Vermont Legislature SmartTranscripts:

[Rep. Alyssa Black, Chair]: Just it. Is Yeah, just bear the doc. Is House Healthcare. You have been with us, Legislative Council to walk us through some changes that have been made to H270 based upon the testimony that we've received. So Katie, if you want

[Rep. Leslie Goldman, Member]: to go ahead and Sure.

[Katie McLean, Office of Legislative Counsel]: Good morning. Katie McLean, Office of Legislative Counsel. You have a new amended document on the website. This is based on feedback and draft language that you received from testimony last week. I've integrated a lot of that with some changes. I will say that this is maybe still a work in progress. There's a few issues that I'll flag for folks that maybe need a little bit more fine tuning. But I'll show you where we are at this point and answer questions if I can. To refresh your memory, this is the peer support counseling for emergency service providers. And we start off with a definition section. And the first definition is emerge. Well, actually, a lot of the definitions from the last version have been removed that use terminology around counseling. There was a lot of conversation when I was last year as to whether this was counseling or a different type of service. So those the language around counseling sessions have been removed from the definitions in the bill. So we have a definition of emergency service provider. If language isn't highlighted in yellow, that means it is the same as the last time you looked at it, with the caveat that if language was removed, it wouldn't show up in yellow highlighting. It didn't show a strikethrough. So we have different entities identified that were in the previous draft. And then we have language about individuals who are currently working as a mental health professional in a crisis setting, who is currently licensed, certified or rostered respectively, to provide mental health services as a physician, an APRN specializing in psychiatric mental health, a psychologist, a peer support provider or peer recovery support specialist, a social worker, an alcohol and drug abuse counselor, a clinical mental health counselor, a marriage and family therapist, a psychoanalyst, applied behavior analyst, or a non licensed or non certified psychotherapist, non certified psychoanalyst, or any other professional that provides mental health services. So that's meant to capture everyone who is providing mental health services potentially in a crisis setting. So that's why it's a lengthy list.

[Rep. Francis 'Topper' McFaun, Vice Chair]: On that first sentence, Kate, Does psychologist

[Katie McLean, Office of Legislative Counsel]: say psychologist? Yes, line 10.

[Rep. Leslie Goldman, Member]: Okay.

[Rep. Francis 'Topper' McFaun, Vice Chair]: Does a person have to have special courses to provide prescribed drugs?

[Katie McLean, Office of Legislative Counsel]: Are you referring to H27? No,

[Rep. Francis 'Topper' McFaun, Vice Chair]: appears when the terminology asks a doctor.

[Katie McLean, Office of Legislative Counsel]: Is that first line, a physician, but a psychologist is in line 10. What this language is saying is that if one of these professionals is working in a crisis setting and as the bill goes on, they're incorporated into the definition of an emergency service provider. So if their organization wants to provide peer support services due to maybe a traumatic experience that the person had because they were working at a crisis setting, then they can receive that service and receive protections for what they say to other peers during that support session.

[Rep. Leslie Goldman, Member]: Okay, I

[Rep. Francis 'Topper' McFaun, Vice Chair]: think I'm reading it differently.

[Katie McLean, Office of Legislative Counsel]: How so?

[Rep. Francis 'Topper' McFaun, Vice Chair]: It says to provide mental health services as a physician.

[Rep. Brian Cina, Member]: Or, and then it says something or something, or, right?

[Katie McLean, Office of Legislative Counsel]: Yeah, so it's a list of everybody who could potentially be providing professional mental health services in a crisis setting.

[Rep. Brian Cina, Member]: Do you see, Topper, how it says, as a physician, and then with a bunch of words, an advanced practice nurse, a bunch of words, a psychologist, a teacher. So it's listing all the possible professions that could serve in the role.

[Rep. Leslie Goldman, Member]: I get that.

[Rep. Francis 'Topper' McFaun, Vice Chair]: What I'm worried about is the psychologist, unless they have certain courses, they cannot prescribe any kind of medication.

[Rep. Brian Cina, Member]: Crisis workers don't prescribe medication usually.

[Rep. Francis 'Topper' McFaun, Vice Chair]: Well, I know that on an ambulance They do.

[Rep. Brian Cina, Member]: Do they prescribe it or do they administer

[Rep. Francis 'Topper' McFaun, Vice Chair]: They administer it.

[Rep. Brian Cina, Member]: A crisis worker though, the role of crisis Hold hold please.

[Katie McLean, Office of Legislative Counsel]: So I think what this is envisioning is not a more traditional practice where a patient is repetitively coming to see their provider for ongoing regular care. I think what this is envisioning is perhaps a 09:11 call, an EMT is going out, and with them is a crisis worker who's going along with them to help deescalate the situation. So I think this is meant to be sort of the person who's helping to de escalate and get the person into more stabilized care, in a more stabilized setting.

[Rep. Francis 'Topper' McFaun, Vice Chair]: I'm okay. I just gotta get

[Courtney Harness, Blue Cross and Blue Shield of Vermont]: it right right here.

[Rep. Francis 'Topper' McFaun, Vice Chair]: Because that sentence about providing mental health services as a physician.

[Katie McLean, Office of Legislative Counsel]: So they're providing it, they could be a physician providing this price of service, particularly if they're a psychiatrist. They could be a mental health, sorry, they could be an APRN specializing in psychiatric mental health care, a psychologist. They could be a social worker. They could be an alcohol and drug abuse counselor. This is just listing all of the professions who could potentially be finding themselves in the role of providing mental health care in a crisis setting.

[Rep. Francis 'Topper' McFaun, Vice Chair]: I just, good, thank you.

[Rep. Leslie Goldman, Member]: Jera? Yeah, I just had question as to what roster it is. Is that defined somewhere or?

[Katie McLean, Office of Legislative Counsel]: Yeah, so in title 26 is where all of our professions live and there are different, OPR sort of describes it as they have like a lighter touch and a more significant regulatory oversight. So there's licensure, which is kind of the highest touch regulation. Then they have a certification and rostered is they're maintaining a list of who these professionals are, but that has the most limited degree of oversight. And if you needed any more depth on that, I would have to call OPRN or the attorney who works on professions more regularly. Because a lot

[Rep. Leslie Goldman, Member]: of these folks, I don't know if they can be faced, but they have a reference in the chapter of how they got your certification in the Multicultural Health and such. I just wanted to understand the category of breast roster. That's why I'm a little interested in

[Katie McLean, Office of Legislative Counsel]: talking about that. You can point me in a direction. I can either look into it or I can maybe pass you along to the right person who can answer that a little

[Rep. Leslie Goldman, Member]: bit better than I can. Let's start. If you want to talk off the record about it, I'm happy to talk about the process of licensure and how getting it fostered as part of it, how works to, as a crisis worker, how it works. But I'm not

[Rep. Brian Cina, Member]: the witness right now, so I won't do it right now unless I'm invited to, but I'm happy to tell you off the record.

[Rep. Alyssa Black, Chair]: Let's try to find your answers for you off the record.

[Rep. Leslie Goldman, Member]: Thank you.

[Katie McLean, Office of Legislative Counsel]: Thank you. So we're still on the list of who is an emergency service provider. Other items or other individuals added to this list, individuals currently appointed with the Department of Health as a medicolegal death investigator or in subdivision I currently serving as a medical examiner or assistant medical examiner as appointed by the chief medical examiner.

[Rep. Alyssa Black, Chair]: I asked Katie to put this in. This was brought to us by the Canadian Department of Health, who said, Oh, wait a minute, these people also.

[Rep. Brian Cina, Member]: It was also in the recommended language that I believe Mark brought us from the firefighters. He had the medical examiner language in there and that came from the EMS, not the medical logical piece, but this part, this medical examiner piece was also in their suggestions from the emergency What is the commission called?

[Katie McLean, Office of Legislative Counsel]: The Commission on Wellness Emergency Survey. They actually had that too. Okay,

[Rep. Francis 'Topper' McFaun, Vice Chair]: It's a foolish question.

[Rep. Allen "Penny" Demar, Member]: With all those titles, and then at the end you do say that, or any other profession, is there any way we can condense all those? We might be missing somebody.

[Katie McLean, Office of Legislative Counsel]: That sentence was taken off of the last draft that I sent. So I think you might have an earlier draft posted. That's the only difference that that sentence was taken out. So that language was proposed in draft testimony that you got. But when I looked back at who is defined as an emergency service provider under 7,257 b, you already have all of those entities on your list. So there's no reason to cross reference them again, which is why I took it off. That language is no longer in in the draft, and I'm sorry you have an earlier draft of that.

[Rep. Leslie Goldman, Member]: Okay. Think we have

[Rep. Alyssa Black, Chair]: draft 1.1 posted. I sent a

[Katie McLean, Office of Legislative Counsel]: second 1.1 after we decided to take that off. So that's okay. There was a miscommunication. All

[Rep. Alyssa Black, Chair]: this had happened five minutes ago.

