Vermont Legislature SmartTranscripts:

[Rep. Alyssa Black (Chair)]: So we're going to do a walkthrough on sixeleven, which we heard about last week? This week, last week. Week.

[Maria Rossi (Doula Association of Vermont)]: Tuesday, this week. Thought

[Rep. Alyssa Black (Chair)]: it was this week. The architect advised me that today was Thursday. I thought it was Wednesday. Sorry, there's a bunch questions. Oh my god. 06:11. Right. Ready for walk through? Ready for walk through.

[Jen Carvey (Office of Legislative Counsel)]: Great. Good afternoon. Jen Carvey from the Office of Legislative Counsel, and I will put the language up on the screen. I know you've already started to take a look at it.

[Rep. Alyssa Black (Chair)]: Hopefully, you exactly what it says.

[Jen Carvey (Office of Legislative Counsel)]: Alright. H six eleven is an act relating to miscellaneous provisions affecting the Department of Vermont Health Access. It starts out with some language around prescription drug cost transparency. This is an existing statute that requires health insurers to provide certain information about, to create lists of drugs that have experienced significant price increases and report those to the Green Mountain Care Board, I believe, and attorney general's office. The attorney general's office does some investigation. You get an annual report. I think they haven't been able to find out as much information as was originally anticipated. So the first thing this does is add a definition of health insurer. As a health insurer, sort of our standard broad definition, but with more than 5,000 covered lives in this state for major medical health insurance, and it does not include Vermont Medicaid. And then it strikes the requirement as it relates to the Department of Vermont Health Access that they annually create a list of 10 prescription drugs on which the state spends significant health care dollars and where the wholesale acquisition cost has increased by 50% or more over the past five years or 15% or more during the previous calendar year, at least one brand name, at least one generic, which indicating with drugs or specialty drugs. This whole requirement would go away as it relates to DIVA and the Medicaid program. It would maintain the requirement for health insurers with more than 5,000 covered lives and just moves that definition of health insurer to the beginning of the section. So again, taking out all references to DIVA and the provisions that specifically relate to DIVA's responsibility and the drugs and Medicaid program.

[Rep. Alyssa Black (Chair)]: I'm just trying to understand what the change is in a sentence or two, like when they took out all this language. What you're saying is they're removing DIVA as any mention of DIVA.

[Jen Carvey (Office of Legislative Counsel)]: Right. They're eliminating the requirement that DIVA provide the list of drugs in the Medicaid program for which the price has increased significantly over the recent past. And that list goes to the attorney general and the Green Mountain Care Board. The attorney general's office is

[Unidentified Committee Member]: supposed

[Jen Carvey (Office of Legislative Counsel)]: to dig into some of the details with the manufacturers, and Diva is asking to have Medicaid and Diva no longer part of that requirement.

[Rep. Alyssa Black (Chair)]: Do we know why? Or do they have to come and talk about it?

[Jen Carvey (Office of Legislative Counsel)]: I assume they would tell you.

[Rep. Alyssa Black (Chair)]: I don't think you've heard me. Talked about this last week. How would the attorney general then, if we're not striking out the attorney general stuff, how would the attorney general procure this information that they're supposed to?

[Jen Carvey (Office of Legislative Counsel)]: They'd still be receiving lists from the health insurers with more than 5,000 covered lives. They just wouldn't be doing

[Rep. Alyssa Black (Chair)]: Medicaid. Got it.

[Jen Carvey (Office of Legislative Counsel)]: And I will defer to Debra to tell you why. Next, we have some changes to the composition of the Medicaid and Exchange Advisory Committee. So right now the language is a federal requirement that we have a Medicaid and Exchange Advisory Committee or advisory committees, and we've combined them. In our existing law, the Commissioner of Vermont Health Access appoints the members. The total membership is at least 22 members. And this would add language specifying that it must include individuals who are also members of the Beneficiary Advisory Committee required by federal law. And I believe it is a requirement under the federal law, although I defer to do that, but that these people who are on the beneficiary advisory committee also be on the Medicaid and exchange advisory committee. So this is, I believe, carrying out a federal requirement. And it deletes language allowing the commissioner to reappoint members to serve more than one term. I don't know the rationale for why that's in there. This is clarifying some of the language around some of the members of the advisory committee. So a quarter of the members have to be from different constituencies. We've got beneficiaries of Medicaid or Medicaid programs. Currently, says individuals, self employed individuals, health insurance brokers and agents, and representatives of businesses eligible for or enrolled in the exchange. And this would change it instead to representatives of those eligible for or enrolled in qualified health plans such as and then individuals, self employed individuals, health insurance brokers and agents, and small business owners. So representatives would apply to all of them as opposed to it having to be those individuals and brokers and agents themselves. Okay. Let's take the numbers.

[Rep. Alyssa Black (Chair)]: Okay.

[Jen Carvey (Office of Legislative Counsel)]: Section three is on reflective health benefit plans and this deletes the reference to registered carriers offering reflective plans to employers of small employees if the federal cost reduction payments are eliminated. Doesn't seem to be anybody from. Yes. Reflective health plans. Okay. They believe this is a technical fix. Since the small group market is separate from the individual market, small employers and their employees don't need reflective plans because small group coverage doesn't affect federal subsidies. The loaded premium issue only applies to individual market plans. So they're picking up a reference to small employees. Employees of small employers here because they would not be purchasing reflective plants. Section four modifies the membership of the Clinical Utilization Review Board. So the first is just some cleanup language that I think I put in here. We no longer need to say not later than sixteen years ago, fifteen years ago. And they're not no longer creating. They're just maintaining this board. Deva wanted to add or or add the potential for more members. So right now it says the board shall comprise 10 members. This would say it shall comprise a minimum of 10 members. It cleans up the reference to the title of the chief medical officer at Diva, which used to be, I believe, medical director. It allows instead of requires the terms to be staggered and gets rid of some language about initial meetings.

[Rep. Alyssa Black (Chair)]: This is the board that decides what they're going to cover, how they're going to cover it.

[Jen Carvey (Office of Legislative Counsel)]: The advice. Right. Advisory. Yep. So they advise their medical professionals. They recommend coverage and changes to the the the Diva leadership. And it sounds like they're looking for ways to increase membership and participation, but it's currently capped at 10 or set at exactly 10 members. They're also concerned about the existing language creating barriers to members serving staggered terms because it requires them to be staggered. Not sure how that necessarily makes a a difference, but but can tell you why they're asking for it.

[Rep. Alyssa Black (Chair)]: We don't need the language about the first six months. Exactly.

[Jen Carvey (Office of Legislative Counsel)]: So I'm just doing some cleanup while we're in there.

[Rep. Alyssa Black (Chair)]: Exactly. On

[Unidentified Committee Member]: page nine, line nine.

[Jen Carvey (Office of Legislative Counsel)]: Line nine, yes.

[Unidentified Committee Member]: I think I heard you say that it was capped at 10.

[Jen Carvey (Office of Legislative Counsel)]: It was currently set at exactly 10. This would

[Unidentified Committee Member]: And this changes it to a minimum.

[Jen Carvey (Office of Legislative Counsel)]: To a minimum of 10, right. 10 plus. Right now it's just 10. Yes. I did say cap. That was a misstatement. Leslie? So one of

[Rep. Alyssa Black (Chair)]: the conversations that came up the other day, now that I'm remembering, was should there be an upper limit? It says minimum of 10, but that can be 100. That was just a question that came up.

[Jen Carvey (Office of Legislative Counsel)]: I think if there's concerns about the size of it, particularly if people are receiving compensation and there may be a cost, you could certainly put a cap on it.

[Rep. Alyssa Black (Chair)]: Do we know if the members of this board receive like a per diem or a

[Jen Carvey (Office of Legislative Counsel)]: I mean, generally, anyone who's not being compensated by their employer for their participation is entitled under 32 VSA ten ten. So if these folks are not are meeting in evenings or or off hours not part of their workday serving in their individual capacities, then they may be receiving per diem and reimbursement of expenses.

[Rep. Alyssa Black (Chair)]: I'm just wondering if there's some parallel, if I may, board or something that language might exist as a minimum or an upper limit or is this where I think

[Jen Carvey (Office of Legislative Counsel)]: it's really, I mean, anything you want to set it at, we can set it at. We can say not fewer than 10 nor more than 15. I mean, how you know, however you wanna say it, we can express it.

[Rep. Alyssa Black (Chair)]: I don't wanna hear from Viva, I guess, or the you know, whoever whoever's the leader of Curve.

[Jen Carvey (Office of Legislative Counsel)]: Yes, and CURB did just recently submit their annual report. You can find that on the legislative reports page, I think it lists the members there.

[Rep. Karen Lueders (Member)]: Would there be a number of how many times they meet a year?

[Jen Carvey (Office of Legislative Counsel)]: There is not. Mean, they are required to meet it under existing law and not changed here at least quarterly. And there was some requirement that they meet monthly, at least monthly when they first started up. But I'm not sure. Trying to convene that many health care professionals at one place at one time or but would allow for very frequent meetings, but I don't know how frequently they meet. But that's a good point as well. That affects would affect per diem. So you may wanna hear from Diva about per diems meeting frequency and upper limit. Section five is making an increase to prepaid burial arrangements for Medicaid eligibility purposes. And this, says subject to approval from the Centers for Medicare and Medicaid Services, the Agency of Human Services shall amend its rules and procedures that allow Medicaid applicants and recipients to preserve monies for funeral and burial expenses to increase from 10,000 to 15,000, the limit on the amount that can be preserved through an irrevocable prepaid funeral arrangement, which is regulated in our funeral directors' statutes, provided that, and there's a couple of requirements. The written contract for the arrangement as described in statute includes a provision specifying that Vermont Medicaid shall receive all amounts remaining after payment of the deceased individual's expenses up to an amount equal to the total Medicaid amount paid on behalf of the deceased individual. And in the event that the person responsible for making the funeral arrangements for the deceased individual fails to have funeral services provided after the retention of assets by the funeral director as set forth again in the funeral director statutes, Vermont Medicaid shall receive all amounts remaining up to an amount equal to the total Medicaid amount paid on behalf of the deceased individual. I'm assuming you heard some about this the other day. This would increase a particular limit, but also make sure that Medicaid is standing first in line after payment of either funeral expenses or retention of assets as allowed to cover costs up to the amount that Medicaid paid on behalf of the deceased individual. This is sort of related to Medicaid estate recovery, I think, but specific to the prepaid funeral arrangement context.

