Vermont Legislature SmartTranscripts:

[Alyssa Black (Chair)]: Welcome back. We are continuing on H583 and we're going to do a walkthrough of the bill with legislative counsel. Take it away, Tammy.

[Ben Harvey (Office of Legislative Counsel)]: All right. Good afternoon. Ben Harvey from the Office of Legislative Council. I will put the language up on the screen and we will go through it together. We are looking at H583, an act relating to healthcare financial transactions and clinical decision making. This creates a new chapter in Title 18 on transaction limitations and clinical decision making. Starts off with a sub chapter on general provisions, which is really just definitions. And there are a lot of definitions. And I don't know much detail you want to go through in these. So I will go with a lot of detail and tell me if you want less. So there's a lot I think there's 20 defined terms in here. A few of them we don't need to talk about much, but some of them we do because they have very specific context. So this is acquisition is the direct or indirect purchase in any manner, including by lease, transfer, exchange, option, receipt of a conveyance, creation of a joint venture, or any other manner of purchase, such as by a health care system, private equity group, hedge fund, publicly traded company, real estate investment trust, management services organization, that's a term you'll see come up later, insurance company or a subsidiary, and the material amount of the assets or operations of a healthcare entity. Some of the reasons for the testimony you had this morning was to give you some basis in some of these these terms and what kinds of transactions they might be engaged in. Affiliate is someone who, and I just paused here, it says a person, a person under Vermont statute based on Title I, unless it says otherwise, is both individual humans and corporations, partnerships, other business entities. So a person does not necessarily mean a natural person. So an affiliate is a person who directly, indirectly, or through intermediaries controls, is controlled by or is under common control or ownership of another person, a person whose business is operated under a lease, management or operating agreement by another entity, or a person substantially all of whose property is operated under a management or operating agreement with that other entity, or is an entity that operates the business or substantially all of the property of another entity under a lease management or operating agreement, or any out of state operations or corporate affiliate of an affiliate, including significant equity investors, health care, real estate investment trusts and management services organizations. So affiliate is sort of your common term, they're a little bit more specific in the context of control ownership operation. Change of control is an arrangement where any other person acquires direct or indirect control over the operations of a healthcare entity in full or in substantial part. And here we're talking about arrangement meaning any agreement, association, partnership, joint venture, management services agreement, professional services agreement, healthcare staffing company agreement, or other arrangement where there's a change in governance or control of a healthcare entity or a department, subdivision, or subsidiary of a healthcare entity. And some of these will make more sense in context. It talks about control and the various forms of the word control, means the direct or indirect power through ownership, contractual agreement or otherwise to vote more than 10% of any class of voting shares of a healthcare entity or direct the actions or policies of the specified entity. A healthcare entity is a healthcare provider, healthcare facility, provider organization, pharmacy benefit manager using our Vermont definition, or a health insurer that offers a health insurance plan in this state. Health care facility, this ties into our existing definition in the Certificate of Need subchapter. Healthcare provider ties into our existing definition also in Title 18 and is a broad definition. Healthcare services has the same meaning as in, and this is using the language from the financial assistance policies chapter, and it includes all of the following. And yes. Go back.

[Alyssa Black (Chair)]: The previous page, lines like 13 around control. Mhmm. Is this are are we talking about so if one of these covered entities or affiliates, if there's, like, a board that if anyone has power, they would be on a board if there were less than 10 people through the voting? Are we

[Ben Harvey (Office of Legislative Counsel)]: talking about boards? Not necessarily. I mean, I think this is voting shares of a healthcare entity, I think would be more in the for profit model. So not necessarily our hospitals, but other types that might be for profit and have a shareholder arrangement.

[Alyssa Black (Chair)]: Okay. Sorry. Keep going. Okay.

[Ben Harvey (Office of Legislative Counsel)]: So healthcare services includes inpatient, outpatient, rehabilitative, dental, palliative, therapeutic, supportive, nursing home, home health, mental health, and substance use disorder services provided by a healthcare entity. Pharmacy services, including drugs, devices, and medical supplies.

[Alyssa Black (Chair)]: Hospice came up this morning. Is that included in one of these?