[Katie McLean, Office of Legislative Counsel]: That's the only difference. Now we've identified it. So we have our definition of employer as an entity that employs or oversees emergency service providers working in a paid or volunteer capacity. Subdivision three. So these are new definitions that are replacing other definitions that had been in the original bill. So a peer support communication means an oral or written communication made in the course of a peer support session. Means a note or report arising out of a peer support session or a record of a peer support session. I'm going slowly over that because in the original bill and some of the markup testimony that you received, This language is repeated throughout the text of the bill and it becomes duplicative. So I'm flagging that we have a new definition of peer support communication. Therefore, we don't need to outline all of these types of communication every time the word communication appears. It will all mean what is in this definition. So that is a change. We have a peer support program, which means a program established or accessed by the employer of emergency service providers to provide support services to emergency service providers working in a paid or volunteer capacity. And subdivision five means an individual or group peer support session provided by a peer support specialist for emergency service providers who have been involved in a potentially traumatizing event or suffering from cumulative or chronic emotional stress by reason of their employment or volunteer services or related to other personal matters. So that's what we mean by the session itself. This is what had been called counseling. And then we have a definition of peer support specialist. It means an individual who is a member of an organized and recognized Vermont peer support program, or an emergency service provider who has received training and providing peer support services from a recognized training resource or a member of an employer based peer support program. So in two places on line seventeen and nineteen, we have the word recognized. The question I'm raising is recognized by who? And I don't think we have an answer to that yet. So that's one of the places we want to flag as a place for further conversation. Also going to flag this definition because there's another place in this statute that sort of has other qualifications to be a peer support specialist. And I'm wondering if there is room to sort of bring those other qualifications into the definition here. So I'm just gonna flag that this definition exists and perhaps it could be tightened up a little bit. Okay, page four. This is language that I added. I know that this committee has spent a lot of time in the past few years talking about certified peer support specialists. And when I heard some of the questions that were being asked last time I was here, I realized there was a lot of, I don't want to say confusion, but it was clear that we were sort of talking about two different things. So I thought it might be useful to add a sentence that a peer support specialist shall not be construed to have the same meaning as a certified peer support provider as defined in Title 26. So our certified peer support provider, this is a certification that can be obtained from OPR to provide peer support services as defined in Title 26. It means something very specific. And I don't think peer support specialist has the same meaning. So I wanted to add this language to clarify what we're talking about. So what is a specialist? A peer support specialist. This is the definition we have here. So it's a person, a member of an organized or recognized peer support program. Or an emergency service provider who has received training in peer support services. Or a member of an employer based program. Whereas the certified person has to have gone through specific education and a whole certification process. It has a different meaning, different training, different certifications.

[Rep. Allen "Penny" Demar, Member]: So there's no really certification for a specialist?

[Katie McLean, Office of Legislative Counsel]: No. I mean, if they're a member of a certain organization or have received certain training from a recognized source, that they would be a specialist.

[Rep. Leslie Goldman, Member]: I just want to clarify

[Rep. Brian Cina, Member]: my understanding now, because I thought I did, and then you explained that, and then I just want to make sure I understand if you fast forward slightly to seven, I think. Oh, B, I mean, sorry, not seven. That certified peer support provider, is that the language in the because I can look up 26 BSA right now, is that the language that describes what the professional peers who were working in crisis or the recovery coaches? Yes. Okay, thank you. That's very much.

[Katie McLean, Office of Legislative Counsel]: Yeah. Okay. So I'm citing to the definition. That definition goes on to reference peer support, which is also defined in Title So 20 that is all there. Then the whole certification process is in that chapter.

[Rep. Francis 'Topper' McFaun, Vice Chair]: We did that last

[Rep. Leslie Goldman, Member]: year or the year before?

[Katie McLean, Office of Legislative Counsel]: It starts to blend, but I think it maybe was two years ago.

[Rep. Brian Cina, Member]: Okay, but now I know what you're referring to and I want to be That's what I thought and I wanted to confirm that, thank you.

[Katie McLean, Office of Legislative Counsel]: Yes. Okay, so in B1, we have acceptance provided, you remember, jump back, but the way this is structured is B and C start with the language except as provided in D. So we have sort of a rule, then we have in D the exception to the rule. So except as provided in subsection D, a peer

[Rep. Alyssa Black, Chair]: My language is

[Katie McLean, Office of Legislative Counsel]: Okay, it's cut off by the text boxes from Zoom. Any peer support communication made by a participant in a peer support session of a peer support program established or accessed by an employer of an emergency service provider shall not be disclosed by any individual participating in the peer support session. So a lot of references to different types of peer support. But if communication that's made in a session run by a program that is established or administered by the emergency service provider, those communications cannot be disclosed. And one noteworthy change on line six or access, there is conversation that the provider itself might not be establishing the program. So this provides some flexibility to an outside entity coming in to provide the service.

[Rep. Debra Powers, Member]: How does it affect the individual who's receiving the services who wants to disclose something?

[Katie McLean, Office of Legislative Counsel]: It will be disclosed, any individual purchasing. I think it would have a chilling effect. I'm not sure the testimony you heard, but I'm sure a lot of what you heard is that if there is a group of peers having a conversation about their experiences, that they would want to feel safe to disclose different experiences and reactions that they're having to those experiences. And that is sort of the purpose that by having this language in place, they would feel more comfortable knowing that somebody else couldn't repeat what they had said.

[Rep. Debra Powers, Member]: Okay. So I'm just confused about individual, I guess. Because if I'm the person who's receiving services, I have the right to disclose whatever I want.

[Katie McLean, Office of Legislative Counsel]: Okay. So what you're saying is if I'm the individual, I said something during this particular group session and I want to repeat what I said, not what somebody else said, but I want to repeat it to a family member or therapist or whoever, what is the impact on that? Oh, that's interesting. Okay. I would say that this would have a chilling effect on that. But I think that you could probably also have some type of carve out if you wanted to, to say something along the lines of, but an individual may I don't know what the right wording would be, but an individual may refer to something they themselves said during the session to a third party.

[Rep. Debra Powers, Member]: HIPAA, you're allowed to talk about yourself. Others can't, of course, but you can. So I'm just thinking about it in the same kind of context. And the chilling effect worries me because I don't want people to feel shut down if they want to talk about it. Maybe that's part of the healing too.

[Rep. Leslie Goldman, Member]: Can I discuss that?

[Rep. Alyssa Black, Chair]: I see Brian out of my peripheral vision. I apologize. So let's go Karen and then Brian.

[Rep. Leslie Goldman, Member]: It was just a follow-up because I was trying to think, if you are an individual in a session and you have a conversation, the content of that, I would think you're still, like let's say you have a family member who's very helpful in sorting things out, would think the content of that would be still something you could share. The chilling effect would be, in this session, I said this and this person said this, right? So it's that sort of subcategory, but you're free to share the content of what you shared in the session with someone you trust, maybe? Or I don't know. So wondering.

[Katie McLean, Office of Legislative Counsel]: I think the language doesn't feel incredibly flexible. I would say that you might want to decide what your policy goal is, and then we could write language to that effect. So

[Rep. Alyssa Black, Chair]: we would just have something essentially this should not be construed as an individual sharing information about themselves with

[Katie McLean, Office of Legislative Counsel]: Yeah, would play with the language a little bit, but something like that, that you could share your own personal experiences elsewhere, as long as you're not repeating something that somebody else said or that the facilitator sort of

[Rep. Debra Powers, Member]: Confidentiality of the group or whatever, except for you have the freedom to express your own experience. Clearly wrong language, but

[Katie McLean, Office of Legislative Counsel]: I can play with it. Can you come back with something?

[Rep. Alyssa Black, Chair]: Please play with this.

[Rep. Brian Cina, Member]: Oh, Brian, go ahead. Yeah, it's kind of When you really think about how this plays out in real life, it's actually really complicated, because I'm trying to, in a simple way, explain it. Imagine you're at work and something bad happens, and then you talk about it with your coworkers to process it, but it's still bothering you. You can go home and talk about it with your partner, or I've called my mom with some things that are really upsetting, and talk about it with her. I have to be really careful to not say the name, the age, where it happened. So I'll be like, this thing happened with this person, and it's tricky, but there's ways you can discuss what happened if you're careful. I think the emergency service providers are people who are always managing this. All those professions, we're always managing this. We're always figuring out how do we manage privacy. But then what happens is these bad things happen that we're part of, and then we can't talk about it with people because it involves other people's health. Respond to an accident, if you talk about it in too much detail, people are going to figure out the accident. They're going be like, oh, they're talking about those four kids on the highway, or they're talking about this. This is why it's like, you have to be careful about talking about it outside of work and even with your partner. So I'm just saying, it's complicated. I don't know how to manage it, it's complicated. But the problem is because of confidentiality, people don't talk about things that they should and then they develop PTSD. So just

[Rep. Alyssa Black, Chair]: to be clear, what we're doing here is we just went through all the definitions and this pertains to the actual peer support session, which is designed to be this session by a peer support specialist certified by we're not sure who yet, or not certified, who's gone through a program to be this. That's the confidentiality we're talking about. We're not talking about two people at the water cooler saying, Oh man, did you see that? Oh yeah, that was terrible. That's not what we're talking about here. We're not talking about all communication, we're talking about it in the context of a peer support session. Session, exactly, that's it. As part of a peer support program. So let's try not to get too broad in everything. I guess that's my question. But I do agree with you, if we need to carve out something to make it explicit, then we should probably do that. The language we develop and not us.

