Vermont Legislature SmartTranscripts:

[Alyssa Black (Chair)]: Good morning everyone, it is January 8, this is TELUS Healthcare and this morning we are hearing from, as soon as I move my agenda to the right day, we're going to start with Mary Kate Goldman from ICY. A little more updates on things that have been happening, because there's been a lot happening in the soft session. I know you've been on vacation for six months, but.

[Karen Lueders (Member)]: I am just waiting to be let into the Zoom. Okay. Thank you. Let me

[Mary Kate Mullen (Bi-State Primary Care Association)]: just pull it all up. I pull it up, before I start, I'm Mary Kate Mullen. I'm the Director of Vermont Public Policy at Biostate Primary Care Association. We represent FQHCs in New England in support of our fellow lobbyists, and as well as Vermont Greenwood Borough Clinics. We support both FQHCs in Vermont as well as New Hampshire. I have to say I have a counterpart in New Hampshire who does the New Hampshire policy, I just want to say

[Jennifer Carbee (Office of Legislative Counsel)]: it was so lovely working on

[Alyssa Black (Chair)]: the Vermont side. Thank you. And if our two new members and our committee assistant would like to introduce themselves to Mary Kate, because Mary Kate's in our room an awful lot and we get to know her. She's a great resource for things. Val, if you want to introduce yourself to Mary Kate.

[Jennifer Carbee (Office of Legislative Counsel)]: Hi, Mary Kate. Val Taylor. I'm a student of eleventh.

[Karen Lueders (Member)]: So it's not Baldwin. Good morning, I'm Karen Lueders from Addison Four. Mari Court Assistant. Yes, thank you.

[Mary Kate Mullen (Bi-State Primary Care Association)]: Well, it's nice to meet you. Thank you both.

[Karen Lueders (Member)]: Hi, I'm Haasha. Yes, we're

[Alyssa Black (Chair)]: going be good friends. Exactly. Still not mean that the most important person that anyone should meet is the committee assistant.

[Mary Kate Mullen (Bi-State Primary Care Association)]: Exactly. All right. So what I'm going to do is I'm going to just give a brief 101 on FQHCs by state, what we do, our presence in the state. A lot of this could be review for many of you, new for some of you. I figured it's good to just run through it, and then we'll get into the update section of my presentation.

[Alyssa Black (Chair)]: Do we have your slides?

[Mary Kate Mullen (Bi-State Primary Care Association)]: No, I'm going send them to you. Whatever reason, it's not letting me convert it to PDF. I'm going to have a conversation with my computer, and we'll figure it out and send it to you. All right, so FQHCs, Federally Qualified Health Centers, these are organizations that have been set in federal statute. This is, I want to say in the 80s. But the idea is that they are community health centers. They provide primary care, but they are broader. We do oral health, reproductive. I'll get into more of the services. But the focus of FQHCs is to serve everyone, to really be that safety net in the community and make sure that the community members have access to primary and preventive care. As FQHCs, they must participate in Medicaid. They must accept patients regardless of their insurance status or ability to pay. And to that point, they have to offer a sliding fee scale based on your income. So it has to offer it up to 200% federal poverty level, but it can go more. If you can't forge your payment, you work it out with the FQHCs and figure out what you can pay and what the FQHCs will cover. This can include uninsured, underinsured, even Medicare. So for people on traditional Medicare who can't afford their 20%, often FQHCs will step in and support them, especially around dental, where Medicare is not a covered service. The other thing is that FQHCs are really intended to be part of the community. And as such, they have to have at least 50% of their governing board has to patients. So there's a real connection between how the FQHC is governed, how the services are offered, the patient's engagement is really rooted in the patient experience. Funding. There's often this view that FQHC is I feel like we have dissuaded this or dismissed this or dispelled this image, but there's this idea that FQHCs are rolling in funding. That is absolutely not true. We operate on a razor edge margin. As you can see here, 75% of our funding is all patient revenue. The other 25% is grants and other sources of funding, 340B savings. And that really goes towards the operation of an FQHC as a community health center that's looking at transportation. I'll get into more of the enabling services. But how do you reduce those barriers that prevent people from coming in to get their care, whether it's financial, transportation, family obligations? There's a real commitment to making sure that people have access. And if you go into many of your FQHCs around the state, one of the things that struck me, pretty much every one I went into, there would be a shelf off to the side with food, diapers. So you can go in and you can It's really, how do we mitigate any barriers to care? And so the other grant funding, our main part, and I'm going to get into this a little bit more, reference this a little bit later, the three thirty grant. That name is just where it is in the public health acts, that new federal statute. That's why we call it the three thirty. But this is that federal grant that supports FQHCs and allows them to operate as these community health centers. Our Medicaid, we are paid through an encounter. Both Medicaid and Medicare were paid for an encounter. So if you go into a visit, whether it's a straightforward wellness visit or if it is a very intensive visit requiring multiple providers to deal with complex chronic conditions, FQHC gets paid the same rate. And that's true for both Medicare and Medicaid. Commercial, we follow generally the commercial fee schedule. So that's very similar to other primary care providers and how they are reimbursed across the state. We have to meet incredibly strict standards. Forget the frequency, but there are on-site visits where HRSA, the Health Resource Services Administration, comes in and reviews all aspects of the operations, including does everyone have a name tag? That's how detailed they get. And they make sure that all of these pieces, that the FQHCs are in compliance with all of these very strict quality standards. Okay, this gets into this broader service. I like this just because you've got your core services. These are the services that are patient facing. You've got your primary care, your mental health, your oral, substance use disorder. All of our members are participating in Vermont's Hop and Spoke program. And then there's the care coordination. Then we have this broader circle, which is Zero Enabling Services. This is looking at economic empowerment support, looking at making sure you get connected to insurance if you're eligible, looking at what sliding fee scale you qualify for, making sure you have access to nutrition. We have Notch up near neck of the woods. They have a grocery store in their base. So they often will talk about, talking to patients about what are the nutritional foods that you need to really keep healthy. There's a lot of health education. Often they all be cooking classes. So this is really that broader community base. I think of this as like, if you think of your core services as your body organs, these enabling services are kind of that connective tissue bringing it all together. Oh, I also want to call out, we do a lot of school based services. We're present in a lot of schools, especially supporting mental health needs, as well as physical and oral health needs for our children. We are present in every county in the state. And we serve over about onethree of Vermonters. We provide primary care to onethree of Vermonters. We see almost all of the uninsured Vermonters, and we're over almost 40% of Vermont Medicaid enrollees are patients. All right, so that's who we are. Any questions?

[Alyssa Black (Chair)]: Yes, it looks like Daisy has a question. Okay. And then Tucker.

[Daisy Berbeco (Ranking Member)]: I'm sorry, I may have missed if you said this, but can you talk a little bit about an FQHC and what that federal designation requires?

[Mary Kate Mullen (Bi-State Primary Care Association)]: Excuse me. Sure. So broadly that we have to take all patients, have to participate in Medicaid. We need to provide the sliding fee scale. I'm trying to think of some of the other standards. We have to have that 50%, more than 50% patient participation on the governing board. Have to provide dental or connect, have a contract with the dental organization so that patients have access to dental. I believe mental health services are also a requirement. So again, looking at that whole person care, that brain, your teeth, your body are actually all one in this day, and they all impact each other. And then it's really looking at how are you engaged in a community? Does that Those are kind of the highest level, representative of I'm

[Daisy Berbeco (Ranking Member)]: thinking higher level. I'm thinking that there used to be, I don't know if it's still true, a requirement that FQHC served underserved populations and that there was actually a requirement around geographic limitations.

[Mary Kate Mullen (Bi-State Primary Care Association)]: Yes. So you have to be recognized as an underserved area. I'm less familiar with the exact requirements of that, but you have to demonstrate that you are meeting the needs of an underserved population.

[Alyssa Black (Chair)]: You all set, Daisy? Okay, she's off of. Topper and then Karen.

[Francis McFaun (Vice Chair)]: From three clinics, how can you talk to us a little bit about how you coordinate with them?

[Mary Kate Mullen (Bi-State Primary Care Association)]: Yeah, so often the clinics do have a good relationship with FQHCs. They will often try to establish a relationship and then work with the FQHCs to get them in a more ongoing patient relationship with a provider, really shifting them more to a patient centered medical home, like a medical home basis. There's also the referral clinics. And these are the clinics that really bring people who don't have a connection with a primary care provider, making sure they are signed up for the appropriate insurance to which they are eligible, and then connecting them with a local primary care provider, which is often the FQHC study. They are distinct, but there is a lot of community engagement and cooperation.

[Karen Lueders (Member)]: Does that answer your question? It can. Thank you. I had one question about, I have two questions. The Medicare, Medicaid payments, are not at, are they at their each respective rates or a different enhanced rate or how does that payment mechanism work for both two?

[Mary Kate Mullen (Bi-State Primary Care Association)]: They are, so the Medicare is set nationally and then there's a geographic adjustment factor, so that's, we don't have any control over that. I can't remember off the top of my head what that is. But it's men adjusted for inflation. Medicaid, and this gets really complicated. I think I understand the distinction. At

[Karen Lueders (Member)]: I go to an HQ page. We hosted Bernie Sanders when it was about to get the establishment of Bristol. I met with the executive director and I thought there was a different payment, like it wasn't just Medicaid reimbursement rate and Medicare, but there's some

[Jennifer Carbee (Office of Legislative Counsel)]: Yeah,

[Mary Kate Mullen (Bi-State Primary Care Association)]: wouldn't say enhanced, that's often what they use for it is an encounter rate And it is an encounter rate that is grounded in the cost of care. I'm happy to get it. It's very complicated, and I'm happy to walk through that and give a kind of a high level.

[Karen Lueders (Member)]: Thank you. Later is just fine. But I'm kind of curious to know how the payment system works.

[Mary Kate Mullen (Bi-State Primary Care Association)]: Yeah. No. We've had a lot of work on this.

[Karen Lueders (Member)]: It's amazing at what they do. It's absolutely off the chair for me, but I just want to understand a little bit more how it works. And then the other thing I was just curious about is the school component, that And again, I don't need to take a lot of time now, but I'm curious to know how that interface works and coming back. Yeah, no, I'd be happy to talk with more about that. Great.

[Mary Kate Mullen (Bi-State Primary Care Association)]: And if that's something that I can.

[Alyssa Black (Chair)]: I'm actually about to ask you that question. So thank you. Always think of school based services. Are we talking about health services, mental health services? I guess I always think of school based services in terms of our designated agencies.