[Ben Harvey (Office of Legislative Counsel)]: Hospice is a subset of palliative care. So I think yes, but we can be more specific if you We think

[Leslie Goldman (Member)]: we need to, but since that seems to

[Brian Cina (Member)]: be a focus maybe. Yeah, I thought about that as I

[Ben Harvey (Office of Legislative Counsel)]: was looking for a shot. That way, it's probably covered under palliative. But but we could certainly call it out. Some of these are you know, could be included in more than one. I can make a note. All right, we've got performance of functions to refer, arrange and coordinate care, if you like care coordination services, durable medical equipment, diagnostic equivalent, surgical devices and infusion equipment, and technology associated with providing all of those services and equipment, such as telehealth, electronic health records, software, claims processing and utilization systems. A healthcare staffing company is a person engaged in the business of providing or procuring healthcare personnel for temporary employment or contracting by a healthcare facility, but does not include an individual who independently provides their own services on a temporary basis to health care facilities as an employee or contractor. So not single, but we're just, yeah, so a healthcare staffing company. Licensee is someone licensed in the state as a physician under the chapters on medical doctor to allopathic physicians and osteopathic physicians, an advanced practice registered nurse or a physician assistant who is authorized to diagnose and treat in the applicable setting. Management Services Organization that came up in some of your presentations this morning means any organization or entity that contracts with a healthcare provider or provider organization to perform management or administrative services relating to, supporting, or facilitating the provision of healthcare services. Material change transaction means any of the following occurring during a single transaction or a series of related transactions involving a healthcare entity in this state that has total assets, annual revenues or anticipated annual revenues for new entities of at least $1,000,000 including both in state and out of state assets and revenues. Again, any of the following transactions that involves a health care entity that fits that criteria. A corporate merger, including one or more health care entities, an acquisition of one or more health care entities, including insolvent health care entities. Any affiliation, arrangement or contract that results in a change of control for a healthcare entity the formation of a partnership, joint venture, accountable care organization, parent organization or management services organization for purposes of administering contracts with health insurers, third party administrators, pharmacy benefit managers or healthcare providers. How

[Brian Cina (Member)]: would this, as written, how would this affect UVM Health?

[Ben Harvey (Office of Legislative Counsel)]: Right now we are just in definitions. Definitions right now. Oh, okay. So nothing is happening yet. I mean, your question if UVM Health were involved in one of these transactions?

[Brian Cina (Member)]: That's my question.

[Alyssa Black (Chair)]: It would fall

[Ben Harvey (Office of Legislative Counsel)]: under the definition of material change transaction, and you have to see how that plays out in the bill. We haven't gotten to that

[Alyssa Black (Chair)]: haven't gotten to what these definitions We're just defining. So if we have questions on what the definition is.

[Ben Harvey (Office of Legislative Counsel)]: On 12A, the material change transaction is an or. So it does total assets, annual revenues, or anticipated annual revenues? Or new entities. Right, new entities. Does that mean So that doesn't mean you would bundle those categories, would it be one? Yes, or would be one Yes, I mean one or more. Okay. So we've got a corporate merger, we've got acquisition, got any affiliation or rank winner contract that results in a change of control for Health Parent's name. We looked at control, the definition of that earlier. The formation of a partnership oh, I went over some of these. Sorry, there's so many words. Joint venture, ACO, parent organization, or management services organization to administer contracts with insurers, third party administrators, pharmacy benefit managers, or healthcare providers. A sale, purchase, lease, affiliation, or transfer of control of a Board of Directors or governing body of a healthcare entity a real estate sale or lease agreement involving a material amount of assets of a healthcare entity or the closure of a healthcare facility or closure, discontinuance, or significant reduction of any essential health service provided by a healthcare entity that is either a provider organization or healthcare facility, or any new contracts or clinical or contractual affiliations that will eliminate or significantly reduce essential services. And some of these we're just going have to look at

[Alyssa Black (Chair)]: in context. What is material amount? What's the determination for that?

[Ben Harvey (Office of Legislative Counsel)]: Immaterial? I mean, some of that is subjective. Think earlier versions of this had some rulemaking that may not be included in here anymore, but it may require either some definition or rulemaking. Material change transaction does not include any of the following: does not include a clinical affiliation of health care entities formed solely for the purpose of collaborating on clinical trials does not include graduate medical education program, does not include the mere offer of employment to or hiring of an individual health care provider. And it does not include situations where the health care entity directly or indirectly through an intermediary already controls, is controlled by or is under common control with all of the other parties to the transaction, like a corporate restructure reshuffling. That is not a material change transaction. Medical practice is a corporate entity or partnership organized for the purpose of practicing medicine and permitted to practice medicine in Vermont, including partnerships, professional corporations, limited liability companies, and limited liability partnerships. We're going to talk in a bit about non competition and non disclosure agreements. A non competition agreement is a written agreement between a licensee and another person where the licensee agrees that the licensee, either alone or as an employee, associate, or affiliate of a third person, will not compete with the other person in providing products, processes, or services that are similar to the other person's products, processes, or services for a period of time or within a specific geographic area after termination of employment or termination of a contract under which that licensee supplied goods or performed services for the other person. So this is like a contract not to compete. Go ahead, Leslie.