[Rep. Debra Powers, Member]: Whatever you say goes.

[Rep. Brian Cina, Member]: I love to say that once we pass this law, we need to make sure that all the workers have access to peer support sessions.

[Rep. Alyssa Black, Chair]: I was gonna say maybe we need to add legislators after all of this. Legislative council.

[Katie McLean, Office of Legislative Counsel]: Except as provided in subsection D, a peer support communication relating to a peer support session between a peer support specialist and another staff member of the peer support program or between staff members of the peer support program shall not be disclosed by any individual participating in the peer support communication. So this is saying that program staff can have communications amongst themselves about the content of what happened during a peer support session. Subsection three, written peer support communications are exempt from public inspection under the PRA and shall be kept confidential. PRA exemptions created in this act shall not be subject to one VSA three seventeen, which is a time period for review of PRA exemptions. Subsection C, except as provided in D, a peer support communication made by a participant or a peer support specialist in a peer support special session shall not be admissible in a judicial, administrative or arbitration proceeding. Limitations on disclosure imposed by the subsection include disclosure during any discovery conducted as part of an adjudicatory proceeding. Limitations on disclosure imposed by the subsection shall not include knowledge acquired by an emergency service provider from observations made during the course of employment or volunteer service or information acquired by the emergency service provider during the course of employment or volunteer service that is otherwise subject to discovery or introduction into evidence. And then we finally come to D, which is our exceptions to the rules. So confidentiality protections described in B and C shall only apply to a peer support session conducted by a peer support specialist who has been designated by an employer or a peer support program to act as a peer support resource, and has received training providing peer support emergency service providers who have been involved in a potentially traumatizing event by reason of their employment or volunteer service. I have two things to say on this. So this is, if you remember when I was talking about the definition of peer support specialist, this feels like it's continuing to define what a peer support specialist is. So my proposal is that I take A and B and try to blend them with the existing definition of peer support specialists. And then in D, it would say something like confidentiality protections described in B and C shall only apply to peer support session conducted by a peer support specialist, period, instead of having these qualifiers. We've already dealt with those in the peer support specialist definition. The other question I have is the term peer support resource is a new one that was proposed to you. I don't know what a peer support resource is, or it's not a defined term. So maybe it's fine, but it was at least a flag for me that this is a new term we're introducing that isn't defined anywhere.

[Rep. Brian Cina, Member]: Okay.

[Rep. Karen Lueders, Member]: Go ahead, Karen. I have a question on B. You talk about the traumatizing event, because they also encompass that sort of chronic long term, which I've found somewhere else,

[Rep. Alyssa Black, Chair]: I just can't

[Rep. Karen Lueders, Member]: find it.

[Katie McLean, Office of Legislative Counsel]: Yeah, I wouldn't interpret that to be chronic. Oh, maybe it would, but you're blending this part of the definition of peer support specialists, and I think it's in the definition of where I they talk about have to double check.

[Rep. Alyssa Black, Chair]: But I could see

[Katie McLean, Office of Legislative Counsel]: that not covering more chronic episodes. So if that's your intent, we should keep an eye on it to see where this lands and if that language should be added in there.

[Rep. Karen Lueders, Member]: I just want to flag, and we can talk about

[Rep. Daisy Berbeco, Ranking Member]: it offline later, but I'm struggling a little bit because peer support specialist is what we call a lot of the folks who are not certified. So I'm just contemplating whether it's worth adding an organizational peer support specialist or something. I'm just tossing that around in my head right now. Because those folks are trained and they go through a lot of training and it's a very different role that they hold where they are counseling someone. So I just am contemplating that.

[Rep. Alyssa Black, Chair]: I

[Rep. Brian Cina, Member]: will say it confused me at first, too, but I'm not trying to complicate it.

[Rep. Alyssa Black, Chair]: And the addition that you had, that it should not be construed as

[Katie McLean, Office of Legislative Counsel]: I don't think it would address that.

[Rep. Francis 'Topper' McFaun, Vice Chair]: Okay.

[Katie McLean, Office of Legislative Counsel]: So I think what you're saying is folks who sort of their full time professional occupation is peer support and they've chosen not to get certified, title is a peer support specialist. But that is different than how it's being used here. So if the committee had a different preferred name for this type of person, that's easy enough to swap out. I'll let you think about that and keep going. I'll think about it. I

[Rep. Alyssa Black, Chair]: just want to talk to

[Rep. Daisy Berbeco, Ranking Member]: the folks that do this work and make sure that it's not going to disrupt too much for them. I know the peer support specialists may have concerns about that.

[Rep. Alyssa Black, Chair]: Maybe that's something that you can talk about with Katie, because I'm sorry, I'm not grasping we're Katie, about Where the concern is.

[Katie McLean, Office of Legislative Counsel]: Okay. Subsection subdivision D two, confidentiality protections described in B and C shall not apply to the following information as it pertains to an individual designated to receive such information in the normal course of the individual's professional responsibilities. So threat of suicide or homicide made by a participant of a peer support session or any information conveyed in a peer support session relating to a threat of suicide or homicide. Any information relating to the abuse of a child or vulnerable adult or other information that is required to be reported by law, any admission of criminal conduct or any admission of a plan to commit a crime. So these items are sort of separate and apart from protections that are being given. If one of these issues is raised, then it's appropriate to raise that with the organization's person responsible for receiving that type of information.

[Rep. Leslie Goldman, Member]: I have a question, let's see. I don't know if this delineation makes sense here, but at times a defense attorney, there's a privilege for crimes you have committed, but if you're going to commit a crime, the privilege just appears. I'm just wondering about, you know, if part of the, I trauma or whatever it is has to do with a crime committed in class, I don't know, that the baby has or

[Rep. Alyssa Black, Chair]: hasn't been dealt

[Rep. Leslie Goldman, Member]: with, I just don't know about that make it exception, or having that come out because that's the issue maybe, that's the thing you need to discuss but maybe can't discuss for you. So I just wondered about

[Rep. Alyssa Black, Chair]: Do you have a question about this? Yes, see. Go ahead, Brian.

[Rep. Brian Cina, Member]: For example, let's say, I'm going be very general, an emergency service provider admits in a peer session that they've been driving drunk and they want to stop, does that mean that now that someone in that group could turn them in to the police for admitting they drove drunk? That's a crime. So I would be concerned because then they're not gonna tell the truth and get help.

[Katie McLean, Office of Legislative Counsel]: Yeah, I take your point. And I don't think there would be a report to the police, unless that is their organization. But it would be to their organization. It wouldn't necessarily be to law enforcement. But regardless, I take the point.

[Rep. Brian Cina, Member]: Yeah, and I've been wondering, is there a way we can create it so that if even law enforcement admits to driving drunk, for example, that instead of it being that they're punished, that they're given help. I would rather this lead people to help versus punishment. Otherwise, that's going to chill the benefits bit.

[Katie McLean, Office of Legislative Counsel]: Maybe outside the scope of this particular but I think you're raising a policy question, honestly. This is your bill if this is language that the committee feels like potentially shouldn't be one of

[Rep. Alyssa Black, Chair]: the items listed, that could be removed. Is this standard language otherwise is around mandatory reporters and I'm

[Katie McLean, Office of Legislative Counsel]: not aware of that. I know that there is similar language in the correctional context. I'd have to see if this language is there, but otherwise, I'm Where

[Rep. Alyssa Black, Chair]: do think this came from, didn't

[Katie McLean, Office of Legislative Counsel]: It's been changed, yes, it's been changed a bit over, so I don't know that it tracks exactly anymore. I hear

[Rep. Alyssa Black, Chair]: people's concerns. I am loathe to delve into this.

[Rep. Brian Cina, Member]: Can I just throw out an example from the parallel example, that in the therapy world, the way this would be framed is not any admission of criminal conduct or a crime to commit a crime, it would be any admission of threat to harm others or property? So it's not about committing a crime or not. It's like, what is that case called? The Supreme Court case that made us revisit? It's like Kuligowski or something. Did I say it right? The duty to warn stuff. I think if it was framed more as duty to warn versus criminal conduct, it might be akin to the confidentiality protections of regular therapy, but I'm not trying to complicate it too much. I'm just saying it would be treating the peer communications more like we would treat communications and therapy, not as some new category where we're turning people in for alleged possible crimes.

