Vermont Legislature SmartTranscripts:

[Jessa Barnard, Executive Director, Vermont Medical Society]: And

[Alyssa Black (Chair)]: we're moving to Jess Barnard. Thank you, and thanks for your patience.

[Jessa Barnard, Executive Director, Vermont Medical Society]: Thank you for having me. Was happy to be rescheduled, actually, because it's helpful to follow so many other witnesses on this bill. So, Jessa Barnard, I'm the executive director of the Vermont Medical Society. I believe, sort of surprisingly to me, this is my first time testifying in this committee this session or this year, but I imagine I will be back. We represent physicians and physician assistants in different practice settings. So primary care, specialty care, hospital based, independent practice, FQHC based, so kind of throughout the health care system, which gives us a perspective on a number of the items in this bill. And I will say at a high level, we absolutely share the concern about the impact of corporate investor partnerships or corporate entity relationships on the practice of medicine, especially around the area of controlling medical decision making. But we also believe we have to balance that with supporting practices in Vermont, especially smaller independent practices who already may have less access to administrative support and capital. And that's crucial to supporting options in our state. We've heard a fair amount of feedback on this bill from our members. And just last week, one sent me some comments that included, again, agreeing that the intent of the bill looks to be to stop large corporations from stripping assets from Vermont practices, it actually presents significant friendly fire risk for independent groups and smaller practices. So I will apologize a bit in advance. My testimony may be a little bit in the weeds, because I actually do think it's really important to look at the specific language in the bill and sort of, I don't know what I'll say in comparison or in relation to some of the testimony and sort of intent we've heard stated, which I do think we share. But I think the words in bill the are actually really important and challenging to current practices in the state. As drafted, we think many of the approaches in the bill are overly limiting and burdensome to health care practices. And I'll go into some examples, but sort of at a high level. Some of them are not even related to or limited to private equity at all, for example, the limitation on taking out loans or mortgages. Others are private equity related, but may limit practices that we think are really important to supporting practices in Vermont, like working, partnering with Medicare only ACOs, which are really the only ACO opportunity available in Vermont right now with the ending of One Care Vermont, or working with organizations called Independent Practice Associations, which help practices work together to do things like negotiate contracts and bargain. And by doing so, actually threatened some of the policies that would support low cost efficient sites of healthcare, like you heard in some of your testimony from the dermatology practice last week. We do have some directions we support going, and we would encourage the committee to look at. I've actually submitted a separate document from my testimony that has some language very specifically targeted at the concept of corporate practice of medicine. And what that language does, and I'm not gonna walk through it, I'm happy to come back if you ever want me to, in more detail on it. It specifically defines private equity groups and hedge funds. And then it has clear language stating that those entities involved in any manner with any healthcare facility should not interfere with the judgment of healthcare professionals, making types of decisions like treatment decisions, scheduling, determining clinical policies. How that differs from the approach in H583 in a number of ways. One of which it addresses actually is broader, and that it addresses the sort of behavior or controlling ability of all healthcare facility types. So there are parts of five eighty three that actually exempts hospitals, FQHCs, ASCs from some of the restricted practices. And it also protects all healthcare professionals. So there's language in H583 right now that's only specific to either, depending on the section of the bill, physicians or medical practices, not other types of healthcare entities, say dental offices or mental healthcare practices. So it's actually in some ways more narrow and other ways broader. That approach is based on language adopted both by California and Oregon. And as I mentioned, that is attached, and I can go into more detail as well. So some other specific comments on sections of the bill. I'm gonna skip around a little bit in my written testimony, because it combines some of the definitions with some of what those definitions do, or how they're used. So there's a definition in the bill of healthcare entity, meaning any healthcare provider, facility, provider organization, PBM, or health insurer. That definition is relevant, that's definition five, because all of those entities, including thousands of individual providers, are the ones required to report ownership information on the later sections around reporting ownership, including things like staffing structures and audited financial reports. I actually just found in preparing this testimony a very helpful spreadsheet from the attorney general's office. There are 49,546 licensed health care professionals in Vermont. Granted many 49,546, quite a few. Now, that includes the whole nursing, different types of nurses, social workers, physicians, different therapists. So a lot of those may be employed by other health care facilities who could report on their behalf, but likely not small independent physicians, mental health, dental, other provider types. Will we question, is there a plan to outreach and educate all of those providers about the transparency requirements? And really, what are we trying to get at with those transparency requirements? Are we concerned about all of those provider types reporting? We also have some concerns. For example, it requires the disclosure of audited financial statements. I am not confident, but would imagine many very small providers do not have audits of their financial statements every year or even every few years. And that's a significant regulatory burden on small practitioners. And given the way the bill is written right now around exemptions from confidentiality, those financial statements could potentially now be publicly available, not only a potential antitrust concern, but getting into areas of what financial information from that practice's health is available to, say, insurers they're trying to negotiate with or other contracts they're trying to sign. And is the question of what the state is going to do and use with all that data, especially paired with the Green Mountain Care Board's testimony early on the bill, saying that they didn't have the capacity to really analyze that information. Sort of my summary of their testimony, they're happy to receive it, but there's a section in the bill around kind of reporting on vertical and horizontal integration that they said they couldn't do. So if we're gonna have reams of data and spreadsheets on all 49,000 of these providers, but we're not analyzing it, I'm not sure the bang for the buck we're getting for all that work from all of those providers needing to report that information. I'm gonna skip through other We have other concerns about definitions that I've included in my written testimony. I really wanna spend a little time on the prohibited transaction section, that's section 5,925. And I think this is also a section where you're hearing a lot of the concern and testimony, and I will try to point out why I think provider and other types of organizations are so concerned about this section. There is nothing that I read in the language that limits those transactions described that would now be prohibited to those involving private equity or any other concerning practices such as leveraged buyouts. We've heard that in testimony that that was the intent, but the words on the page in no way limit the prohibition on these transactions. They are prohibited in their entirety. So for example, a transaction that would give a party ownership of an essential community provider, which is, as I read, defined in federal regulation as any