Vermont Legislature SmartTranscripts:

[Rep. Alyssa Black (Chair)]: Welcome back. We are continuing to house healthcare reimbursement rate recommendations that we've received from various organizations, providers. Do you want to keep going, Daisy? Yeah. Going great. So,

[Rep. Daisy Berbeco (Ranking Member)]: we are in that about middle of the spreadsheet, which is in our budget folder on our House Health Care web page. I'm at the Visiting Nurses Association recommendation for a 3.5% increase,

[Rep. Alyssa Black (Chair)]: which would add $28,000

[Rep. Daisy Berbeco (Ranking Member)]: to the base, bringing them up to 70% of Medicare. So

[Nolan Langweil (Joint Fiscal Office analyst)]: I just want to qualify that I cannot verify any of these rates or any these numbers. These are what the advocates tell us, which may be correct, they don't know, but we haven't verified.

[Rep. Alyssa Black (Chair)]: Can I ask the VNAs in the room why is it only in base? Or not base, why is it only in general fund or is there a match?

[Eric Covey (VNAs of Vermont)]: It's probably match price. That $3.28 is the worst. Okay. I think

[Nolan Langweil (Joint Fiscal Office analyst)]: it just wasn't building on the sheet.

[Mike Fisher (Chief Health Care Advocate)]: Okay. And

[Eric Covey (VNAs of Vermont)]: I'm happy to sit down with you anytime. We've worked up a rate model. There's a funding to cork in the people.

[Nolan Langweil (Joint Fiscal Office analyst)]: I appreciate that. I just need to hear from the administration what that number would be. So I I always appreciate hearing, but I just need them to verify.

[Rep. Alyssa Black (Chair)]: But can I assume, Nolan, that if it's a net increase, a gross increase of $3.28, that this is all math

[Nolan Langweil (Joint Fiscal Office analyst)]: I would assume

[Rep. Alyssa Black (Chair)]: funds, so it's

[Nolan Langweil (Joint Fiscal Office analyst)]: like one twenty two this is math?

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

[Rep. Daisy Berbeco (Ranking Member)]: Okay.

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

[Nolan Langweil (Joint Fiscal Office analyst)]: Same with the next one.

[Rep. Daisy Berbeco (Ranking Member)]: Okay, so the next one, Vermont Care Partners, 3.5% increase. This is our designated agency's mental health. This includes the SSAs also in me. 5,800,000.

[Rep. Alyssa Black (Chair)]: Any questions about that? And again, we can assume that that's not all general fund, that might be a lot of federal. Then last question, how much is federal?

[Rep. Daisy Berbeco (Ranking Member)]: Yeah, we

[Rep. Alyssa Black (Chair)]: don't know. We don't know.

[Nolan Langweil (Joint Fiscal Office analyst)]: It's a VR always clean especially this one. It's not always a perfectly straight match, something that might be true general bond, so I can't tell you what the number is, but the fact that these, they will be matched up light on the one, but what percentage?

[Rep. Daisy Berbeco (Ranking Member)]: Lori, do you want to talk about this one? Because I still always struggle to understand this one. Which one are you at? The medical society,

[Rep. Alyssa Black (Chair)]: No, the I can do this one. Oh, I can.

[Rep. Daisy Berbeco (Ranking Member)]: You're so much better at this.

[Rep. Alyssa Black (Chair)]: So they're asking for an increase in the professional fee schedule, which is basically everything paid to physician assistants, the fee for service fee schedule. So they're asking for this increase because of the Medicare economic index that Medicare's rates kind of get adjusted for, they're asking for a match of that because that didn't She's like, Oh, don't screw it up, Alyssa.

[Rep. Daisy Berbeco (Ranking Member)]: I'm sorry. You I was gone this last

[Rep. Alyssa Black (Chair)]: year And essentially, so Diva this year did not raise any rates whatsoever. They kept the same conversion factor for Medicaid. And so even though there was a slight increase from Medicare, there was no increase from Medicaid, which means that I give the example of our enhanced primary care rates, we're paying at 114% of Medicare's allowed amount. And this year, because of not having this increase, they're now at 110%. So there's no inflationary increase on Medicaid rates. Did I get that kind of right? Yeah. So could you say those percents again? So from 140 to one hundred ten? Fourteen. That was just on the enhanced primary care, I believe. That was the example think Jessa gave. Oh, I'm sorry. Say that again? 114. 114 to one. Now 100 Because and obviously if one went up, but the other stayed the same, the percentage of it would be a decreased percentage. And I will say that over the years, we have intended that the Medicaid rates keep in line with Medicare's rates. So when we don't raise Medicaid, but Medicare does go up and the Medicare Economic Index, by the way, is basically the rate of inflation in medical costs that's federal. And we've tried to keep them in line so that they don't fall back down to where they were. Alright, if I may. So it looks like there's $2,000,000 for psych, and I'm just wondering what's the thinking behind that? Do we know? Where are you? In the break room. Oh, no. Yeah, so it's just a lot compared to others. Well, so I'm assuming it's a breakdown by specialty type. So there's primary care and then they break out through specialty care, which I think is around, where is it like 80% now? It's less than what Medicare pays. And they're just giving examples here that if this increase went into effect, it would have this sort of effect upon these certain types of provider types. Which means that psych is really bad. Psych is really, really expensive and hard to get people here for, so we need to pay premium salaries to get folks to come. So is that sort of part of what it is? It's affecting a workforce? Is that what we're thinking? It's reimbursements, right? I was going say something, but I don't want to say it because that could be inaccurate.