[Rep. Alyssa Black, Chair]: Well, we're not turning people in, we're sharing information with the employer. But this is information that if in the course of a peer support session, a peer support specialist should have the freedom to be able to disclose that to the employer.

[Rep. Debra Powers, Member]: If you're suicidal,

[Rep. Alyssa Black, Chair]: why would they inform you? Because these are people who have these are not certified peer support specialists. These are not they have received training to serve in this role, in this particular role as a peer support to their peers in the context of the work that they do, which makes them specialized. And I don't think we should be putting more responsibility on them when they're not licensed, certified, register or whatever the categories of things. I think we're parsing this a little bit too much. I think that's what I'm saying.

[Rep. Leslie Goldman, Member]: Yes. And I would want to know from people in the field who would actively make use of this, but any admission of criminal conduct, know, I did some lines of cocaine and that's how I dealt

[Katie McLean, Office of Legislative Counsel]: with this trauma, whatever. Exactly.

[Rep. Leslie Goldman, Member]: Just if you really want them to freely avail themselves of the pulp, I would want to know from folks in the field who are thinking about this, whether any admission of criminal conduct would be one of the appropriate exceptions. All the other ones make perfect sense. You have a plan to commit a crime, to do harm to, all those things are

[Rep. Brian Cina, Member]: I could even understand if fraud was included, because you have to report fraud in these settings. If someone's admitting they're doing fraud, you would have to tell your employer. We get that training. The issue for me is the substance use piece, because we criminalize substance use, and it's actually a health condition. That's the part

[Rep. Alyssa Black, Chair]: on. Can I throw out an alternative scenario? Yes. Let's say, and I'm going pick on a profession, I'm not picking on this profession, I'm just like, I'm thinking about a police officer. If they conveyed in a peer support session that they are regularly using cocaine, even when they're on the job, don't we think that as far as public safety goes, that the employer might be privy to the information that one of their employed officers is driving around I can't believe I just quoted a song lyric. So it's hard to say. I mean, don't you think that's important?

[Rep. Brian Cina, Member]: I do, but I don't think it should be framed as criminal. Should be like, there's some other risk there, you know? But I I hear your point.

[Rep. Alyssa Black, Chair]: I think that's what this is trying to get to.

[Rep. Daisy Berbeco, Ranking Member]: I think it's a different crime to admit, or it's different to admit the crime of Karen's example of, I did a lie because I was self destructive as I was trauma Self medicating. I don't know if it's medicine, but It's cool.

[Rep. Brian Cina, Member]: I think it's both.

[Rep. Alyssa Black, Chair]: But my point

[Rep. Daisy Berbeco, Ranking Member]: is, it's both. My point is the individual who is supporting this person in a session has to bear the burden of determining what is a crime and what isn't. And it's our responsibility to make that crystal clear for them, I think. As much as I don't want to delve into it either, I think we have to make it clear and at the same time respect that the language in this is exactly what the folks who do this work told

[Rep. Alyssa Black, Chair]: us they want. That's what I'm saying. That I think it is best determined by the people who do this work that

[Rep. Brian Cina, Member]: They will determine if the crime is reportable or

[Rep. Alyssa Black, Chair]: They they're the ones who came

[Rep. Francis 'Topper' McFaun, Vice Chair]: to us.

[Rep. Alyssa Black, Chair]: It's just language. I don't think the 11 of us should sit around and purse this. I think we should leave it to the experts.

[Rep. Daisy Berbeco, Ranking Member]: Doing it right now, they're doing fine with it, or they would ask

[Rep. Allen "Penny" Demar, Member]: for it? Don't we have laws on our now? Protect that?

[Rep. Alyssa Black, Chair]: Again, think a lot of this came from what we have currently in law around corrections. Can we move on? Sure. Thanks. And Katie has to

[Katie McLean, Office of Legislative Counsel]: get moving here because human services needs her. Three more subsections. So nothing in this subsection shall prohibit any communications between peer support specialists regarding a peer support session or between a peer support specialist and another member of a peer support program. This is the piece that I wonder if we Any communications? I wonder if we're being duplicative, is it a B2? Is except as provided in any peer support communication relating to a peer support session between peer support specialists and another staff member or program staff shall not be disclosed by any individual participating in the peer support communication. And then we have this language in E. That nothing in this section shall prohibit communications. Oh, this is saying inverse that you're wanting to allow free conversation between them. And subsection F, an employer shall not be subject to civil liability. I'm using the same language that we're using in G for consistency. For any disclosure made in violation of this section by an emergency service provider who participates in a peer support session. And in G, a peer support specialist or a peer support program providing peer support shall not be subject to liability for any injuries or damages arising from the provision of services, peer support services, unless the conduct of the specialist or program constitutes gross negligence, recklessness or intentional misconduct. So this is offering protection to the specialist and to the provider unless they're acting with gross negligence, recklessness or intentional misconduct. And we have our effective date that we'll have to change. Okay. Okay.

[Rep. Alyssa Black, Chair]: Quickly, because Katie has to go.

[Rep. Debra Powers, Member]: Oh, I'm sorry. Could ask another time. Oh, well, I'm just wondering, your peer support, employee programs, schools, and stuff like that, and how do those programs deal with hearing about intention of suicidality or criminal intent? And I'm struggling with telling the employer, because that's not helping the person necessarily. I'm wondering, I'm frightened for the person who's suicidal, I guess, as a result of this experience and what the obligation of the next step is for them. I don't get that. Does that make any sense? Am I not making sense? That's why we have that in there.

[Katie McLean, Office of Legislative Counsel]: But you're saying that we're telling the employer. Does it say the employer? It says the person responsible for receiving that information, let's say, shall not apply to the following information as it pertains to an individual designated to receive such information in the normal course of the individual's professional responsibilities. So it doesn't necessarily mean the employer.

[Rep. Alyssa Black, Chair]: It could mean reaching even outside the organization to a professional resource. Yeah, it would be you're allowing this peer support specialist to call a licensed psychologist to say, have someone that I really think you should see because they're suicidal. That's what they're saying. Because if it's not in there, we're basically saying you can't tell anybody.

[Rep. Debra Powers, Member]: Right. No, I get that. And I really want it to be told to the right person, not the employer. Got hung up on that, but maybe I'm misunderstanding. So I

[Rep. Francis 'Topper' McFaun, Vice Chair]: get it.

[Rep. Alyssa Black, Chair]: We are ensuring that there is disclosure allowed in certain circumstances in order to actually assist. But not just

[Rep. Debra Powers, Member]: this doesn't say to whom.

[Katie McLean, Office of Legislative Counsel]: Yes. Okay. Thank you. I've been listening to the testimony and I was reading some stuff last night. It sounds like it's a program that's taken very seriously, so there must be some sort of hierarchy in the training, but maybe they don't go right to the employer. Maybe there's steps, like, we don't know, but I'm going

[Rep. Alyssa Black, Chair]: to give them credit for

[Katie McLean, Office of Legislative Counsel]: That finding that they

[Rep. Debra Powers, Member]: was just my worry about it.

[Rep. Leslie Goldman, Member]: Yeah, I get that.

[Rep. Alyssa Black, Chair]: Thank you, Katie. So we'll keep working on this. Yes. We'll make some changes. For anyone who's listening, particularly around the piece of recognized by whom is who we're looking for an answer for. Yes. Thank you. You're welcome. Thank you. Pivoting back to $5.77, which is the prescription drug discount program. And we're joined by Courtney. I thought we should get some testimony from insurance and also part

[Rep. Debra Powers, Member]: of

[Rep. Alyssa Black, Chair]: financial regulation. Thanks for joining us.

[Courtney Harness, Blue Cross and Blue Shield of Vermont]: Thanks for having me. Nice to be here for the first time this morning, this session. Thank you very much for the record. Courtney Harness with Blue Cross and Blue Shield of Vermont. I do think that my testimony will be rather brief and hopefully can cover some of the questions brought up in previous testimony. That said, I want to start by first making sure that we thank the treasurer's office for putting forward this bill and this program that's had success in other states. And you've heard folks from our team say this before. Vermonters need some relief at the point of sale, at the point of service. They need it now. They don't need it in 2029. They don't need it in 2028. And good, bad, big, small, we believe that ArrayRx accomplishes that goal for Vermonters. And we're really happy to work with both the treasurer's office and the Department of Financial Regulation to implement this if given the chance. Talking about implementation, from our perspective, I want to make the committee aware that deductible or not, we already receive paper claims on deductibles. That's something that's very easily implemented. I would also defer to our partners at DFR and in the treasurer's office on implementation to make sure that we do follow their guidance when it comes to exactly how this program would be rolled out. So I want to make sure that you're hearing our support for this program as soon as possible. Also, I know that you heard from folks from the state of Connecticut last week. I will just provide some frame of reference into how they've dealt with the question around application to deductibles. They implemented the program and you may have heard this last week, but I'll reiterate it. They implemented the program, waited a year to see how the rollout went, to see how the uptake was, and frankly, sounds like to figure out how the heck they would apply this discount to a deductible in a way that is least difficult to the consumer. We're perfectly happy to take mail in claims. Like I said, we do that regularly now. Don't mind it. I'll just talk from personal experience. When I have the chance for a mail in rebate, it almost never happens. So I hope that you'll keep the consumer Vermonters in mind when we talk about applicability of deductible. To do it in a way that's different than mailing it in does get complex and complicated. And I don't believe that that should pause the implementation of this program. Think that we've seen states have success with it in a way that where it is implemented rather quickly with a timeline for implementation of more easy application to a deductible. So that's the extent of what I have. I do want to say we've been very, very pleased with the level of and depth of communication from the treasurer's office and with our partners at the Department of Financial Regulation. And we think that Vermonters really need this.