practice that serves predominantly low income, medically underserved individuals. So no one could purchase a practice that serves predominantly low income individuals. The bill prohibits a transaction that involves financing the acquisition of a health care entity through the use of debt. Again, we heard testimony that maybe that was intending to get at leveraged buyouts or other use but debt includes mortgages, bonds, other loans. And there is nothing in the language now saying that allowing that to continue to happen. So basically saying acquiring any health care entity through taking on debt would now be prohibited. And then I'll skip to the transaction that would result in a health entity that could not accept or place limitations on patients covered by Medicaid, original Medicare, or Medicare Advantage. We certainly understand the goal of as many healthcare facilities and practices in Vermont as possible accepting patients with all sorts of health insurance. On the other hand, requiring that any transaction would then lead to that entity having to accept all of these plans. There are many reasons why, especially smaller private practices or other practice types, don't contract with certain providers at certain times, especially Medicare Advantage, which historically, we know we don't have a lot in Vermont right now, but historically, and when they were present in Vermont, tend to have really burdensome prior authorization requirements, contracting requirements. And this basically says, No, sorry, you can't make that decision as a business decision, or even if it's best for you or your patients, you have to accept it. And could lead to some unintended consequences as well. So like an example of say, does that mean a pediatric practice that's been purchased would now have to contract the Medicare Advantage plans even if they don't see Medicare patients? So that, again, I think that section has raised a lot of concern because of even if it's not the intent, the actual language on the page now outright prohibits all of those types of transactions. The corporate practice of medicine section as drafted, I think raises also a lot of questions about by requiring ownership only by licensed MDs or DOs. I know a lot of other states do have such language on the books. My understanding of researching how these statutes have been used and implemented, or they're actually, at this point, considered fairly antiquated. Are you state firstly, they've been on the books for decades. They sort of historically arose out of prohibiting unlicensed practice of medicine. But now it led to really confusing corporate structures in those states. If hospitals have to be physician owned, they lead to all these odd physician separate corporations. It leads to all these structural oddities that many states are actually moving away from, and have found doesn't necessarily, in and of itself, prohibit private equity investment. And so states are looking at other, how can we get at the private equity issue directly, rather than just by controlling who owns a medical practice? So I would encourage Vermont to look at that direction of how can we directly address the negative private equity implications, rather than having to now create all sorts of maybe convoluted ownership structures of medical practices. And again, the language that we submitted would move in that direction. I will jump to a section we really like. This is the prohibition on what's called restrictive covenants. And we haven't spent a lot of time hearing testimony on this section of the bill, so I do wanna just go into this a little bit. Non compete agreements are historically types of agreements and employment contracts that say, if you leave this employer, you can't practice in a certain geographic area or a certain amount of time in sort of the same area of business. In Vermont, we don't think they are particularly common in healthcare employment agreements, but we also think they're particularly important to prohibit in healthcare employment agreements because of the patient care implications. First of all, it's a workforce piece. It prohibits people from being able to go work, maybe start their own practice or go to move to another practice, but it can also be really disruptive to patient care. If your provider leaves and goes to another, and can't work in that same area and can't serve you anymore, and maybe you have a rare condition and now you can't even see anybody in the UVM area, you'd have to go to Dartmouth or something like that. So the Federal Trade Commission has weighed in on non competes in healthcare. The American Medical Association doesn't support them and has policy on them. I will say that the bill, five eighty three, addresses them quite briefly. It basically just says they are prohibited. I actually would suggest that with the committee's interest or indulgence, that we spend a little more time developing that language to make sure that it addresses some issues that have come up in other states. Many states actually do prohibit non competes in healthcare, but there are a couple specific areas that I think could be important to address. For example, what do we want to say around out of state healthcare contracts? So an example we've heard come up is with staffing agencies, so maybe a little bit less of a physician issue, but it could be a physician issue, but more in nursing even, if you have a nurse who's been working in your facility, you really like them, you want to hire them, but that contract was actually formed in another state. Does Vermont non compete prohibition apply? So could they hire that nurse? There is, New Mexico actually had some language that passed fairly recently addressing that. So I would suggest we look at incorporating that. I think we should address, or the bill should address, is this retroactive or only prospective? There are some details that I think would be great to bring into the bill. And I have submitted some suggested language. I actually spent a lot of time diving into this over the summer and fall. There was a work group that the House Commerce and Economic Development Committee is looking at around non competes. In fact, they're taking testimony, they've had a walkthrough and they're taking more testimony tomorrow. So I will be sharing similar comments with them. And I do think just to flag, there will need to be some work to harmonize the two bills, because there is a little sentence in that bill specifically on non solicitation from healthcare entities. So non solicitation is you leave your current employer, maybe you don't have a non compete, so you can go to another practice, but can you communicate to patients about what can you, and can you communicate with patients about the fact that you've left that practice? My opinion, or BMS's position, is actually they should at least be able to communicate that they have left the practice, and that we should also not have non solicitation agreements. That's addressed a little differently right now in the House Commerce bill. So again, I just think we just want to make sure that they're not at odds, or that they work together. I think I've already talked about the sections of the bill around reporting of ownership. I do wanna actually mention a piece about enforcement, because I don't think I've heard other witnesses bring this up, except with the walkthrough and then the attorney general's office talking about enforcing it through the Consumer Protection Act. What that also would do, to my understanding, is allow Under the Consumer Protection Act, it allows citizen lawsuits to enforce the law as well. It's not just enforcement through the attorney general's office, but it allows citizen suits for violations. And we are quite concerned, especially paired with a very detailed reporting requirement, for example, that it could open up small practices to threat of litigation. And I'm not sure necessarily why we would, if we want to or need to, tie enforcement to the prospect of more litigation in our healthcare system. Thank you very much. I know that was a bit in the weeds, but again, I'm happy to come back. I submitted everything in writing, including the language on corporate practice of medicine and non competes, would love to work together with anyone interested to really make sure that we kind of right size getting at the concerning behaviors we want to without prohibiting practices that are important to support practices here in Vermont.