[Rep. Alyssa Black (Chair)]: Can Medicaid or the state make themselves sort of the first beneficiary above a federal? Let's say you owe the IRS, typically the IRS would be the first paid. I don't know how that I can't answer that question. State law go above that and say, oh, no, no, it's gonna be Medicaid? In

[Jen Carvey (Office of Legislative Counsel)]: general, no. Federal law is supreme over state law. But I don't know how those would fit together. I think you would need to either talk to Yeah.

[Rep. Alyssa Black (Chair)]: And to be honest with you, I have no no inclination of going into 26 VSA.

[Jen Carvey (Office of Legislative Counsel)]: It's just the funeral director's dentures. It's not gonna speak to it either. It just tells you what a prepaid funeral arrangement is. Alright. And then subject to approval from CMS on the top of page 11, the agency's amended rules and procedures would apply to prepaid funeral arrangements entered into on or after 07/01/2027, so for fiscal year twenty twenty beginning fiscal year twenty twenty eight. Section six amends a provision that was passed by this committee and others last year directing DIVA to seek a state plan amendment from the Centers for Medicare and Medicaid Services to allow Vermont's Medicaid program to provide coverage for doula services. And that date in in last year's act was not later than July 1. Diva is requesting to push that out until 07/01/2028. It is a not later then, so it could be anytime between now and then, but it sets the deadline two years later.

[Rep. Alyssa Black (Chair)]: Don't know. Maybe this is a question more for Debra. When does the eleven fifteen waiver need to be renegotiated? I believe I've

[Jen Carvey (Office of Legislative Counsel)]: heard it's in effect for the '27.

[Rep. Lori Houghton (Member)]: Yeah, think they said '27 is the negotiation year maybe.

[Rep. Alyssa Black (Chair)]: So they'll be negotiating our entire 11/15 waiver in '27.

[Jen Carvey (Office of Legislative Counsel)]: That is my understanding.

[Rep. Alyssa Black (Chair)]: Is the state plan amendment like? State?

[Jen Carvey (Office of Legislative Counsel)]: The state plan is is both part of and not part of global I mean, the state plan is a piece of implementing your Medicaid program. Every state has a state Medicaid state plan. There are a lot of things that are required to be in a state's Medicaid state plan. But there's a lot of what happens with our waiver that is outside of the Medicaid state plan. And it's part of our waiver negotiation that isn't standard for every state or isn't part of sort of standard provisions that have to

[Rep. Alyssa Black (Chair)]: be addressed for every state. I'm just trying to think that if we're in the middle of renegotiating, we're spending a year renegotiating our eleven fifteen waiver, wouldn't the state plan also be sort of included in? I think that's a deep question. I know what the impact. I don't know how they interrelate to

[Jen Carvey (Office of Legislative Counsel)]: that level of detail about whether they open up the entire Medicaid state plan at that point or whether there are certain things that are sort of constants and only pieces get negotiated. Just don't know. Question for Debra. Yes. Section seven is just a conforming change for the change in Section six, which is pushing out the Medicaid coverage date for doula services to take effect on the later of 07/01/2028 or approval of the State Plan Amendment. And the remain and then keeps the same. And then this act would take effect on 07/01/2026.

[Rep. Alyssa Black (Chair)]: Questions for Chad. You don't remember recall the last time we had a technical update, a Diva technical bill.

[Jen Carvey (Office of Legislative Counsel)]: Diva housekeeping bill? Yeah. Diva housekeeping. We have one every year or two.

[Rep. Alyssa Black (Chair)]: I guess I blanked on them. Yeah, Allen. Do you know how many

[Rep. Karen Lueders (Member)]: certified billboards we have here now?

[Jen Carvey (Office of Legislative Counsel)]: I believe none. Don't think the program has been stood up yet.

[Rep. Karen Lueders (Member)]: But we did this last year.

[Jen Carvey (Office of Legislative Counsel)]: You did this last year and you directed had the certification program, I'll put the language back up on the screen, take effect on 07/01/2026. So it has not started. They have not started certifying anybody yet. And if you remember, certification program is voluntary. Only have to get certified. Somebody only has to get certified if they want to be eligible for, reimbursement through the Medicaid program so they can continue to provide doula services.

[Rep. Karen Lueders (Member)]: And then be certified to get to reimbursement.

[Rep. Alyssa Black (Chair)]: To get Medicaid, yes. So remember it was sort of in two parts where first we had to get OPR to set up the certification. Certification can start on July. And then at the same time, we had to have DIVA go in. We made it so that it has to be covered under Medicaid and DIVA had to go and get a state plan amendment. They had to modify our state plan amendment and they had until July to do that. And they're asking to push it out two years. I'm assuming I talked to you about some of that the other day as well.

[Jen Carvey (Office of Legislative Counsel)]: Perhaps was concerned about choosing the right time to approach CMS Yes. Request.

[Rep. Alyssa Black (Chair)]: Right. Oh, go ahead. Well, I'm just thinking, as you were mentioning about renegotiating our waiver, could we say that that just gets into the negotiation? I mean, what would be a process? How would that Well, having

[Jen Carvey (Office of Legislative Counsel)]: I think the extent to which the state plan is involved in the waiver negotiation process, which I just don't know because that's sort of a deep operational question. But the timing of this, not later than 07/01/2028, if it was the state plan is implicated in the waiver negotiations, they could seek the state plan amendment as part of that process. I mean, timing, I think works because they would have to have sought it by 07/01/1928 if you moved out the date.

[Rep. Alyssa Black (Chair)]: Because then I would worry, I don't know if this is legit, to worry that it could get overlooked in the negotiation of the new state plan and then, oh, oops, it's now '28 and we forgot to talk about it. Am I remembering that in the burial, to modify they the state, the SPA as well? Yes.

[Jen Carvey (Office of Legislative Counsel)]: They have to get approval from Centers for Medicare and Medicaid Services. So I don't know if is the same. I don't know if they have to amend the Medicaid state plan or not. Think they said it was a lower level. They just need approval to amend their rules and procedures.

[Rep. Alyssa Black (Chair)]: I just didn't know. I guess my question is how do we know

[Jen Carvey (Office of Legislative Counsel)]: how that is? These are good questions for Diva and I can't

[Rep. Alyssa Black (Chair)]: answer them. Yeah, I apologize everyone, I was not able to be here during Diva's testimony and I have not had a chance to go back and look, considering I didn't even know what day it was. Thank you, Jen. Yes. So I asked, know, obviously you remember, or most of us remember that we spent a lot of time on this very last year, and think Diva is acting for further delay on the bill we passed last year around coverage of doula services. I thought it would be important to have representatives from the doulas back, just to speak of this and get their thoughts on this extension. So, if you want to join us. I'm on next week's agenda, which is why I can't find anybody's No, no

[Maria Rossi (Doula Association of Vermont)]: problem. Thank you for allowing me the time to talk with you today. My name is Maria Rossi. I've been a doula for fifteen years, and I'm also a social worker. I work for Washington County Mental Health Services, where I coordinate a doula program there that is embedded in the designated agency that I helped develop about fourteen years ago. I'm here today providing testimony on behalf of the Dual Association of Vermont, a group which I co founded a couple of years ago as we were going through this Medicaid process. When I was here I was here last year when this committee took up the bill, Act 50, and it's really nice to see you all again. Thank you for having me, and we appreciate your support in getting that passed last year. I am here to share some potential concerns that we have about the delay in making Medicaid funding available for doula services. Doula services are an evidence based, cost effective service and are unfortunately out of reach for probably the majority of Vermonters, especially those families that stand to benefit the most. A little bit of background, the doula project out of Washington County Mental Health is one of four regional programs working to provide community doula supports to our most vulnerable Vermont families. We work with braided funding, so we access our resources within a designated agency. We also have various grants. All four programs are funded, at least in part, through a grant through the Department of Health and utilize the community dual model, which provides intensive, longer range support to at risk families. The emphasis is really on culturally congruent community based care to underserved individuals and families. Two of the programs, that would be Washington County Mental Health and NCSS, are well established, and there's two additional ones that are in the early building phases. It's really critical to understand that doulas provide nonclinical services to families, nonmedical services, interpersonal, person to person to support. Dual care is emotional support and often actually mental health support. Some data points to illustrate the importance of our work and just for you to wrap your head around what we're talking about. But in 2021, there was twenty twenty one Medicaid births in Vermont, so about thirty eight percent of total births at that time. Over forty years of research show us very clearly that doula care leads to a thirty percent reduced risk of labor reduction, twenty eight percent reduced risk of cesarean birth, and a fourteen percent reduced risk of newborn admission into the neonatal intensive care unit, or mostly usually known as an NICU. The doula's role in addressing perinatal mental health issues has really been promising in many recent studies, including one that Washington County did last year with UVM and Department of Health. Over the last eighteen months, some incredible work has gone into a very thoughtful and thorough process in implementing Act 50. OPR had worked hard to develop the professionalization of doulas who aim to provide Medicaid services. They worked collaboratively with DIVA, DAV, Duo Association, the Duo community, and other stakeholders to develop some draft regulations. Unfortunately, as the process was close to concluding in the fall, it was put on hold when DIVA indicated it would request an additional delay in seeking federal approval through the SPA, as I heard you guys talking about. This would delay delivery of services three years out. I think it's important to remember that when they opened the SPA, we still have another year before delivery of services was implemented. So opening it in 2028 would mean 2029 implementation. And originally, it was supposed to be opening in 2026, and we were aiming for a 2027 start date. In May, they asked for an extension, and that extended it to 2027 for a 2028 start date. So sometimes we keep talking about the years, and it's not just the year that it's not a switch. There's a process that comes after the request to CMS. So we've naturally been pretty disappointed that they're requesting this delay. And we understand that there are some political challenges in applying for federal approval and believe that this does not need to be a stop sign to all the progress that's been made. Unfortunately, Vermont has fallen behind in nearly the rest of the country on this issue. We started this process close to ten years ago. And all but four states are currently at varying stages of this process. Louisiana, Arkansas, Montana, and Utah are expected to start coverage this year. Just to give you some idea of the range of different kinds of states that are implementing coverage, By the 2026, our neighboring states, New Hampshire, New York, Massachusetts, and maybe even Maine, will have coverage. And so Vermont will really be especially in New England, as a state that doesn't offer that. Some states have already required private insurance coverage as well. We maintain that between projected cost savings from averted treatments, likely a very modest beginning take up rate, the cost of providing Medicaid coverage would be extremely small to the state. OPR has formed a working group with DAB, VDH, Diva, and some other stakeholders. And we greatly appreciate that collaboration and hope to work together to identify a path forward. If passed, the language in H611 could delay implementation for up to three years, if not longer. Given all the progress we have made in strengthening the profession and deepening positive relationships, we really don't want to lose the trust of the doula community in Vermont, as well as delay services to families by putting this work on hold for an additional two, three years. And we would like to explore ways to at least sustain the four existing programs. This would keep momentum and trust. And when federal approval is obtained, we'd be well positioned to expand services throughout Vermont. We're hoping for some creative conversations around that possibility. And while we continue to fully support and remain committed to partnerships, it is our hope that DIVA will agree to submit the SPA as outlined in Act 50 rather than an additional delay. Doctor John Kendall, a pediatrician and researcher, once said if a doula were a drug, it would be unethical not to use it. So we hope that, to not further delay providing access to this critical service to Vermont families any longer. Thank you. Happy to answer questions.