[Leslie Goldman (Member)]: So licensees, you define a physician, NP, blah, blah. But what about an RN? Are they considered at risk here or not necessarily? They are

[Ben Harvey (Office of Legislative Counsel)]: not included in the definition of licensee. Here. So we'll have to look at how licensee is used. It's often on how they can work in the area. So I don't know if that's an issue that has been encountered with with RNs who are not APRNs or not. I think the licensee part was PAs, MDs, and Yeah, was APRN. I was just wondering about nurses

[Leslie Goldman (Member)]: who are employed, and then everything blows up, and what happens to them? Yes. I don't know

[Ben Harvey (Office of Legislative Counsel)]: the extent to which they tend to be covered under GAAP

[Leslie Goldman (Member)]: clauses That or

[Ben Harvey (Office of Legislative Counsel)]: is certainly something we can look into. And there may be a reason that they were not included in the definition of licensee, in which case if there are specific concerns, we could always add them in as appropriate.

[Alyssa Black (Chair)]: Thank you.

[Ben Harvey (Office of Legislative Counsel)]: A nondisclosure agreement. So that was non competition. I agree not to compete after I leave. Nondisclosure agreement is a written agreement where the licensee must refrain from disclosing partially, fully, directly, or indirectly to any person other than someone who is party to the written agreement or the person or somebody who they're allowed to specifically in the agreement won't disclose to anyone a policy or practice that a party to the agreement required the licensee to use in patient care other than individually identifiable health information that they already can't disclose under HIPAA, a policy, practice, or other information about or associated with their employment, conditions of employment, or anything about their pay or compensation, or any other information the licensee possesses or has access to because of their employment or provision services to the party to the agreement other than information that is subject to protection under applicable law as a trade secret and is otherwise proprietary to another party to the or to another party to the agreement or a person specified in the agreement. So, again, sort of not disclosing anything that is proprietary or secreted except to somebody who is also party or specified in the agreement as allowable. That was non competition and non disclosure. Now we have non disparagement. Non disparagement agreement is a written agreement under which the licensee must refrain from making statements to a third party about another party to the agreement or someone else specified in the agreement, the effect of which causes or threatens to cause harm to the other party or person's reputation, business relations, or other economic interests. So really as it sounds, an agreement not to disparage something. Ownership or investment interest means any of the following: direct or indirect possession of equity in the capital stock or profits totaling more than 5% of an entity interest held by an investor or group of investors who engage in raising or returning capital and who invest, develop or dispose of specified assets, or interest held by a pool of funds by investors, including a pool of funds managed or controlled by private limited partnerships, if those investors or the management of that pool or private limited partnership employs investment strategies of any kind to earn a return on that pool of funds. And again, you heard from Professor Sung's images in his presentation this morning, kind of the different types of ownership interests that there can be in some of these transactions. A private equity fund is a publicly traded or non publicly traded company that collects capital assets from individuals or entities and purchases a direct or indirect ownership share or controlling interest of a health care entity. Up to 19, we're only going up to 20 here. Provider organization is any corporation, partnership, business trust, association or organized group of persons that is in the business of health care delivery or management, whether or not incorporated, that represents one or more healthcare providers in contracting with health insurers for payment of healthcare services, and includes physician organizations, physician hospital organizations, independent practice organizations, provider networks, accountable care organizations, management services organizations, and any other organization that contracts with health insurers for payment for health care services. And lastly, yes.

[Alyssa Black (Chair)]: Is this sort of, I'm thinking about here we have Health First. I

[Ben Harvey (Office of Legislative Counsel)]: think it depends if they're in the delivery of healthcare management and represents providers and contracting with insurers. I don't know if that's within their scope or not. Christine, what?

[Alyssa Black (Chair)]: Sorry. I didn't hear what you were saying.

[Ben Harvey (Office of Legislative Counsel)]: So there's a definition of provider organization that talks about a corporation, entity, etcetera, that is in the business of health care delivery or management and represents one or more health care providers and contracting with insurers for payment for health care services. Is Health First in that category?

[Alyssa Black (Chair)]: You're considered a provider. Thanks. Just wanted to put context. Alright,

[Ben Harvey (Office of Legislative Counsel)]: and lastly, we have significant equity investor. And that means any private equity fund with a direct or indirect ownership or investment interest in a healthcare facility, an investor, group of investors or other entity with a direct or indirect possession of equity in the capital, stock or profits totaling more than 10% of a provider or provider organization, or any private equity fund, investor, group of investors or other entity with a direct or indirect controlling interest in a healthcare entity, or that operates the business or substantially all the property of a health care entity under a lease management or operating agreement. I know you have another witness after me who I believe has entered, and it may have time constraints. Do you want me to pause here?

[Alyssa Black (Chair)]: Yes, let's go to 01:30. So, oh yeah, we should probably stop here.

[Ben Harvey (Office of Legislative Counsel)]: Okay, I can take you. Okay. I go four minutes.

[Alyssa Black (Chair)]: We've got four minutes if anyone has any questions about definitions, and I know it's really confusing.