[Alyssa Black (Chair)]: Any questions for Jessa?

[Brian Cina (Member)]: You for providing details in writing for us to consider

[Jessa Barnard, Executive Director, Vermont Medical Society]: Yes, definitely I needed it in writing for myself. Thank you. Thanks very much.

[Alyssa Black (Chair)]: I'm sure that you will be, because I know you'd be willing to work with Absolutely. All

[Jessa Barnard, Executive Director, Vermont Medical Society]: I will actually, sorry, I do want to mention that the language on the corporate practice of medicine, we actually did work with a lot of other hospitals, long term care, some other folks. So the provider associations that I've been in touch with are supportive of that approach, and

[Susan Ridzon, Executive Director, Health First (Vermont Independent Practice Association)]: it would work for those folks. So thank you. Thank you.

[Alyssa Black (Chair)]: Great, next we have Susan.

[Susan Ridzon, Executive Director, Health First (Vermont Independent Practice Association)]: Yes, I did a lot

[Alyssa Black (Chair)]: of mic work for You know, I feel like you've said that before, Susan. Next time, I'm You gonna keep it in may have just gotten yourself into a little bit of trouble.

[Chris D’Elia, President, Vermont Bankers Association]: I also appreciate your

[Brian Cina (Member)]: presentation being ready for us to look at.

[Susan Ridzon, Executive Director, Health First (Vermont Independent Practice Association)]: Alright. Need to find a

[Brian Cina (Member)]: little Swipe through

[Susan Ridzon, Executive Director, Health First (Vermont Independent Practice Association)]: it. Yep. Need to share here.

[Alyssa Black (Chair)]: I like your questions, person.

[Brian Cina (Member)]: Wait for what? How do think? Oh, the guy, or the person, I'm sorry.

[Susan Ridzon, Executive Director, Health First (Vermont Independent Practice Association)]: The share is

[Brian Cina (Member)]: The person with the beard and a white robe. No, wait. That is weird. The t shirt with the shirt over it. It looks like he's wearing a robe.

[Susan Ridzon, Executive Director, Health First (Vermont Independent Practice Association)]: Yeah.

[Brian Cina (Member)]: Or a cape.

[Susan Ridzon, Executive Director, Health First (Vermont Independent Practice Association)]: It's much bigger than this guy. So for some reason, it's telling me that I'm sharing on another window, I'm not. So it doesn't seem to be letting me do this. I could talk through it since you all have it in front

[Brian Cina (Member)]: of you, right? And members of the public can find it on our website right now. I will try

[Susan Ridzon, Executive Director, Health First (Vermont Independent Practice Association)]: it one more time now. Just to see. Oh. Yeah. There it goes. Okay. Alright. What I don't know is if it'll let me do presenter view. Yeah. You guys don't wanna see the presenter view.

[Alyssa Black (Chair)]: Gosh. I feel like we just got this

[Susan Ridzon, Executive Director, Health First (Vermont Independent Practice Association)]: Alright. Behind the curtain. I know it.

[Alyssa Black (Chair)]: That's why I appreciate it.