[Rep. Alyssa Black (Chair)]: You've outlined all the benefits. Have you is there

[Maria Rossi (Doula Association of Vermont)]: a financial analysis of what you see in the system when you do use tools and have those results? I don't have that number, but there have been many financial analysis done. So it's certainly something I'm happy to send to you. And I don't know if Diva did their own. I that might have been talked about, but I don't

[Rep. Alyssa Black (Chair)]: know if they have any. Yeah.

[Maria Rossi (Doula Association of Vermont)]: I can say that, for example, the WHO, the World Health Organization, recommends that countries and states don't have a higher than twenty percent cesarean rate. And in our program, the time we've been doing it, we've never had more than fifteen percent. That could although we're very small, right, and we're in a small state and all of that, I think that is reflected pretty consistently over time on all size cohorts and groups that are studied.

[Rep. Alyssa Black (Chair)]: Do you know of other states? I think there were eight states that took actions around Medicaid coverage last year. Do you know if any of those states have

[Maria Rossi (Doula Association of Vermont)]: So New Hampshire, I'm sorry, let you finish.

[Rep. Alyssa Black (Chair)]: I guess, have they been approved through their spas? I don't know

[Maria Rossi (Doula Association of Vermont)]: if I can't say for certain they've been approved or not. But I do know New Hampshire is one example of a state that's actually done so pretty quickly by comparison of other states. Their legislation was only introduced two years ago, maybe. And they're set to, as far as I know, unroll out this year. The same thing with Massachusetts. Massachusetts has had a really robust has done some really robust work. And they're starting to roll out this year as well. So I don't know exactly when their spas are submitted or anything like that, but I do know that they're set to begin.

[Rep. Alyssa Black (Chair)]: Yeah, I think I'm just trying to get a read on what states had to do this in 2025.

[Maria Rossi (Doula Association of Vermont)]: Yeah. Well, I assume that they had to do something if it takes a year's time for implementation. But I don't know that for certain.

[Rep. Alyssa Black (Chair)]: I going to ask you about that. Other questions? Oh, go ahead.

[Maria Rossi (Doula Association of Vermont)]: So, the dual services are throughout the pregnancy most part of your following? Yes, that's correct. Yeah, okay. And do

[Rep. Alyssa Black (Chair)]: the services kind of

[Maria Rossi (Doula Association of Vermont)]: parallel the amount that you would see

[Jen Carvey (Office of Legislative Counsel)]: your gynecologist?

[Maria Rossi (Doula Association of Vermont)]: No, they're much more. So typically, what most states have outlined and what we had discussed with DIVA and OPR and what we do, and what's being done currently in programs, is that it depends a little bit on the program. But it's at least 10 to 11 visits, and those can be used in any way that a family needs. So majority of people use a lot of those visits postpartum and have a couple of prenatal ones. But it might look different for different families for varying reasons. And for the programs that are embedded in a higher need in a designated agency, we don't have limits on how often we can see people. But that's really specific to being able to access designated agency services.

[Rep. Alyssa Black (Chair)]: Reminds me, you missed all the Doula stuff last year. It was great testimony, actually. Great! Thanks for coming. We'll have Diva back in with some of these questions. I just want to remind the committee of why we supported that legislation last year. Okay, so we're going to move back to five eighty three and or we're going to take a break, but we're going get back to five eighty three. Jen, you can actually say if you want. Yeah, okay. Sort of finish our walkthrough. Yesterday we made it all the way through the deaf and mute button. But I thought it would be important to have this walkthrough before we take our next diagnosis. And I think we'll have time to do the whole thing. Section one zero two. Alright.

[Jen Carvey (Office of Legislative Counsel)]: Hello again. Jen Carvey, Office of Legislative Council. I will put the language up on the screen. We are now looking at H five eighty three recently yesterday. Finished the definitions. So next, we get to prohibited transactions. This is a sub chapter on prohibited transactions that would prohibit certain listed transactions. The following transactions are prohibited. First, a transaction that would give a party ownership of the core business operations of an essential community provider. As defined in federal law. So an essential community provider.

[Rep. Alyssa Black (Chair)]: It's

[Jen Carvey (Office of Legislative Counsel)]: a federal definition. It's a provider who mainly serves low income medically underserved people. It includes things like providers under the 340B that qualify for the 340B drug pricing program, federally qualified health centers, critical access hospitals, disproportionate share hospitals, which I believe is all of our hospitals, although I will look to the hospital association. Thank you. So yeah. So FQHCs hospitals, family planning clinics, things like that are central community providers under the federal definition. So a transaction would give party the ownership of the core business operations of an FQHC critical access hospital, and Eagle Mountain Hospital, etcetera, is prohibited. Also prohibited is, and I know there's been some confusion about this one, so I'm going take it slow, a transaction that involves financing the acquisition of a healthcare entity. And remember, acquisition is a defined term as is healthcare entity, through the use of debt that will become an obligation of one or more of the healthcare entities that are party to the transaction. So acquisition, in our definitions, means the direct or indirect purchase in any manner, such as by a healthcare system, private equity group, hedge fund, publicly traded company, real estate investment trust, management services organization, and insurance company, or subsidiary of any of these of a material amount of the assets or operation of a healthcare entity. So a transaction that involves financing the acquisition of a healthcare entity, any of those kinds of actions, through the use of debt that will become an obligation of one or more of the health care entities that are party to the transaction. You saw an example yesterday with Doctor. Song showing you instead of it being like a health care entity takes out a loan, this is another party basically takes out a loan and makes the acquired entity responsible, financially responsible for it. So this language itself may need some clarifying because I think it's caused a lot of questions. And I think we're going be having further conversations, but I wanted to stop and highlight this one a little bit.

[Rep. Alyssa Black (Chair)]: It doesn't stop a transaction that maybe I shouldn't have said that. Never mind. Yeah, I think you

[Jen Carvey (Office of Legislative Counsel)]: can get into some nuances, I think it may depend. You may want to make some clarifications about who's doing the acquiring. But I think the takeaway, at least I think the intent of this provision is it's not the acquiring party that is taking on the debt, it is the acquired party that becomes responsible for the debt. That's what's prohibited. Also prohibited is a transaction that involves issuing dividends or other shareholder returns financed by debt that will again become an obligation of one or more of the healthcare entities that are party to the transaction. Also prohibited is a transaction that involves entering into any contract or other service or purchasing agreement with an affiliated legal entity, except for a contractor arrangement to provide services or products for both that are necessary to accomplish the legitimate health care purposes of the relevant health care entity. And the contract or arrangement provides for compensation or reimbursement that is consistent with the fair market value of the services rendered or products delivered. The transaction involves entering into any contract or other service or purchasing agreement with an affiliated legal entity, except if it's sort of legitimate for the purposes of providing healthcare services at fair market value kind of arrangement. Also prohibited is a transaction that would result in one or more healthcare entities that does not accept or that places limitations on patients covered by Medicaid, Original Medicare or Medicare Advantage. And then it specifies that nothing in this section shall be construed to limit or alter any existing authority of the Attorney General or any other state agency to enforce any other law, including state or federal antitrust law or to review transactions involving nonprofit entities.

[Rep. Alyssa Black (Chair)]: Next question about five. So let's say I'm a independent practice. I don't participate with any insurance. What I refer to as a concierge practice. I just agree to take care of my patients for a set dollar amount that they give me every year. I don't bill Medicare, I don't bill Medicaid, I don't bill Blue Cross Blue Shield. I don't bill anyone. What if that practice wanted to sell their practice to another provider who would then become that concierge? Are they able to like, would they ever be able to sell their practice?