[Ben Harvey (Office of Legislative Counsel)]: It's very dense and some of them may make more sense in context once we look at how they're used and then go back and see what the language and the definitions are. I think this is very simple, but when we're talking about and I might have heard this wrong, but as far as competing within that area, would area because I know, I think it was Professor Song that had said they had put a number mileage on that, like a 100 or 200 mile radius. Would that be We'll have to see how it gets used in here. I think we may just generally have a prohibition or limitations on non compete clauses or non competition agreements. So, yeah, sometimes that is the way they work and that you set a geographic area. It can be challenging to prohibit somebody from ever doing work in that field again. We'll have to look at how it's actually used in here because I don't recall offhand. Think

[Alyssa Black (Chair)]: in here it might be that they just expand it. So it wouldn't matter what the mileage is.

[Ben Harvey (Office of Legislative Counsel)]: Because we just said, think we just said no.

[Alyssa Black (Chair)]: It just says you may not do. Yes.

[Ben Harvey (Office of Legislative Counsel)]: It just says non competition agreement between a licensee and employer or other entity is void and unaffordable. It's zero. Okay, alright. So I will pause and step over here and hear from somebody else.

[Alyssa Black (Chair)]: Hi Doctor. Goldman. I know you have time constraints, but we appreciate you coming in and sharing with us because I yeah. So if you wanted to go ahead.

[Dr. Glenn Goldman (Witness, Four Seasons Dermatology/Integrated Dermatology Group)]: Very good. Thank you for having me today. I just want to check that everybody can hear me.

[Alyssa Black (Chair)]: Yep.