[Susan Ridzon, Executive Director, Health First (Vermont Independent Practice Association)]: We've some notes and everything with it. So thank you for inviting me today. Appreciate it. My name's Susan Ritson. I'm the Executive Director of Vermont Health First. We're an independent practice association. For those of you who might not know what that is, we're basically an organization that was formed in 2010. Our sole mission is to support and foster independent practices. We do that a variety of ways. We do some discounts for medical malpractice. We do education. We do testimony like this. We do have payer contracts. And we own no medical practices. In fact, members own us. So just a little bit about our network, we're currently have 66 member practices across 11 counties. Have both primary care and specialty care practices. We have a number of specialties in our network. We have about two thirty five physician in APPs or NPS and PAs. You can see all of our member practices on our website or practice directory. And I wanted to just call out a couple things. You'll see that bubble with the 21% direct care or concierge practice. I called that out because this is a growing sector of our membership. And this is something that's being nationwide. And if folks aren't familiar with the term, I'll just briefly describe. So a direct care practice is one that charges a membership fee to the patient, either monthly or quarterly or annually. It ranges what the fee is, but usually between 100 and $200 a month sort of thing. And they accept no insurance. Whereas a concierge practice, they also charge a membership fee. But like a hotel concierge who works with different restaurant things, that a concierge practice does accept and show. So that's the distinction there. And then I also want to just note that a number of our members have been instrumental in bringing lower cost care options to Vermont and those include the Green Mountain Surgery Center, the Vermont Eye Laser Center, and most recently Vermont Diagnostic Imaging. So these are more, the independent practices and facilities are definitely lower cost options for Vermont. And I'm just going to say right out, our members overwhelmingly agree that patient care needs to come first and should not be influenced by private equity, profits or other factors. Members are adamant about that. They totally understand why you're doing this bill. They don't like to see the nefarious private equity behaviors happening either. But they also think the bad behavior should be curved no matter who it's coming from, whether it be private equity, private investors, or even nonprofits. And in fact, many of our clinicians went into independent practice to preserve that patient interaction and not have that core board control over how they practice medicine. Any questions so far?

[Alyssa Black (Chair)]: Is Four Seasons STIR part of health care? They are. Doctor. Goldman testified that himself.

[Susan Ridzon, Executive Director, Health First (Vermont Independent Practice Association)]: Exactly. So, and I'll admit, know, Jetsa did a great job with her lawyer, Pat. I am not a lawyer. I've read this bill so many times and I have to admit that it makes my head hurt. So as I read through the bill, and I know some of this has been discussed, I asked many of the questions that Jessa did, can our practices who are doing an ACO, PE backed ACO, will this bill allow them to do that? How is this going to affect Health First as an organization or how we support our practices? How does this affect a clinician's ability to sell to other clinicians or even just private business people that are involved in the medical decision making, but they might not be physicians who own the practice. This just happened yesterday. I got a call. One of our practices sold to two private businessmen. And I think it'll be okay. I will still exploring that, but should that be permitted? The flip side is this provider who is ready to retire could close the practice and then there's no access. Sometimes you have to make a choice. And then, all the things that other testifiers have talked about, can a practice still participate in the New England Collaborative, the management services organizations, PEOs, which is professional employer organizations that offer like HR support or Toppersville, called for association health plans. Is that in any way affected here? And then the debt, the ability to use debt to start, expand or improve a practice or facility. And more questions, Jessa brought up the points that I was going to bring up about Medicare Advantage. And then, we have real concerns just about the practice's burden on this for the reporting, the privacy, and just as the bill is written, I mean, I think every practice would probably need to consult a lawyer to really understand what they can and can't do and what they need to do. And whenever you have put a burden on an independent practice or any practice for that matter, and that drives up costs and it also limits how much time you're spending with patients. So just something to keep in mind. How will this bill affect investment in independent practices and facilities? And although they're not part of our network, I know there's an infusion center in Williston that is offering lower cost services to Vermonters. What happens with someone like that or a lab? There's also labs that are offering lower. Just want to make sure that we're not throwing the baby out with the backwater, getting friendly fire as they say. And then just other questions, is this bill going to be retroactive? You know, the Green Mountain Care Board, if all the practices have to report as the introductory draft calls for. That's a lot of information and the board doesn't even regulate independent private companies of that work.

[Alyssa Black (Chair)]: Did you have a question for me?

[Brian Cina (Member)]: No. I'm acknowledging that I'm hearing the concern. Okay.

[Susan Ridzon, Executive Director, Health First (Vermont Independent Practice Association)]: Thank you. I will say that we are supportive of the prohibition on the non competes and disclosure. This is just a mention and brought up some good clarifications to consider. I know the committee has talked about this, about narrowing and simplifying and clarifying the language and intent. That would help me personally just to understand it. And then just, we ask that as you go through the bill, just thinking about how this might affect the viability of current and potentially future independent practices or facilities. Are there perhaps unintended consequences? How will this affect competition? We already have a really consolidated system, narrowing that investment might not be good. Workforce concerns. How will this improve Vermont's access affordability crises? Make sure we're not contributing to those. And importantly, I would urge folks to think about what other ways can we support practices so that PE isn't seen as the only option. I mean, there are, there's reasons why practices are turning to these options, because it's, it's tough out there for them. And then other suggestions explicitly stating in the bill that independent clinician owned practices and facilities and IPAs are not the intended targets. Also applying the requirements evenly across healthcare entities. Doctor. Song made the statement that there's way more consolidation than it's not PE. PE is just one version of ownership in hospitals. But this bill acutely lands in the lap of independent practices, we feel like it really should apply to any problematic behavior. And we also suggest you think about adding language that would explicitly allow clinician to clinician practice sales, independent to independent mergers, use of loans or financing for, you know, to start or expand the practice or, you know, do some of the upgrades or technology. And then we, we talked about shared and administrative services agreements. And it sounds like that's not the intent to restrict those. And then importantly, this is a huge concern for our members thinking about every one of our practices having to do extensive financial reporting is I think Jessa mentioned, most of our practices I would gather do not do audited financials on a regular basis, especially the smaller ones. And then all of the concerns that Jessa raised are huge concerns for us as well. We would suggest that you exempt practices and facilities who attest to not engaging in the prohibited transactions. There is information about businesses on the Secretary of State site. You can find out who these owners are and so forth, to some extent through that. And just simplifying and allowing confidential reporting of sensitive financial information, I think that's really key as well.