[Jen Carvey (Office of Legislative Counsel)]: I don't know. This is language about a transaction, which not defined and quite broad. So I don't know. But I think that would be up to enforcement discretion, as in it would be up to whether the attorney general's office thought that that was prohibited under this existing language. So it may be something you want to clarify if you're looking to to allow certain types of transactions. Alright, next we get into Subchapter three, which is the prohibition on corporate practice of medicine. And the first section in that subchapter says it is unlawful for an individual corporation partnership or any other entity without a license under 26 VSA Chapter 23 or 33. That is the licensure of physicians by, Board of Medical Practice and Office of Professional Regulation. So allopathic and osteopathic physicians unlock for an individual corporation partnership or any other entity without a license to practice medicine as a physician to own a medical practice, employ licensees or otherwise engage in the practice of medicine. Notwithstanding an individual corporation, partnership or other entity without a license under 26 BSA Chapter 23 or 33 that is permitted to employ licensees, under the next section we're going to look at, shall not indirectly or directly interfere with, control or otherwise direct the professional judgment or clinical decisions of a licensee. So nobody without a license can engage in the practice of medicine and an entity that is permitted to employ licensees a corporate entity that is permitted to employ licensees shall not directly or indirectly interfere with, control or otherwise direct the clinical judgment or professional judgment or clinical decisions of a licensee. 9532 specifies the criteria under which corporate entities may employ physicians. This says that a medical practice organized for the purpose of practicing medicine may employ physicians and engage in the practice of medicine only if the following conditions are met. First, licensees who are licensed in this state to practice medicine must hold the majority of each class of shares that are entitled to vote. Licensees who are licensed in this state to practice medicine must comprise a majority of the directors. All officers except the secretary and treasurer, if any, must be licensees who are licensed in this state to practice medicine, and the same individual may hold any two or more offices. Notwithstanding any provision of subsection A to the contrary, the following entities may employ physicians and engage in the practice of medicine. We have federally qualified health centers, rural health clinics, free and referral clinics, nonprofit hospitals, hospitals and other health care facilities owned or operated or both by the state, ambulatory surgical centers, and school based health clinics, including student health centers and post secondary schools. Next, have Regulation of Contracts between medical practices and management services organizations. Remember from our definitions yesterday, a management services organization is an 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. So first, there's a prohibition on straw ownership, which says that each licensee owner of a medical practice must exhibit meaningful ownership of the medical practice. And meaningful ownership means that each licensee owner is duly licensed and present in the state and is substantially engaged in delivering medical care or managing the medical practice for both. Then there's a prohibition on dual ownership or interests. Those except as provided in subdivision two, a shareholder, director or officer of a medical practice shall not do any of the following. They shall not own or control shares in, serve as a director or officer of, be an employee of or an independent contractor with, or otherwise participate in managing both the medical practice and a management services organization with which the medical practice has a contract, And they must not receive substantial compensation or remuneration from a management services organization in return for ownership or management of the medical practice. So remember, we had acceptance provided in Subdivision two. So Subdivision two says, Subdivision one does not apply to the shareholders, directors or officers of a medical practice if the medical practice owns a majority of the interest in the management services organization or separate legal entity. We have a Prohibition on Stock Transfer Restriction Requirements. This prohibits a medical practice from transferring or relinquishing control over the sale, restriction of the sale, or the encumbrance of the sale of the medical practice's shares or assets. It also prohibits a medical practice from transferring or relinquishing control over the issuing of shares of stock in the practice, in a subsidiary of the practice or an entity affiliated with the practice, or the paying of dividends. And we have some prohibitions on restrictive covenants. And you heard some about these, I think, yesterday. The first is non competition agreements. So we have a lot of acceptance provided below. So acceptance provided in Subdivision B, a non competition agreement between a licensee and another person is void and unenforceable. B says, Notwithstanding A, a non competition agreement between a licensee and another person is valid and enforceable if the licensee is a shareholder or member of the other person or otherwise owns or controls an ownership or membership interest that is equivalent to 25% or more of the entire ownership or membership interest that exists in the other person. So no non competition agreements are allowed except in very narrow circumstances. I do just want to flag here that it's my understanding that there's a bill moving right now in house commerce that also deals with non competition agreements. It's significantly broader than this, but may just be something to bear in mind.

[Rep. Alyssa Black (Chair)]: Deal with non competition agreements, particularly in healthcare services or just small? No, much broader. Okay, much broader.

[Jen Carvey (Office of Legislative Counsel)]: Okay. But it may affect what you're looking at here. So I was just made aware of it by a colleague yesterday. So we're keeping each other in loop. Next, have nondisclosure and nondisparagement agreements except as provided in subdivision B. A nondisclosure agreement or nondisparagement agreement between a licensee and a management services organization is void and unenforceable. Then in B, it says, Subdivision A shall not be deemed to limit or otherwise affect any cause of action, meaning something you could take somebody to court for, that a party to or a third party beneficiary of the agreement may have with respect to a statement of a licensee that constitutes libel, slander, atrocious interference with contractual relations, or another tort for which the party has a cause of action against the licensee, basically, if you have enough to take somebody to court for, legitimately, you have a cause of action, then you're allowed to say things. And does not depend upon or derive from a breach or violation of an agreement described in subdivision one, which is the noncomplicated clause. All right, now we have limitations on advertising. It is unlawful for a management services organization or other legal entity that is not a medical practice to advertise the medical practice's services under the name of the entity that is not the medical practice. And there's prohibition on relinquishing control of the medical practice. Medical practice shall not buy away the contract or other agreement or arrangement by providing in the medical practices articles of incorporation or bylaws, by forming a subsidiary or affiliated entity, or by other means, medical practice shall not relinquish, give up control over or otherwise transfer de facto control, so like effective, in fact or effective control over any of the medical practices, administrative, business or clinical operations that may affect clinical decision making or the nature or quality of medical care that the medical practice delivers. Medical practice can't make any arrangements that give up its authority over the medical services or clinical decision making. Conduct prohibited under subdivision one Oh, go ahead.

[Rep. Alyssa Black (Chair)]: So administrative and business. So it's not just clinical. It could

[Rep. Lori Houghton (Member)]: be your billing, it could be paying the bills. Well, it's

[Jen Carvey (Office of Legislative Counsel)]: over any of their administrative business or clinical operations that may affect clinical decision making or the nature or quality of the care provided. So, yeah, so some of the business stuff may not affect depending on how it's structured. Conduct prohibited under Subdivision one includes giving up ultimate decision making authority over things like hiring or termination, setting work schedules and compensation, or otherwise specifying terms of employment of employees who are licensed to practice medicine in this state, or who are licensed in this state as a physician assistant or advanced practice registered nurse. Includes the disbursement of revenue generated from physician fees and other revenue generated by physician services, includes collaboration and negotiation with hospitals and other health care facilities in which the licensees of medical practice may deliver clinical care, including controlling licensee schedules as a means of discipline? That could be.

[Rep. Alyssa Black (Chair)]: Can you tell me like in plain language, so we're banning ownership, what does that mean by the dispersed kind of revenue generated by people? I mean, Because, Backing think up we should to begin here,

[Jen Carvey (Office of Legislative Counsel)]: we have medical practice can't give up its rights or its ability to do things that may affect clinical decision making or the nature or quality of medical care. And that includes giving up ultimate decision making authority over disbursement of revenue generated from physician fees and other revenue generated by physician services. Okay.

[Rep. Alyssa Black (Chair)]: So we're not saying that revenue can't be generated. We're saying the provider who's providing the service has control over what is dispersed. The medical practice does, right.

[Jen Carvey (Office of Legislative Counsel)]: The practice can't give up ultimate decision making authority over how physician generated revenue is dispersed. Can't give up authority over collaborating and negotiating with hospitals. Can't give up ultimate decision making authority over setting staffing levels or spec specifying the period of time that a licensee may spend with a patient for any location that serves patients. Can't give up making diagnostic coding decisions or setting clinical standards or policies or setting policies for patient, client or customer billing and collection. Again, this is ultimate Ultimate decision decision making around policy is not necessarily the act of doing the billing. Can't give up ultimate decision making authority over setting the prices, rates or amounts that the medical charges for a licensee's services or giving up authority over negotiating, executing, forming, enforcing, or terminating contracts with third party payers or persons who are not employees of the medical practice. And then subdivision three says that the conduct in that long list does not prohibit collecting quality metrics as required by law or in accordance with an agreement to which the medical practice is a party or setting criteria for reimbursement under a contract between the practice and an insurer or a payer or entity that otherwise reimburses the practice for providing medical care. It does allow specifically allow, medical practice to give up or transfer control over its administrative business or clinical operations that will not affect legal decision making or the nature or quality of medical care that medical practice delivers, provided the practice executes a shareholder agreement exclusively between or among and for the benefit of a majority of shareholders who are physicians licensed in this state to practice medicine and the shareholder agreement. All right, protections for employed licensees. Now we have the provisions set forth in this section apply to licensees who are employed by or provide services under contract with an unlicensed person, corporation or other entity under Section 9,532. That was the part that said corporate entities are permitted to employ physicians under certain circumstances. So these are the protections for those licensees who work for the corporations who are permitted to employ them. There's prohibition on restrictive covenants. So a lot of these are going to look familiar. Non competition agreements between a licensee and an employer as between a licensee and a management services organization or other entity is void and unenforceable. Similarly, nondisclosure agreements and nondisclosure agreements between a licensee and employer or other entity are void and unenforceable. But this does not limit or otherwise affect a cause of action that someone would have, a party or third party beneficiary of the agreement may have with respect to the statement of a licensee that constitutes libel, slander, tortious interference with contractual relations, or another tort for which the treaty has a cause of action against the licensee? Yes. Basically, I think. Just so

[Rep. Alyssa Black (Chair)]: I'm clear, so if you're a provider practicing in the state anywhere, it doesn't matter, pick a place, a hospital, you're an employed position, and you signed a contract and that contract specifically had like a non disclosure or a non compete, if this bill were to pass that entire contract, your employment contract would be null and void as far as the non compete, non disclosure, just the That aspect