[Jennifer Carbee (Office of Legislative Counsel)]: Yeah, so designated agencies

[Mary Kate Mullen (Bi-State Primary Care Association)]: also provide school based services. And often, in the best case scenario, there's a real complementary collaboration between the FQHC and the designated agency. FQHCs are allowed to go in to provide these services, and they're allowed to bill insurance. So for Medicaid children, they can bill Medicaid, commercial bill commercial. Designated agencies do not have a billing setup. And I am less familiar with how that funding is arranged. I know it has something to do with the school

[Alyssa Black (Chair)]: I'm hoping you're going through Success Beyond six or drawing down federal funds?

[Mary Kate Mullen (Bi-State Primary Care Association)]: No, we would do the services based on billing.

[Alyssa Black (Chair)]: On billing, which would draw down if it's not a draw down a federal match.

[Mary Kate Mullen (Bi-State Primary Care Association)]: Yeah. And then also, if the kids aren't able to pay or the families aren't unable to pay, then

[Alyssa Black (Chair)]: they also then qualify for that sliding fee scale.

[Mary Kate Mullen (Bi-State Primary Care Association)]: I wanna go over a little bit, start with a big thank you for last year. Last year, we, the legislature, all of you, especially in this committee, really the support you demonstrated for FQHCs was greatly appreciated. We were able to increase our FQHC rates. This has been a four year project on my part. But we were really able to bring those rates closer to the cost of providing that care. So that was a really big step forward. We were able to, through, Wendy being on the act now, but protect the contract pharmacy relationships under 340B. This has been an issue with pharmaceutical manufacturers limiting how QHCs can contract with pharmacies participating in the 340B program. And the savings they get by participating in this program is really instrumental in reducing prescription prices, providing free care or reduced cost care to Vermonters. We were able to strengthen primary care fire authorization exemptions, funding the Blueprint for Health Medicare payments through 2026. And then we continued to work with ADEVA, and we were able to accomplish this one time historical change in scope adjustment, which goes back to my previous point about this ongoing dialogue with our Medicaid rates and making sure that they are reflective of the cost of care. So we made a lot of progress last year. Unfortunately, what's happening at the federal level is cutting into that. This isn't something that I am asking you to do. There's not really much you all can do. But where it connects with this committee is the potential cuts to savings in the 340B program, the increase in uninsured and underinsured, which gets pulled out of our three thirty grant funding, as well as flat federal grant funding could limit our ability to provide and continue to provide the level of access and services that we currently provide. So there's this sense that we want to dispel the idea that FQHCs are just here. They continue to face threats around their ability to continue their process.

[Alyssa Black (Chair)]: Do you have any idea how the grant we got from the federal government is gonna help all the rule? Do you have any it happened quick and everything, when do you see it? Any connections with the

[Mary Kate Mullen (Bi-State Primary Care Association)]: So that gets into our priorities for this coming year. The Rural Health Transformation Program funding, as Jill said Tuesday, that is really, it is one time transformational funding. So it is buying the stuff to get us to a better place. And hopefully the idea, I think being that once we are in this better place, that the cost of care is lower. That's the hope. That's the dream. Whether or not reality fits that is yet to be determined. But I think looking at, do we have investments for one of the things that FQHCs have really prioritized is support for investing into scribes, AI scribes, which has really been seen by a lot of providers as taking off that administrative burden, looking at upgrading their EMRs, increasing their interoperability so we're able to share information across organizations better and in a way that better supports coordinated care management, especially for complex patients. Do

[Alyssa Black (Chair)]: all the FQHCs use the same EMR? That would be easy. Is it your talk that maybe, I mean, you are the primary care for a third of Vermonters?

[Mary Kate Mullen (Bi-State Primary Care Association)]: Do not have, each FQHC goes in and they do their RFI process and look at what are the EMRs that work best for their organization. We have obviously offered support, but a number of them have recently switched EMRs. Think the idea of switching again would Yes, I'd kill them. Yeah, you'd send everyone into a swivel at minimum. So we are working really closely with the state. We are also in constant conversations with our national partners, other state partners. There are PCAs in every primary care associations in every state, understanding how to use this money, what is the benefit. And I really want to back up Jill on her comments that the Rural Health Transformation is not the health care reform plan. I think that is some of that jumpstart, that startup funding to make that transformation to get us to the better place. But underlying all of this needs to be that plan to change how the system functions so that we are in that better place when that funding runs out. So this is where we've got the one time transformation investment. That's the rural health transformation. Then there's the ongoing health system transformation that has started with the hospitals. But we, BioState and our members, are really committed to also having those conversations with the administration and the Agency of Human Services about how do you incorporate primary care into that. How do you make sure that there is enough investment in primary care so that we are able to provide the access and services that would then allow fewer people or that would support fewer people needing to go into the hospital. Not that you're denying care at the hospital, but that you want fewer people needing that care, and that you are getting that upstream preventive care before they're in a place where they're in the emergency room or needing to be admitted for an inpatient procedure.

[Alyssa Black (Chair)]: I see you talk to her. Let me just really quickly, Mary Kate, if you can refresh me, the 340B bill we did last year, H. 66, there were reporting requirements for Did we put reporting requirements for hospitals? Just hospitals. We exempted the FDAC. So there's no report coming from you saying how much you got from 340B and what you used it for? No. Okay.

[Karen Lueders (Member)]: All right. Don't worry, I'm not going join this.

[Alyssa Black (Chair)]: It's small

[Mary Kate Mullen (Bi-State Primary Care Association)]: part of the program, but it has a huge impact of our operations.

[Katie McLain (Office of Legislative Counsel)]: I just couldn't remember if

[Alyssa Black (Chair)]: it was a problem. Can

[Francis McFaun (Vice Chair)]: you talk a little bit about your cooperation with the hospital? How do you work with the hospital? If I'm a patient and I have to go to the emergency room, how do the records with all of the things that you've been doing with that patient get to the hospital so that they know about the present.

[Mary Kate Mullen (Bi-State Primary Care Association)]: That is a really excellent question, I think the heart of a lot of what we're trying to accomplish. I'm not necessarily the best person to answer that. I would love maybe at a future date where we're looking at that care coordination or talking about the health system transformation, bringing in one of my members who can talk more explicitly about that information transition. I think we have regions where there's really tight collaboration between the hospital and the

[Alyssa Black (Chair)]: I think the closest would be Gifford, which is both the

[Mary Kate Mullen (Bi-State Primary Care Association)]: hospital and FQHC. But in general, I think there is a lot of, I would say there is. I can't speak to the exact mechanisms of that. I would rather bring a member who can really be more explicit about that.

[Alyssa Black (Chair)]: We get your slides? Absolutely. Yeah, I missed that.

[Mary Kate Mullen (Bi-State Primary Care Association)]: Yeah, I'd be like Yeah, no, no, no. I had issues with transitioning it to a PDF, so we're going to chat. So the other things that we have for this upcoming year, as you saw yesterday in the Diva BAA presentation, there is the 2.7 MEI inflation adjustment. This is one that is applied every year to our FQHC rates. And this is really we brought our rates up to a big catch up last year with that rate increase that this committee in particular supported. And then this is just to try to keep up, maintain, not fall back again. We are supportive of any investments in workforce development and recruitment efforts. By state, in particular, is really working with national partners around how to reduce the administrative burden around the Medicaid work requirements. So looking at the data and seeing how we can easily figure out who's medically exempt from work requirements. So looking at claims data and see what we've been identified for those complex individuals who would be then medically exempt from a work requirement. So that's one of the things. It's not what you guys But I want to make sure I want to just let everyone know that this is some of the things that BioState's working on. There are questions. We're happy to answer them. BioState has also set up a Food as Medicine Task Force. There's no legislative ask at this point, but we are really exploring how can we better support expanding medically tailored meals, medical nutrition therapy, and then food as prescriptions. We're working with a number of our members on this. And then we're also but we've got this task force that has been pulled together to look at how can we financially support this. Because it's one of those The long term payoff in keeping people healthy through nutrition, getting them off of prescriptions, medical prescriptions, that they can make sure they're eating the right foods. There's a lot of return on investment there. We are working with the American Heart Association on this and a number of other organizations, Vermont Food Bank. There's a lot of collaboration in this effort. And so we're exploring this, like how do we really bring this more front and center? So if anyone's interested in that, I'm happy to provide

[Karen Lueders (Member)]: more information. Brian,

[Brian Cina (Member)]: what I'm wondering is, I haven't heard about that work yet, that's great. Have you reached out to any of the food justice or mutual aid work that's happening in the state right now? Because I haven't heard of you yet and if not, I'd like to connect you with people because I think there's a lot of people getting free food through mutual aid networks and there just might be potential there to expand the work if it isn't already happening.

[Mary Kate Mullen (Bi-State Primary Care Association)]: Okay. I did talk to the chair about this. We're going to have a presentation probably after crossover, but I'm also happy to share

[Alyssa Black (Chair)]: the list of collaborators on this project. Talk a little bit more about the you sort of skipped over the workforce development recruitment. More specifically, what type of workforce are we talking about? Where are you talking struggles? Are we talking about physicians? Are we talking about nursing? Would say it's all of the above.

[Mary Kate Mullen (Bi-State Primary Care Association)]: Yes and yes. A lot of what the workforce development, what was included in the Rural Health Transformation application, we were very supportive of all of those initiatives. So bringing up nurses, physicians, scholarships training, the clerical, anything that helps both train in house, like we can grow our own, but also the Bi State has a recruitment center that looks nationally and trying to bring physicians, dentists, nurse practitioner, and physician assistants into both New Hampshire and Vermont. We provide services, not just for FQHTs, but for anyone who wants to use our recruitment services. So those are the, I would say, of the above, any support we can have to make sure we have the staff to provide the services we need, especially if we're going to put more emphasis on primary care and preventive services. We need the people to provide the services.

[Alyssa Black (Chair)]: Is that the end of your

[Mary Kate Mullen (Bi-State Primary Care Association)]: Yes. And because the way the world is, I try to all of our meetings at FISA, we try to end with funny animal videos, so

[Alyssa Black (Chair)]: this I is keep telling people I want less words on their decks and more all hat and dog. And you I didn't even tell them that, and there it is. So this

[Mary Kate Mullen (Bi-State Primary Care Association)]: is Juniper and her best friend, Adina.

[Alyssa Black (Chair)]: What kind of dog is that?

[Mary Kate Mullen (Bi-State Primary Care Association)]: No. This is she goes on a pack walk every Tuesday.

[Brian Cina (Member)]: Did you just ask if it was a horse?

[Alyssa Black (Chair)]: No. No, Yours is. No. It does look large. I the black one. Bernie Doodle. What is that? It's a

[Mary Kate Mullen (Bi-State Primary Care Association)]: Bernie Doodle. Bernie's Mountain Dog. It's

[Alyssa Black (Chair)]: a Bernie Doodle.