[Alyssa Black (Chair)]: Can I ask about that since we're on it?

[Susan Ridzon, Executive Director, Health First (Vermont Independent Practice Association)]: Yeah. So,

[Alyssa Black (Chair)]: and I realize that this is a little bit more expansive in this bill than requirements, but if you participate in Medicare, you participate in Medicaid, you have to disclose ownership, percent of ownership to both Medicare and Medicaid, other than adding a small financial piece, which is not public, by the way, because you had said you were worried about the confidentiality of this. I'm not sure how this is any more prohibitive as far as administrative burden than currently what has to be done now.

[Susan Ridzon, Executive Director, Health First (Vermont Independent Practice Association)]: Would you accept the Medicaid and Medicare versions of reporting rather than requiring a whole new thing? And then there's also the direct care practices who don't accept any insurance. They don't go through that. And honestly, don't Are you familiar with the reporting that practices do with Medicaid and Medicare? I'm not

[Alyssa Black (Chair)]: Shouldn't we know who owns our healthcare and is profiting off of our healthcare entities? Shouldn't we know that?

[Susan Ridzon, Executive Director, Health First (Vermont Independent Practice Association)]: Well, profiting and sustainability, I you know, think there's this negative connotation with for profit means bad and nonprofit means good. And I think that's unfair.

[Alyssa Black (Chair)]: I'm not arguing that it's bad. I'm just, shouldn't we know who owns a practice?

[Susan Ridzon, Executive Director, Health First (Vermont Independent Practice Association)]: I don't know. Go ahead, Brian.

[Brian Cina (Member)]: I mean, I'm curious around the nation and in the world in different healthcare systems, who owns what, and to what degree is that information available to the public? I feel like, to your question about should we know, I think if we're spending taxpayer money on something, we should know where that money's going. So that means if there's a public private partnership in any capacity, like in the healthcare system, and private equity money is getting thrown in with taxpayer money, but they have a controlling interest on that money that the rest of us don't have, then we should certainly know that. But to my opinion is like, because you asked it generally, would be like, if it's all private investment, then what business is it of other people? But I don't know if that's the case in healthcare. I don't know if this is risk.

[Alyssa Black (Chair)]: I would expand it of shouldn't the entities that are taking care of the health and safety of Vermonters shouldn't we know that? I don't think folks

[Susan Ridzon, Executive Director, Health First (Vermont Independent Practice Association)]: are hiding from that, but there's a burden and there's, mean, if you owned a, let's say, a auto parts store or whatever, but you need be a little more specific. We're not requiring this of other businesses. And these are private investments by clinicians primarily who are wanting to provide patient care.

[Alyssa Black (Chair)]: Well, we do. I mean, can look up any business on the Secretary of State's and the ownership.

[Brian Cina (Member)]: Although it might say one hundred twenty three Corporation and you're like, what the hell is that? So, sorry to speak vulgar What

[Alyssa Black (Chair)]: if I realized in the bill there is a two year requirement for every two years? What if it was changed to over time ownership change change?

[Susan Ridzon, Executive Director, Health First (Vermont Independent Practice Association)]: Well, I guess, you know, what is the goal of having practices go through the exercise of submitting this information? Will be done with it? I mean

[Alyssa Black (Chair)]: Well, it'll be held and it'll be used by the attorney general to investigate

[Susan Ridzon, Executive Director, Health First (Vermont Independent Practice Association)]: practices that are not in compliance with us. So, could we do it like an attestation method though, where you have clearly outlined what is not permitted or what you want to know about. And if a practice says, I don't do any of these things, I attest to that. Make it more limited and targeted.

[Alyssa Black (Chair)]: It's to think about. Brian?

[Brian Cina (Member)]: I don't know if our witness asked the question or the chair asked the question a second ago about why people would want to know that or need to know that. I would say it goes back to this issue of choice and competition that we hear about, that the consumer, who owns a practice, may or may not choose to do business with them. So a person might say, I don't want to go to a doctor who's profiting a private equity firm because of what they're doing nationally to our economy for the average working person. So it gives the consumer more choice knowing who owns the practice that they're giving their healthcare dollars to, whether it be out of their pocket or their insurance company. So I think that would be one additional benefit of having some kind of disclosure of ownership that's more specific. A question I have, which you may not be able to answer completely, but you might have recommendations or help us bring in other witnesses, is around competition in the healthcare system, because we've heard a few witnesses say they're concerned about us affecting competition. The question I have is like, what's the balance between a system that promotes competition and a system that promotes collaboration? Because humanity, if you look at our evolution biologically, we're social creatures, and so it is working together that has allowed us to survive, not working against each other, but then rival groups work against each other so that one group can outcompete another, like nations versus nations or tribe versus tribe. But within these groups, collaboration is what allows us to move forward. So I think there's a balance between competition and collaboration and in the healthcare system, what is that healthy balance? Are there any examples globally or nationally of a healthcare system where there's a good amount of competition, but the right amount of coordination, for example? And at what point does competition become damaging to a healthcare system? Like for example, a certificate of need, if there was an MRI on every street corner, is that good for us or not? Don't know. So I just want put that out there for further reflection and also further recommendations that you might have for who we can hear about to better understand the right balance.