[Jen Carvey (Office of Legislative Counsel)]: of it, right. It doesn't invalidate the entire contract, it invalidates the restrict, the prohibited court fees. And then similar language about the cause of action that does not depend or upon or derived from a breach or violation of the covenant not to compete or the non competition agreement. Prohibition on directing a licensee's professional judgment or clinical decisions. This is a conduct prohibited under nine thousand five thirty one generally is the corporate practice of medicine prohibition. So conduct prohibited as corporate practice medicine includes controlling either directly or indirectly through discipline, punishment, threats, adverse employment actions, coercion, retaliation, excessive pressure, or otherwise, any of the following. So prohibited conduct includes controlling in any way the period of time a licensee can spend with a patient, including the time permitted for a licensee to triage patients in the emergency department or evaluate admitted patients, controlling the period of time within which a licensee must discharge a patient, clinical status of a patient, including whether the patient should be admitted to inpatient status, kept in observation status, received palliative care, and whether and where the patient should be referred upon discharge, such as a skilled nursing facility, the diagnoses, diagnostic terminology or code that are entered into the medical record by the licensee, the range of clinical orders available to licensees, including by configuring the medical record to prohibit or significantly limit the options available to the licensee or any other actions specified by rule. There was an earlier version of this that had some rulemaking requirements in it. So we need to revisit this. That constitute impermissible interference or control over the clinical judgment and decision making of a licensee. We're getting close to the end. Yes. So that was the list of things that basically constitute corporate practice medicine that are banned. So Lyme six, page 20, why do

[Rep. Alyssa Black (Chair)]: we need that if we have line 10 on page 17? I mean, I'm sure that I can just need there's a reason I just can't orient myself to why we need.

[Jen Carvey (Office of Legislative Counsel)]: So that is a prohibition on a medical practice relinquishing ultimate decision making over certain things. This is conduct that is prohibited by the corporate entity. So they can't direct the licensee's professional judgment. So the owner, corporation, the corporate entity that would be authorized to employ physicians cannot control their practice of medicine in any of these ways. It's a bit of the flip side of medical practice can't give up its authority and a corporate entity can't control an individual provider's exercise So of one of them is directing the medical practice, the other one that is sort of the physician owners. The other is talking about what the corporation that has acquired or is somehow in charge can direct of the individual providers. It's just definitely protective. Yeah. I think it's dealing with a lot of the same behavior, but directing or regulating the activities of different parties. Got it. Thanks. All right, now we're up to subchapter four, transparency in ownership and control of health care entities, and this is some reporting. We heard some about this yesterday from the Attorney General's office in Green Mountain Care Board. Except as otherwise provided in Subsection B, which is some exemptions, each health care entity must report to the attorney general and the Green Mountain Care Board at least once every two years and upon the consummation of a material change transaction involving the entity in a form and manner required by the board the following information: healthcare entity's legal name, its business address, the locations of its operations, its business identification numbers as applicable, including its taxpayer ID, national provider identifier, employer identification number, CMS Certification Number, National Association of Insurance Commissioners Identification Number, Personal Identification Number associated with a license issued by DFR, and a Pharmacy Benefit Manager Identification Number associated with a license issued to a PBM in this state. So they may not all apply in all circumstances. Also report the name and contact information of a representative of the healthcare entity. The name, business address and business identification numbers listed in that list of identification numbers for each person who, with respect to the relevant health entity, has an ownership or investment interest, a controlling interest, is a management services organization, or is a significant equity investor, which was a defining term. They also have to provide a current organizational chart showing the business structure of the healthcare entity, including anyone listed on this list. And six, affiliates, including entities that control or are under performing control as the health care entity and subsidiaries. For health care entity that is a provider organization or health care facility, the affiliated healthcare providers by name, license type, specialty, national provider identification, and other applicable identification number listed in number four, the address of each healthcare provider's principal practice location, whether the healthcare provider is employed or contracted by the entity and the name and address of affiliated healthcare facilities by license number, license type and capacity. The names NPI if applicable and compensation of the members of the entity's governing board, board of directors or similar governance body, any entity owned or controlled by, affiliated with, or under common control as the healthcare entity, and any entity that was listed in number six, which again is people who have sort of ownership and controlling interests or significant investors. They also have to provide a comprehensive financial reports of the healthcare entity and any ownership and control entities, including audited financial statements, cost reports, annual costs, annual receipts, realized capital gains and losses, accumulated surplus and accumulated reserves. So certain entities are exempt from the reporting requirements. Those are a healthcare entity that is an independent provider organization without any ownership or control entities, consisting of two or fewer physicians, provided, however, that if that entity experiences a material change transaction, which was governed by Subchapter two, the health care entity is subject to reporting upon the consummation of the transaction. And a healthcare provider or provider organization that is owned or controlled by another healthcare entity, if the healthcare provider organization is shown in the organizational chart that's submitted and the controlling health care entity reports all the information required under subsection A on the CAMP or the controlled or owned entity, provided, however, that health care facilities are not subject to this exemption. A lot of people have to report, some people don't. Okay. Now, moving on. Sharing of ownership information to improve transparency. Information provided under this section to come is public information and shall not be considered confidential, proprietary or trade secret, provided, however, that any individual healthcare provider's taxpayer identification that is also their Social Security Number is exempt from public inspection and copying under the Public Records Act and shall be kept confidential. So this says starting on or before 02/01/2027, and every three years after that, the Green Mountain Care Board must post on its website a report with respect to the previous two year period, including the number of health care entities reporting for the year disaggregated by the business structure of each specified entity, the names, addresses, business structure of any entities with an ownership or controlling interest in each healthcare entity, any change in ownership or control for each healthcare entity, any change in the tax ID number of a healthcare entity, as applicable, the name, address, tax ID number, and business structure of other affiliates under common control, subsidiaries, and management services entities as the health care entity, including the business type and tax ID number of each. And, and we talked about this yesterday, an analysis of trends in horizontal and vertical consolidation disaggregated by business structure and provider type. It allowed the Green Medicare Board to share information reported under this subchapter with the Attorney General, Secretary of State, other State agencies and other State officials to reduce or avoid duplication and reporting requirements or facilitate oversight or enforcement under State law or both. And any Tax ID numbers that are individual Social Security numbers may be shared with the Attorney General, other state agencies, and other state officials who agree to maintain their confidentiality. The Board, in consultation with the relevant state agencies, may merge similar reporting requirements where appropriate.

[Rep. Alyssa Black (Chair)]: So there's a lot of information they have to report to include financial information, but the board posts publicly essentially just sort of the ownership and chains of ownerships. Right. No financial information. It does not appear that way. Okay.

[Jen Carvey (Office of Legislative Counsel)]: Alright. Finally, we get to enforcement of the chapter. A violation of this chapter would be deemed a violation of the Consumer Protection Act, which is in 9BSA Chapter 63. And this gives the Attorney General the same authority as provided in that chapter that includes things like notices of discontinuance and bringing litigation if necessary. And then we're notwithstanding any provision of a particular section of that chapter that specifies penalty amounts to have different penalty amounts. So for a violation of sections 95, 31, 95, thirty two and ninety five, 34, that's corporate practice medicine, corporate employment of physicians and protections for employed physicians. I think Todd Delos described yesterday sort of operational violations. The the civil penalty imposed would be not more than $10,000 per violation and for violation of section ninety five twenty five or ninety five thirty three. So ninety five twenty five is prohibited transactions and ninety five thirty three is contracts between medical practices and management services organizations. The more transactional violations, the civil penalties shall be not less than so the other one was not more. This is not less than $100,000 per violation. And I heard the conversation yesterday about whether there should be something about how to unwind or how that penalty would be enforced if it persisted. Penalties collected pursuant to this section would go into the Transaction Oversight and Clinical Decision Making Fund established in the next section. So then we have that section, and it establishes the Transaction Oversight and Clinical Decision Making Fund as a special fund for the purpose of providing a financial means for the Attorney General's office to administer its duties under this chapter, including hiring outside experts and investigators as needed. And the fund would consist of the penalty sums collected pursuant to 3,547. There would be some ability to self sustain if there are violations. And the act would take effect on July 1.

[Rep. Alyssa Black (Chair)]: Any questions? Oh, I thought everybody understood everything, 100%.

[Rep. Karen Lueders (Member)]: Why do I get my lawyer's cratty done?

[Jen Carvey (Office of Legislative Counsel)]: A third

[Rep. Alyssa Black (Chair)]: player. You want to put my lawyer hat off,

[Rep. Karen Lueders (Member)]: and that's it.

[Rep. Alyssa Black (Chair)]: A lot of section there. Is

[Unidentified Committee Member]: there any money, any place that is gonna be put up to stand this thing up?

[Jen Carvey (Office of Legislative Counsel)]: It's not specified in here, but you may hear testimony from the, I don't recall if the attorney general's office mentioned anything yesterday or not.

[Rep. Alyssa Black (Chair)]: Is it absolutely?

[Jen Carvey (Office of Legislative Counsel)]: Yes. There yes. There may need to be initial resources until they have money in the fund from penalty amounts.

[Rep. Alyssa Black (Chair)]: Alright. It's a lot. Go ahead. There is I'm looking for the page. Sorry, Debra. A place where health care entities were listed, FQHCs, yada yada, where physicians are employed. Is that intended to be a comprehensive list of places that physicians are employed in Vermont? I don't believe so.

[Jen Carvey (Office of Legislative Counsel)]: Trying to remember where that was, too.

[Rep. Alyssa Black (Chair)]: Yeah, I'm looking for it, too. It's on page 13. Page 13. Line four, it begins.

[Jen Carvey (Office of Legislative Counsel)]: So, I mean, it's a list of entities that may employ physicians and engage in the practice of medicine without having to worry about meeting these conditions. So if there are others that people want to add to the list, I think that's certainly something to be discussed. The model so this is based largely on the NASHV model language. So you heard a lot about NASHV yesterday and from NASHV. And they had a list in their model language that is not exactly this list because it seemed like it it didn't align necessarily with the provider types that we or facility types that we have in Vermont. But I think it was looking mainly at facility types. So if there are others CCBHCs are not here. I don't know what that means.