[Rep. Daisy Berbeco (Ranking Member)]: Isn't it just the on top of the rate that's already been established? Yes. So if you do that rate across all of these types, that's just what the bad dollar amount

[Rep. Alyssa Black (Chair)]: Which means that psych is so low that it's such a big Would I be accurate in saying that psych is reimbursed by Medicare and Medicaid actually at a higher amount than even commercial. Not saying it's high, I don't want to put it out there that it's high, but that typically this is the one area where commercial rates end up being lower than Medicare and Medicaid?

[Karen (Vermont Medical Society representative)]: You probably know something about that in the eye, but

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

[Karen (Vermont Medical Society representative)]: Joseph, I'm Karen from the Vermont Medical Society. We did put that chart on the back of our budget asks, and it's a little confusing, but we were trying to show how that came out, think, went above the indirect rates, and it's a little confusing way that it

[Mike Fisher (Chief Health Care Advocate)]: I

[Rep. Alyssa Black (Chair)]: remember the chart. From my handout. Sorry, did I make that as clear as mud or as Leslie? Silver not loading. I think they were just giving us an idea of how it would impact different specialty types.

[Rep. Daisy Berbeco (Ranking Member)]: So can we go to the next one? Can

[Nolan Langweil (Joint Fiscal Office analyst)]: I go back to the remarks from our partners? Two clarifications. One is that request from our care partners is actually their estimates of the general fund and not the growth. So they're actually asking for their estimates of the general fund. The second piece I would flag is that it's also across budgets across EVA, DMA, so like last year you guys did a joint request with the Human Services Committee on this, so that's another avenue to do as well. But just know this is a request across all AHS and not just people. So it does kind of blend with the school services.

[Rep. Daisy Berbeco (Ranking Member)]: Got it. So if we voted for that, it would be support, not have to be, but it would

[Rep. Alyssa Black (Chair)]: be supporting the services they do for Dale as well. Yeah. Which we don't often hear about in this committee.

[Mike Fisher (Chief Health Care Advocate)]: Which one is this? We're talking

[Rep. Daisy Berbeco (Ranking Member)]: about Vermont Care Partners and their requested increase.

[Unidentified Committee Member]: Yeah. Oh, okay.

[Nolan Langweil (Joint Fiscal Office analyst)]: And the last thing I'll add to that too is, like last year when we did rate increases, it wasn't just DAs and SSAs, we did that across the board, were servicing that stuff. The number, it could be different if you are just specific to DAs and SSAs versus including the other folks that get raised, so you think about that as well. The cost could be more, unless you're just specific to DAs and SSAs.

[Rep. Daisy Berbeco (Ranking Member)]: Number in this request is specific to DAs and SSAs.

[Nolan Langweil (Joint Fiscal Office analyst)]: That's Correct, but last year when we did the rate increase, it's different public, you can't focus on them. There's other home and community services outside the VAs and SSAs, you did a rate increase for other services. And

[Rep. Daisy Berbeco (Ranking Member)]: those folks are, like the VNAs in the line above, requested the same exact placement increase.

[Nolan Langweil (Joint Fiscal Office analyst)]: Yeah, so there is, yeah. So you could combine them.

[Rep. Alyssa Black (Chair)]: Actually, can I, I just want to clarify, Eric, with the VNAs? So this increase, is this just targeted to home health, like nursing home health? Or is it because this is what happened last year, that the VNAs, you also do home care services?

[Eric Covey (VNAs of Vermont)]: So this is just the Medicaid skilled home health, the license.

[Rep. Alyssa Black (Chair)]: Thank you.

[Mike Fisher (Chief Health Care Advocate)]: Physical therapy, occupational therapy.

[Eric Covey (VNAs of Vermont)]: There's a series of

[Mike Fisher (Chief Health Care Advocate)]: codes. Yep,

[Rep. Alyssa Black (Chair)]: yep. This is the, you get discharged from the hospital and the nurse comes and helps you for whatever time. Not the person who comes to help with daily living.

[Mike Fisher (Chief Health Care Advocate)]: The difference being licensed medical. Yes. Okay.

[Rep. Alyssa Black (Chair)]: Want to Make sure everybody understands it.

[Rep. Daisy Berbeco (Ranking Member)]: Okay, the last line on there. One Care Vermont population health per member per month and comprehensive change through form payments, dollars 7,700,000.0. Primary care alternative payments funding gap. UVM Health Network settlement funds through January 27 and AHEAD funds begin in 2028, anticipated. So this is gap funding or bridge funding? Yes, which we did. UVM did last year through the settlement, yeah. So there will be no per member, per month payments without the $7,700,000 for the year ahead. We really have a choice on this? We the year ahead.

[Mike Fisher (Chief Health Care Advocate)]: Yes, we do.

[Rep. Alyssa Black (Chair)]: What happens if we don't fund it? They don't get their The primary today is primary care pets. The ACO ended, so primary care practices don't get those per member per month. That was this famous gap that we talked about. I will say that I believe in the rural health transformation that they're talking about a lot of things to do through the blueprint. Since they can't do rates or services that are paid for, it thinks that they're targeting this per member per month. Am I right, Jill? Are you of nodding your head?

[Karen (Vermont Medical Society representative)]: There's really not. Hopefully not clear on

[Rep. Alyssa Black (Chair)]: what your choices are.

[Karen (Vermont Medical Society representative)]: What we know is that you only pay providers 15% of that $195,000,000 So, it really can't be gone before, and they don't want to, they can't backfill any of the kids'

[Rep. Alyssa Black (Chair)]: it's I I come up with new programs. Okay.