[Dr. Glenn Goldman (Witness, Four Seasons Dermatology/Integrated Dermatology Group)]: All right. I recognize and know some of you, so I appreciate the opportunity to speak with you. And thank you for working on health care. And thank you for allowing me to testify regarding House five eighty three, where just to be honest, I do have some concerns and I'd like to maybe provide a little bit of education and maybe, you know, request a little bit of thinking regarding this, this potential bill. So my name is Glenn Goldman. I'm a dermatologist. I moved to Vermont in 1996, and I worked at the UVM Health Center for twenty six years, starting when it was Fletcher Allen. I retired as the Follansby Professor in Chief of Dermatology. And in my time there, I established the dermatology residency and the dermatologic oncology fellowship. I trained about 50 residents and fellows who work nationwide, including multiple faculty and private physicians who have remained in Vermont. And I've served as a board member of several national organizations. I'm the past president of the American College of Mohs Surgery, and I've dedicated my life to dermatology and skin cancer surgery. I performed about 30,000 surgeries and I follow several thousand patients longitudinally each year. And at age 60, I work nine to ten hours a day, five days a week. I have extensive experience with systems of care, and I am the deputy chair of the private payer engagement committee of the American Academy of Dermatology. I believed that I would retire from the UVM Medical Center, but in the later years of my tenure, I grew disenchanted with the direction of leadership there and with the inability to care for patients the way I wished to. In 2022, I was fortunate to join Four Seasons Dermatology where I now provide care. And in 2024, we were purchased by Integrated Dermatology. Integrated Dermatology was founded by Jeff Queen in 2004, and is a private family owned business of many dermatology practices in 25 states. And in fact, IDG is the largest provider of dermatology care in The United States. And our experience with them has been exceptional. And I'm delighted to be a member of that organization. Since being acquired by IDG, we've added a Vermont native and former faculty member from Yale dermatology. We've trained three new physician assistants to work with us. We're in the process of hiring an outstanding new Mohs surgeon whom I've known for about five years since lecturing at Wake Forest. And in addition, because IDG is a national organization, the provider we're hiring will be able to spend three weeks per month here with us in Vermont, and one week per month working for IDG near his family in Virginia. Integrated has enabled us to expand our services to Rutland, Vermont. The organization invested its own capital to create a new clinic there and found us a highly experienced physician assistant to provide care in an underserved area. In Colchester, they assisted us in acquiring and developing a state of the art new space for me to provide surgical dermatology care. And since IDG took over, we've been pleased with the experience they bring to running a practice. We have dramatically improved human resources and hiring. We have improved prior authorization. We are no longer responsible for negotiating with insurance companies as that is done by IDG. We have a legal team to assist us as needed. We are regularly audited to ensure that we are compliant and the auditors do not up code us. We are able to obtain supplies using the large network built up by the national organization. We can purchase and use whatever supplies we wish to use, and they don't tell us what to do. We are provided with a planning and hiring team to assist with recruitment. Our practice reviews have improved. We spend less time on administration and more on patient care. We have more staff per provider. We are more professional. We're about to implement a state of the art computerized phone system that assists patients with messaging appointments and questions. Our schedules have not been altered. And my salary is based on production, but we are not told how to practice. Of note, all practices, including academia, set targets for providers. At UVM Health Center, providers are required to have a certain work RVU target to earn their salary. My salary at Integrated is actually lower than it was at the medical center, but I am far happier. Everyone on the team is rowing in the same direction. With IDG, I have an expanded support staff. This enables me to provide a higher level of personal care. We have a dedicated patient portal, improved access, and a greater ability to be flexible. The organization is run efficiently and questions are directed to a regional vice president who responds to me about issues always within a day and often within minutes. We see any patient who calls to make an appointment as opposed to the medical center where all dermatology care is now on a referral only basis. IDG supports me to be a member of multiple national organizations and gives me the freedom to travel annually for medical volunteer meetings. This year, I'll be in Romania at the dedication of a hospital for oncology surgery performing complex tumor removal and reconstruction. In my prior employment, I was restricted on the days and times I was permitted to work. Now, if I wish to work on a weekend and pay staff overtime, this is permitted and happens regularly. If I have cases that will last long into the evening, no one objects. We can and do see patients pro bono. Our office serves as a training area for medical assistance. Each year, we hire young individuals to work with us after graduating UVM and other regional schools. We provide them with hands on experience and many go on to be physicians and physician assistants. Some return to Vermont to work with us. I would like to note that in the absence of an overarching organization, it is exceptionally difficult to run a practice in 2026. Endless change in the field of medicine, along with ever decreasing payment for services provided has created a very complex landscape. Currently care at our practice is provided for approximately half the cost of other care at hospitals in the state of Vermont. Blue Cross Blue Shield has been asking for people to shop around for care, and we are the care that they are looking for. At our practice alone, we see over 300 patients a day. Consider us fortunate to have an organization that manages our practice, does our hiring, and allows us to do what we do best, which is to practice medicine. Many of you are our patients. I do recognize the concerns relating to corporate medicine and about half of states have laws regulating the practice of corporate medicine. Some national PE groups, and again, I say some of them, aim to resell a practice. Such groups often mandate a high patient volume and delineate many aspects of care for patients. We did not sign up with such a group. I will say I am saddened that no one reached out to us as part of a large private equity group to see how we might feel about the legislation that would directly impact our practice and the delivery of care to many thousands of Vermonters prior to a law being proposed. I do respect the opinions and new ideas, and I appreciate the ability to speak today and to testify. This legislation was drafted by a healthcare advocate who is not a physician and someone who has a very defined and well spoken but outspoken point of view. There are differing opinions on what system of care is most beneficial, right now ours works. It works for our providers, it works for our patients, it is highly sustainable, it is economical, and we provide excellent care. It is also an investment in Vermont at a time when we need other avenues of care rather than just one dominant health care system, which has shown itself at times to be expensive and at times to be inadequate. There are portions of this bill that are beneficial. It is certainly reasonable to create safeguards regarding how patient care is provided. However, it should be noted that all major academic medical centers have their own guidelines and they are enforced by their administrators. It is reasonable to remove non compete clauses and non disparagement clauses because they are counterproductive. My concerns with this legislation are multiple, and the details which I have read and get a bit confused by because I'm not a lawyer, are important. The language about the inability to finance with debt, I believe to be counterproductive to an investment in our state. The way this works, when a practice is sold, the partner physician receives shares in the company that can be redeemed following an agreed upon timeframe. The partner then agrees to stay on and work usually for five years. The partner has not actually assumed any debt, but has simply agreed to work and maintain the practice. The only requirement we have is to be as productive as we were at the time of sale. Given that Integrated has grown our practice, this is readily achieved. We need more investment in health care in Vermont and more providers, not less. We have chronic access issues, a lack of choice, inadequate competition, and the highest cost for health care in the country. Groups like IDG provide excellent care at a fraction of the cost of large academic centers. IDG does accept all forms of insurance, public and private, including Medicaid. But there's a clause in this that states that it would be a legal obligation for this organization to accept Medicare, Medicaid and any insurance. That is not required of a physician in the state of Vermont. And it might be inappropriate to have this be a requirement for some physicians and not for others again would not affect us but that aspect of the bill is something that concerns me The requirements that concern me the most are that all but secretary and treasurer be licensed MDs in the board of directors or the board of the company. That is restrictive and in my mind not rid of the world. If I read the law correctly, our practice would be in violation of this. I would note the UVM Medical Center Board of Trustees is composed of 16 members, only four of whom are licensed MDs and only one of whom practices medicine. The Green Mountain Care Board only has one MD and has two JDs. A medical company should certainly have a Chief Medical Officer, But the business of medicine should be run by business people. That's the way it is these days. I don't want to do it. That leaves the rest of us to practice medicine the way we see fit. Integrated dermatology does have a physician advisory board, but I'm also very happy that they're coding and billing as someone who's devoted their entire life to that instead of a doctor shooting in the dark for it. My overall assessment is this legislation is well intended, and I appreciate the effort, but has the ability to cause harm by restricting investment. Absent grandfathering, I don't even know that our practice would be permitted to continue in its current form. I would urge that the bill not be passed on from committee in its current form. If we were permitted to have input in a meaningful way, I would be very happy to contribute, as I feel like it is an important thing to contribute to delivery of health care in Vermont. And I appreciate that those on this committee are committed to health for our state. For my entire career, I've tried to participate in health care and have have worked hard with education. But I've also listened to health care advocates detail how as a provider I should practice and be paid for health care. And Vermont has experimented in a number of ways with health care. I would request respectfully that our voice be heard, because I think what we're doing is good for Vermonters and cost effective. Our arrangement guarantees a healthcare provider in Vermont, which has a national backing and flexibility. If and when we do go to value based care, the organization already has a blueprint to do this and understands that's the direction we may go. I don't always agree that the interventions of government in Vermont regarding single payer, the Green Mountain Care Board and the assumption of risk with our failed ACO have been uniformly effective. And I hope I'd ask you to consider the consequences before limiting a system which is currently functional. And I guess what I would say is, while the bathwater may be dirty, please don't throw the baby out with the bathwater. And I'll leave you with a review, which is a typical review from a patient coming to our office. And I recognize that some people have good experiences and others bad, but I will tell you that this is just personal experience. The last few years that I was at UVM, I had stopped getting gifts. You know, you can't accept much of a gift, but yeah, you try to give it back and then some people throw it at you anyway. And I had stopped getting cards saying how nice the service was and all of those things. And it's part of why I left. Well, since I started here and since I work, it's every day. And I got a message yesterday regarding me and my medical assistant. This is for, you know, a privately owned business. I leave you with a review from my veterinarian whom I saw for a surgery. She noted, I thoroughly enjoyed everything about my experience with you. I count on a simple and complete recovery, which I know will happen. May your assistant, Mia, follow her dreams. May Glenn enjoy his work for a good long time in those beautiful surroundings. What a perfectly lovely office. It was fun to receive the education and care I received. Thank you. And so as I read this, I would just ask that we'd be allowed to have input because I think that what we're doing is helpful. I love my patients. I love the state of Vermont. I want to do what is right for the state of Vermont. I want to care for people in a cost effective way, but I hope that I'm not restricted from doing that, so thank you, and I can answer questions.