[Susan Ridzon, Executive Director, Health First (Vermont Independent Practice Association)]: It's a totally fair point. I think collaboration is key. And perhaps competition isn't the right word. It's more choice. I I think we all are aware that Vermont has embraced traditionally a very hospital centric system for years. We're starting to move away from that. And it really has not helped us in terms of access and cost. So I think Vermont has two ambulatory surgery centers. We're the lowest in the nation. And I don't think there's any, I think there's a connection between our costs and access and that fact. So it's really about expanding choice and working together. I think that's fair. Our practices, from what I've seen, they do want to work together. They work very hard to keep people out of the ED and so forth and connect with their colleagues at the hospital and outside of the hospital.

[Alyssa Black (Chair)]: I'm going go to Tupper, but can I expand on that? Which is a question I had asked Doctor. Goldman. I mean, I see this as actually increasing competition because we have a lot of good actors and I'm trying to stop the bad actors from coming in who are well funded, who have predatory practices that they put in place, and by trying our best to keep them out, the good actors can't compete with that.

[Susan Ridzon, Executive Director, Health First (Vermont Independent Practice Association)]: I see

[Alyssa Black (Chair)]: it as increasing competition in the types of care and the types of healthcare that we want to have. I see it as supporting that so that they don't have to compete with

[Susan Ridzon, Executive Director, Health First (Vermont Independent Practice Association)]: that's the intent, then great. I just worry about the language in the bill being overarching.

[Alyssa Black (Chair)]: That is the intention. And we are working on language. That's all for.

[Allen "Penny" Demar (Member)]: Thank you, madam.

[Alyssa Black (Chair)]: You tell everybody, we're working on language.

[Allen "Penny" Demar (Member)]: A couple of things that you said that I would like some clarification. Said at one point, maybe all we need to do is attest to the fact that we're not doing these prohibitive activities. If a company was caught doing these things, what kind of consequence would you say would be appropriate?

[Susan Ridzon, Executive Director, Health First (Vermont Independent Practice Association)]: Good question. I mean, I guess it depends on the behavior.

[Allen "Penny" Demar (Member)]: Well, he attested to the fact that they weren't doing any of this stuff. Now he finds out, oh, on this one.

[Susan Ridzon, Executive Director, Health First (Vermont Independent Practice Association)]: Yeah, I mean, you know, the right level of penalty is not something I feel like I can speak to, and I'm sure it depends on the size of the organization and things like that.

[Allen "Penny" Demar (Member)]: Well, don't want, period, we do not want that kind of activity happening in the state, no matter whether it's big or small. So that would be a question that I, you know, how would we, there's gotta be a consequence somehow. We're gonna make sure that it never happens again.

[Susan Ridzon, Executive Director, Health First (Vermont Independent Practice Association)]: I agree. And that's gonna be,

[Allen "Penny" Demar (Member)]: see a lady, can't practice. The other one is, talk about accidents, we're moving away from the hospital and you don't see any evidence of it costing less, or access is better. I'm wondering where that information is so that I could read it. Because we just started doing this, and I don't think there's any information yet.

[Susan Ridzon, Executive Director, Health First (Vermont Independent Practice Association)]: Let me see if I understand your question correctly. So you're wondering what data is out there to verify that access and affordability has improved? Is that what you're saying?

[Allen "Penny" Demar (Member)]: Well, it's not improved, because your statement was you haven't seen how much the moving away stuff out of the hospital is affecting the access and cost. So I interpret that to mean the cost is still high.

[Susan Ridzon, Executive Director, Health First (Vermont Independent Practice Association)]: I think so, yeah.

[Allen "Penny" Demar (Member)]: Or worse. If it's less, it's better. So it's costing more. And the access is the same thing. If it's not improving access, then we'll write back as if we were in the hospital, providing the service at a high cost. You said the cost is, in some cases, higher. Where did you get that information so that I can read it?

[Susan Ridzon, Executive Director, Health First (Vermont Independent Practice Association)]: So I'm still not sure I understand what you're asking exactly. Mean, we all know that hospitals are more expensive than independent facilities. I mean, they have more costs generally. And they have, particularly in consolidated markets like Vermont, some of them have significant negotiating power to drive up costs. So it makes complete sense that as you move care out of more costly hospitals, when the care doesn't need to be done in a hospital and you're moving it to ASCs and so forth, the cost of care should come down. And I think there, I mean, I know that Green Mountain Surgery Center has saved the commercial insurers significant amount of money over the years since they've been open. I do think though, that we're still in the infancy. I mean, thankfully, this committee passed the CON bill last session, and that I think will help to spur more lower cost care options. But it's going to take a while. You can't just take all the care out of the hospital. You have to support the alternative that you want patients to use, and that's And we're working on

[Allen "Penny" Demar (Member)]: that restructuring. Right. Was just You made a statement, I was trying to figure out where you got that information.