[Rep. Daisy Berbeco (Ranking Member)]: Is that all general fund? I'm trying to read in the notes. Okay, yeah. 5.95% general fund for population health, and payment reform is 1.75%. Okay. Anything else on that section of reimbursement rate? The coupon for the other non government recommended requests, starting with the pending This referral request is for $462.5 general fund dollars with a gross of $9.25 This would bring some positions to full time in order to increase access to people. Also infrastructure, including repairs and dental program equipment, and keeping their electronic medical record up to date. The request is a Medicaid administrative funding match, so that has a fifty-fifty match. And then there's a breakdown in how that money would be directed within the free and referral clinics. Brian?

[Mike Fisher (Chief Health Care Advocate)]: If we give

[Rep. Brian Cina (Member)]: them more, can they draw down more from the federal government and serve even more people?

[Rep. Daisy Berbeco (Ranking Member)]: Fiftyfifty math. Would you like to answer that?

[Mike Fisher (Chief Health Care Advocate)]: Be great, yes. I think we should

[Rep. Brian Cina (Member)]: at least give them that amount, if not more. Considering the need, the government We're not talking about taking a position. Oh, my bad. Thank you.

[Rep. Daisy Berbeco (Ranking Member)]: And then any other questions about getting referral clinics? I still go to Bridges to Health. Which is a half million general fund to support transition of the organisation to the free referral clinics. Bridges to Health has been looking for a home base for years. They have finally found one. And just to refresh everybody, this work would support People who work for small employers that can't offer insurance are often those that get care in these places. So that's what the money would go toward. It's often, if I remember right, dental services, adults and youth.

[Rep. Alyssa Black (Chair)]: For a population who's only access to health care essentially is through our emergency rooms.

[Rep. Brian Cina (Member)]: Brian? And this is just, the ask here is transitional money, that's what it's saying, one time, funding to support a transition. So then once that transition happens, the program can be sustained how?

[Rep. Daisy Berbeco (Ranking Member)]: I know we asked that question in testimony.

[Rep. Brian Cina (Member)]: Yeah, I

[Rep. Daisy Berbeco (Ranking Member)]: can't remember. It's going to Referral credits.

[Rep. Brian Cina (Member)]: But then how do they sustain the funding after the transition? I think that's the question.

[Rep. Alyssa Black (Chair)]: Becomes part of their budget.

[Nolan Langweil (Joint Fiscal Office analyst)]: That's a

[Rep. Brian Cina (Member)]: fun time.

[Rep. Alyssa Black (Chair)]: Can

[Rep. Brian Cina (Member)]: they bill? Is that what it is? They bill?

[Rep. Alyssa Black (Chair)]: Yes. We ask? And I realize that you're not, but you're representing free and referral clinics. So the bridge is funding. They're asking for transition money to become part of, be housed within free and referral clinics. What is the plan for funding moving forward to sustain that?

[Mike Fisher (Chief Health Care Advocate)]: I know they have a role, oh sorry, Dan Farlow, Executive Director of People's Health and Wellness Clinic Chair of the Vermont Free and Referral Clinic Board. I'm not the person doing the negotiation on this contract, but my understanding is that they have a pretty robust fundraising mechanism already, that they've been talking to Senator Sanders as well about some federal resources and that for the VFRC, our budget would be separate from Bridge's budget internally, so they'd be responsible for their fundraising, would not be relying on the core grant we get from VDH.

[Rep. Alyssa Black (Chair)]: Can anyone remind me what happened with bridges in the BAA? We've already funded it. We did. What do mean on where?

[Nolan Langweil (Joint Fiscal Office analyst)]: Maiden looks in screen.

[Rep. Alyssa Black (Chair)]: Can we move forward? Yeah.

[Rep. Brian Cina (Member)]: It looked like appropriations was talking about it again. Moved. January this week, so I don't know how

[Nolan Langweil (Joint Fiscal Office analyst)]: works. Yeah,

[Rep. Alyssa Black (Chair)]: that's right. I think it was like, help us get to July. Talk, Topper

[Rep. Brian Cina (Member)]: said that we're not weighing in on stuff now, we're just asking questions. So I think my question is just, it would be helpful by the time we make a decision to know a little bit more about this plan to sustain the money so we don't just throw $500,000 away on the transition and then the program fails anyway. That would be my concern. So if we can just get some info about that.

[Rep. Daisy Berbeco (Ranking Member)]: We asked for $167,700

[Rep. Alyssa Black (Chair)]: in the BAA.

[Rep. Brian Cina (Member)]: We did already.

[Rep. Alyssa Black (Chair)]: No one will have to ask my doubt. People still know what happened to it.

[Rep. Daisy Berbeco (Ranking Member)]: Okay. Can we talk about Benefit Assisters? Yep. Benefit Assisters is to assist this, if I understood right, would support staff at two eleven, Hunger Free Vermont, the Language Justice Project, and other nonprofit organizations to support Medicaid enrollment and re enrollment, as well as SNAP eligibility and enrollment services direct with folks that are already interacting with They their would need to get certified by DIVA as a benefit assister and also training for Medicaid enrollment and eligibility. And this would be about five now.

[Rep. Alyssa Black (Chair)]: Can I ask a question about that? So, it's one time. I'm not sure I understand how that works over time.

[Rep. Daisy Berbeco (Ranking Member)]: Yeah, that's a good question, Leslie.

[Rep. Alyssa Black (Chair)]: I mean, 5,000,000 is significant. We can use it elsewhere.

[Rep. Daisy Berbeco (Ranking Member)]: It's certainly an easier ask. But if recall, Amy said they would accept it being in the base one time for now. Did you want to go ahead? Yes.

[Karen (Vermont Medical Society representative)]: The The idea is that there will be a sort of influx of need in this fiscal year as the appointments actually change.

[Rep. Alyssa Black (Chair)]: Well, of HR1, is that what you're saying?