[Alyssa Black (Chair)]: Thank you, Doctor. Goldman. Does anyone have any questions? Go ahead. I'm just gonna

[Brian Cina (Member)]: you said right off the bat the company was ITG. What did that stand for?

[Dr. Glenn Goldman (Witness, Four Seasons Dermatology/Integrated Dermatology Group)]: IDG. IDG. It's called Integrated Dermatology Group, IDG. Okay. And I guess technically they're not actually private equity because they're a family business, they own the whole thing and they are the largest provider of dermatology care probably in the world. But I don't know if we would technically qualify to be able to provide care if this law were passed, and we already do.

[Alyssa Black (Chair)]: Questions? I had just a couple. So first of all, full disclosure, by the way, I go to Four Seasons, Stern, and you're right, it's a beautiful office. I have a vast location overlooking up there on Water Tower Hill. And I've always received fantastic care from there. IDG, it sounds like they're doing everything right. It sort of sounds like they're doing what we want investment to be. So I guess I'm asking if we can ensure the bill, and we have not walked through the bill totally yet. So we're not real clear in some of the language what is prohibited, what is not. If we're not banning this and we're not banning this type of investment and we can make sure that the language is ensuring that, isn't it in the interests of IDG and your group to make certain that we are stopping the more predatory process, which would be competition for you?

[Dr. Glenn Goldman (Witness, Four Seasons Dermatology/Integrated Dermatology Group)]: Yeah, well, yeah, I mean, I'm not worried about competition, but the answer to your question is absolutely, of course, definitely. And by the way, as I said, there are horrible providers of care. There are providers of care who have shut down hospital systems because they paid their chief executive of $300,000,000 and we're well aware of these and my main thing was as I read the language it almost seemed like what we were doing would not be permitted. And I do want to make sure that, you know, that we're able to get investment, but absolutely, and I also do think that I mean, I could provide resources because our organization has resources and guidelines on, and I'm not talking about IG, I'm talking about our national or like the American Academy of Dermatology on what is an ethical practice of medicine and how things should be done. I just, I don't like it when someone says, well, you have to have only doctors doing things, because sometimes doctors aren't the greatest at running something. And I mean, there are aspects where I think it's important to have that for sure. And I would certainly agree with you that if we were permitted to have active input in this, that there are things that could be done to safeguard the practice of medicine and would be valuable.

