,000, for additional primary care transition. And those will go out in two payments, in January, and then one in June and July. And

[Robin Scheu (Chair)]: this was, we're dropping the ACO, but we're going to go to ahead, except ahead is probably

[Multiple members (diarization mixed)]: behind and not really going happen. Unless

[Stephanie Barrett (Financial Director, Department of Vermont Health Access)]: you know anything more about.

[Robin Scheu (Chair)]: But that was the plan, That we were going to, this was the bridge to ahead. We haven't heard anything more about AHEAD at this point. No,

[Stephanie Barrett (Financial Director, Department of Vermont Health Access)]: but we are we do know that we have six hospitals that are in the hospital global budget for the calendar year 2020 That's moving forward. Is that everything? That's everything really fiscal. What else would you like to tell?

[Robin Scheu (Chair)]: If you have other questions? Did we have other things on our list, no? Did we have other things, or were there other things besides the utilization and a couple other things? One more thing. Obion. Obion. I didn't know what that meant.

[Stephanie Barrett (Financial Director, Department of Vermont Health Access)]: Oh, so we buy folks at certain income levels into Medicare. So we pay their Medicare premiums and co pays depending on what program they're in. So all duals are basically in buy in, both in Medicare and Medicaid. So Medicare is the first payer of the services, and then we're paying the buy in and anything that Medicare doesn't cover. And then we also have the Medicare Savings Plan programs, the QMB, and the qualifying individual, programs, the expansion of that, which is turning on now in January as well. And so that bill comes as an invoice from the federal government for Medicare. Most people get that bill, and if they're on social security, it's but for states, we face the full impact. We're not held to the increase in social security the way individuals are. We get the full impact of Medicare financing as a state on the cost of buy in, and that we have to pay for that when we get the bills from the federal government. So every January, there's an adjustment, up or down. Sometimes we are slightly off with the number. What we're seeing in accounts, the federal government lags us a little bit in timing, and then it catches up. This is a payment that we have to make? This is a payment that we make on behalf of How much has it been typically? So I didn't bring my budget book, but it's a $40 something million line item in gross dollars. The majority of is matched. Qualifying individuals are 100% federally funded. So that's a And then a very, very tiny amount of it is in our state only, like three invoices, three people. It's a very, very small amount. And that's going up to a bigger amount because of the expansion of the MSP program.

[Multiple members (diarization mixed)]: We increased the program.

[Robin Scheu (Chair)]: This is great. They've been on Medicaid, and now they have to go to Medicare. And we put money, and we said, well, we'll expand the population who we'll pay for, David? To some percentage, we could only do a little bit, but we did some, but now that's been serving.

[Multiple members (diarization mixed)]: And the great thing is it doesn't look at resources, meaning it's not like, whoops, you've got more than 2,000 in the bank, it doesn't look at that.

[Robin Scheu (Chair)]: Right. But I think it's related to the also to the dual.

[Stephanie Barrett (Financial Director, Department of Vermont Health Access)]: Well, duals are by nature, dual is both on. And so they're on Medicaid and they're on Medicare. And so we're paying first for their Medicare coverage, and then we're wrapping around what Medicaid will cover that Medicare does not. And those people are fully Medicaid eligible. It's the qualifying individuals and the qualifying Medicare beneficiary that, are the expansion population and the population where we, want to make sure that because we can match that buy in. And the qualifying individuals are they have a slightly lesser benefit, but it's fully funded by the federal government.

[Robin Scheu (Chair)]: So Dave, you're conversing in buy ins?

[David Yacovone (Member)]: Well, I'm conversant in the Medicare Savings Program, which is I guess

[Stephanie Barrett (Financial Director, Department of Vermont Health Access)]: A big chunk of that is buying. Part of it.

[Robin Scheu (Chair)]: Yeah. I don't remember hearing about the phrase buy in here in the past, but

[Stephanie Barrett (Financial Director, Department of Vermont Health Access)]: When they started shorthand, we buy you into the yeah. Actually, the federal government uses it on its invoices. Yes, exactly. That's exactly. I just signed one the other day. I was like, yes.

[Robin Scheu (Chair)]: Thank you, Nolan, remembering. That was one of our questions. Did we

[Multiple members (diarization mixed)]: get everything on your list? No,

[Robin Scheu (Chair)]: we're good. Anybody else have other questions for Doctor. Leanne DeShawn? Anything else you want us to know about?

[Stephanie Barrett (Financial Director, Department of Vermont Health Access)]: There is, I can't think of it.

[Multiple members (diarization mixed)]: Thank you.

[Robin Scheu (Chair)]: We appreciate you coming in very much. This was our last presentation of the day and everybody hung in there, so I appreciate that that happened. Committee tomorrow, we are going to start, so we're going to end a little early today, a few minutes, so we can hit that. Tomorrow we're starting at nine with judiciary, state's attorneys, taxes. Emily Bird is going to talk to us about the budget letter we sent out to agencies so that we can start to become conversant as we're asking them to do. Maybe And do it again in January once again. We'll put it together first, look at that. And then the Criminal Justice Council, and then we'll have corrections and DCF. Oh, we're going to take a bill off our wall and just look at it. We can't vote. We're not officially in session. But S-sixty, the Farm and Forest Security bill. So

[Multiple members (diarization mixed)]: we're going

[Robin Scheu (Chair)]: to learn about that. My thinking on that and I've talked to Tom, who's got this agency back, is that we'll probably strip the money out, have legal contingency language, send it back over to the Senate, because House Ag made some significant changes. Then any money decisions would be made at the end of the session as part

[Dr. Rick Hildebrandt (Commissioner, Vermont Department of Health)]: of the committee conference budget.

[Robin Scheu (Chair)]: So we'll take that up tomorrow as well and end the public safety. So we have another full day, but we're dumping around. We've gotten through most of AHS today. So thank you for your time.