[Susan Ridzon, Executive Director, Health First (Vermont Independent Practice Association)]: The statement that access and affordability are

[Allen "Penny" Demar (Member)]: You all stated once, it hasn't helped us at all. The access and cost.

[Susan Ridzon, Executive Director, Health First (Vermont Independent Practice Association)]: Oh, I don't believe I said that, but I hope I didn't say that, because that's not what I meant.

[Allen "Penny" Demar (Member)]: I mean, that's what I thought I heard.

[Susan Ridzon, Executive Director, Health First (Vermont Independent Practice Association)]: Okay, so did you hear? Yes, but I don't think that's what you meant to Okay. I think you guys are yeah, but I heard that too, but I don't think that's what you meant to say. I don't know how to say that.

[Allen "Penny" Demar (Member)]: It's a simple statement to me. I heard you say something,

[Susan Ridzon, Executive Director, Health First (Vermont Independent Practice Association)]: I I wrote it down and you said heard it too. And

[Allen "Penny" Demar (Member)]: I was just asking where that information is.

[Susan Ridzon, Executive Director, Health First (Vermont Independent Practice Association)]: I apologize, I did not intend to say that if

[Allen "Penny" Demar (Member)]: I mean, it's pretty obvious. I think everybody around the table knows, if you take services out of the hospital and put them out in the field, it's gonna be cheaper.

[Susan Ridzon, Executive Director, Health First (Vermont Independent Practice Association)]: Right. But you also have to support You want

[Chris D’Elia, President, Vermont Bankers Association]: get around

[Susan Ridzon, Executive Director, Health First (Vermont Independent Practice Association)]: the house. Yeah, you have to support that, like, you know, rural health funds would be a good opportunity to support independence. I'm not sure that it'll be used that way, but to a certain extent maybe, but. Okay, so yeah.

[Alyssa Black (Chair)]: Data from features.

[Susan Ridzon, Executive Director, Health First (Vermont Independent Practice Association)]: If not mistaken.

[Chris D’Elia, President, Vermont Bankers Association]: You're Well, coming out

[Allen "Penny" Demar (Member)]: with that kind of information, hopefully

[Susan Ridzon, Executive Director, Health First (Vermont Independent Practice Association)]: over time it

[Allen "Penny" Demar (Member)]: will allow you to think that information's wrong, because it

[Chris D’Elia, President, Vermont Bankers Association]: costs less. Allen,

[Alyssa Black (Chair)]: do Lori brings in

[Susan Ridzon, Executive Director, Health First (Vermont Independent Practice Association)]: my practice.

[Chris D’Elia, President, Vermont Bankers Association]: I'll take

[Alyssa Black (Chair)]: the power off just to get to you. Thank you, Susan. Any other questions? Great. Chris, you've never come into this committee. This is exciting. I know.

[Chris D’Elia, President, Vermont Bankers Association]: It's a welcomed oasis from my other committees today. Thank you.

[Alyssa Black (Chair)]: We are the best committee. Oh, I said that.

[Chris D’Elia, President, Vermont Bankers Association]: I feel 03:30 when I go see my next committee. We are the best. Good afternoon for the record, Christina, you're president of the Vermont Bankers Association and correct. I can't think of the last time that I was in here, maybe a couple of years at least. So I appreciate the opportunity. You all know this world much better than I do, and all of your other witnesses know this world much better than I do. So I wanna come at this from the perspective and share some thoughts, that I got from my members because my members, who work in their communities are very in tuned with their local hospitals, their local providers, they're on boards, whether it's the hospitals or the FQHCs, and they see the critical need for adequate health care and providers in our communities. In looking at this bill, I'm just gonna touch on three areas. The first one is on page 10 where you talk about the prohibitions. And I like others, am questioning the prohibition on financing because it's not clear if you and I, Madam Chair, are providers in the community and you and I want to merge into a partnership, is there a prohibition of financing that partnership? To me, it's just not clear the way it's written. So I think clarity on that would be very helpful because we I think we want to provide opportunities if necessary for mergers to occur with local providers if it makes sense, and they're gonna need access to capital for whatever reason. So that prohibition may be a bit too far, just needs clarity. It does take me to my second issue and and in listening to others testify and listening to your comments about everybody that's outlined, if you will, in the acquisition definition of private equity, the institutional investors, and so on. Clearly, as an outside observer, there's some concerns about some of the practices that they engage in, whatever those practices may be. I guess I would offer us as an example of having dealt with bad practitioners in the marketplace and a response that creates a blanket that impacts everybody. And then those good actors can no longer do what they were doing in the market that was good for the community. So another way of looking at this, and I think you've heard snippets of it already, is if there's a way to parse out what are those bad behaviors that you want to go after and limit those bad behaviors with consequences because there may be a situation in the future, none of us could predict it, where you need those outside investors or private equity for very legitimate reasons to save a practice or do whatever. And if you have that blanket prohibition, that may have dire consequences for the people they're serving. So I just think of it, there's good actors, there's bad actors. Go after those bad, practices and figure out how to narrow those. And then the final thing I'll just comment on is is Jess spoke about earlier. So, I led the noncompete discussions at the request of chair, Mark. Think we had a group of practitioners, representing different entities and individuals come in and we all work together. And I think it became very clear to us that in the world of healthcare, there's much greater policy implications that were way beyond our working group. And for you to look at those here makes sense. I would echo what Jess has said and just suggest you look at what the new draft of H two zero five is down in commerce. They are going to move the bill forward. It does have a small reference to health care in there, but there's also broader implications that I think you ought to just be aware of and what the practitioners were looking at. There is a report that was filed by the Department of Financial, excuse me, I filed the report, I'm thinking of another report that they filed, but I filed a report with them. It's 14 pages. It's a quick read if you wanna look at it, but just throw that out there as to some coordination down the road may make sense for you. Whatever your outcomes are are totally up to you. That's not my bailiwick, but I just wanna make you aware that that's out there and being discussed vigorously.