[Brian Cina (Member)]: You're gonna start calling Bernie that

[Katie McLain (Office of Legislative Counsel)]: watch. Birdie doodle.

[Brian Cina (Member)]: Daisy's got her hand raised.

[Alyssa Black (Chair)]: But I usually defer to

[Francis McFaun (Vice Chair)]: the child.

[Brian Cina (Member)]: Oh, just saw it.

[Alyssa Black (Chair)]: Val, did you have a question? Karen, and then I have actually a question.

[Jennifer Carbee (Office of Legislative Counsel)]: Okay. I'm sorry to backtrack a little bit. The contract with pharmacies, could you elaborate on that a

[Alyssa Black (Chair)]: little bit with 340B?

[Mary Kate Mullen (Bi-State Primary Care Association)]: Yeah, so the 340B program, just at a high level, it allows, as a requirement for participating in Medicaid and Medicare, pharmaceutical manufacturers are required to sell their prescriptions to participating covered entities, which would be FQHCs, critical access hospitals, Planned Parenthood, as an example of a few, sell the drugs to those pharmacies at a reduced price. And then when that prescription is administered and they get reimbursed by the payer, the covered entity gets reimbursed at a full price. That difference, that savings, that lower amount that we have to expend at the first part versus the reimbursement is used to provide a number of services, including reducing prescriptions for those who really are struggling with the ability to afford their prescriptions. Not every FQHC is able to offer an in house pharmacy. So they will contract with other pharmacies in the community to offer these lower price or these 340B covered prescriptions. Manufacturers had limited how many pharmaceutical or how many contract pharmacies an FQHC could engage in. And there was also a lot of reporting requirements. Last year, this body passed a bill that said that manufacturers were not able to which restrict those contractual relationships with pharmacies. So that allowed that three forty, that footprint of who was able participate in the program to expand again back to what it was. So that's what that bill did. And that is we would have been able to expand that footprint again and maintain that level of 340B billing, 340B savings. Is that okay?

[Alyssa Black (Chair)]: Thank you.

[Mary Kate Mullen (Bi-State Primary Care Association)]: It's a complex program.

[Alyssa Black (Chair)]: I know somebody, either one of you, would ask about the family. Do like a whole craft board here on three point B. Karen, you want to go ahead? Yeah, actually, this is a yes or no question, and then a comment. So is that 340B, just curious, part of the encounter terminology, is that separate?

[Karen Lueders (Member)]: Just yes or Separate. We'll get around to that in a minute. I just wanted to share a comment that I got from the executive director of our FQHC in Addison County, and that is that workforce support really depended on affordable housing, available housing. They had great people coming in ready to work, and they did not have a place where they could live. So I just wanted to put that comment up there. No, that is not an uncommon comment.

[Alyssa Black (Chair)]: Jill indicated yesterday that was one of the incentive that had been in the original grant application the federal government said no. I wanted to ask you about the typically you come in here and at top one of the top slides, you sort of say you're in trouble. You didn't really give us any indication as to the financial health. And I know that we got the report from Diva on the provider stabilization grant. Several entities that are FQHCs received money. So how are we doing financially? I think there's a pending application for another one. Is For another one I think there's a pending application that hasn't made a decision Oh, on another no, no, no, I'm sorry. Sorry, designated agency. So

[Mary Kate Mullen (Bi-State Primary Care Association)]: I didn't have a we're in trouble sled because a lot of the we're in trouble is at the federal level. We had that increase last year through Medicaid rates, and that has been a big step forward. And it's the federal policies that are eroding that progress. Did those rates go into effect January 1

[Alyssa Black (Chair)]: or July 1? July 1. July 1, okay.

[Mary Kate Mullen (Bi-State Primary Care Association)]: Obviously, support for the EMI inflation adjustment is important to us and for our members. And I think it's looking at more broadly, what is the investment? How do we increase the investment in primary care? Full stop. Like I said, we don't have a specific Medicaid ask this year, but we want to be part of the conversations around how do we reallocate the resources in the system so that we are spending money on the right preventive care, not the acute, expensive care that could be potentially avoidable or should be potentially avoidable.

[Alyssa Black (Chair)]: Leslie? You knew I was going to bring this up. Last year, we talked about closing North Star, and that was in Bells Falls and really affected the community in a really impactful way. I'm wondering if you, the umbrella organization or North Star itself, has done any analysis of the impact of that closure and whether people in Bells Falls have been able to get the care that they need and get access to that care.

[Mary Kate Mullen (Bi-State Primary Care Association)]: I would have to double check with the CEO of that organization to see if they've done any follow-up. I have not been aware of it. But they are actively exploring other ways to expand access to care in that region. The

[Alyssa Black (Chair)]: map looks pretty deserted. Of course, I couldn't help but I know. I'm pretty worried still.

[Mary Kate Mullen (Bi-State Primary Care Association)]: Yeah, as are we. And there have been conversations like, what are the collaborations with, whether it's the Rutland, FQHC, conversations with the Sanders team about how do you bring more primary care into the Brattleboro area?

[Alyssa Black (Chair)]: Yeah, well, we're way north of Brattleboro. Brattleboro is certainly helping. But it's Windham County, I get it. But it's a big county.

[Mary Kate Mullen (Bi-State Primary Care Association)]: Yes, it is. So I will follow-up on that question. Thank you.

[Alyssa Black (Chair)]: Great. Thank you so much. Oh, wait, Daisy has a question. Guess.

[Brian Cina (Member)]: I'm sorry. I can't

[Alyssa Black (Chair)]: Yeah, I'm sorry. Yeah. It's okay. I Tiny little box in the corner.

[Daisy Berbeco (Ranking Member)]: My question was related to the Rural Health Transformation innovation program. And I'm curious. You know, we were hearing from Jill Olson yesterday, and, it sounds like there is a bit of debate or or noodling on what the definition of rural is, and and that would impact who is eligible to receive some of those funds, which could massively transform, the way that we get care. So in my community, we have an FQHC which is concerned that they could potentially be left out of those those, funds and the the program. And so I'm curious, you know, what concerns do you have about maintaining equity across the FQHC network when it comes to having access to things like funding to advance technology and innovate, how practices operate. Because I know one thing, you know, Winooski constituents deserve to have the most advanced technologies the same as folks in the NEK do. Mhmm. So I'm just concerned, you know, as a network, how do you how are you having those conversations with the state?

[Mary Kate Mullen (Bi-State Primary Care Association)]: Yeah. Representative Berbeco, that's an excellent question. That has been something that we raised with the state say, in November. Bi State was one of the key collaborators with member of Congress to include FQHCs in the definition of a rural health facility. In fact, they're referenced twice in that definition, both explicitly as FQHCs and indirectly as three thirty grant recipients. Also in that list is community mental health centers, which we in Vermont refer to as our designated agency. So Howard Center is in the same situation. We have taken the position that since they are defined as rural health facilities, they are eligible recipients of Rural Health Transformation Program funding. And we have been in had a number of conversations with the state. I think one of the concerns, to their credit, is they don't want to expend money that could potentially be clawed back. I think that is a real risk, especially under this administration. I think there's a sense that we want to make sure we're spending money in allowed ways. We think that as designated or defined as rural health facilities, FQHCs and community health or VAs would qualify for that funding. We've reached out to our national partners. We've reached out to other states. New Hampshire has not expressed any concern. And so they are expecting to share money with their QHCs in Manchester and Nashua. So we've shared that information with the agency. They are reviewing it internally to make sure that they are all in agreement that this is an allowable expense or allowable disbursement of funding. And they are also let us know that they are also working with other states and other affinity groups to understand how other states are interpreting the parameters and requirements and restrictions around how to use the money with the Rural Health Transformation Program. So I think I am cautiously optimistic that we're going to land in the right place, particularly for FQHCs and RDAs. I can't speak more broadly about the availability of funding for other recipients that are not on that list of rural health designees. But I will also call out that there's no restriction on the funding going to a urban organization if the funding is benefiting people in rural areas. So it could be UVM coordinating care in rural areas. That would be, as my understanding, the FAQs for the transformation program, that would be an allowed funding. I don't want to get too ahead, and I'm not a lawyer. I am an epidemiologist by training. But that is my understanding of the reading of the FAQs and what other people have said. And I think the state would also agree with that. It's just whether or not, say, community health centers or Howard Center can expend fundings on their urban populations. So talks

[Alyssa Black (Chair)]: are happening.

[Mary Kate Mullen (Bi-State Primary Care Association)]: Talks are happening, and I am cautiously optimistic. Okay.

[Alyssa Black (Chair)]: Thank you so much. Thank you so much. Jessica. Sorry, we've cut into your time a little bit. Can we have two bills on the floor today? I'm sorry,

[Karen Lueders (Member)]: I went on to Sean's last name. Great.

[Alyssa Black (Chair)]: Commissioner Groves, in the BAA, there were several line items that pertained to Planned Parenthood, And I thought we should definitely have Planned Parenthood come in and talk about some of these things, especially around Title 10 and what's happening at the federal level that has necessitated a few of these things.

[Jessica Barquist (Planned Parenthood of Northern New England)]: Well, thank you for having me. Nice to see you all. Jessica Barkwiss, I'm the Vice President of Public Affairs for Planned Parenthood of Northern New England. And it's great that you have us after the FQHCs because we are also a member of closely with our FQHCs in the state. I'll start by giving a little background for those of you who don't know about us, and then we'll dig into Title X, and then we'll talk about the federal stuff. So Planned Planned Parenthood of Northern New England, we proudly serve about 14,000 Vermonters annually across our six health centers. We're in Burlington, Williston, Barrie, White River Junction, Rutland, and Brattleboro, as well as statewide through our telehealth program. And patients come to us every day for compassionate, high quality, affordable, reproductive, and sexual health care. And that includes things like wellness exams, birth control, STI testing and treatment, cancer screenings, abortion care, gender affirming care, and essential primary care services. No one is turned away based on their ability to pay. And in fact, fifty six percent of our patients are defined as having low income. Thirty three percent of our patients use governmental insurance, like Medicaid. And last year alone, we provided $1,240,000 in free and discounted care to Vermont. I've been in this role about three years now. And when I started, that was about 600,000. And so every year, I have to update that talking point for you all because that free and discounted care just keeps growing in our state. So Title X I'm going to give you a little bit of background because Title X is complicated but really important. So it's a federal program. It's a family planning program that was put into place in 1970 by President Nixon with strong bipartisan support. This program provides funding to assist individuals in determining the number and spacing of their children to promote positive birth outcomes and healthy families. So Title X health centers deliver clinical, informational, educational, and referral services as appropriate for health and social needs related to family planning services at our health centers statewide. And the overarching goal of our Vermont Title X program is to provide high quality clinical family planning and related preventative health services, education, and counseling to Vermonters who would not otherwise have that access. So there's a special focus on low income and rural populations. The program ensures access to comprehensive reproductive health care and really emphasizes that lower income individuals and allows our health centers to use a sliding scale fee for services. So this Title X program supports family planning services that ensure access to not just family planning but preventative health care for Vermont, women, men, their partners. And it includes things like patient education and counseling, breast and pelvic exams, breast and cervical cancer screenings, all two nationally recognized standards of care. It is important to note that Title $10 are not used in any abortion related work, including abortion follow-up visits, behavioral health, or gender affirming care services. So

[Alyssa Black (Chair)]: here

[Jessica Barquist (Planned Parenthood of Northern New England)]: in Vermont, PPN and E is the sole subrecipient of the Department of Health, BDH's Title X grant. And we receive approximately $760,000 annually in these Title X funds from the state. And that can fluctuate depending on the federal award amounts from OPA. Vermont did leave the Title X program during the first Trump administration. And then in this past calendar year 2025, out of our six Vermont Title X sites, we saw 8,648 unique patients across 13,147 visits. Thirty five percent of these patients incomes at or below 100% of the federal poverty level. And the overwhelming majority of them were 30. And approximately 17% of them were men.