[Karen (Vermont Medical Society representative)]: Yes, this is a new record, this whole package

[Rep. Alyssa Black (Chair)]: is a dual practice on stage one. How is that different than, I guess it's a whole different thing, than we're already adding 12 positions. Wouldn't some of

[Rep. Daisy Berbeco (Ranking Member)]: those 12 positions sort of take up the slack or not really? No, because these folks interface with people at Hunger Free Vermont, blah, blah, blah. And those internal 12 people are going to be doing things internally to Diva. So that's sort of a different end of the process is my understanding.

[Rep. Alyssa Black (Chair)]: But that it's not gonna be required after this year. Everyone's gonna be totally perfectly up to speed.

[Rep. Daisy Berbeco (Ranking Member)]: No, I think it's just that they realize that we're tight on a budget.

[Rep. Alyssa Black (Chair)]: That they just couldn't add it to the base.

[Nolan Langweil (Joint Fiscal Office analyst)]: You It's a workaround. Assume that there'll be another asset.

[Mike Fisher (Chief Health Care Advocate)]: But it

[Nolan Langweil (Joint Fiscal Office analyst)]: would be more refined based on their one year experience.

[Rep. Alyssa Black (Chair)]: But also a lot of this was to get people up and trained and so that maybe that's something, yes.

[Rep. Daisy Berbeco (Ranking Member)]: That's right.

[Rep. Alyssa Black (Chair)]: But I think Nolan is right and expect to see next year as well. This did have

[Rep. Daisy Berbeco (Ranking Member)]: a sync training component

[Nolan Langweil (Joint Fiscal Office analyst)]: to It'll be different next year.

[Rep. Daisy Berbeco (Ranking Member)]: Any other questions on this one for benefit assisters?

[Nolan Langweil (Joint Fiscal Office analyst)]: Can I just answer the Bridges question? Yes, it is in the Senate BAA as well, for $167,000 for bridges.

[Rep. Alyssa Black (Chair)]: That was for them to move, right? That was like moving costs.

[Nolan Langweil (Joint Fiscal Office analyst)]: But anyway, the answer is it was in BAA.

[Rep. Daisy Berbeco (Ranking Member)]: Okay, the American Heart Association needs $150,000 one time, which would be grants for schools to implement the cardiac emergency response plans, which

[Rep. Alyssa Black (Chair)]: are required to be in place by this fall. I think we required that. I was going say who required it. We did. I don't

[Nolan Langweil (Joint Fiscal Office analyst)]: remember, yeah. I'm not sure.

[Mike Fisher (Chief Health Care Advocate)]: What was

[Rep. Brian Cina (Member)]: it, what piece of legislation, wasn't it?

[Rep. Alyssa Black (Chair)]: It was part of the miscellaneous the Teenage Student American Heart Association, it was part of the miscellaneous Ed bill, sent the cell phone, made it hard to speak.

[Rep. Brian Cina (Member)]: Oh, so it wasn't us, this committee,

[Mike Fisher (Chief Health Care Advocate)]: it was us.

[Rep. Alyssa Black (Chair)]: We did hear

[Rep. Daisy Berbeco (Ranking Member)]: it, we did hear about

[Rep. Alyssa Black (Chair)]: it, yes. So they don't have

[Rep. Daisy Berbeco (Ranking Member)]: a choice, that is something that they need money to do what we ask them to do.

[Mike Fisher (Chief Health Care Advocate)]: How can we track and make them the ad fund? Yeah, this is going to be my test phone.

[Rep. Brian Cina (Member)]: I didn't raise my hand, I'm sorry.

[Rep. Alyssa Black (Chair)]: Because, is Caledonia at this line item? You've asked them, I'm not in your house, I don't know.

[Karen (Vermont Medical Society representative)]: We've we've asked around times, not really come

[Rep. Alyssa Black (Chair)]: from the ed financing schools, a lot of schools have AABs, A lot of schools have CPR training, but they would grant funding we thought they could use. It seems like it's being used for other stuff. It's been saving grants. This is mostly used for security purposes, and this helps for the schools who are most in need. Not everybody would be need based. So you have a request in with House Ed as well? Or to put it in the budget. Go

[Rep. Daisy Berbeco (Ranking Member)]: ahead, Brian.

[Rep. Brian Cina (Member)]: This would be a question that may not be answered today, this is not once again about supporting or not supporting. So I don't want to be cheating that way. The question is like, once we invest in this, how do we sustain this equipment? Because AEDs don't last forever and there should be some plan in place to make sure schools are maintaining this equipment so that if there is a cardiac emergency, we can be guaranteed that that stuff is there, because it would be sad if that stuff failed when it was needed after we spent money on it now. So I don't know, will it be maintained by school budgets in the future, or is state gonna have to plan for this? That would just be a question here.

[Rep. Alyssa Black (Chair)]: May I ask Tina, how much was the,

[Mike Fisher (Chief Health Care Advocate)]: how much are

[Rep. Alyssa Black (Chair)]: the grants through this bit? Safety grants that are up to $10,000 that schools can use for safety issues. And so, they tell us that they can be used for ADDs, and now it's been denied to use them for ADDs, but they've also them for things like security cameras, signage, go kits. So if a school has those needs, then they would, in which case, continue absorbing the school budget for the schools.

[Nolan Langweil (Joint Fiscal Office analyst)]: Between Any other

[Rep. Alyssa Black (Chair)]: questions, Elise? Great. Oh,

[Rep. Daisy Berbeco (Ranking Member)]: I'm sorry. Go ahead, Beth. No. I don't. I'm sorry if I'm Back up. I'm sorry. To Vermont for your rural permit.

[Karen (Vermont Medical Society representative)]: So it looks like well, I'll ask.