[Rep. Alyssa Black, Chair]: So thank you. Thanks, Courtney. Any questions? I have a couple. I guess just me. So currently, we have that discount cards or current discount is applied to deductible, okay, whatever. That's easily achieved because the prescription is still running through the PBM, you're getting the claims data, patient doesn't have to submit it on their own. Does that apply to all Blue Cross Blue Shield self insured ASOs?

[Courtney Harness, Blue Cross and Blue Shield of Vermont]: It's a good question. So we are PJM is Optum. So with OptumRx, our version of the drug discount card is built into the plan. So when a Blue Cross and Blue Shield member goes to a pharmacy to purchase and swipe their card for payment, that drug discount is already built in to the plan. So, yeah, it happens automatically. That happens automatically because of the relationship with the PBM that's built into our plan. So, when it's outside of the plan, like I said, the process becomes slightly more complex.

[Rep. Alyssa Black, Chair]: How do you communicate currently that members can use a discount? Do you communicate to them at all?

[Courtney Harness, Blue Cross and Blue Shield of Vermont]: Yeah, it's part of the plan.

[Rep. Alyssa Black, Chair]: Right now, for our members, it's not an option. It's just automatically applied. So the discount through OptumRx and Optum as our PBM is automatically applied on all applicable drugs at the point of sale. You've seen Blue Cross seems enthusiastic about this. We received testimony from Connecticut that one of their frustrations a little bit has been the uptick of it and getting information out. The treasurer has an appropriation, essentially advertising. Does Blue Cross Blue Shield see themselves as having a role in ensuring that their members know that this is an option? And if so, what would you I mean, you've been very public about your recent communication on, Hey, we're all in this together. Here's how you can save some money. Would Blue Cross Blue Shield be willing to work with them to get it out there and advertise that this is a great way for Vermonters to save?

[Courtney Harness, Blue Cross and Blue Shield of Vermont]: Yeah, think it's a great question. As far as what the actual plan is, I would defer to the treasurer's office for what their use of the funds would be for the actual plan. But and I would say, with the FR, I would imagine that covering 200,000 Vermonters, we would be a part of whatever that rollout plan is for uptake. And we have no reason to not participate in whatever way the treasurer's office or DFR thinks would be helpful.

[Rep. Alyssa Black, Chair]: Do you have online claim submission for individuals, for members, or do they have to still print off and fill out a claim and attach a receipt?

[Courtney Harness, Blue Cross and Blue Shield of Vermont]: Yeah, like you said, most of it is happening electronically, especially if it's at a provider or at a hospital. But we do have some that we get by paper. And so it doesn't happen nearly as frequently as it used to. But that's a process that we're familiar with. So when we talk about the opportunity to do that with ArrayRx, it is something that we handle currently and would be prepared to do.

[Rep. Francis 'Topper' McFaun, Vice Chair]: Okay, great.

[Rep. Alyssa Black, Chair]: Any other questions? Just me. Yeah, go

[Rep. Allen "Penny" Demar, Member]: ahead. You handle OptumRx now. What's compared to as far as it's going to be in your system? Yeah, Optum is our PBM, our pharmacy

[Courtney Harness, Blue Cross and Blue Shield of Vermont]: benefit manager. And so from that perspective, they're built into our plan. So there's no real opt in for our members. It's baked in. So it's automatic. And it's not state funded. It's funded by premium. So just the mechanics of how they work are different, but the end result, I think, is similar. Does that make sense?

[Rep. Allen "Penny" Demar, Member]: Well, I didn't know because I knew they're affiliated. This one isn't, but will it be?

[Courtney Harness, Blue Cross and Blue Shield of Vermont]: Yeah, ArrayRx seems again, just from our research and what I've heard from the treasurer's office, ArrayRx seems to be a different model than OptumRx at its built indoor plans, so built more on cost share across states than necessarily plan.

[Rep. Alyssa Black, Chair]: I have Topper and Barron.

[Rep. Francis 'Topper' McFaun, Vice Chair]: And now, all of this is reported till you get to

[Rep. Leslie Goldman, Member]: your deductible,

[Rep. Francis 'Topper' McFaun, Vice Chair]: so the amount that you have out of pocket. Why can't we just have the pharmacy do the same thing that they're doing now and report it instead of the individual?

[Courtney Harness, Blue Cross and Blue Shield of Vermont]: Oh, have the pharmacy. I think that's a good question. I would say they're particular and it's not even a concern as much as it is an awareness that pharmacies are pretty overloaded, as they are, and have a number of responsibilities or duties that we've added on to them, particularly with some of the things that can happen at pharmacies. And those are all good things. To add to them the responsibility of having to mail in claims, one has a potential to create even more lag. So maybe they're collecting them. And again, this is speculation, but the pharmacy is collecting ArrayRx purchases and mailing them to a provider on a weekly or monthly basis. It slows down the process a little bit and probably doesn't make it as accurate as we'd like it.

[Rep. Francis 'Topper' McFaun, Vice Chair]: How does this happen now? Take my case. I have the state insurance, and every month I get a report about how much spending added on to my commitment. Sure. So that's a process that works flawless. It just happens and I know where I am and then all of a sudden I don't have to

[Courtney Harness, Blue Cross and Blue Shield of Vermont]: pay anything. Yeah, and to Chair Black's question, I think it's different because you're part of our plan. And so as you're receiving medical care attention or purchasing your prescriptions or drugs from the pharmacy, those things are automatically deducted because it's all connected. ArrayRx is not technically part of the Blue Cross Blue Shield plan. So how it would work, the mechanics of it, if you were to participate, if the committee decided that the savings should go towards the deductible, you would mail in a claim as soon as we get it. We would apply that to your deductible. And then in that monthly report that you get from us, you would see that as a line item. Does that help at all? Yeah, it does.

[Rep. Francis 'Topper' McFaun, Vice Chair]: Okay.

[Rep. Leslie Goldman, Member]: I just trying to think about a way. Certainly, if you want to add it.

[Courtney Harness, Blue Cross and Blue Shield of Vermont]: Yeah, I think that was to my earlier comment, and it's a great question. And the automatic deduction or the automatic application to the deductible becomes more complicated and complex. And I think our position would be, in an effort to not slow this down, potentially roll it out as is and allow, whether it's the treasurer's office in DFR and potentially with input from us, we'd certainly be willing to do that, navigate through a system that would potentially allow that to happen.

[Rep. Francis 'Topper' McFaun, Vice Chair]: And that's what BrightPurse is the one that does that.

[Rep. Alyssa Black, Chair]: You have an online clean reimbursement form. Seemed pretty easy. I'm on your website right now, going through putting in a pretty

[Courtney Harness, Blue Cross and Blue Shield of Vermont]: It could be easier. Yeah, that's for sure.

[Rep. Alyssa Black, Chair]: Pretty easy. Great. Well, Karen, well that was one question I had.

[Rep. Leslie Goldman, Member]: If had an option for submitting the claim, the online access that The

[Rep. Alyssa Black, Chair]: paper one and the online one.

[Rep. Leslie Goldman, Member]: You could do paper, could do online either.

[Courtney Harness, Blue Cross and Blue Shield of Vermont]: Yeah, again, I think that's probably a solution that we come to when we figure out a lot of things, whether or not this is applicable to a deductible and what the timeline is and once we get the full and complete wording of how the program will operate, then we have the opportunity to work with everyone involved to decide what the easiest pathway is.

[Rep. Leslie Goldman, Member]: But it sounds like you're supportive of the deductible being applied.

[Courtney Harness, Blue Cross and Blue Shield of Vermont]: Yeah, again, I think from our perspective, Vermonters need to feel some relief immediately. And I know that we've had discussions in past sessions about a variety of ways that that can happen, whether it's reference based pricing or otherwise. We think that ArrayRx is a really good way for people to feel immediate relief at a point of sale with goods and services. And from that perspective, we're supportive of it.

[Rep. Leslie Goldman, Member]: And just for clarification, earlier, you said the savings, but you mean what they actually paid. Correct. And then the 200,000 people that you do cover, remind me again who those folks are. Who are they? I mean,

[Rep. Alyssa Black, Chair]: what category of people? Vermonters.

[Rep. Leslie Goldman, Member]: But I mean, if they exchange, are they the ones, is it every state?