[Rep. Alyssa Black (Chair)]: Certified behavioral Well, I don't know. We have a new Vermont language for them, but CCBHC, Certified Community Behavioral Health Clinics.

[Jen Carvey (Office of Legislative Counsel)]: Do they employ physicians? Yes. And engage in the practice of medicine? Yes. So they may be something you want to add as well. So I think that's all.

[Rep. Alyssa Black (Chair)]: Aren't they our designated agencies? They are not our designated think the department's We think the power center is CCBHC. I just did the training. They're not the same thing. They can have certification, but that doesn't mean that they're a DA.

[Jen Carvey (Office of Legislative Counsel)]: So I think if there are

[Rep. Alyssa Black (Chair)]: They're not one and the same, but they can be

[Jen Carvey (Office of Legislative Counsel)]: missing, certainly we can have committee discussion about adding anything you want.

[Rep. Alyssa Black (Chair)]: Thank you. And these are the ones that we're exempting from this?

[Jen Carvey (Office of Legislative Counsel)]: Yes, it says not right, notwithstanding that list. So a medical practice organized for purpose practicing medicine can employ physicians and engage in the practice of medicine only if certain conditions are met. And then it says, Notwithstanding any provision of that requirement, the following entities may employ physicians and engage in the practice of medicine.

[Rep. Alyssa Black (Chair)]: Then it I was there again for a second. Yeah. Does this cover? I'm trying to read it more carefully before I ask a stupid question. Do you want Karen to ask her a question while you're thinking of your I'll just ask it and if it's stupid, it'll just go out there with all the other stupid questions that get asked. Does this cover methadone clinics? I don't think it does, the way that that's listed.

[Jen Carvey (Office of Legislative Counsel)]: I don't know. I mean, don't think so. It's a pretty discreet list, but I don't know the auspices under which methadone clinics are organized.

[Rep. Alyssa Black (Chair)]: Not school based health clinics, that's for sure. Not in Houston, actually. Karen, and then Leslie. I'm just wondering, under the reporting requirements to be met Chair Board and Attorney General, see page 23, line six. This is the financial reporting piece. Is that, I don't know, is that not publicly available or how does that, how does,

[Jen Carvey (Office of Legislative Counsel)]: know, is there, is that something that would be subject to being looked at? Being looked at by the Green Mountain Care Board? No. By the So I think it would be helpful to I you know, I'm looking at the language. I think it would be helpful to clarify what is subject to the Public Records Act and what is not. Yeah. I think, you know, some of the information is public as it relates to something like a hospital because that's already public. Most of it's already public Yeah. Because we specify that in another statute. But I do think there yes. I think it would be helpful to specify what the public or confidential nature of this is since especially since the next section says information is not confidential. Right. Thank you for flagging that.

[Rep. Alyssa Black (Chair)]: Karen, I had a question. And then Daisy. Last one. Oh, that's right. I'm sorry. Okay. It looks the same here. A little purple. I'm just talking about that list on page 13, and it just seems like it's going be really easy to overlook something. So I'm just wondering if there's language or a process to include that could take that into account somehow.

[Jen Carvey (Office of Legislative Counsel)]: I I have to say I'm not clear enough on the purpose of this list and, you know, why it was included in the model language that certain types of entities are are listed notwithstanding the requirements in subsection a. So to the extent we can get some clarity on what the goal is, I think it will be easier for us to either decide to have a very comprehensive list or to have a broader list or to have who's out rather than who's in or no list. I think

[Rep. Alyssa Black (Chair)]: that this list is not a list that Helps us. I think that we need to go into this list a little bit because I'm frankly wondering why ambulatory surgical centers are on that list. Right. Well, because they could probably be bought up by private equity. Well, remember, these are the ones that are exempt. From this.

[Jen Carvey (Office of Legislative Counsel)]: Not from all this, but for existing one section. Corporate entities permitted to employ positions. Yes. Okay. Daisy.

[Rep. Alyssa Black (Chair)]: Page 11 then, number five, does that mean, is it saying that a transaction cannot result in an entity that doesn't accept Medicaid?

[Jen Carvey (Office of Legislative Counsel)]: Under the language as I read it, I think yes, because the lead in says the following transactions are prohibited and number five is a transaction that would result in one or more health care entities that does not accept or places limitations on patients covered by Medicaid.

[Rep. Alyssa Black (Chair)]: So then every transaction, merger, acquisition, yada yada, going forward, The

[Jen Carvey (Office of Legislative Counsel)]: result of every transaction is an entity that has to accept that. Okay. It's a health care that results in a health care entity. That's how I read the language. It's if I'm misunderstanding it, then I'm sure I will be corrected. But that's what the plain language seems to say.

[Rep. Alyssa Black (Chair)]: Great. That's my thought. Thank you, Jen. Yes. Allen, we never get to see you in this committee.

[Helen Laban (Executive Director, Vermont Health Care Association)]: No, that is because I spend my days in House Human Services.

[Rep. Alyssa Black (Chair)]: I know. I feel like we used to see you more. Well, that's when I was representing FQHC. Was not the same. The last That season. Role, new ish role. So, I'm gonna

[Helen Laban (Executive Director, Vermont Health Care Association)]: get this set up here. I think Jen's still sharing. I did want to say before

[Rep. Alyssa Black (Chair)]: we got started, because we don't, in this committee, have sort of because you represent long term care skilled nursing facilities. Because we don't have jurisdiction of that in this committee, we are quite ignorant in what happens in this space. Have I got a PowerPoint presentation for This

[Helen Laban (Executive Director, Vermont Health Care Association)]: is what we're doing here. Let's see, I'm going

[Rep. Alyssa Black (Chair)]: to share I think this is gonna work.

[Helen Laban (Executive Director, Vermont Health Care Association)]: PowerPoint and slideshow.

[Rep. Alyssa Black (Chair)]: Is it up behind me?

[Helen Laban (Executive Director, Vermont Health Care Association)]: Yes, is. Look at this. Alright. So I'm Helen Laban, executive director of the Vermont Health Care Association. And as noted, we represent nursing homes, residential care homes and assisted living residences, which generally do not appear in this committee. We appear in housing and services. So what I've done, you have I pre submitted our testimony that is a response to the bill's language. And so that goes to the different sections and does our responses. I put together this presentation to emphasize those elements of how our sector works that tie in directly to that language. So that's how I'm trying to make this all come together into something coherent and intelligible. We'll see how that works out, But stop me with questions. So just quickly, in terms of our membership, these are all forms of residential long term care. Some of them also offer short term rehabilitation care. And these sectors all have different considerations for who they serve, the services they offer, how they're regulated, how they're paid. In this presentation, I'm going be focusing on the nursing homes. So what I say from here on out is true for nursing homes. Don't assume that it is true for assisted living and residential care. If questions come up about those, call me and we'll look at those later. So first, I just wanted to do a quick, this is who is in the sector. And this data comes from Diva. It comes out, I think this is from October. It comes out semi regularly, looking at different characteristics of the sector in Vermont. How many beds there are, how many facilities, what the payer mix is. So here you can see on one side, have there's different reasons why you would consider licenses in different ways. But here I'm breaking them up into a for profit structure, which is the majority, a nonprofit structure, A hospital owned facility, which works a little bit differently. We have three of those. And then what I call specialized. And in this sense, specialized means that they aren't broadly open to the public. It's something like the Veterans Home, which is our only publicly owned facility that serves veterans, as the name implies. Wake Robin, which is a different structure that's a continuous care retirement community. Or Mission Care, which is a for profit special contract entity down in Bennington that works with the state. And then I also have, of the beds that are being utilized in any given time period, what the breakdown is in the payers there. And we're about 65 Medicaid, which is standard. That's usually what you would expect to see. And then it's also divided between Medicare, self pay and other and other hearings, primarily VA or hospice coverage. An important thing to know, and here's your first confusing thing about long term care. We are talking about people more or less over the age of Well, in our case, the average age is 84, but the Medicare population. But the primary payer isn't Medicare, it's Medicaid. And that's because if you're in short term rehab, so less than one hundred days, and that's a Medicare situation. But if you're a long term residential care, say, then that's Medicaid. So when you see this breakdown like that, that's not just a difference in terms of who your care is. It's also loosely reflecting differences in the types of services that you're receiving. This is nursing home capacity. So the main line, there is the national census. And can see an obvious dip for obvious reasons in 2020. And then going back up, the important thing to take from this graph is that the census has essentially recovered to where it was before the pandemic nationally, which is also true in Vermont. Additionally, Vermont's a little bit above the national average in terms of census in our nursing homes. Now, one thing that I think people get tripped up on is they see that you're at 84% capacity and you think, well, that means that we've got a lot of margin here. That's not actually true. And here are some reasons why you're never going to If you saw that at 100%, that'd be cause for a significant alarm, and I would've been in here shouting a long time ago. So you never wanna see 100% as your average capacity. And some reasons for that are that some beds are for short term rehabilitation. That has both turnover and also a seasonality element to it. Also, rooms maybe are often licensed for a semi private. So you have a room, you hold two bed licenses, but that doesn't mean that you're really gonna be using those two beds. So you need to have an ability to move for infection protocols. You have residence conditions that require not having a roommate. Advanced dementia would be a very classic example of this, where you wouldn't necessarily find it healthy or safe to have a roommate, family privacy at the end of life. And then also we have some legacy licenses for old configurations. So some folks are holding on to licenses for triples or quads, but they aren't actually using it that way. They just wanna keep those licenses so that if they expand the building, they don't have to apply for new licenses. And then additionally, nursing homes are slowed down or paused admissions for various reasons. COVID outbreak, renovations, like veterans home, for example, was running low for quite a while for renovations. Key staff transition, new unit licensing. There are reasons why you would pause your admissions to manage those things. So we would say that we have a pretty robust, relatively full census in Vermont, which is good news. Here's the bad news side of that. Here's the bad news, half of that good news, which is that age is the number one predictor of whether someone is going to require nursing home care. These slides are from the JFO's presentation on demographics in Vermont. And I think they also made a point similar to the one that I'm about to make. Vermont has an older population, and that is growing quickly. So here you can see some graphics to that effect. And you can see significant increases in that 65 79 and 80 ages. And so we look at that and we conclude that

[Rep. Alyssa Black (Chair)]: we're

[Helen Laban (Executive Director, Vermont Health Care Association)]: going to need more nursing home care than we are currently seeing. And then just some other ways to think about nursing home capacity in Vermont. So two counties in our state have no nursing homes, and three have only one. And this becomes particularly a problem because if you are going to residential care or short term rehab, generally one's goal is to be near their home communities. Many current independent owners, much like the rest of the population, are at or past their preferred retirement age. And then additionally, many buildings need to be upgraded to reflect current standards for nursing home care. So I mentioned the triple and quad licenses. Today, we have different expectations around, say, memory care configuration. We need different services that need to be offered. So there's a fair amount of deferred work on our infrastructure as well. So the conclusion being that Vermont cannot lose many more nursing home beds and will likely need to gain capacity soon to match our demographic trends. And I do not know the last time a new nursing home opened in Vermont. I know the last time one closed in Vermont. That would be last week. So if you go to look at our written

[Rep. Alyssa Black (Chair)]: Leslie, so you haven't given any We don't have your slides, so it would be wonderful.