[Rep. Daisy Berbeco (Ranking Member)]: So how much of that goes directly

[Karen (Vermont Medical Society representative)]: to the people who are seeking help? I mean, this looks like it's staff

[Rep. Daisy Berbeco (Ranking Member)]: and infrastructure. I see

[Rep. Alyssa Black (Chair)]: the free and referral clinics, first of there's no cost for people seeking care. And also, I do know that their providers are all voluntary. So the actual provider is providing this money is for staffing, like the person, the receptionist that checked in. And I know that I had, I'm not sure if it was within committee, but I do remember I had a conversation with Dan Barlow, who just left the room, that his clinic in Berry, their need has been so great that he's trying to expand the hours of it. So he needs the staff personnel to be able to expand the hours. I think they're only open, many days they're open now?

[Unidentified Committee Member]: I didn't know they weren't open all five days.

[Rep. Alyssa Black (Chair)]: I think this is to expand actually to seven days, because their need is better. Right, so I love what they do, I'm just wondering how much of that money is for

[Karen (Vermont Medical Society representative)]: the actual medicines

[Rep. Alyssa Black (Chair)]: and all of that that

[Karen (Vermont Medical Society representative)]: people need. Doesn't seem to

[Rep. Alyssa Black (Chair)]: $5.87 for increased staffing. So those are the people that just staff the clinic for sort of administrative purposes. 60,000 for IT, I think EMR for their electronic medical record, increased costs on that. And then $2.78 for infrastructure, I'm assuming that's for things like fixing a hole in a roof. Is that specifically things like equipment, dental equipment, things like that?

[Karen (Vermont Medical Society representative)]: So where does the funding come from that they used to buy all the medical necessities that help these people.

[Rep. Alyssa Black (Chair)]: I think it comes from all of this sort of stuff. Yeah, mean, there's a base amount already in the budget that we This has an increase, they do have a base amount.

[Unidentified Committee Member]: And then also, people donate, they have fundraisers people donate to the free clinics. The person who goes in there doesn't pay anything.

[Nolan Langweil (Joint Fiscal Office analyst)]: I would add though, that if you, this is a recommendation the committee adds, that you include language being very clear about what the money is used for, so that when a department goes to issue a grant, it's clear what's the expense of that money. Otherwise, they may do grants that aren't specific for intent.

[Rep. Alyssa Black (Chair)]: And just to let you, I'm looking under our testimony for budget and there is there is something from if you look under Dan Barlow, there's written testimony in there that tells you

[Mike Fisher (Chief Health Care Advocate)]: where everything's going.

[Rep. Alyssa Black (Chair)]: Okay. Any other questions on that? Can we flip the page? It's such a big Don't get chicks. Okay. Alright, does Adair, Daisy, or Lori want to speak to this because we didn't actually hear anything directly on Dulce, but people on the committee will remember probably that program. Does anyone want do you want to speak to it?

[Rep. Daisy Berbeco (Ranking Member)]: What I remember about this is it's not funded, again, in the governor's budget, but it works across six different sites and that funding's in big. So it just simply was not funded this year,

[Rep. Alyssa Black (Chair)]: but it's been in the BDH budget for as

[Rep. Daisy Berbeco (Ranking Member)]: long as I can remember. Works with mothers and children. Okay, so we need

[Rep. Alyssa Black (Chair)]: to have an understanding of Dulce. What? What do say? He doesn't know what Dulce is. Recall Gosh, it's deserted. Oh, oh yeah, let's ask somebody else. Hi.

[Karen (Vermont Medical Society representative)]: Dulce, what's up, Karen? So it's a team approach to providing care for newborns and their families. And so it typically has a pediatrician, there'll be children's child development, there'll be other services that are connected So you're getting this background services and it's just had really great outcomes for families that are at risk.

[Rep. Daisy Berbeco (Ranking Member)]: Is this the full program or was this an expansion?

[Rep. Alyssa Black (Chair)]: Last year,

[Karen (Vermont Medical Society representative)]: I think it was funded at $600,000 And I don't think this is an expansion. I just think that this is the cost for the fund. So if we don't

[Rep. Alyssa Black (Chair)]: fund this, it goes away.

[Karen (Vermont Medical Society representative)]: Right, so I can double check on why from 600 to 1,000,000, I think it's just the cost. Yeah, this is the

[Rep. Daisy Berbeco (Ranking Member)]: If you could double check that, because I also remember us having a big debate about this and there potentially being an expansion.

[Rep. Alyssa Black (Chair)]: Is it a blueprint? I can still remember Doctor. Levine sitting in front of us talking about it. This is

[Karen (Vermont Medical Society representative)]: the only funding for it now.

[Rep. Daisy Berbeco (Ranking Member)]: Next, we have a request from United Way. This would help to integrate their Epic EMS and two eleven, so that those data systems can talk to each other, allow clinicians to be more seamlessly communicating, and theoretically, patients to be treated with a more comprehensive view of their whole health. The request is $332,000 I didn't have a general fund amount for that. I don't know if Nolan

[Nolan Langweil (Joint Fiscal Office analyst)]: I think you would assume that's a general fund grant.

[Rep. Alyssa Black (Chair)]: VMH Now, have in their budget a cut kitchen wipes. Yeah. This is essentially replacing the cuff that was made.

[Rep. Daisy Berbeco (Ranking Member)]: This is for something different. That was for services that would reduce the hours of availability of 02:11.

[Rep. Alyssa Black (Chair)]: Getting rid of the overnight.

[Rep. Daisy Berbeco (Ranking Member)]: Yeah. Specific to the connection with Epic to be able to refer people seamlessly.

[Rep. Alyssa Black (Chair)]: Where was that on our spreadsheet? I see a notes on it, but it's not actually aligned.