[Jennifer Carbee (Office of Legislative Counsel)]: 17%, you said? Yeah.

[Jessica Barquist (Planned Parenthood of Northern New England)]: So in terms of future for Title X, that's what we're all wondering. No federal grant is ever guaranteed, especially in today's landscape. But Vermont has a really well established Title X program. And so PPN and E and VDH are currently collaborating on our non compete application for the final year of this five year award cycle, which is slated to begin in April. And so it is kind of too early to say what funding will look like later in the year. We have the funding to that April line. So that's the timeline that we're looking at in terms of Title X. I have been told that I just am the bearer of a lot of bad news recently, so I wanted to bring in some good news. And in March, PPN and E received notice in New Hampshire that our Title X award had been frozen due possible violations of terms and conditions related to an executive order. And then we submitted things. And after further clarification, Hampshire they were satisfied that we were in compliance. And as of last week, New Hampshire has now had their twenty twenty five Title Title X X brands restored for their four health centers after they've been frozen for nine months. A little bit of promising news on the Title X brand.

[Alyssa Black (Chair)]: How much was it?

[Jessica Barquist (Planned Parenthood of Northern New England)]: I'm not exactly sure. Their words are a little bit smaller than ours. Yeah.

[Alyssa Black (Chair)]: And so 10 questions or should I? I have title 10 questions in regards to the budget adjustment. So last year, the legislature added into budget, the big bill funds for family planning rate increase. And they're now in the BAA because they said that they couldn't do it.

[Karen Lueders (Member)]: Do you have thoughts on that?

[Jessica Barquist (Planned Parenthood of Northern New England)]: Yeah, absolutely. Yes. So that is separate from Title X. So Title X is a separate program. That is on Medicaid. So happy to jump to Medicaid.

[Alyssa Black (Chair)]: And Title X services are actually eligible rather than the typical FMAP, roughly sixtyforty or fifty eight forty two. Where's no one when you need them?

[Jessica Barquist (Planned Parenthood of Northern New England)]: That's still Medicaid. Title X is separate.

[Alyssa Black (Chair)]: Title X, those services are eligible for a ninetyten match, correct? Through Medicaid. Through Medicaid.

[Jessica Barquist (Planned Parenthood of Northern New England)]: Yeah. So Title 10 is completely separate. Title 10 allows us to provide the sliding scale fee and provide that free and low cost care, particularly to people who are uninsured or have inadequate insurance.

[Alyssa Black (Chair)]: Okay.

[Jessica Barquist (Planned Parenthood of Northern New England)]: What's happened since So let's talk Medicaid. Talk

[Alyssa Black (Chair)]: about Medicaid.

[Jessica Barquist (Planned Parenthood of Northern New England)]: Okay. There's two different things here. So the piece that you're talking about, I'll talk about first. So last session, when Planned Parenthood was still very much a part of the Medicaid program, this committee put into your budget the Medicaid increases for family planning services. So federal Medicaid provides an enhanced federal match rate of ninety-ten for family planning services, meaning that the federal government covers 90% of that rate and the state only has to cover 10% for family planning qualified codes. And so what you all did was create a Medicaid supplemental reimbursement for core family planning services. And so you used a modest state investment of $85,000 And that was intended to unlock $850,000 in additional funding for these essential services for Planned Parenthood. At the end of the session, after you all adjourned, but prior to the federal defund going into effect in July, Diva let us know that they were unable to implement those rates due to their inability to determine which codes met the requirements for the ninetyten match. So it's important to note that this enhanced family planning federal match is not new. It has been in place since 1972. So the inability to implement these rates raises a bunch of questions and concerns for us. And I do think it will be important for this committee to work with Diva and us to figure out what those barriers are and how we can circumvent them, not just so we can implement these rates that you put into play last year that we haven't been able to utilize, but also so we can make sure that we're effectively drawing down all of these federal family planning dollars and we're not leaving that precious federal funding on the table.

[Alyssa Black (Chair)]: I guess I'm a little confused because at a ninetyten match, it would have been $85,000 general fund investment, 850,000 federal funds. Yes. And the BAA came through yesterday or in December. They're actually having they actually have 350 as general fund with the $8.50 federal?

[Brian Cina (Member)]: I

[Jessica Barquist (Planned Parenthood of Northern New England)]: think that would be a good question for Debra. I know that in the budget you all appropriated 85,000. That was

[Alyssa Black (Chair)]: on that piece of Sorry. Yeah. That was on that piece of paper, right, where it was all I was looking for that yesterday. Okay. Yeah.

[Mary Kate Mullen (Bi-State Primary Care Association)]: Yeah. Mhmm. And it

[Jessica Barquist (Planned Parenthood of Northern New England)]: made it through the entire budget process at the 85,000 appropriation level. So we were the smallest appropriation in the whole budget.

[Brian Cina (Member)]: Really? It's like the shortest verse in the Bible. But

[Jessica Barquist (Planned Parenthood of Northern New England)]: it could have had such a huge impact. So it is something I think that is definitely a priority of ours to continue to figure out what is wrong there and how we can actually implement that because that would be a huge benefit to patients to access those services. I see you hold up. Has there conversations

[Alyssa Black (Chair)]: with Diva on ways to possibly implementation so that we are drawing down the appropriate federal dollars?

[Jessica Barquist (Planned Parenthood of Northern New England)]: Yeah, yeah. Candidly, we started those conversations and then we were defunded from the Medicaid program in July. And so our work with Diva pretty much since then has been in crisis mode and really trying to address the defund. So we will and I can talk about this in a minute. But we will ostensibly be in this defund until July unless something happens. So we have a little bit of time. But we're not the only ones that can bill for family planning codes. So there should be other providers in The States, like our FQHCs and others that provide family planning services that should be also able to access this ninetyten match. So that would be a good question for Diva as well.

[Alyssa Black (Chair)]: Okay. Lori. I'm curious when they reached out to you after we left session to say they couldn't do it. Were there discussions amongst the parties as to trying to find a solution, or was it just we're not doing it?

[Jessica Barquist (Planned Parenthood of Northern New England)]: We reached out to them. And we started those conversations.

[Mary Kate Mullen (Bi-State Primary Care Association)]: Okay, but they didn't get anywhere.

[Jessica Barquist (Planned Parenthood of Northern New England)]: We ended up. Thank

[Alyssa Black (Chair)]: you. Leslie, I guess I'm a little confused about where this all lands. So theoretically, was $85,000 in our budget last year that would draw down $850 So you lost all that money, it's gone. It never got made up anywhere else in any other Exactly. Okay. How did you, without that big sum of money, you went on anyway? You still going? Are you going to talk about what happened after you I'm going talk about that next.

[Jessica Barquist (Planned Parenthood of Northern New England)]: So we had this conversation. We got these Medicaid rate increases, started to have those conversations with DIVA. And then July 4, HR1 included a defund provision, which prohibited Planned Parenthood specifically from accepting Medicaid as a form of insurance for one fiscal year, so July to July. And this is a blanket provision, which was not narrowed to services offered. So abortion has not been federally covered by Medicaid since the introduction of the Hyde Amendment in 1976. So this defund is not about abortion. It is about all those other services that we provide. And we have been unable to be reimbursed for our routine visits, like the cancer screenings, the STI testing, well person visits, menopause care, all of those other things that we do. So it was really the intent was to target Planned Parenthood for providing abortion care. But really what it did was restrict access to health care, especially in states like ours where abortion is legally protected. So overall, across the country, this defund is estimated to cost about $52,000,000 in taxpayer funds and has the potential to shutter the doors of more than 200 Planned Parenthoods across the country, many of which in states like ours where abortion is fully legal. A study by Guttmacher Institute found that no other provider in the country can fill this gap that losing Planned Parenthood would leave. In Vermont here, where we know rural health care is already a struggle, Guttmacher estimated that our FQHCs would need to increase their patient volume by 206% to take on our patient capacity, which we know is just not feasible. So we have been working with DBA and the state. And we are so grateful that have. That was one of the line items in BAA was that continued funding to ensure that Vermont patients who use Medicaid can continue to receive their health care at Planned Parenthood Centers for the remainder of this defund period.

[Brian Cina (Member)]: Brian? What do you mean that it's going to cost taxpayers $52,000,000 Like how?

[Jessica Barquist (Planned Parenthood of Northern New England)]: So it's a complicated analysis. But across the country, the loss of that preventative care, if they estimate that will actually cost more on the back end. Because we know when folks don't get preventative care over control, health care costs rise.

[Brian Cina (Member)]: Do we know how much the preventative care would have cost? In other words, how much would we spend to prevent the cost of the $52,000,000

[Jessica Barquist (Planned Parenthood of Northern New England)]: As an entire country?

[Brian Cina (Member)]: I'm just trying to understand that if it's going to cost the taxpayers 52,000,000 to not have that care, how much does that care actually cost that's being cut? For example, if the federal government was paying 10,000,000 for that care, it would save us 62,000,000. So 52,000,000 minus 10 equals 52,000,000.

[Jessica Barquist (Planned Parenthood of Northern New England)]: I'm happy to add the study to my testimony. I believe it's 52 additional. So it would actually cost us more than just funding the Medicaid for this program. And this is supposed to end July 1. Yes, unless Congress were to enact a new budget that also included a new defund provision. But they would have to pass another defund for it to continue past July.

[Alyssa Black (Chair)]: That's why I understand. So it'll be automatically funded if it's not intentionally defunded?