[Courtney Harness, Blue Cross and Blue Shield of Vermont]: Oh, the breakdown. Yeah, so state employees, so VSEA, BI, those are the two largest groups of folks that we cover. And then from there, it gets pretty scattered.

[Rep. Alyssa Black, Chair]: There's It's self insured. They're self insured. They exchange. Yeah,

[Rep. Leslie Goldman, Member]: correct. Supplemental, Blue Cross supplemental. Good question. Thanks.

[Rep. Alyssa Black, Chair]: See, I shouldn't have asked any questions. No, are great questions. Go ahead, Beth.

[Rep. Leslie Goldman, Member]: Okay, so I'm sorry, it's hard for me to wrap my head around this. Is the process the same, if I were to just go on the

[Rep. Daisy Berbeco, Ranking Member]: internet me thinking, okay, I don't want

[Rep. Leslie Goldman, Member]: to pay the full price for a prescription, and I see GoodRx, and maybe it's more of a discount, does it have to be recognized by you in the same way? Or is it the same process? Does GoodRx have to be recognized by Blue Cross Blue Shield?

[Courtney Harness, Blue Cross and Blue Shield of Vermont]: My understanding and I'll talk about ArrayRx. My understanding is that people have to opt in and participate in the program. And if they're plan members, yeah, it's recognized by us. And there's a variety of factors. So the thing that would make it most applicable would be in the question about the deductible of whether or not this goes to the deductible, then it would be plan members only because other people would obviously have a deductible with us. Does that make sense?

[Rep. Leslie Goldman, Member]: Yeah. So I couldn't have multiple prescription cards. You pick and choose.

[Courtney Harness, Blue Cross and Blue Shield of Vermont]: My understanding of how the language in this bill is that you would have to pick either or. Right. So you wouldn't I don't believe that you would be able to use some combination of discount cards at the point of sale. That's my understanding.

[Rep. Debra Powers, Member]: For the same prescription, but

[Courtney Harness, Blue Cross and Blue Shield of Vermont]: you

[Rep. Debra Powers, Member]: might use it for different cards for different ones. Thank

[Rep. Leslie Goldman, Member]: you. Great. Thanks Courtney. Welcome.

[Jeff Houghton, Executive Director, Rutland Pharmacy Group]: Thank you.

[Mary Black, Deputy Commissioner, Department of Financial Regulation]: Nice to have you for

[Rep. Leslie Goldman, Member]: the first time.

[Courtney Harness, Blue Cross and Blue Shield of Vermont]: Yeah, thanks very much. Can't wait for the

[Rep. Leslie Goldman, Member]: next one. I was gonna say.

[Rep. Francis 'Topper' McFaun, Vice Chair]: I'll see you soon. Okay.

[Rep. Alyssa Black, Chair]: BFR, Department of Financial Regulation. Mary, I think, is joining us via Zoom. And Joe's Joe, you're here, but you're not testifying. No. It's Mary. Hi, Mary.

[Rep. Leslie Goldman, Member]: Excuse me. Sorry. I couldn't

[Mary Black, Deputy Commissioner, Department of Financial Regulation]: be with you, but I seem to have picked up one of the many bugs going around and didn't wanna share my germs with all of you.

[Rep. Alyssa Black, Chair]: We thank you for that.

[Mary Black, Deputy Commissioner, Department of Financial Regulation]: It is a small room. So, you know

[Rep. Francis 'Topper' McFaun, Vice Chair]: So small.

[Mary Black, Deputy Commissioner, Department of Financial Regulation]: Oh, for the record, Mary Black, deputy commissioner of the Department of Financial Regulation. We also support the bill. We think, like Blue Cross does, that this is another way that, you know, Vermonters can get some relief and and feel like every place that we can figure out a way to get some relief is is a good thing. We have had conversations in the past with Oregon and Connecticut about sort of how this played out for them. And it seems to be working well for them. I think the uptick uptick is always the issue, right? I literally while I was listening to testimony the other day was texting my sister-in-law who's in Connecticut and saying, do you use this? And she doesn't. So, you know, I I I said something to her and and so I think the uptake's going to be the big thing. The deductible issue is, you know, it it it can be a pain point. I was remembering during COVID when people could go to the pharmacy and buy a COVID test and then send the claim to their insurer to get payment back. You know, there were lots of pain points in that process. People forgetting to send it in, not having the documentation needed to send it in, and then, you know, six months later wanting to get credit. And so there's lots of pain points that can occur in that process, but we'll just have to figure it out. Connecticut has language now, as as Courtney said, they they rolled it out first without the deductible piece and then later came back and added the deductible piece because it takes a little bit of time, I think, to to figure out how to make that work as easily as possible. I don't think it's gonna be easy regardless because, you know, it's voluntary. Right? We're gonna have to rely on insurance to to make take that step to notify and then and then the insurers will process. But other than that, you know, I know, I think Jeff is testifying from a pharmacy perspective after I have no idea what the impact on the pharmacies are with respect to this. So he can he can give you that perspective. But from our perspective, we very much support it and support it being counted towards the deductible.

[Rep. Alyssa Black, Chair]: So the current language that we have around discount cards and PBMs, do you think that that language is sufficient for this or do we need to incorporate something else to ensure that it covers this for deductible?

[Mary Black, Deputy Commissioner, Department of Financial Regulation]: It would be clearer if we added language. Yes. That language is, you know, can be a little circuitous and, you know, is left open for interpretation, doing some clear language like Connecticut did would be the safest way to make sure this is clear to everyone that this is how it needs to operate.

[Rep. Alyssa Black, Chair]: Would this extend just to qualified health plans or what about ERISA plans since we don't really have any control over them?

[Mary Black, Deputy Commissioner, Department of Financial Regulation]: So the card extends anybody can use the card. Whether the ERISA plan is willing to count it towards the deductible, I think is probably up to the plan itself.

[Rep. Leslie Goldman, Member]: Okay.

[Mary Black, Deputy Commissioner, Department of Financial Regulation]: I don't know that we can impact that because it's ERISA, and we're not allowed to sort of impact the benefit. Okay. But they certainly would still be able to use the card.

[Rep. Alyssa Black, Chair]: Okay. But by adding language, it would really just be extended to qualified health plans. It wouldn't.

[Mary Black, Deputy Commissioner, Department of Financial Regulation]: Yeah, and anything else that sort of we have jurisdiction over. Which

[Rep. Alyssa Black, Chair]: would be MedSup.

[Mary Black, Deputy Commissioner, Department of Financial Regulation]: MedSup.

[Rep. Alyssa Black, Chair]: Or Part D, I should say. The

[Mary Black, Deputy Commissioner, Department of Financial Regulation]: state plan. The state employee plan. Yeah, teachers. But the only

[Rep. Alyssa Black, Chair]: ones that wouldn't apply to would be the self insured, or not state funded.

[Mary Black, Deputy Commissioner, Department of Financial Regulation]: Yeah. The yeah. The ERISA funded ones that those those become more difficult. And I I haven't done any analysis to to to verify that, but usually that's the hiccup is the the ERISA plans with of ERISA gets in the way of us getting them to do things.

[Rep. Alyssa Black, Chair]: Okay. Go ahead, Leslie. Thank you.

[Rep. Leslie Goldman, Member]: I was wondering if we could get written testimony both

[Rep. Debra Powers, Member]: from DFR and Blue Cross documenting their support so that we have that in our chain of testimony. That would be great. Doesn't have be fancy, but just that we heard from you and you support it.

[Rep. Leslie Goldman, Member]: Yep.

[Rep. Alyssa Black, Chair]: Oh, go ahead. Wait, I've got Allen, and then I get

[Rep. Allen "Penny" Demar, Member]: the stop there. Thank you. I'm not sure if it's under Department of Financial Regulations, but I support this bill. I have a concern with a couple of things. Number one is the fact that anybody from another country, another state, could qualify for this by just giving their date of birth and a address. Do you have any types of concerns over that?

[Mary Black, Deputy Commissioner, Department of Financial Regulation]: I hadn't thought about it, to be honest. It is an interesting thought. My real question is, what's the impact? So we, I, I have to think about it. We'd have to think about that one, about whether, and, and we can certainly ask or have the treasurer's office ask the other states whether they've run into those situations.

[Rep. Alyssa Black, Chair]: Thank you. Would it be accurate to say that the more states and the more people this applies to, that probably the better negotiating power with drug manufacturers for lower prices would be?

[Mary Black, Deputy Commissioner, Department of Financial Regulation]: Yeah. Usually, those economies of scale definitely apply in drug manufacturer space, so it gives us more bargaining power. And it wouldn't cost Vermonters anything. It's not costing anyone anything other than the user. Yep.

[Rep. Leslie Goldman, Member]: My

[Rep. Francis 'Topper' McFaun, Vice Chair]: question is, how does this apply to other insurance like this is going to be a blanket thing, isn't it? For anybody. Anybody can use the card, I am talking about being added to the deductible.