[Rep. Daisy Berbeco (Ranking Member)]: For the removal, we did not include it.

[Rep. Alyssa Black (Chair)]: For the down of the cutting of the overnight. We did

[Rep. Daisy Berbeco (Ranking Member)]: not include it. We can include it. And I put the line in the wrong spot. So where it says Epic and two eleven integration under the outreach, that actually should be

[Rep. Alyssa Black (Chair)]: on the 211 line, which is what I'm fixing. Okay.

[Rep. Daisy Berbeco (Ranking Member)]: Any questions about that Epic two eleven integration? Help with referrals?

[Rep. Alyssa Black (Chair)]: Can I ask our JFO or even our legislative council? We have a health information technology fund. Does this seem like the type of thing that perhaps would qualify for an appropriate use of our HIT fund?

[Nolan Langweil (Joint Fiscal Office analyst)]: I would think it does, and if it doesn't meet specific languages, you can always not withstand, but I think it probably does fall onto an appropriate box. I don't have the inkjet, he's done my own, probably. I can see, Joe. But in terms of the surface, seems like an appropriate use, and there is money in the butt.

[Rep. Alyssa Black (Chair)]: Thanks. As long as it requires you to vote.

[Rep. Daisy Berbeco (Ranking Member)]: Okay, last and definitely not least in this section is for the Office of the Healthcare Advocate for staffing and services. They're looking for $450,000 That's listed in here as general fund. However, it's not really all general fund. There's a breakout of it that Mike can get to us. So it wouldn't actually be a full board.

[Rep. Brian Cina (Member)]: And you might've just said this, but is this an increase or is this the yearly amount that we invest in the office?

[Rep. Alyssa Black (Chair)]: This is an increase in the base, an increase in the base. Can you maybe remind us what your base has been and how it maybe has changed over the years?

[Rep. Brian Cina (Member)]: And what percentage this is, addition.

[Mike Fisher (Chief Health Care Advocate)]: This has been for a couple of years, dollars 2,000,406.

[Rep. Brian Cina (Member)]: It's like a 25% increase.

[Mike Fisher (Chief Health Care Advocate)]: So three years, I think. Just to, sorry, Mike Fisher, healthcare advocate. I don't know how much of this could be general fund, but of our base, a section that comes through the remounted careless build out provision, 27.5% of that is general fund and the rest is back to the industry. Section of our money comes through DFR. I actually don't know. DFR is generally a bill back machine that generates money for repurposing and a section of it of our funding comes from Diva and there's a small Medicaid matched portion of that. I think my memory serves me right 275,000. And so what I'm trying to say is we come from all kinds of different places to fund our office because we serve people throughout all over the state government. So we don't know what opportunity for the additional piece of work to come from. I

[Rep. Daisy Berbeco (Ranking Member)]: think Brian has another question.

[Rep. Brian Cina (Member)]: So just that what I was hearing is that there's a variety of mechanisms that generate the revenue needed to fund the office, and that those mechanisms and that revenue do trigger some Medicaid money as well. And so this $450,000 will this trigger Medicaid money?

[Mike Fisher (Chief Health Care Advocate)]: Don't. Okay, it's okay if you don't, I'm just curious.

[Nolan Langweil (Joint Fiscal Office analyst)]: I think it depends upon what they're using the money for, so I think we would need a cost allocation of this many people who do this, and that's how you determine what can be built where.

[Rep. Brian Cina (Member)]: Thanks. The reason I ask ultimately is just understanding what investments are going to yield, and sometimes when we invest in something and it draws down money, that money is yielding more than what it says on paper. I think it's important that we understand that. Even if you don't know it perfectly, it's good to know at least it could, this appropriation could trigger some investment from the federal government.

[Rep. Alyssa Black (Chair)]: Can you remind us what the intention intended uses are?

[Mike Fisher (Chief Health Care Advocate)]: This is I think remember I had the picture of our staff who are running our office. This is the cost of doing business, the increased increased cost of doing business including health insurance and various other inflation to run our office. I also mentioned last year we asked for and you gave us some increased responsibilities and we are doing our best to show everybody that there was responsibility.

[Rep. Alyssa Black (Chair)]: I forgot we did write you into a whole bunch of things.

[Unidentified Committee Member]: So this is to be

[Mike Fisher (Chief Health Care Advocate)]: official setup to do certain things? No, this is steady state. So

[Nolan Langweil (Joint Fiscal Office analyst)]: then we'd have to figure out percentages, just like a percentage increase. So we had to figure out the breakdown.

[Mike Fisher (Chief Health Care Advocate)]: And what can you do with doing fiscal and land operations committee I can't represent to try and get a breakdown.

[Nolan Langweil (Joint Fiscal Office analyst)]: Yeah, he just called me, so. Mike,

[Rep. Daisy Berbeco (Ranking Member)]: the tasks that we have for your team that were in '26,

[Rep. Alyssa Black (Chair)]: x '68? Were those? Yeah.

[Rep. Daisy Berbeco (Ranking Member)]: And did those have money attached to them? They gave you more authority, but they didn't task you with anything specific, did they?

[Mike Fisher (Chief Health Care Advocate)]: No, mean, in fairness, it expanded where we are required to show up to The United States after

[Unidentified Committee Member]: The Bahamas, in

[Mike Fisher (Chief Health Care Advocate)]: line with what we were trying to achieve anyway. Think the solution previously recognized our goal with D Bus in particulars, and we advocated with the DFR or with every part of state government. But there was no money attached to those.

[Rep. Alyssa Black (Chair)]: And you said it's been three years, so we've gotten that.

[Rep. Brian Cina (Member)]: No further questions, your honor. Did

[Rep. Daisy Berbeco (Ranking Member)]: it decrease last year? Or is the DAA in fact you did a three point zero? No, am I imagining that? Because there were like two years that you didn't remember because I said you should have asked for more.