[Jessica Barquist (Planned Parenthood of Northern New England)]: That is my understanding, is that after this defund period ends, we would be allowed to resume billing for our Medicaid patients.

[Alyssa Black (Chair)]: So how do we do that? What's our job?

[Karen Lueders (Member)]: Returns. Returns?

[Brian Cina (Member)]: We establish universal primary care and then that could help support Planned Parenthood.

[Alyssa Black (Chair)]: It's always how it's fun. Right. With the Trump tax cuts. Yeah, go ahead.

[Karen Lueders (Member)]: Just one quick question. The distribution of Planned Parenthood throughout the country, what does that look like? You've given us Vermont, New Hampshire, but this systemic defunding, are they well situated in every state, or how does that look?

[Jessica Barquist (Planned Parenthood of Northern New England)]: It truly varies widely from state to state. I sit in a group of other access states. And everybody often turns to me and says, what is Vermont doing? Because Vermont routinely steps up first and is really committed to making sure that patients have health care. There are other states that are also investing in their Planned Parenthoods as well. Thank you so much.

[Alyssa Black (Chair)]: And to your point, I have to give kudos to Diva. Diva stepped in and said, no, going to do this. But I also want to remind people that this happened and you continued to deliver services with nobody. That's right. Thank you. Thank you.

[Jessica Barquist (Planned Parenthood of Northern New England)]: And we were able to do that because we have such generous donors and we have a really great supporter base. And it's important for me to say that essential health care should not be funded by donors.

[Alyssa Black (Chair)]: Thank you. That's what you said. Right, exactly. Moving on. Oh my gosh, look, I cried for the first time this year.

[Brian Cina (Member)]: Wait, I was crying? Well, yeah. I define it worse. I didn't say caring. What is emotional?

[Alyssa Black (Chair)]: I don't think she's a party gym. I see the caveats with us. Suspect to talk about

[Jennifer Carbee (Office of Legislative Counsel)]: the reports. Is

[Brian Cina (Member)]: Is that that what this is, reports? Yeah.

[Jennifer Carbee (Office of Legislative Counsel)]: All right, good morning. Jen Carby from the Office of Legislative Counsel. I am here to just give you a little reminder for those of you who were here and then introduction for those who were not, to what was in Act 167 of 2022, specifically related to some healthcare reform efforts, because you'll hear Act 167 mentioned a lot when we're working on some of this transformation work. And I just did this downstairs as well. Think in both committees, there was a feeling like it was important to understand what that was or be reminded what that was. So I'm just pulling up this one pager that I had shared at the Health Reform Oversight Committee meeting this fall, and I think earlier as well. So this is just a summary of the two sections of Act one sixty seven of 2022, and then there was a section two a added to it the next year just because it made sense in context. And so there's links throughout this as well. So starting with AQ1-seven itself, section one had a few different pieces to it. It required the Director of Healthcare Reform and the Agency of Human Services in collaboration with the Green Mountain Care Board to develop a proposal for, and the terminology used here is a subsequent all payer model agreement. This is really an agreement. All payer model agreement was a federal, an agreement we had with the federal government that included Medicare participation in some of our payment and delivery system reform efforts. That was a time limited model. And so there was going to need to be as if we were going to have Medicare continue to participate in our efforts, a future subsequent agreement. And so it required the Director of Health Care Reform to develop a proposal for what that future agreement with the federal government might look like to secure Medicare's continued participation in Vermont's multi payer alternative payment models. And it specified that the development of the proposal had to include considering alternative payment and delivery system approaches for both hospital services and for community based providers. So that was a piece for the Agency of Human Services around federal collaboration. It also directed the Green Mountain Care Board in collaboration with the Agency of Human Services to develop value based payments. So payments sort of based on the value of the care provided, both looking at quality outcomes and the appropriateness of care, including global payments from all payers to Vermont hospitals or accountable care organizations. Let's give you an idea of the point in time we're at where accountable care organizations were a big part of what we were focused on, or both Determine how best to incorporate value based payments into the board's regulatory processes. Recommend a methodology for determining the allowable rate of growth in hospital budgets, because the board establishes hospital budgets. And consider the appropriate role of global budgets for Vermont hospitals. So this is, again, that idea of global hospital budgets that we were talking about the other day. Not a new topic. And that was one of the things that the board was directed to look at a few years ago as well. Section two, where we start using this term transformation and hospital system transformation. Section two directed the Green Mountain Care Board in collaboration with the agency of human services to conduct a data informed patient focused community inclusive improvement process for Vermont's hospitals to reduce inefficiencies, lower costs, improve population outcomes, reduce health inequities, and increase access to essential services. So again, a lot of these themes are similar to what we talked about with act 68 yesterday, two days ago. But continuing this is sort of the beginning of that work, and what we're talking about now is a continuation of that work. You'll see the name down below, but if any of you remember that Oliver Wyman report, the big topic of conversation two falls ago, I think that was the outcome of this community engagement process. Section 2A was what was added in 2023, And that directed the agency of human services to engage in transformation planning with up to four hospitals to be informed by the data analysis and community engagement from section two for the progress report due to legislative committees by 02/15/2024. The act 167 of 2022 appropriated $5,000,000 for this work. It was $900,000 to the Agency of Human Services in fiscal year twenty twenty three for its work, including hiring consultants and a little over $4,000,000 to the Green Mountain Care Board for its work, including again hiring consultants. There were a number of deliverables required in that Act, which will set us up nicely for Katie and me to go through more deliverables from all the reports that you've requested or are in statute. The Act required the agency of human services to report on its Section one activities, its development of the subsequent all payer model, and the Green Mountain Care Board on its activities both in Section one and two by 01/15/2023. And I've given you links to various presentations and updates. And it required the agency human services to provide an update on its stakeholder engagement by 03/15/2023. There's a link there. And then the board through consultant Oliver Wyman produced a community engagement report as part of its work under section two. So that is sort of the background of what it means when we talk about Act 167 and transformation, kind of all of these pieces.

[Alyssa Black (Chair)]: What in Act 51, what was the timeline for AHS? I missed that.

[Jennifer Carbee (Office of Legislative Counsel)]: I don't think there was a specific timeline in it. It was just that a progress report was due by 02/15/2024. So I don't believe there was actual time they had to start. It just authorized them to get started with up to four hospitals.

[Brian Cina (Member)]: Okay.

[Jennifer Carbee (Office of Legislative Counsel)]: Click I on it. Lori. I was

[Alyssa Black (Chair)]: gonna say, do we have a link to that? You didn't link that in this document.

[Brian Cina (Member)]: I'm not sure if there

[Alyssa Black (Chair)]: was a report or I a search and I couldn't find it.

[Jennifer Carbee (Office of Legislative Counsel)]: I don't know that much had happened at that point.

[Alyssa Black (Chair)]: Yeah, so not questions for Jen, but definitely questions for AHS at some point on that. Yeah. Did you That was my question. Because I just did a quick search and I couldn't find that report.

[Jennifer Carbee (Office of Legislative Counsel)]: Yes. I tried I think I tried to put in links to everything that was available on related to to those acts. K. Alright. So that's act one sixty seven. Wanna pivot to reports generally. And Let's pivot to reports Is

[Alyssa Black (Chair)]: there anyone have any questions about 01/1967? I

[Francis McFaun (Vice Chair)]: just have one question. Since some of the people are looking for a report, Is there one?

[Jennifer Carbee (Office of Legislative Counsel)]: That's what we were just talking about. I don't know that there was a report. People have to

[Karen Lueders (Member)]: use this another thing.

[Jennifer Carbee (Office of Legislative Counsel)]: Oh, I got it.

[Brian Cina (Member)]: I got

[Jennifer Carbee (Office of Legislative Counsel)]: it. I don't know that there was a report because I'm not sure there was Not sure much had been done at that point. I think authority had been sought, but there was not

[Karen Lueders (Member)]: necessarily the action.

[Alyssa Black (Chair)]: Were you all set? In section one, Fremont and Care Board was to develop value based, which, do you know which one of these reports? I guess I thought AHS did that.

[Jennifer Carbee (Office of Legislative Counsel)]: This is the language from, no, there's been a lot of sort of cross pollination here on who does what in this case. So some of it may have changed over time. I mean, do think the the Agency of Human Services and Diva have had certainly done a lot of work around value based payments. I'm not sure that was specifically as a result of act one sixty seven. I think that's the work that they have been doing for a while and that the idea behind this act may have been more systemic than just Medicaid funded.

[Alyssa Black (Chair)]: Okay. And that was in 01/1967, not '51, right? Right. '51 was just the four pilots. That was the four pilots, which I believe they've done. For the global budgets?

[Jennifer Carbee (Office of Legislative Counsel)]: So the pilots was not specifically global budgets. Pilots was transformation Oh, that was transformation. Okay. And the yes. The the Green Care I'm just looking at the act itself now. The Green Mountain Care Board work around value based payments and other other avenues is all payers. So it was looking at building on successful health care delivery system reform efforts by developing value based payments, including global payments from all payers to Vermont hospitals or ACOs or both, to help move away from fees for service, provide hospitals with predictable, sustainable funding aligned across multiple payers, some other provisions. And this is just sort of a summary of the language itself and act as much more extensive and we can walk through it if it would be helpful. No, that's okay. It's nice to get a refresher. Now I'm going to let Katie drive on the report stuff because my computer battery is lost. Reports. Yes. So first, Have you been in here? I haven't been

[Daisy Berbeco (Ranking Member)]: here yet.

[Jennifer Carbee (Office of Legislative Counsel)]: So crazy. We have new members.

[Alyssa Black (Chair)]: Yeah. We have two new members. And have you met Tasha for any assistance? Yes. Okay.

[Jennifer Carbee (Office of Legislative Counsel)]: Good. We've already been relying on Tasha a lot.

[Alyssa Black (Chair)]: Okay. Alright. Karen, you want to introduce yourself to Katie?

[Karen Lueders (Member)]: Katie, I've met you by phone already. We discussed a couple of things. So glad to meet you in person. Good to

[Alyssa Black (Chair)]: meet you. I'm from Addison Forum, Lori Houghton. I'm Val.

[Jennifer Carbee (Office of Legislative Counsel)]: Hi, Val Taylor, District of London. Good to meet you.

[Katie McLain (Office of Legislative Counsel)]: Should I just give a little for the new members? So it's Katie McGrinn, Office of Legislative Counsel. Jen and I are the Healthcare and Human Services team. You will likely be seeing a lot more of Jen than me. I probably spend most of my time down the hall in human services, but you'll see me in this committee on maybe some public health issues or mental health issues. Katie is

[Alyssa Black (Chair)]: sort of our mental health expert, which reminds me I have a question for you. Okay, great.