[Helen Laban (Executive Director, Vermont Health Care Association)]: Oh yeah, I'll send those definitely. That would be great.

[Rep. Alyssa Black (Chair)]: About the distribution of ownership of nursing homes in Vermont.

[Helen Laban (Executive Director, Vermont Health Care Association)]: That was the first slide. Can I

[Rep. Alyssa Black (Chair)]: ask what nursing home you guys last week?

[Helen Laban (Executive Director, Vermont Health Care Association)]: Green Mountain Nursing Home. They notified that they were going to close. They give a ninety day Thinking

[Jen Carvey (Office of Legislative Counsel)]: about equity, like, what are the programs for?

[Rep. Alyssa Black (Chair)]: Oh, so the

[Helen Laban (Executive Director, Vermont Health Care Association)]: primary private equity owner in Vermont would be Genesis Healthcare, and that has three facilities.

[Rep. Alyssa Black (Chair)]: Springfield, right?

[Helen Laban (Executive Director, Vermont Health Care Association)]: No. Bel Air, St. Albans, and Mountain View.

[Rep. Alyssa Black (Chair)]: And what about Springfield?

[Helen Laban (Executive Director, Vermont Health Care Association)]: That's owned by Alair.

[Rep. Alyssa Black (Chair)]: Okay. I live in that area, and I've heard some

[Helen Laban (Executive Director, Vermont Health Care Association)]: pretty recent reports about that. Yep. It's one of the troubled facilities. They are working on it.

[Rep. Alyssa Black (Chair)]: But Alair is private equity.

[Helen Laban (Executive Director, Vermont Health Care Association)]: No. It's not. No. They're nonprofit. They sort of specialize So in the ownership world, in nursing homes, there owners that specialize in different things. So for example, Eye Care, which owns Mission Care, specializes in the types of contracts they have with The US, with Vermont. So a state identifies a group that they're having trouble finding nursing home placement for, and iCare will develop systems to take those folks. Others specialize in kind of turning around nursing homes that are having difficulty. So that would be more of bucket of work. Allaire and Skeller tend to work more in that field or two ownership groups that

[Rep. Alyssa Black (Chair)]: are in Vermont right now. So did Allaire take over in trying to rescue Springfield Health and Rehab? Who wounded before? I guess this

[Helen Laban (Executive Director, Vermont Health Care Association)]: is taking.

[Rep. Alyssa Black (Chair)]: I don't know if I lost my time on it, but I am curious.

[Helen Laban (Executive Director, Vermont Health Care Association)]: Yeah, so I represent all of my members equally and I would be loathe to describe one of them as rescuing another one. Yeah. So perhaps that's the question you could ask a lair to speak to. But I think we can agree that the quality track record left allure with challenges to address. Yes. So just on the question of the overall capacity concerns and how it relates to this bill. I have detailed testimony that you'll find discussing this. But we are concerned at how it would cut off our ability to access capital to make these needed investments in capacity. And so one example is that question of prohibiting debt, right? So a debt instrument be a loan, be a bond, it could be a mortgage, it can be leasing equipment. It's the majority of our funding. So the primary structure, what you really hope for in a nursing home for a stable funding structure is again that called a HUD Section two thirty two loan, which is a long term mortgage. So that's the primary financing mechanism. And additionally, there's concerns when you look at the prohibition on debt and the question of who assumes what debt, because that is also a very common thing. So for example, if Helen Porter is currently part of the UVM Health Network, but say they were newly joining UVM, you would want UVM to assume all of Helen Porter's debt because you want to put it in the same place to improve the credit rating and also to streamline the transaction costs. You don't want dozens of different debt instruments out there within the network. The way to get the best deal for that money is to consolidate and use the master structure that UVM has in place. So that's the standard way you would address debt in those kinds of acquisitions. So we become concerned not just in terms of reducing access to capital, but also increasing the cost of that capital. I'm worried that this bill does both. I would also add, in another part of the bill where it talks about shared services and fair market value, the reason why you enter into a lot of these contracts to work together isn't to hit fair market value, it's to get discounts. Like a group purchasing type system, right? So we have a lot of concerns in this bill about the combined problem of cutting off access to sort of stable capital and then also increasing the cost of that capital. I would say that I have an academic understanding of this. I am not the person you want to go to. Like, if you find yourself in a securities market, don't call me. I'm not the person. I don't know how to put these deals together, but I'm sure there are others you'll hear from who do. Bond Bank, I see Chris is I think Chris on the spot, but there are folks who can talk to you in more detail on these issues. So that's an example of one of the concerns that we have with this bill.

[Rep. Alyssa Black (Chair)]: Lori? Just a question kind

[Rep. Lori Houghton (Member)]: of related to this. So I know the state for the past couple of years has had a provider state stabilization

[Rep. Alyssa Black (Chair)]: fund. Is that what I'm

[Jen Carvey (Office of Legislative Counsel)]: trying to say?

[Rep. Lori Houghton (Member)]: And nursing homes have taken advantage of that. And we've had to really help prop up some nursing homes that were declining. Did any of that money go to nursing homes that

[Rep. Alyssa Black (Chair)]: are owned by private equity?

[Rep. Lori Houghton (Member)]: My concern being private equity coming in, yet they're taking money out, and now the state's having to fill up.

[Helen Laban (Executive Director, Vermont Health Care Association)]: Yeah. You're sort of conflating two things, but very, very close. So provider stabilization does not go to nursing homes. Extraordinary financial relief. That's right. That's probably And that's a little bit of a different mechanism. So what extraordinary financial relief, it's in our regulatory structure. And EFR, I'll use the acronym now, EFR, is a mechanism where you can adjust the rate to preserve access to Medicaid beds. So the original intent of it is if you're as like a small nursing home, again, are residential, right? So you can't change your flow or your services to respond to small changes. The example that I use that happened recently was a member, there was a processing issue with Medicare. They weren't gonna get paid by Medicare for six months. They were small, they didn't have the cash flow to cover that. The state gave them money to cover it, and then they recouped it. So that's sort of like the traditional use of this tool. Since COVID-nineteen stabilization funding went away, the state used an expanded definition of EFR to backfill that lots, it was primarily addressing workforce shortages. Extraordinary financial relief.

[Jen Carvey (Office of Legislative Counsel)]: Sorry.

[Rep. Alyssa Black (Chair)]: Yeah.

[Helen Laban (Executive Director, Vermont Health Care Association)]: So last year, it was 14,000,000, I think. So the Division of Rate Setting is presenting on this in House Human Services in the next two weeks. Their report just was posted yesterday. I cannot claim to have read and or memorized it. There is a report. There's a two part report that was submitted to House Human Services. I don't want to represent what they did because I know they have that report out there that I have not read yet. I was busy preparing testimony for this.

[Rep. Alyssa Black (Chair)]: So, but it's I just

[Helen Laban (Executive Director, Vermont Health Care Association)]: It would make sure your answer Yeah. Yeah. I think I'm gonna read the report. Invested.

[Rep. Alyssa Black (Chair)]: Right. So

[Rep. Lori Houghton (Member)]: the majority and did it go to homes that

[Rep. Alyssa Black (Chair)]: are?

[Helen Laban (Executive Director, Vermont Health Care Association)]: Yeah. A component of demonstrating access to this is you have to demonstrate you have no other funding sources available. So I know that that is one of the components of it. And so I don't know how they interpreted that, and I won't speak for them. And I

[Rep. Lori Houghton (Member)]: think my concern is just more broadly speaking. If ownership has changed, it is now partly owned by private equity or some other type of entity. I'm not trying to pin it on private equity. And finances shifted, and so money was taken out for whatever reason, now the state is coming in and backfilling it, that would be really helpful to understand.