[Mike Fisher (Chief Health Care Advocate)]: Last year you did. Last year you said I should have asked for some.

[Rep. Daisy Berbeco (Ranking Member)]: Yeah. That's what I'm thinking of. Thought You were right, too.

[Rep. Alyssa Black (Chair)]: You were right. Okay.

[Rep. Brian Cina (Member)]: We're on to the language only part.

[Rep. Alyssa Black (Chair)]: The language only.

[Rep. Brian Cina (Member)]: Well, doesn't this language have a fiscal impact?

[Rep. Alyssa Black (Chair)]: Am I? I'm so sorry, I'm upset. Never mind. It's my bad.

[Rep. Daisy Berbeco (Ranking Member)]: I think everybody now at the screen level considers their top five priorities, and remember we're going to add a line for staff and they're reaching down for two and one on the BMH section. So maybe, should we put those in and then we'll print it for people?

[Rep. Alyssa Black (Chair)]: I don't know. You don't want one?

[Rep. Brian Cina (Member)]: Can we go just write the change on this and save it to me?

[Rep. Daisy Berbeco (Ranking Member)]: That's fine.

[Rep. Alyssa Black (Chair)]: Can I just say,

[Karen (Vermont Medical Society representative)]: for those of you

[Rep. Alyssa Black (Chair)]: haven't had this before, it's really hard?

[Rep. Daisy Berbeco (Ranking Member)]: And we have a very, very, very tight budget.

[Rep. Alyssa Black (Chair)]: So, let's get new spreadsheets. So, is how I'd like this to work. So, we will go through and I will ask each person to prioritize personally their top five. We're gonna do three, we're gonna do five, And then what we do I well, actually, technically, we've particularly in the governor's recommend, I don't think unless you have something firmly that you are automatic should not be put or should not be there. We're going to kind of ignore the rest that nobody rises to any level whatsoever of concern. Say that again.

[Rep. Daisy Berbeco (Ranking Member)]: Typically, we've always kind of done

[Rep. Alyssa Black (Chair)]: it where, oh, we'll rank the governor's recommend and then we'll rank all the other things.

[Rep. Brian Cina (Member)]: So without objection, we're going to just let those move forward. Yes. Okay. Yes.

[Rep. Daisy Berbeco (Ranking Member)]: But we can object.

[Rep. Alyssa Black (Chair)]: We can object. But your objection needs to be in your ranking five.

[Rep. Allen “Penny” Demar (Member)]: Okay, what if we object or don't object, but we don't agree with the figure?

[Rep. Daisy Berbeco (Ranking Member)]: Well, prescription co pays, for example. Prescription co pays, I

[Rep. Alyssa Black (Chair)]: think the prescription co pays, personally, I think that that's something that we all should talk about as a committee and then maybe come up with a recommendation of where we'd like it to be. If we have consensus around that, then we would say, yes, this, but we recommend that. I think for things like that, that we're changing those numbers.

[Rep. Allen “Penny” Demar (Member)]: So what about like, and you all know this, I'm an advocate of the Visiting Nurses Association, important up my way, but it's 3.5%. And what if I say, well, I'm looking out for some other things too, maybe 2.5%.

[Rep. Alyssa Black (Chair)]: Okay, so this is where I'm giving the Great question. Allows me to say, I really don't want people to concentrate on the numbers that are on the sheet because remember we're a policy committee. I want us to make our best recommendations to house appropriations on the policies and the areas that we are clearly ranking as. So what I would do Allen is I would, if I was you,

[Rep. Daisy Berbeco (Ranking Member)]: just based

[Rep. Allen “Penny” Demar (Member)]: on what you said,

[Rep. Alyssa Black (Chair)]: I would give B and A as my number one priority because I guarantee you this is going get to house appropriations and they're going to look at it and say, hey, it was a really, really big recommendation, but now we've got to find the money and they're going to figure out the money because I think it's up to us to figure out.

[Unidentified Committee Member]: They're not. Fair.

[Rep. Alyssa Black (Chair)]: The co pay thing's a little different, because the actual dollar amounts are in the policy.

[Rep. Allen “Penny” Demar (Member)]: No, that's fair.

[Rep. Alyssa Black (Chair)]: I'm gonna go tougher, and then Brian.

[Unidentified Committee Member]: So, just so that I'm clear. This talk piece here. Yes. We're not gonna do anything

[Nolan Langweil (Joint Fiscal Office analyst)]: with that.

[Rep. Daisy Berbeco (Ranking Member)]: Well, no.

[Unidentified Committee Member]: Unless we want language that we might disagree

[Rep. Alyssa Black (Chair)]: with Unless you care very, very deeply that nothing in here gets cut. But we add that. So if I wanted to do third priority is education, loan repayment.

[Rep. Daisy Berbeco (Ranking Member)]: It's just the first

[Rep. Alyssa Black (Chair)]: thing I saw on the list, so don't anyone at all consider it. It's just different job. Well, can see from here. Then that would be one of your priorities. I do not want that.

[Rep. Daisy Berbeco (Ranking Member)]: So we prioritize them. Prioritize them. We don't change any of the proposed description.

[Unidentified Committee Member]: Where does that come out?

[Rep. Daisy Berbeco (Ranking Member)]: And this we usually get

[Rep. Alyssa Black (Chair)]: a job explaining it very well. And that's language. That's just language we're putting in. That doesn't change anything. Then The

[Rep. Daisy Berbeco (Ranking Member)]: easiest way to explain it is don't look at the divisions. We used to look at the division. We are just going to rank your top five on this entire list.