[Jennifer Carbee (Office of Legislative Counsel)]: Okay, so our role here is to go through, and we've put together a list of reports that are due to this committee and we call it late twenty twenty five and early twenty twenty six. Occasionally, we stray from that, including we have some some placeholders for future. It's just so that we don't lose track of things you've asked for in the out years. And we're gonna go to anywhere there's a blue line is a lie should be a live link. That means the report has come in and been posted on the usually the legislative website. A few of them are the joint fiscal website or another state agency. So we put them here so it's easy for you to identify them. And in general, Katie and I will be talking about the ones that are in our subject areas. So that's why you'll be hearing a lot from me. So the first one on here is it was dated on our list on the legislative website. It is dated from sometime this summer, but the report itself is dated from March 28, although I don't know if I was aware that it was out. But this is the expenditure analysis, the Green Mountain Care Board's expenditure analysis, and it's looking fairly historically at this point. Usually it's a little closer in time, but I think they did some significant overhaul on their approach to the expenditure analysis that is talking about expenditures on health care, both by Vermont residents, on behalf of Vermont residents and paid to Vermont providers. And so I think they're doing a little catch up now. That's why they've got the 'twenty one and 'twenty two expenditure analysis combined. But this is a huge source of information about how healthcare services are used and delivered in Vermont. The next one is approved hospital spending reductions. So several of these that came in over the summer and fall were due to some of the committees that meet during the legislative interim or year round. So in this case, the Joint Fiscal and Health Reform Oversight Committees. This comes from Act 68 of last year, the approved hospital spending reduction. This was a requirement that the Agency of Human Services report by July 1 on the spending reductions it had approved for hospitals as part of trying to meet that 2.5% reduction across the hospital system for hospital fiscal year 2026. Next, have the Vermont State Health Improvement Plan.

[Alyssa Black (Chair)]: Want a question? Sure. This isn't really a question. I've just noticed that that report was produced by Brendan Krausz and he would know he's gone and I've lost track of it. Has that position been filled or? It's interim. That's Sarah Gurlesen Bloom and that's interim. Okay, thank you.

[Jennifer Carbee (Office of Legislative Counsel)]: So the Vermont State Health Improvement Plan, it was submitted by the Department of Health, which is technically due from the Agency of Human Services, but it is an existing requirement, long standing requirement for a plan setting forth the health goals and values for the state. And I actually, this one wasn't on my radar that it was necessarily coming in, but it might be worth taking a look at to see what they have identified as the goals and values of the state for this five year period. The next two are an update on the outcome measures for healthcare transformation. These are monthly reports. So you're going see these show up a lot. I'm only going to really talk about them once. Just note that come to another one. But all of these links are to a different report because the agency did provide monthly reports. This is where in Act 68, and I say you, I realize only nine of the 11 of you were part of that. But in Act 68, you asked the Agency of Human Services to identify some outcome measures for how to tell whether and when we have met, the state has met the goals of the transformation work. And so to identify outcome measures and then give updates on the extent to which they are being met. So you have that started in August and you have the August and September monthly reports. And we'll come to some others in just a moment. Next up, we have the Medicaid program enrollment and expenditures quarterly report. Just like it sounds, it's a quarterly report from the agency of human services on enrollment and expenditures in the Medicaid program. Next, we have an annual report on the receipts, expenditures and balance in the Health Information Technology Fund. And that one, it comes from the Agency of Administration and goes to the Joint Fiscal Committee. So I've linked to it here. Next is the Green Mountain Care Board annual bill back report. We talked briefly when we're doing the overview the other day bill back and that the agency, the agreement with their board can bill the regulated entities a portion of the cost of regulating them. We talked about it because one of the acts last year took out the allocation for the accountable care organizations because for the most part, those have gone away. But the board provides an annual report and it's required to provide an annual report on what it could have billed to the regulated entities and what it actually billed to the regulated entities. Next is the first of another monthly report from Act 68. This is on implementing and achieving hospital spending reductions. So in addition to that one time report that you asked them for in July, you asked the Agency of Human Services to provide monthly updates on how they're doing and how the hospitals are doing in meeting those spending reduction requirements. Then we have the October update on outcome measures for healthcare transformation. Next is the Global Commitment Investment Report. This is an annual report on all of the approved global commitment investments authorized under our global commitment section eleven fifteen demonstration, and how much, I believe, what they are and how much was spent. Then we have a biennial report from the Department of Health on deaths and what settings Vermonters died during that period and also the extent to which they were receiving hospice services prior to their death. So that's a report on the 2023 and 2024 information. Top of page two, I see you're keeping up great. Thank you. We have the pharmacy best practices and cost control program. This is the Medicaid Prescription Drug Cost Containment Efforts and Medicaid Prescription Drug Programs Annual Report. And we have the next two are the November reports on the hospital spending reductions and transformation outcome measures from Act 68. Now we're up to the first one I think that we don't actually have, at least we didn't have it on our legislative website and have not seen it. This is coming out of Act 15 of 2023, which was the first of the shield bills for legally protected health care activity. And the legislature to ask the Office of Professional Regulation and the Board of Medical Practice to report back on any recommendations or issues they had encountered with Vermont's participation in interstate compacts, like the Nurse Licensure Compact and the Interstate Medical Licensure Compact related to our legally protected health care activity law. So we'll keep an eye out for when that comes in. Next we have from 2024, that was directed to the Agency of Human Services to kind of take a look at itself and come back with some recommendations for re envisioning the Agency of Human Services, including whether it should be split into two separate agencies or otherwise reconfigured. So their recommendations have come back. I'll give you the one spoiler. They did not recommend splitting up the agency. You have some recommendations for changes going forward or increasing some efforts in certain areas, but they did not recommend splitting up

[Alyssa Black (Chair)]: the agency. I think we had a joint hearing. Yes, that's right. We've got a joint hearing with Human Services on this. Yes, next week. Yes, that's great. Thank you. So you can meet your report over the weekend.

[Jennifer Carbee (Office of Legislative Counsel)]: All right, then we have, again from Act 68, a domestic health insurer sustainability. This was the requirement that the Department of Financial Regulation look at. And if you recall, domestic health insurer is our statute speak for Blue Cross Blue Shield to run. And so looking at how to ensure a plan for ensuring their sustainability going forward. The next is language from last year's budget, and it required the Green Mountain Care Board to report back and did not have a specific date specified. But some of you may recall, there were settlement funds that were due to primary care providers who were not affiliated with the hospital. This is settlement funds from the University of Vermont Medical Center based on a settlement entered into with the Green Mountain Care Board. And there's supposed to be a report on how that distribution had occurred. We don't have anything in writing. There was a bit of discussion about it at one of the Health Reform Oversight Committee meetings, but we don't have a written document, so there's nothing to link to here.

[Alyssa Black (Chair)]: And we don't chair Foster in today. Great. I've flagged that as a

[Jennifer Carbee (Office of Legislative Counsel)]: also, 68. This is a review of the accountable care organization capabilities that were funded in whole or in part by state dollars that might be worth or able to be continued after the wind down of One Care Vermont. So that report has come in. It was due to the help of former oversight committee. Then we have a one time report from Act 68 on the Hospital Transformation Incentive Grant Awards. This is the $2,000,000 that was appropriated in Act 68 to the agency's human services to provide some incentives to hospitals to engage in transformation efforts. And this is an update on those grant awards, the money disbursed or obligated as of November 15. Then we have the December reports on the hospital spending reductions and transformation outcome measures. The next quarterly report on prescription Medicaid program enrollment and expenditures. We have an annual report from the Office of the Attorney General on prescription drug cost transparency related to certain high cost prescription or drugs for which there had been a significant increase in the cost reported to the Attorney General's office, which is supposed to look into them and provide some information. I think there have been some limitations on their ability to get information that is included in that report and I think has been annually as well. Now we're up to page three. You're almost good to hear from Katie for the first time. Two reports do, one has come in, one has not from the Emergency Medical Services Advisory Committee. Both of these come from the 2024 Act. The first is an inventory and assessment of emergency medical services available in Vermont. And this is part of creating a plan for better distribution going forward. The second report that has not come in, and I don't know if it will this year or not, has to do with progress from the Emergency Medical Services Advisory Committee, progress toward meeting the goals in its five year plan, which you only required them to create in 2024. So I'm not sure if they have actually created that. It was a pretty big overhaul of their charge in 2024 and also their goals for the coming year. So you may get something from them, but it is a little bit of a time of flux.

[Katie McLain (Office of Legislative Counsel)]: The next two reports have to do with the Human Services Board proceedings. So this was a bill that Human Services worked on last year. At the time, it was their intent to gather more information and continue to look at the issue. So there are two reports coming back. One is from the agency of human services. The second is from the board itself. The first report looks at an inventory of the type of cases that are being heard by the board, the current capacity to collect data on those hearings, and there's some other topics that are being reported there. The board is reporting on how it can improve understanding of its processes for people appearing before the board. Also how to encourage periodic exchange of feedback among professionals who are presenting in front of the board. And also considering how to make it feasible for a person presenting before the board to present a personal narrative of their experience with the agency of human services and the process of being in front of the board.

[Jennifer Carbee (Office of Legislative Counsel)]: Next is a report.

[Francis McFaun (Vice Chair)]: So we didn't get a report.

[Mary Kate Mullen (Bi-State Primary Care Association)]: It just came

[Alyssa Black (Chair)]: in, I think.

[Jennifer Carbee (Office of Legislative Counsel)]: Oh, did? We had not.

[Katie McLain (Office of Legislative Counsel)]: They were due in December.

[Jennifer Carbee (Office of Legislative Counsel)]: Something did come in and has not been posted yet on our legislative website. So yes, I think

[Alyssa Black (Chair)]: Probably saw that like a day or so.

[Jennifer Carbee (Office of Legislative Counsel)]: I think maybe one of the two reports maybe in, but we'll update these. We'll try to update these links as reports get posted.

[Alyssa Black (Chair)]: Alright. With that, I can forward to you what I thought.

[Francis McFaun (Vice Chair)]: I would love to get to say that. Yeah. That would be wonderful.

[Alyssa Black (Chair)]: If he remembers to do it, but we'll to sacrifice it.