[Alyssa Black (Chair)]: Maybe you can help me because I haven't had a chance to speak with chair Marcotte. So the only thing that's not addressed in theirs is the non solicitation you said or the Or is it the

[Chris D’Elia, President, Vermont Bankers Association]: So the new draft of the bill today deals with non competes, non solicitations, and state of pay provisions, which is a new section that was added. It doesn't, have the non disparagement section in there. The non solicitation piece that was added today, there's a there's a a general notion of not allowing solicitation for a period of time if it meets certain criteria. However, in the case of healthcare practitioners, if I was a practitioner and I left the practice to go somewhere else, there's contemplation in the new draft that would allow me to notify my clients that I am leaving, and it included the legal community and financial advisers. I that that probably makes sense, but my comments to the committee tomorrow will be perhaps you want some more guardrails around that because we could have 12 different versions of what that notice to the client looks like. And I think that might be a recipe for somebody getting tripped up along the way. So maybe some standardized form that a practitioner uses so that they don't get caught in between. Well, just letting somebody know, well, this one looks more like soliciting your business. All of us agreed during the summer that a client of a healthcare provider should absolutely have every right to go with their practitioner. No question about it.

[Alyssa Black (Chair)]: What's the bill number?

[Chris D’Elia, President, Vermont Bankers Association]: H205. H205. And there was a new draft released this morning under sophie's.e. Okay.

[Alyssa Black (Chair)]: Great. Yeah. Go ahead, Karen.

[Karen Lueders (Member)]: You mentioned non compete,

[Alyssa Black (Chair)]: non solicitation, and there was a third Non disparagement? The third category was non disparagement.

[Chris D’Elia, President, Vermont Bankers Association]: Yeah, that's not in their bill, but I think it was mentioned in your bill.

[Susan Ridzon, Executive Director, Health First (Vermont Independent Practice Association)]: Okay, thank you.

[Alyssa Black (Chair)]: We keep track of our own bill numbers.

[Susan Ridzon, Executive Director, Health First (Vermont Independent Practice Association)]: No, have to keep track of commerce.

[Jessa Barnard, Executive Director, Vermont Medical Society]: Anything else?

[Chris D’Elia, President, Vermont Bankers Association]: Happy to answer any questions.

[Alyssa Black (Chair)]: Well, thanks for having us.

[Allen "Penny" Demar (Member)]: Thank you, good

[Chris D’Elia, President, Vermont Bankers Association]: to see you. Want

[Alyssa Black (Chair)]: to schedule you on our next meeting.

[Chris D’Elia, President, Vermont Bankers Association]: You know what, I'm happy to put me in Alpine on things that I have nothing or knowledge whatsoever about.

[Alyssa Black (Chair)]: As much money as

[Susan Ridzon, Executive Director, Health First (Vermont Independent Practice Association)]: there is in health care, you should be here more often. Yeah. Thank

[Chris D’Elia, President, Vermont Bankers Association]: you, representative, for the offer. I've got my own crisis this year.

[Alyssa Black (Chair)]: I will say that I had this moment of panic. If we do move forward on this bill, and I'm not even sure we're moving forward, if we do, I will be the one reporting it, and I am deeply, deeply fearful because I'll have to learn way too much about banking and financing things. I'm coming to you, Chris, to give me

[Chris D’Elia, President, Vermont Bankers Association]: a Oh, I'm gonna be on vacation. I would say, so my side is strictly on the banking. I would suggest that maybe you contact Aaron Ferenc at DFR, Department of Financial Regulation. They a whole group of licensed lenders, etcetera. And when you're starting to get into institutional investors, etcetera, they may be able to help you fill in that picture of how those groups typically function in the marketplace. You can call me anytime. I'll try and help if I can.

[Alyssa Black (Chair)]: Okay. Think we're all done for the day. Let's get out a little bit early.

[Allen "Penny" Demar (Member)]: You're smiling at me.

[Alyssa Black (Chair)]: Because you threw your pen down like, pew pew. Okay, so we're back here at 12AM at 9AM. Thank you everyone.