[Rep. Alyssa Black, Chair]: So right now it would affect our qualified health plans, which are offered by MVP and Blue Cross Blue Shield. It would be our self funded state plans such as the teachers, the state employees, municipal employees, although I'm not sure if they are actually on that. Is Courtney still here? Would it apply to the federal Blue Cross Blue Shield workers?

[Courtney Harness, Blue Cross and Blue Shield of Vermont]: What I understand, it would apply to anyone in the state.

[Rep. Francis 'Topper' McFaun, Vice Chair]: It

[Rep. Alyssa Black, Chair]: doesn't really apply to Medicaid because they have $1.02 dollars $3 co pays and it would apply to any Medicare Part D prescription drug.

[Mary Black, Deputy Commissioner, Department of Financial Regulation]: Not Medicare Part D. We don't have jurisdiction over Part D.

[Rep. Alyssa Black, Chair]: Oh, we don't.

[Mary Black, Deputy Commissioner, Department of Financial Regulation]: We jurisdiction over MedSup, but not Medicare Part D.

[Rep. Leslie Goldman, Member]: Goodness. Okay.

[Rep. Alyssa Black, Chair]: So if someone had Medicare Part D through, I would throw out, like UnitedHealthcare, then they would not be required to apply this to someone's deductible?

[Mary Black, Deputy Commissioner, Department of Financial Regulation]: I don't think so.

[Rep. Leslie Goldman, Member]: But it Yeah. Could be used for Part D? But it can be used. It could be used.

[Rep. Allen "Penny" Demar, Member]: Yeah, use it. Anyone can

[Rep. Francis 'Topper' McFaun, Vice Chair]: use I'm just talking about being applied to it.

[Rep. Leslie Goldman, Member]: Because that's Medicare. Thanks,

[Rep. Alyssa Black, Chair]: Mary.

[Rep. Leslie Goldman, Member]: You're welcome.

[Rep. Alyssa Black, Chair]: Appreciate you not coming in today, but we appreciate you being here available for us.

[Mary Black, Deputy Commissioner, Department of Financial Regulation]: That's what everybody keeps telling me.

[Rep. Alyssa Black, Chair]: Feel better. Yes. Alright, thanks. Great. So we've got Jeff Houghton. Is Jeff here? It's confusing to me because unless someone's There you are, Jeff. Unless someone's on camera, you don't even really know if they're in the waiting room before. Nice to see you.

[Jeff Houghton, Executive Director, Rutland Pharmacy Group]: Nice to see everybody, too. Thank you. Thank you for the invite. For the record, Jeff Houghton, Executive Director of the Rutland Pharmacy Group. So I've been listening to some of the testimony only briefly today, but I did look at some of past stuff. I went through the slide deck that was presented, and I even spoke with the array folks. And I do have a lot of concerns. And I'd like to pose this in a form of kind of a question to the committee members. How exactly does this pooling negotiate prices down from the manufacturer that the pharmacy who pays those acquisition costs from the wholesalers realizes? Yeah. So the reality is is this the coupons do nothing to affect the direct price that pharmacies can purchase pharmaceuticals, thereby turning around and lowering the price. Now, arguably, this is really just the same old song and dance that we've seen time and time again. This is a PBM. Navitas is a long existing PBM, not immune to some of the criticisms that have played out over the last decade. They still use an antiquated reimbursement methodology of MAC plus a very low dispensing fee. The example given where think simvastatin, they had the the normal retail price of excessive of $30 for a thirty day supply. I sell ninety day supplies for less than 20. So it's not real. Those numbers were kind of put in there, I think, based upon what I think this community well knows is the AWP, the eight months paid. And because all contracts, including the contract with Navitas, is based upon this AWP methodology. But the reality is the only one benefiting from potential savings directly from manufacturers by pooling together state markets in this fashion, is any pharmacy affiliated directly with Navitas, I. E, their owned mail order pharmacy or their partnered specialty mail order pharmacies. It does not drive the cost down for me and my pharmacy locations. All it does is squeeze my margin potential, Potentially really just making me further underwater as we already are. How many of the committee members actually have a pharmacy still in their communities? How many have lost one over the last year? There are five Vermont owned independent pharmacy groups in the state. We have 11 independent pharmacies. The rest are chains. Out of state pharmacies, mail orders. Those chains are closing their doors. Entire market on this side of the aisle, and I've always described pharmacy as the front lines between capitalism and social welfare. We're retail commerce. I'm not a health care provider. We are retail commerce. We're based upon the fluctuations of the markets. And what's happening is is with all the pressure put on PBMs of late that and this committee is very much a part of that, and we thank you very much because it's well overdue. Everyone's realizing it needs to change. Those MAC prices, those those reimbursement caps that everyone sets really just drives the reimbursement rate right down to actual acquisition costs. So margins within the entire industry are just getting squeezed and squeezed and squeezed and squeezed as everyone then tries to reshuffle and say, how do we do this? What's the real leverage we're trying to get? We're trying to drive prices down directly from manufacturers to patients, but we're bypassing the pharmacy acquisition. We're bypassing the wholesaler acquisition. Those are the actual delivery models of of of the product itself that the retail and the commerce side play on. This whole insurance and price capping, all it does is obfuscate the real price to the consumer, but it does lower the the out of pocket expense to average consumers, which is definitely necessary. We need to do that. But is that going to change the actual cost of the price and therefore the effect it's going to have on the overall premiums? Answer is no. You know, we put up the federal government put in a price cap for $30 for insulins. Did that change the price of insulin? No. It was still the same cost to me. I still had to buy insulin at the same price, but the out of pocket cap and the requirement of insurers to ensure that patients and beneficiaries don't pay more than that was imposed and that was a saving grace for the patients. But it didn't change the cost of the med. That is a completely different animal.

[Rep. Alyssa Black, Chair]: Can I interrupt just a minute because I'm a little confused and maybe maybe you can put this in context for us? So for your example, I think you used simvastatin, right? Okay. So if I have Blue Cross Blue Shield of Vermont and I have simvastatin.

[Rep. Francis 'Topper' McFaun, Vice Chair]: I

[Rep. Alyssa Black, Chair]: want my ninety day script. I go to my Rutland pharmacy and you're there and Optum, which I believe is the PDM for Blue Cross Blue Shield,

[Jeff Houghton, Executive Director, Rutland Pharmacy Group]: how

[Rep. Alyssa Black, Chair]: much would someone pay for a ninety day prescription and how much would you receive of the amount that they're paying? Are you getting the full amount and that is your profit over your acquisition price? Or are you only getting, how much are you getting out of this? That's what I'm not getting.

[Jeff Houghton, Executive Director, Rutland Pharmacy Group]: Sure, pharmacies get the reimbursement structure, but it's in two forms, right? So whatever your plan is with Blue Cross or MVP or whatever insurance carrier you have, even Med D, you know, we're gonna I'm gonna process the claim through my system. It's gonna go out nine out of 10 times. It's gonna be based on the same methodology that has and says, okay, it's gonna be this is the MAC price of the drug, which is really my acquisition price of the drug, plus a 30¢ dispensing fee. I'm gonna get maybe 3 to $5 for a prescription that I mean, the the ingredient cost is probably a dollar. But that 3 to $5 that I'm gonna get for that prescription isn't even gonna cover the cost of the labels that go on it. It's not going to cover the cost of the staff. It's not going to cover the cost for a pharmacist to review and make sure this medicine isn't going to kill you. Now Medicaid operates on what's called a true survey, a true cost plus modeling, Right? Medicaid does a survey, and they recently did one, although I think it's still pending results. But Medicaid does a survey to all the pharmacies and says, what is the cost to produce a prescription? What are the costs for your insurance? What's the cost for your labels, your vials, the computer equipment? The transactional fees that I think this program stated, oh, there's no transactional fees. Those are those are just built into the system. They're built into the pharmacy contracts. I pay transactional fees to the insurers every time I process a claim. Every time I process to CVS or Optum, it's 10¢ that I send out the door whether the claim goes through or not.

[Rep. Alyssa Black, Chair]: I think what I'm trying to ask, though, is that it's no difference for you. And I realize that you don't think it should be this way, but it currently is this way, which is not what this bill is dealing with, you're being reimbursed from Navitas in the exact same methodology that you are currently being reimbursed by the PBM, this bill doesn't change that. It just makes it less expensive for the out of pocket for the consumer or the patient.

[Jeff Houghton, Executive Director, Rutland Pharmacy Group]: But all you're doing is eliminating the cash. You're giving a benefit to all cash customers and just creating a nexus there. Correct. You're absolutely right. This does nothing to really change anything. That's the the real both bottom line point is that this these coupons do nothing to change an already failed system. It will not impact Vermont in any substantive way. The number of cash claims and cash customers we have from actual Vermonters is very, very low. We have a very high coverage rate in this state. The cash customers we see typically are on usually, quite frankly, controlled substances or compound medications, which are not covered by insurances. So are we just gonna offer a cash discount for all controlled substances? That doesn't matter. It's it's not gonna I I I'm just my point being is that you can do this. And I I I support the committee doing and going down this road because I think the concept of pulling together states and their market power to create leverage upon manufacturers is the absolute correct goal. This just fails because it doesn't actually can't negotiate or change anything within negotiation structures with manufacturers. All this does is set the price and set price limits at the retail level.