[Jennifer Carbee (Office of Legislative Counsel)]: All right, next we have from last year's Budget Act, I remember if this committee was part of this discussion or not, I don't think I was, but there was $10,000,000 in Medicaid provider stabilization grants. And this report from the Department of Health for One Health Access is on grant distribution, information about the recipients, what the outcomes have been, and any recommendations for stabilizing them moving forward. The next

[Katie McLain (Office of Legislative Counsel)]: report is the report of the Emergency Service Provider Wellness Commission. This commission was created by this committee, I wanna say six years ago or so. And the commission does what it sounds like. It focuses on the experience of emergency service providers, which can at times be traumatic experiences. And the commission focuses on how to ensure wellness, mental health services for those professionals. And they're required to do a report on the activities of the commission each year. And so that is what is in that report. The next report is from the Mental Health Crisis Commission, different commission. This group looks at sort of individual incidences of interactions between law enforcement and the delivering crisis mental health services. So they will select an incident and sort

[Karen Lueders (Member)]: of do a deep dive on

[Katie McLain (Office of Legislative Counsel)]: that incident to gather lessons learned to sort of share with the broader community of law enforcement and crisis mental health professionals. So that is an annual report with no specific date as to when it comes in.

[Alyssa Black (Chair)]: So both of these reports, they're annual reports, but they haven't started yet. They're supposed to start in 2026.

[Katie McLain (Office of Legislative Counsel)]: They just have to submit a report a year, but it doesn't specify in statute. Does this report come

[Jennifer Carbee (Office of Legislative Counsel)]: in January or December? So ongoing. Have we gotten any of these in the past?

[Katie McLain (Office of Legislative Counsel)]: I believe so. But you haven't received one yet for this year. So I'm guessing we haven't gotten one in December. Through and I don't know what I

[Jennifer Carbee (Office of Legislative Counsel)]: just put it in at the 2026, but there's no specific date, I think, specified in the legislation for when in 2026.

[Alyssa Black (Chair)]: Do we have any idea who would be sending me or posting these? Are they on the on the JFO reports?

[Katie McLain (Office of Legislative Counsel)]: When they come in, they should be.

[Jessica Barquist (Planned Parenthood of Northern New England)]: They should go out of

[Jennifer Carbee (Office of Legislative Counsel)]: the legislative reports page.

[Katie McLain (Office of Legislative Counsel)]: If we have specific questions about where our report is, I would probably reach out to DMH on both of these. I would guess they're staffing both of those commissions. If you'd like me to do that, I can circle back with them.

[Alyssa Black (Chair)]: No, I think I can find it.

[Brian Cina (Member)]: Okay.

[Jennifer Carbee (Office of Legislative Counsel)]: All right, next we have the January monthly reports on achieving hospital spending reductions and outcome measures for transformation. Then we have the Annual Report from the Office of the Healthcare Advocate, which was not posted yet. I saw him downstairs, but I didn't think to ask. Next up is Notice of Introduction of New High Cost Prescription Drugs. I'm not seated here. There is, these get posted on the Attorney General's Office website. I did, I brought a post a link or I have a link for their June to, no, April to June 2025 is the most recent. But when manufacturers are getting ready to introduce a new prescription drug that has a cost over a particular threshold, they're supposed to notify the office of the Attorney General. And there are a bunch of those notices listed on their page. So I will update the link here. Next is an annual report from the Green Mountain Care Board that just gets posted on their website, but I found it and put a link. The impact of prescription drug costs on health insurance premiums. I took a brief look at it yesterday, there's some good information there. Next, and now we're up to January 15, so anything that is actually posted here is early. I'm not sure there is much posted, but the Green Mountain Care Board is supposed to provide a final plan for implementation of its prescription drug cost regulation program based on language from 2024. And they did provide a preliminary report last year, and this is the final plan.

[Alyssa Black (Chair)]: We're going hear on this actually coming up, I think, next week. Okay.

[Jennifer Carbee (Office of Legislative Counsel)]: The next is something from the budget that I was not aware of until I started looking through some of the report requirements. And this is on smoking cessation grants and outcomes. And it's a report from the Department of Health about what they have done in the past with funds for smoking cessation. Particular requirement seems to be related a grant to the parent child center network of Vermont for smoking cessation. So as part of before giving that we're giving that money out, they're supposed to find out from the parent child centers what they're gonna do with the money for smoking cessation and then provide that and a report on what has been done in the past with smoking cessation money to the legislature. The

[Katie McLain (Office of Legislative Counsel)]: next report was also from this year's budget. This requires reporting from the Department on State and Federal Expended Funds for Prevention for Substance Use. There's also a requirement that recipients of these funds are listed and then accounting of any unencumbered funds for these purposes. Next is a provision from that

[Jennifer Carbee (Office of Legislative Counsel)]: I was vaguely aware from last year's transportation bill. And this has to do with working or the report of a working group on individuals enrolled in demand response transportation programs and how better to coordinate their healthcare and transportation service needs. Next is a report from the Agency of Human Services. This came out of Act 68. So even though there is a statutory reference, noted that this was just added in 2025 because this is the report that I think the Chair will be particularly interested in on whether and to what extent to integrate claims and clinical data and the unified health data space. This had come up as an issue, a particular issue in the conference committee. That's why I'm mentioning the chair. And she had wanted this report to understand more about what was envisioned here. So that should be coming in shortly. Here's one we talked about a couple years ago and then haven't really talked about as much in this committee since, which is the new licensure statute for chapter for pharmacy benefit managers. And this is the first I believe of the annual report due from the Department of Financial Regulation on pharmacy benefit manager compliance with those new requirements. Exciting. I if Mari's

[Alyssa Black (Chair)]: I was just gonna say, where's Maureen?

[Katie McLain (Office of Legislative Counsel)]: The next report is an annual report from the Agency of Human Services. It requires that the agency submit an inventory of all the grants issued in the previous year. Following that is another annual report. This is the report of the Human Services Board. And this has information like the number of fair hearings that were provided and the number decisions and the outcomes of those decisions. Next is the Health Department's Community Violence Prevention Program reporting on this annually. This has to do with the grant application process and how the grants were awarded, who they were awarded to. Next is a report of the Health Equity Advisory Commission. This commission was also set up maybe six or seven years ago. That long now.

[Brian Cina (Member)]: What? That long it's been? I think so.

[Katie McLain (Office of Legislative Counsel)]: I'm trying to remember when. It was when the room was on that side. Yeah, it was about early COVID too. Remember, yeah.

[Brian Cina (Member)]: 2021, I think it

[Alyssa Black (Chair)]: was It was 2021. I remember sitting at my dining room table doing it.

[Jennifer Carbee (Office of Legislative Counsel)]: It might have started four

[Alyssa Black (Chair)]: years ago, but still it's

[Francis McFaun (Vice Chair)]: a long time.

[Alyssa Black (Chair)]: Same with the emergency responder one, that was 2021.

[Katie McLain (Office of Legislative Counsel)]: That was also?

[Alyssa Black (Chair)]: Yep, I can see myself sitting in my dining room.

[Katie McLain (Office of Legislative Counsel)]: Okay, so that is a standing group that looks at health equity issues and they are required to do an annual report of their activities and recommendations for the general assemblies consideration. Similarly, there's an annual report from the Department of Health that is supposed to do an analysis of health equity data. This would

[Jennifer Carbee (Office of Legislative Counsel)]: be statewide data that's analyzed and presented by the department. Next is the annual report of the Maternal Mortality Review Panel. I think technically it doesn't come to this committee, but it was created by an iteration of this committee across the hall many years ago. I included it on here. And this is looking at deaths that occurred either during pregnancy or within one year postpartum and trying to identify and make some systemic changes to prevent future deaths.

[Katie McLain (Office of Legislative Counsel)]: Next is an annual report on the extent to which individuals with a mental health condition or psychiatric disability receive care in the most integrated and least restrictive setting available.

[Jennifer Carbee (Office of Legislative Counsel)]: This looks at capacity at each level of hospital care and it looks at patient experience across those levels of care. Next, have the Vermont Information Technology Leaders VITAL Annual Report, followed by the Green Mountain Care Board Annual Report. And there's a number of items have been added to that over the years. There's a lot of different topics addressed. Great.

[Alyssa Black (Chair)]: These are all great, but they're not all great, sorry.

[Jennifer Carbee (Office of Legislative Counsel)]: The next is the statutory requirement for the health care expenditure analysis. It is due technically by January 15 annually. As I showed you, there was the one that came in last year 2021 and 2022. So they're a little off cycle right now, but I think doing some catching up. Next is an annual requirement as part of the budget presentation, and this is the cost of what it would cost to reimburse emergency medical service providers at Medicare rates for all services provided to Medicaid beneficiaries. So some of you may recall last year or the year before, there was a requirement two years ago to do some additional reimbursement, I think particularly around treatment without transport at some percentage or some portion of Medicare rates. And there was interest at that time of what would it look like if Medicaid reimbursed at Medicare rates for all EMS services. Next, we have the annual report of the Clinical Utilization Review Board. This is a board that advises the Department of Vermont Health Access. This report is on the activities of the

[Karen Lueders (Member)]: board. It's from

[Jennifer Carbee (Office of Legislative Counsel)]: the Department of Vermont Health Access, but also the results of DIVA's evaluation of the Clinical Utilization Review Board's success in improving clinical and utilization results.

[Katie McLain (Office of Legislative Counsel)]: The next report is a consolidated report and it was this committee that decided to consolidate those two reports. There was one report from an independent consultant, a separate report from the Department of Mental Health on the same topic, which was evaluating the administration of involuntary non emergency psychiatric medications. So now that comes in as one report too. Next is another

[Jennifer Carbee (Office of Legislative Counsel)]: report, actually not a report, but a making themselves available to provide an update requirement. This is from the transportation bill, the language sort of made me laugh. But it's about expanding the volunteer driver pool for Medicaid non emergency transport, and it's a joint availability, I guess, from the Vermont the Department of Vermont Health Access and the Vermont Public Transit Association. So on or after January 30, they're supposed to make themselves available to provide an update if one is requested. Next we have a report that I couldn't find one for last year either, but this came out of the first Legally Protected Healthcare Activity Shield bill. And this is a report on the status of gender affirming healthcare and reproductive healthcare readiness at higher education institutions. Report itself is due from the Agency of Human Services, but it is supposed to be just a compilation of information they have received from the University of Vermont and the Vermont State Colleges of Vermont State University System schools. And this has to do with the institution's readiness to either provide services to students or help them to obtain services. Next, have the Blueprint for Health Annual Report. And then we have the February monthly reports on hospital spending reductions and transformation outcome measures. Then we have the, by February 15, the Green Mountain Care Board implementation report on Act 68. So this is when they're supposed to give you a more specific update on reference based pricing, any work they're doing on global hospital budgets, and also the effects of their efforts on access, quality of care and costs. Similarly, just below that is the update on outcome measure. Oh, Sorry. Giving you the wrong one. The update on the strategic plan and health care delivery advisory committee from the agency of human services. Again, I've noted that this statutory requirement was added in 2025. That's an act 68 requirement. So they're supposed to talk to you about their work on the health care delivery strategic plan and the work of the health care delivery advisory committee and also those effects on access to care, quality of care and cost of care. All right, then for the rest of the session, it's where we sort of put it, it's just the monthly updates on the hospital spending reductions and the outcome measures for healthcare transformation. And then under future reports, we have those monthly reports as well for a number of months you're getting both reports on both. And then top of page seven, right, then hospital spending reductions ends at the end of hospital fiscal year '26, and you just have a few more months of updates on the outcome measures for healthcare transformation. Then in December, you're supposed to get the recommendations for the design of a statewide emergency medical services system. So again, we've gotten some further out reports, but we're both bookmarking them for ourselves for next year's report and just reminding you of what's coming up.