[Alyssa Black (Chair)]: I worked for doctors for twenty five years. They're terrible at business. Absolutely. I think I, I'm sorry, I have another question as you were, oh, I seem to recall, and it wasn't testimony from today, although I believe Doctor. Song did touch on it a slight bit, but I seem to recall from last year's testimony that we took on age 71 that dermatology, the specialty of dermatology was sort of the largest sector or the largest specialty that a lot of private equity had acquired in an attempt to kind of gain market share and then ultimately sort of driving up costs. Are you is the model that you're under in your understanding different from that model that we heard of last year?

[Dr. Glenn Goldman (Witness, Four Seasons Dermatology/Integrated Dermatology Group)]: I would say entirely because I mean, there's no change in costs with I mean, again, I, you know, we're our our fee structure didn't change a cent from when we went through and we're also not pushed there there's you know there are so if you if you look nationally there are organizations such as forefront dermatology there are organizations like Schweiger dermatology and some others where what the group does is to go in, they buy a business, they throw a whole bunch of PAs in and then they just ramp everything up like crazy and that is inflationary and bad And then there are other groups like Qualderm and like Integrated where you, they run your practice, you are a business person for them, doctor, but they don't inflate costs and I mean I know because our budget annually is, I mean the fees we would charge are the same, I mean the other thing to remember, and you're correct there are areas for example Florida where a lot of this has happened but in Florida a dermatologist is like Starbucks, I mean you know it's like every corner is a dermatologist and there's a lot of other, no for real I mean there's predatory behavior in my opinion on Medicare patients and inappropriate care provided. I think the key would be that there are safeguards placed. And I mean, I could even get best practices. I'm just, you know, I just want to make sure I know what we're doing. I mean, the care that I provide here costs exactly half of what I used to charge people. I know that because I know what we used to collect and we have no facility fee here and it's, you know, it's we're a private office so you get paid less. We hospitalize better negotiating capabilities even than we do. I just want to make sure that we that what we're doing is okay and that we are able to invest. Mean they put a whole new clinic in Rutland with with an experienced PA who was one of their PAs who wanted to move to Vermont and you know the guy that I'm hiring is this remarkable human being who would not come here and join me. He's got a 76 year old mom, they're originally from Afghanistan, He needs to help care for her, and I can get him a job there working with them one week a month, then he comes here because it's a it's a national organization. But it is a I I I fully appreciate that this is different. I also would say, you know, Doctor. Partillo, who arranged this, not me, he you know he owned the practice, not me, I work here, he met with like five different people who wanted to come to Vermont, and this is who he chose because he wants to keep a leg of having a good practice. I mean, you know, nothing is perfect. Our practice is not perfect, I'm not saying that, but we try and it's just very hard to be on your own these days. It's really hard to be on your own and it's nice to have like, and I'll tell you, for example, there was a whole, I know this happened, but when, because I unlike other organizations I actually get to talk to Jeff Queen regularly like the head of the company comes and visits us and we talk to him and he'll take my phone call and this is not like a huge group where nobody cares there was a situation where there was a major employer and a company one of the insurers was going to drop the entire employer in the town and jeff queen called them up and said don't do that We we have market share. Don't drop this entire company. They didn't. And so it's helpful to have the the gorilla in the room with you when you're trying to, you know, because if you're on your own and you're a physician these days by yourself or with two other people, it's almost impossible to practice medicine. That actually makes me really sad. But, and again, as I said, they already have a method for when we go to value based care, because they're a large company, they can set a budget like the hospital and do that. Whereas people who are in private practice on their own, I think will be lost.

[Alyssa Black (Chair)]: I think Leslie has a question.

[Leslie Goldman (Member)]: Thank you. Thank you, Doctor. Goldman. I'm looking at the website for integrated dermatology, which looks really good, amazingly excellent. So can you maybe talk for a minute about the downside? And you may not want to

[Ben Harvey (Office of Legislative Counsel)]: say that in public, that

[Leslie Goldman (Member)]: might be hard. So I'm just curious to know what isn't felt perfect.

[Dr. Glenn Goldman (Witness, Four Seasons Dermatology/Integrated Dermatology Group)]: So a downside. I'll give you a downside. When, you know, I wanted to offer more money to the guy who's coming here and guarantee him a higher salary, they said, no. We're not gonna do that. You know what I mean? Like, they they do get to make the final decision on certain things that are hard, you know, and I so I don't, you know, I I have to follow. I got you know, I have there are negatives, you know, to every situation that you're in, of course. And I will say this, they don't tell me what to do. And I've been working for them for a year and a half now, And I used to get told what to do all the time. And that's why I left. It was kind of driving me crazy. Now, if I want to do something, I know the other thing is they they give you an answer. It may be not the answer that you want, but you actually get an answer from them. So like if you email someone, they respond to you. So they are negatives. Yeah. I mean, and I'm not, you know, nothing is is is positive. And also, I have friends who work for other organizations that are private equity companies that hate them. So, you know, for other other private equity in enterprises, and there are bad ones. And so I I recognize the need to do something. I just want to make sure that it, you know, that there's a, I guess being selfish, want make sure we're able to continue to do what we're doing. I like working here.