[Helen Laban (Executive Director, Vermont Health Care Association)]: I'll read it for you. And one reason why I'm deferring more to them than I would normally is that they do a very detailed review of the financials before like, it's a multi month process, and I can't pretend to understand that. Thank you. I can't. I don't know. Yeah. So next sort of section of concerns. I want to talk a bit about, and this is just true in general, some regulatory distinctions for skilled nursing facilities. So the federal government is the primary regulator of nursing homes. And they have very extensive regulations. And then the state performs inspections under federal contract. There's a lot to be said about that. As it relates to this particular bill, a key component of it is how they regulate who you accept into a nursing home. So unlike, say, the FQHC, so I used to represent where their structure was set up with the federal government so that they take anyone regardless of payer source or ability to pay, the opposite is true for nursing homes in the federal structure. So that tends to be built around the concern that do not want a nursing home to accept someone that they don't have the capacity to care for. So strong there's emphasis on reviewing what admissions work was done ahead of time. And if you do admit someone who then you prove not to have access to the appropriate care levels, you get in a lot of trouble with your regulators. Additionally, they want to prevent low acuity admissions because this is your highest cost. I mean, it's cheaper than being in a hospital, but it's your highest cost of care in terms of residential long term or in terms of long term care, sorry. This is your highest cost. So if there's another option for where someone goes, the regulators want them to go there. And usually the individual also wants to go to the lower intensity option. So there's a way on the regulatory side to manage the resident assessments, make sure that people are at the correct level. That's both a quality regulation and also a payment issue. You'll lose money off of your rate across the entire facility if you have too low of an acuity. And I would also say, and this is something that if we were in human services, Chair Wood talks a lot about this. So I'd be remiss not to note that Vermont has sort of bolstered that element of expectations by investing in assisted living and residential care homes as an alternative option for folks, which cannot be said of all states. So sort of one element of this as it connects to the concerns about this proposed bill is we really cannot abide by the rules around placing no limitations on Medicaid, Medicare or Medicare Advantage. We're required to limit services on the Medicaid side. Additionally, Medicare and Medicaid pay for, as I said at the top, are two different sets of services. They mean two different things. One is skilled nursing and one is long term residential care. Additionally, there are some structures that are sort of beside the point for those. So Wake Robin would be the example of something that's itself an insurance product. That it's sort of irrelevant when you talk about a primary payer there. I mean, the legislation says patients. This is an area where if someone's a patient, it's also combined with someone's home and where they live. So it doesn't work quite as cleanly as it might in, say, an FQHC setting. And then I would additionally add on the Medicare Advantage side of things. Nursing homes are known for not loving Medicare Advantage as a payment mechanism. We have a lot of concerns about enforced short term stays, interference with clinical decision making, underpayment or retroactive removal of approvals. There is a laundry list. Senator Sanders, I believe, has investigated this in the past. The only the only tool that nursing homes have to deal with these concerns in Medicare Advantage contracts is to not sign the contract. So to require them to place no limitations on Medicare Advantage paves away their only negotiating power in this market. Isn't Medicare Advantage essentially gone?

[Rep. Alyssa Black (Chair)]: I mean, there's a couple of counties that still have it, or do you have longer term contracts that So it's

[Helen Laban (Executive Director, Vermont Health Care Association)]: This is Helen's personal opinion, not the opinion of the Vermont Health Care Association. My concern would be when you see a collapse like we've had in the Medicare Advantage market in Vermont, that a payer will, in the Medicare Advantage world, will say that and say, oh, look, here's a monopoly waiting for me to sweep back in. So I understand that we currently do not have this as a major option. I have significant concerns that that would be a short reprieve.

[Rep. Alyssa Black (Chair)]: But that's I like your description of a short reprieve. Yes.

[Helen Laban (Executive Director, Vermont Health Care Association)]: But that is neither here nor there for our opinion on this particular bill. That's just on the list of things that keep

[Rep. Alyssa Black (Chair)]: me up at night. Okay.

[Helen Laban (Executive Director, Vermont Health Care Association)]: I know that I that we started late, then Devin has wonderful things to say. No.

[Rep. Alyssa Black (Chair)]: Devin got bumped. I already called her.

[Helen Laban (Executive Director, Vermont Health Care Association)]: Sorry. Sorry, Sorry, Devin. We were

[Rep. Alyssa Black (Chair)]: just sitting here waiting for Devin. All

[Helen Laban (Executive Director, Vermont Health Care Association)]: right. Devin, I was looking forward to your testimony, so I'll have to come back. So just on our waltz through the regulations of nursing homes. Another one is, and this is gonna connect both to sort of the structure of where regulations such as this bill lives and then also, the reporting requirements. So, the way it works right now when a nursing home wants to change ownership is that there's an application review process. It's pretty intensive. It was just updated last year with the Agency of Human Services and Dale in particular. In 2018, this moved from the Green Mountain Care Board to DLT. And I was not around then, so I cannot say much about that, except for that there was an active decision made that this is where this should live in 2018. On top of that state level control over who's allowed to have a license for the facility, CMS will review ownership changes for Medicare enrollment, plus they have ownership transparency and financial disclosures. And then, so at the end of the day, we've got reporting on financial arrangements, cost related entities and audited financial statements that are going to, in addition to when you have this licensure change, DIVA and rate setting, Dale and CMS. So in my testimony, I do list out an example of just off the top of my head what's reported. So you have audited cost reports, you have audited financials, you have related entities, entities that provide administrative services, clinical consulting, accounting, or financial services for validation, regular revalidation and with any material change. Ownership structure control interests, real estate control interests, payrolls every quarter, affiliate entity identification and payments. So we have a lot of reporting right now. So I know So on one hand, the things that are outlined in this bill get reported, right? And it might, on the face of it, seem easy to just add another place to report them, but it's not actually that easy. If it's set up with a different reporting schedule, if it's set up with a different reporting system, if in the process of negotiating the definitions of all these terms between the Green Mountain Care Award and trying to true up all the sectors, some of them change in their legal language a little bit, then all the reporting needs to be redone. It's a very heavy burden to be reporting this much information with a very already complicated set of structures that you're reporting it to. So it's not that we object to If the Green Mountain Care Board feels they need this information to regulate this sector, then this information is available. We would prefer not to be additionally reporting it. A concern that we always have, even in the systems now when we report this valuable information, is now what's being done with it? Are people who understand the nursing home sector reviewing this? This is a question, I think, both for the providers who are giving this information, and they're more concerned with administrative burden, but also for the policymakers who are relying on them to regulate it. As I understand it, and again, was not here in 2018, that was part of the problem when there was a transition to the regulators receiving this information from nursing homes to go from the Green Mountain Care Board to the Agency of Human Services. So if we are now adding the Green Mountain Care Board back in, I guess my primary question is going to be what has changed since 2018 that they now feel they have the capacity to adequately review, understand and comment on this? And why are they doing it on top of the folks that they sent it to back then? Which should be a question for them, not for me. Like I said, I was not there in 2018. But it is certainly a question that we have. And then, know, kind of then on top of that, I'm not a lawyer, but if you have regulatory structures at DLP, at DIVA, at Broader AHS, at the Attorney General, at different divisions of CMS, overseeing all these transactions, and you add on this Consumer Protection Act connection on top of that, are they in complement? What gap is being solved? Are they reinforcing efforts, or are they detracting from efforts? And what sort of risk are these entities assuming when a regulator that's never worked in their field before takes on this new vast set of responsibilities? That's a high regulatory risk for an already very heavily regulated industry. And I know that my members will likely express significant concern. I know our lawyer expressed significant concern, and our auditor expressed significant concern. So I'm guessing our members will also express significant concern at that addition into their current framework. You know, and then not surprisingly with with with those, comments, we find that 07/01/2026 effective date is not not reasonable. So so that would be my last comment. You know alright. And then oh, shoot. Have one more comment. I forgot about the workforce shortages. We got workforce shortages. This is actually a complicated and important one, although I do have it in detail in my written testimony. And this is around physician access. Short version is that nursing homes are required to have physician coverage for medical directors and rounding physicians. They do not directly employ those physicians. They work through a medical group. Back in the day of five years ago, pre COVID, these were often covered by hospital contracts, sort of in addition to the hospitalist duties at the hospital, they would go to surrounding nursing homes. That changed for a lot of reasons, one of which being just overall physician shortages, but also the expectations of that nursing home medical director changed. There was a heavy push for this to be a very specialized field that really focused on nursing home care, were a physician who understood the regulations, who understood gerontology, who really understood how to serve that population and wasn't doing this as an add on to other duties as assigned in a hospital. Which is overall a good thing. But with that grew up a very specific set of regulatory requirements, documentation, billing practices, like all the back office work that goes into being a physician also evolved along a specialized path, as did malpractice questions, insurance questions and those elements. As a result, it is now much more of a common practice to have a medical group that specializes in long term care and has systems set up to manage the long term care structures. And then we will contract with that medical group for physicians in Vermont. Not surprisingly, we have a specialized form of medical group. We don't have them in Vermont. We just got through with a grant from Dale to study this in a fair amount of detail, what the options would be. We know that it's not currently working. Our members are very much struggling to find medical directors. And we think partially because we, when I say we, I mean VHCA, as well as working with the state, we've been working with them for a long time. We probably spent too long trying to bend the rules to make the local practices work for this. We looked for waivers from CMS to let more nurse practitioners participate. They didn't come through. We looked for ACO structures that could help cover this. It wasn't lent to the ACO structure and the ACO closed. We went through a lot of different attempts to try and solve this problem. And I think perhaps to our members a bit of a disservice not to go immediately to hiring in the groups that specialize in this. We're now trying to pivot towards that. But we aren't there yet, and this bill would prevent us from doing that. There, I'm done.

[Rep. Alyssa Black (Chair)]: I just want to get my question on the table and then we'll We're gonna have to call it back. That's great. She doesn't know that. I did not know that, We can

[Jen Carvey (Office of Legislative Counsel)]: get this question on

[Rep. Alyssa Black (Chair)]: the table if I may. From the extraordinary financial From the report you just mentioned, I'm just looking at the list of nursing homes. They're vastly for profit. And I was wondering if we could get some information about their margins because we get it for the hospitals. So it would be very interesting to also have for nursing homes because yeah, I think that would be very helpful and to try to understand the ownership structure behind that. And I

[Helen Laban (Executive Director, Vermont Health Care Association)]: would strongly recommend bringing Jamie Mooney in from the division of rate setting who reviews these every year. So she'll have the most detailed information.

[Rep. Alyssa Black (Chair)]: I can only give you roll up reports, but you'll know the details. I've been looking through this either clarify or check. And then, if you want to see the subject, I'll give back in to talk about it at that point. Thank you everybody.