[Katie McLain (Office of Legislative Counsel)]: In 2027, you're getting a biennial report from conditions and treatment of patients and hospitals, the need for community services. As the name suggests, covers conditions of hospitals, medical treatment for hospital patients, and an inventory of any gaps in services in terms of community service needs. In January 2027, you

[Jennifer Carbee (Office of Legislative Counsel)]: will be getting the reports that this committee asked for in 2024 when there were limits placed on prior authorization, the availability of prior authorization requirements. We talked about this the other day when going through the ANCs. Primary care providers can't be required to obtain prior authorization for a number of services, And there was interest in seeing what the impact was both on insurers and on providers of that prohibition on prior authorization requirements. So we did that,

[Alyssa Black (Chair)]: we asked for the first one in 2027?

[Jennifer Carbee (Office of Legislative Counsel)]: Yes, because it was going to take a bit for it to roll out. So I think it didn't start until 2025.

[Alyssa Black (Chair)]: And I thought we had asked for 2026.

[Jennifer Carbee (Office of Legislative Counsel)]: No. I think you were giving it two full plan years. We can look at the language, but no. It's not I don't believe it's due until 2027. I

[Alyssa Black (Chair)]: for was that information coming up here.

[Jennifer Carbee (Office of Legislative Counsel)]: I mean, they may be able to give you a sense for where it is. Had also asked in the 2024 budget bill for some cost estimates for expanding the Medicare Savings Program eligibility. So it was further expanded slightly last year beyond what it had been the year before. But there was interest in seeing what it would cost to expand it even more than that. And this is for helping certain low income individuals afford coverage on Medicare if they're eligible. Then there's the first of the annual updates on the Unified Health Data Space once you get the kind of integration recommendations this year. And finally in 2028, you'll be getting the first statewide healthcare delivery strategic plan.

[Alyssa Black (Chair)]: Doctor. I

[Francis McFaun (Vice Chair)]: have a very quick question. Be vital. Yes. Do you know if they have a different mission a than they did in the beginning?

[Jennifer Carbee (Office of Legislative Counsel)]: I mean, you have modified their statute, the legislature have modified their statute. So yes, to some extent, mean, I think they're still responsible for the health and mission exchange and working on interoperability. I don't know. I'd have to look up what else has changed.

[Francis McFaun (Vice Chair)]: Okay, because what I'm concerned about is I hear as we listen to the reports that the patient's medical records are all, there's a whole bunch of different ways that they're doing it.

[Jennifer Carbee (Office of Legislative Counsel)]: So there's a difference between the electronic health records and the Vermont Health Information Exchange. And I think some of the work you may have even heard about yesterday with the Rural Health Transformation Program grant is looking at creating greater uniformity or interoperability among electronic health records. And Vital may have some role in helping with that, but that's not their charge.

[Francis McFaun (Vice Chair)]: It used to be,

[Karen Lueders (Member)]: though. I'm not

[Jennifer Carbee (Office of Legislative Counsel)]: sure if that was ever Vital's charge around, because that was really an independent business decision. I think there was some, and I think they were not allowed to recommend or then the state was not allowed to require a particular electronic health record.

[Francis McFaun (Vice Chair)]: They were supposed to make sure that they all coordinated with them.

[Jennifer Carbee (Office of Legislative Counsel)]: That's the interoperability piece. So I'd have to look at vitals. Hold on, let me pull up vitals stat sheet.

[Alyssa Black (Chair)]: I'll ask a question of Lori.

[Jennifer Carbee (Office of Legislative Counsel)]: Do you remember,

[Alyssa Black (Chair)]: first of all, I'm thinking, did it even go through the Senate and pass the technical analysis? Bill? Technical analysis of

[Jennifer Carbee (Office of Legislative Counsel)]: that very small, the one that was in age 07/21. Yeah,

[Alyssa Black (Chair)]: don't know. Oh. It was the Medicaid expansion turned into a technical analysis budget,

[Jennifer Carbee (Office of Legislative Counsel)]: but in a very, in a much narrower So

[Alyssa Black (Chair)]: that would have been 2024. I can find it. But yeah, I remember it was very narrow,

[Katie McLain (Office of Legislative Counsel)]: but there is a paragraph.

[Alyssa Black (Chair)]: Went into the budget. I can look for it.

[Brian Cina (Member)]: And then before that, wasn't there, there was a report, maybe it's not relevant, who remembers the report that came back with all these little things we could do to save money in the healthcare system, but then recommended like a handful? I believe Lori, Leslie, myself, and Alyssa were on the committee then. I don't know if you were, because I can't remember when you joined us. Was like, Bill Lippert was the chair. It was like, so maybe the staff can help. Do you remember? There was kind of There's all these working groups, study group things. There was one that was formed and they looked at ways I can look it up myself and then tell you the name of it, and then that'll help. So I don't take any risks.

[Jennifer Carbee (Office of Legislative Counsel)]: I do remember that there was one, the agency of human services came back and one of the things they were looking at was the possibility of reinsurance.

[Brian Cina (Member)]: That's the one. Yes.

[Jennifer Carbee (Office of Legislative Counsel)]: I it was 2019.

[Alyssa Black (Chair)]: It before COVID. I'm sorry.

[Brian Cina (Member)]: It's hard. It's all a big blur at this point of reports and studies and working groups.

[Alyssa Black (Chair)]: They're an interesting quarter, the value of reinsurance. Yeah. That's come

[Karen Lueders (Member)]: up in the- That's

[Brian Cina (Member)]: what AHS was fixating on, but there was other things that could save money.

[Alyssa Black (Chair)]: What you're talking about, it looked at reinsurance, it looked at the community rating. I remember it was in the back as was the one delivering it. Also looked at the benchmark plan and how much it would cost to

[Jennifer Carbee (Office of Legislative Counsel)]: assess everyone.

[Brian Cina (Member)]: I do remember, did it talk about the emerging markets in it too though? Think that was one of the things implying we needed to look at that.

[Jennifer Carbee (Office of Legislative Counsel)]: Yes. So you'll see a few pieces of that reflected in Representative McFaun's bill. Number of your bill is it?

[Francis McFaun (Vice Chair)]: 585.

[Alyssa Black (Chair)]: That's a good number. It's got an eight and M. Alright, well I think Jen is refreshing.

[Jennifer Carbee (Office of Legislative Counsel)]: There's a lot on Vital, I don't know how to parse out what I mean, and it's been amended a number of times over the years, so.

[Alyssa Black (Chair)]: Was time sitting down with a Jen refresh?

[Francis McFaun (Vice Chair)]: Hell yeah, I would like to do that, Jen, because I don't want to get on their back if their mission has been changed because I'm just part of the group. I

[Jennifer Carbee (Office of Legislative Counsel)]: mean, think in looking at some of this, I think a lot of what you're talking about is really the health information technology plan, and that's DIVA's responsibility at this point. So you may want to talk to them. There is a bit in the vital statute, which is 18 BSA nine thousand three and fifty two, if you want to look, I can send it to you. But they are to operate the Health Information Exchange. That's the main thing. They are authorized to certify meaningful use of health information technology and electronic health records. You can establish criteria for creating or maintaining connectivity to the Health Information Exchange Network. That's

[Brian Cina (Member)]: it.

[Alyssa Black (Chair)]: That was a Medicare thing.

[Jennifer Carbee (Office of Legislative Counsel)]: I think it was, I mean, I think that was really part of encouraging adoption of records.

[Brian Cina (Member)]: You still hear about it. I just saw a report recently sent to me from someone as a social worker talking about Meaningful Use, so it's still being discussed. Meaningful use of Of the HR, so I'd have to look through all my emails as a social worker to figure out what it was, so the term is still out there. Just don't know.

[Alyssa Black (Chair)]: Yeah, it used to be Medicare would pay you had to have a certified EMR that was designated as meaningfully useful, I guess, in order to not get a payment cut, I think, from Medicare. I think that's been phased out though. So that's probably what that was. Any other questions? Leslie, I'm sorry. No worries. My question is actually for you. A2C Human Services reports that we're getting every month, everyone is different and has a different approach, a different idea. And I'm wondering if we can kind of get some kind of summary from them about where they've been the last six months and what they've accomplished through this work. That

[Karen Lueders (Member)]: I mean, they because it's part

[Alyssa Black (Chair)]: of this accountability I'm thinking about So transformation. You want a summary of transformation? Wish we will be. Yeah, the healthcare system transformation report that we get every month. Thank you very much. It was really great.

[Karen Lueders (Member)]: It's just an amazing accomplishment.

[Alyssa Black (Chair)]: And pretty scary because that was a lot of work. Thank you so much. I mean, I'm just wondering how we think about these transformation reports as a committee, and what we want from them and hear from them so that we understand where we're at. I think that one of our charges this year obviously is oversight and we have been doing monthly reports throughout knowing that we didn't want to drop the ball throughout the off session, but now we're back in session. And I think that the same level of oversight will be put on that. So we're going to ask Douglas to We will be talking to them a lot about where are you, what's going on, what have we got to do. We're going to be talking to a lot of the hospitals and where they are in their transformation efforts, what they may need from us to facilitate and better coordinate efforts. Yeah, we're going I'm just thinking about current state, because six months ago we were at that current state. What's our current current state? Yeah, and the work that they've doing. Because I keep hearing about how we know how enormous that I don't know how big the team is, and I'm very curious actually about that in the transformation team. And that's being run-in the health office. Health care department. Sarah Rosenberg. And throughout, there were some changes that were made through the fall, which they have in their updates. Some kind of summary, I guess. Yes. A thought call. We will be getting That was just all I was thinking about in lunch too. We'll get that. I was insistent we do it monthly and I'm going to make a flippant comment. I forgot the fact that I had to attend a meeting every single month and like, oh my gosh, is it already August? September already? I wanted to also, but I lost track of the time. Was kind of Okay. Lori, could you I found the language. Now I'm just trying to find if it made it in the budget. I will get back

[Brian Cina (Member)]: to you. Okay.