[Alyssa Black (Chair)]: May I follow-up?

[Leslie Goldman (Member)]: Yes. Because I'm just looking here, it says keep your staff and choose their salaries, but I'm hearing that maybe not always. Well,

[Dr. Glenn Goldman (Witness, Four Seasons Dermatology/Integrated Dermatology Group)]: you can't, you can choose your staff and salaries. I mean, the nice thing here, and this is true. So then I'm just gonna, this is sharing. I mean, this is, I mean, it's public thing. When I wanted to hire someone at my prior job and I said, will give up part of my salary if you will let me hire that person, the answer was no. Here, if I wanna hire someone, wanna pay for it, because here I, there I had one medical assistant, here I have three, and I earn less, and it's totally cool, and it's great, and I have the ability to do that. Now if I were to, I mean I suspect like anywhere, if I were to not, you know, just stay home and not work very hard they wouldn't be happy with me, but they're willing to that I and the other thing is it's completely transparent. I am not the owner of this practice, as Doctor. Partillo is. I see all the financials, every penny for everything they do. They share it with us every month, so that it's just and all of the employees get to see it's just it's open. So that that makes me feel good about it. I know how much they're earning. I'm happy to do that for them. I I but as I said, there are negatives. I mean, don't, you know, you don't get to to make every decision. But then again, sometimes I'm happy that they make the decision for me.

[Leslie Goldman (Member)]: Yeah, yeah, that makes a lot of sense. Do you see a distinction between like a dermatology practice like this and maybe a hospital or long term care facility that may need different There kinds of

[Dr. Glenn Goldman (Witness, Four Seasons Dermatology/Integrated Dermatology Group)]: are some real problems with long term care facilities. Like real problems and bad care from bad entities. So yes. The answer to that question is yes, I don't know how to solve that problem.

[Leslie Goldman (Member)]: I think that's why we're looking at this bill.

[Alyssa Black (Chair)]: You. Long term

[Dr. Glenn Goldman (Witness, Four Seasons Dermatology/Integrated Dermatology Group)]: care facilities that are run by national organizations have a track record of not caring about people, and it is very problematic.

[Alyssa Black (Chair)]: Thank you. Brian, did you have a question? I thought I saw your view.

[Brian Cina (Member)]: No, the only thing I would ask though is that if there's other providers like yourself who want to talk with us, you encourage them to reach out to us so that we could more from your perspective.

[Dr. Glenn Goldman (Witness, Four Seasons Dermatology/Integrated Dermatology Group)]: I'm happy to have anybody come here anytime, spend a day with us, see what it's like. I mean, to be honest with you, the other thing is the head of integrated dermatology would be happy to, any of these people would be happy to talk to you. They're, I actually, their guy lives in Upstate New York and you know so it's just I just want to make sure we can keep doing what we're doing. I'm actually very happy here. I love I mean they let me just kind of go and do my thing, which is what we all want to do for medicine and provide good care.

[Alyssa Black (Chair)]: Thank you and thank you for the time.

[Dr. Glenn Goldman (Witness, Four Seasons Dermatology/Integrated Dermatology Group)]: I really do appreciate the opportunity to talk to everybody today, And I also know it's a hard issue, so I'm just thank you for working on it. I'm just expressing my concerns, but it doesn't mean I mean, I get it that you gotta do something.

[Alyssa Black (Chair)]: Yeah. And and I will just say, because I've said this a couple times today, a couple of times in the previous, this bill, which was brought to us by NASHP and sort of as their language that they're working through with other states, trying to develop these policies with other states. This bill is a work in progress. We're going to take a lot of time with this as we go through. If we identify things, your testimony will be very prevalent with us in our minds. And if we're making changes along the way, would you be amenable to us reaching out if you'd like to see if, you know, if any concerns are addressed?

[Dr. Glenn Goldman (Witness, Four Seasons Dermatology/Integrated Dermatology Group)]: I would love it. And I've met with several of you in here before to talk and it's great. I love it. Thank you I so appreciate it a great deal.

[Alyssa Black (Chair)]: For making Thanks your time. You probably could have done two Mohs surgeries in time.

[Ben Harvey (Office of Legislative Counsel)]: Want to

[Dr. Glenn Goldman (Witness, Four Seasons Dermatology/Integrated Dermatology Group)]: know something? I have a patient waiting, but I've known him for, I told him I had to talk today and I've known him for twenty nine years, so it's all fine.

[Alyssa Black (Chair)]: All right, thank you. Great, so

[Ben Harvey (Office of Legislative Counsel)]: we're going to go off

[Alyssa Black (Chair)]: of live now. We're going into executive sessions for some safety with the committee, then we'll be going to the floor, but we are coming back here after the floor. So I'm going to say this again, ten minutes after the floor, in this