[Rep. Alyssa Black, Chair]: I have one question. Daisy has a question, but I have a comment, which is, you you said something, it does nothing to fix a failed system, but I think that and you work in healthcare, I think a lot of people would recognize that almost every single thing we do is setting policies to mitigate the damage of a failed healthcare system. We do this in every single and I share your frustration. It shouldn't be this way, but it is this way correctly. One question is that because people would be using this discount, they have a choice of either getting it through a mail order through Navitas, which would imply that they would then have to keep changing which mail order pharmacy they use depending on whether or not they want to use this discount as opposed to their insurance. Wouldn't you think that actually if people could get such a deep discount in their out of pocket that it might actually drive them to say, I'm going to run over to my Rutland pharmacy and get it, this prescription, and then I'll have my other stuff mail ordered, which actually could increase your or any independent pharmacies or you don't think it would increase the people using in person rather than mail order?

[Rep. Leslie Goldman, Member]: No.

[Jeff Houghton, Executive Director, Rutland Pharmacy Group]: Although I would argue that that every Vermonter needs to prepare for going mail order because I think there's a premise here that pharmacies are solvent. Pharmacies are not. We are all in dire straits and ready to close our doors. Rite Aid was the first one. Walgreens just took private equity last year. They're gonna be shuttering doors. Several independents closed last year. But back to your quest your point, this doesn't drive business my way. My my point is quite the opposite. When people walk into my stores and they say, hey. I have a GoodRx coupon card. I look at that, and I know right off the top of my head that I can beat that price, and I do. My cash prices are already lower than most of these cards. A lot of these discount cards operate in a functionality where they do those negative clawbacks. They'll charge you $50, take $25 back from the pharmacy in a negative reimbursement because the MAC price of the drug is $25. Okay. Now Navitas coupon does not do that, but this is the historical model and subject to a lot of litigations that are going on federally. As a matter of fact, federally too, there's a current bill in place about making sure that PBM contracts are sustainable, that they are appropriate reimbursement rate methodologies. And hopefully that does pass as part of the spending bill. But I guess all going change of everything. So you're right. None none of this is really gonna change anything. That's that's the real point. It it doesn't. And and we're looking at it the wrong way. We keep looking at it as and I this is the question that I ask. How does changing the price at the retail level for consumers by utilizing this, you know, insurance price setting scheme? How does that drive the price down from the manufacturers? How does that create actual leverage? That's the question I pose to the committee because it truly does not, in my opinion.

[Rep. Alyssa Black, Chair]: I think that we've learned that five seventy seven does not fix our broken health care system. What it does is it makes the out of pocket costs for a family on a Browns plan who now has a $10,500 deductible. It makes it a little bit less for them. Do you No, have

[Rep. Daisy Berbeco, Ranking Member]: I think you just made my point. I just completely disagree that this doesn't do anything. I think my goal in this bill is to help Vermonters have more choices in how and where they get their drugs and what they spend their money on. And this allows them that. That is the issue that is plaguing every home in Vermont. And so I really invite, sincerely, whatever recommendations you have for a policy that will address the issue that is facing pharmacists today. But at the same time, I want you to know that as a health care leader in this state, I am not going to entertain status quo. We can't afford it anymore, and I would love to have your thought partnership and how we can address what's happening to pharmacies, But we have to think outside the box and we have to welcome giving households more affordability and more choices.

[Rep. Leslie Goldman, Member]: I think this bill does that.

[Rep. Alyssa Black, Chair]: Yeah. And I ask you to testify on May and more than happy to have you testify on what we can do to support pharmacies, but that's not this bill. I guess I would just ask that you keep your comments to five seventy seven. Karen and then Topper.

[Rep. Leslie Goldman, Member]: Thank you. First of all, agree with Chair Black and Representative Berbeco in terms of the focus of this bill and what it does accomplish. I have two questions for you. If I come to the Rutland pharmacy, we used to have Marble Works in the Middlebury area, the most wonderful pharmacy, and we're sad that it isn't there anymore, but gladly Rutland has you. If someone shows up with RA Rx, but you can do that, do you advise the customer at the and say, that's nice, that's well and good, but you could also do this other thing and save some more money? Is that something you do at point point of of sale or not? I was curious how that actually worked.

[Jeff Houghton, Executive Director, Rutland Pharmacy Group]: All the time. We always advise customers and patients, is it cheaper through your insurance or is it cheaper cash? Because that's real. That that truly happens. We actually advocate that to businesses because businesses ought to be looking at their insurance plans as to what they're actually paying for. When there's preferred brand name drugs over cheaper generic alternatives that are, again, just driving up the actual premium dollars as opposed to the actual out of pocket dollars. That's all built into this whole mechanism.

[Rep. Leslie Goldman, Member]: That's great. The other question I had on this bill is some of the testimony we heard was that it is private or small pharmacy friendly. And I'm just wondering, is there anything that you see that is helpful? I'm just curious. Is there something pharmacy friendly about this or not? I didn't sound like it, but from your perspective, but I wanted I know that it's consumer friendly, but I just was wondering because we heard testimony to that effect.

[Jeff Houghton, Executive Director, Rutland Pharmacy Group]: Yes. Now, it's friendly in the shape that, again, I had the chance to speak with the consortium and those folks there. And in that respect, it's beneficial. It's adding a voice to what I think is playing out right here where it's we're not given the time. We're not given the opportunity to really dive into where is the actual leverage points in this industry. You know, everyone throws up prescription drug prices as a driver for health care, but no one knows what the real costs are. No one wants to dive into that. That is what is necessary. And those folks have been added a while. I know many of them personally especially over in Oregon, a lot of the pharmacy leaders out there. So they've been at it.

[Rep. Allen "Penny" Demar, Member]: And

[Jeff Houghton, Executive Director, Rutland Pharmacy Group]: understanding the PBMs have been kind of doing this shell game for a long time. This is the same kind of modeling. When I spoke to Array, they recognize that it falls short of doing the cost, utilizing the NADAC plus language that is being instituted across the country that's subject to the federal discussions at hand. So it's progressive in its thought, just not hasn't gotten on any off the ground yet. Speaking to other pharmacy providers in Connecticut, who I think Connecticut Comptroller was testifying, They're not a fan of it. They'd rather see a discount card program. And there are other discount card programs, and I recommend investigating them, that utilize true cost plus methodologies. The cost plus model from Mark Cuban. He was a very successful businessman that has recognized where the games are actually being played out and creates a similar discount card that is more sustainable in its application to the existing infrastructure of health care delivery, I. E. Pharmacies. That's what needs to really kind of be vetted.

[Rep. Alyssa Black, Chair]: Lori, I think Lori has a question.

[Mary Black, Deputy Commissioner, Department of Financial Regulation]: Actually, don't have a question.

[Katie McLean, Office of Legislative Counsel]: Just have a statement. So Jeff, I appreciate your testimony and joining us. And you're a frequent person that we have come in and testify had done that for two previous chairs have always brought you in. And I think I just want to respectfully say we have done a lot in this committee to take testimony on pharmacies, pharmacy benefit managers, the true cost of drugs. We are doing what we can at our level to impact the price to consumers, which is what this bill is about, and at the same time pass legislation that will help pharmacies and make an impact.

[Rep. Lori Houghton, Member]: It is complicated, as you know, but I just feel like your statement that we're not allowing that testimony here is not accurate. I just wanted to put that on the record. Thank you.

[Rep. Alyssa Black, Chair]: Thank you. Thanks, Jeff, for joining us. We do appreciate your perspective. That's why we asked you in here. And we do look forward to having more conversations. Obviously, I mean, we have had these conversations or else I wouldn't know what things like whack and that mean.

[Rep. Daisy Berbeco, Ranking Member]: I wrote them down and hooked them up. And

[Rep. Alyssa Black, Chair]: also why we miss Marie Cordes so deeply in this committee. And we will have you in on this. We will talk more about this prescription drug and the sustainability of our pharmacies, a vital, vital cog in our healthcare within our communities and an important resource for everyone for Vermonters. We understand that. And we will have you back when we discuss those things. Thank you for your testimony today. Really appreciate it.

[Jeff Houghton, Executive Director, Rutland Pharmacy Group]: Thank you for

[Courtney Harness, Blue Cross and Blue Shield of Vermont]: having me.

[Rep. Allen "Penny" Demar, Member]: John. You had a good year.

[Rep. Alyssa Black, Chair]: So We're done yet? Yes, I think we're done for the morning. Sorry, it's for planning. So you get a long, long lunch