[Mike Fisher (Chief Health Care Advocate)]: Including the top five.

[Rep. Daisy Berbeco (Ranking Member)]: The entire list. I

[Rep. Brian Cina (Member)]: thought you just said we weren't going to rank those.

[Unidentified Committee Member]: Yeah, it's like

[Rep. Brian Cina (Member)]: You said that we were going to let them move forward without objection.

[Rep. Alyssa Black (Chair)]: No, I don't want you to rank like, again, I'm throwing out whatever I can happen to see unused drug repository. If you want this, I don't want you to rank that as your top priority because you agree with it. So

[Rep. Brian Cina (Member)]: we don't put one, two, three, four in the top ones. No, just flag it if we

[Rep. Alyssa Black (Chair)]: if you object and if it's a real priority for you to object.

[Rep. Brian Cina (Member)]: Oh, if we object, then we should rank it once we object.

[Rep. Alyssa Black (Chair)]: Okay. That's what I've got. Thank you. That's another one.

[Rep. Brian Cina (Member)]: Okay, so can I ask my question? Was at the top So of now I understand it differently. If we support the recommendations or requests below the governor's recommendations, we would express our support by voting yes and ranking it in order of priority. Yes. And if we oppose one of the governor's recommendations, we would include it in those rankings as a vote of opposition, but that you are not asking us to vote in support of the governor's recommendations as a priority Yes. Because they're going to pass otherwise. Yes. That is helpful. So we don't waste a vote on something that's going to pass anyway. You want us to rank one to five? One to five. And you want us to indicate that in the priority position on our new spreadsheet?

[Nolan Langweil (Joint Fiscal Office analyst)]: Yep.

[Rep. Brian Cina (Member)]: Okay, that's all I need to know. Can complete my baller team.

[Rep. Alyssa Black (Chair)]: So we will go around tomorrow, everyone will rank their one to five, we will tally up all the votes that all the things got. Nolan hopefully will do the math. I always say, if it's your top priority, number one priority, Allen, V and As, and he ranks at number one, that's going be five points. It's ranked by his voting. Yes. So every vote gets a rank and then we add up the ranks of everybody's and those are the recommendations that we give to house appropriations. We will send them this whole spreadsheet, by the way, but we will have on it where the committee landed. And then we'll do a straw poll on whether or not we agree with sending our voices to The final results. Our final results.

[Rep. Brian Cina (Member)]: We'll ratify our part that. Brian,

[Unidentified Committee Member]: Now I got cup of chippling.

[Rep. Alyssa Black (Chair)]: Let's take a question first. Mine's clarification, mine's easy for Amy, if I may. It says here that it brings up to 70% of Medicare for the skilled nursing.

[Eric Covey (VNAs of Vermont)]: That's me,

[Rep. Alyssa Black (Chair)]: That's not you, sorry. That's you, sorry. Can you tell me what it is now?

[Eric Covey (VNAs of Vermont)]: It's a little under, like

[Rep. Alyssa Black (Chair)]: seventy

[Eric Covey (VNAs of Vermont)]: percent, ever coming for

[Nolan Langweil (Joint Fiscal Office analyst)]: the record, being able pull a lot.

[Eric Covey (VNAs of Vermont)]: And that brings up most skilled home health Medicaid rates to at least seventy percent of

[Rep. Alyssa Black (Chair)]: the I didn't hear what you said. What is it now?

[Eric Covey (VNAs of Vermont)]: Like 68%. It depends on the billing codes. It's different from each billing

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

[Eric Covey (VNAs of Vermont)]: Actually, other vendors or physical therapists or whatever the code that's being billed.

[Rep. Daisy Berbeco (Ranking Member)]: So it's really only bringing it

[Rep. Alyssa Black (Chair)]: up 2%. Is that what I'm understanding?

[Eric Covey (VNAs of Vermont)]: That's correct. Okay. 3.5%

[Nolan Langweil (Joint Fiscal Office analyst)]: on there is actually correct.

[Rep. Alyssa Black (Chair)]: Says 3.5%

[Eric Covey (VNAs of Vermont)]: is the dollar.

[Rep. Alyssa Black (Chair)]: That's the dollar amount but it's the actual

[Eric Covey (VNAs of Vermont)]: But in comparison, that is the percent increase to the dollar amount for the rate against your 70%. It's not a clean 70 because I just went with a flat 3.5%. And again, some of this is imputed because Medicare pays on an episodic basis, whereas Medicaid pays on a per visit basis. So there was methodology with Diva we had to work out on how to do the comparison.

[Nolan Langweil (Joint Fiscal Office analyst)]: Diva's spreadsheet. Yes. Okay, we'll just look at the detail here.

[Eric Covey (VNAs of Vermont)]: The one thing just about 70% because there's a policy component around making some numbers component that doesn't account for rating rates to at least the benchmark of 70% for those rates like pediatric palliative care and high-tech nursing I discussed that are really out of balance right now. Those are maybe at like 30% or so of their corresponding Medicare rates and that would be a bigger fix to change those. So the 3.5% just accounts for 3.5% of those rates. Those wouldn't get to the 70%.

[Rep. Alyssa Black (Chair)]: But it's almost every rate.

[Nolan Langweil (Joint Fiscal Office analyst)]: The 70% was Yeah, it's a specific piece.

[Eric Covey (VNAs of Vermont)]: And that was just a narrative. So you know that the 3.5% gets most rates to approximate, like at least that benchmark of 70% of Medicare. Now, if there was a policy decision of we're going to bring home health rates to 70 or 75% of Medicare, it would be a different calculation, but would be over prepared to do that too.

[Rep. Alyssa Black (Chair)]: So could you remind me of your name so I

[Rep. Daisy Berbeco (Ranking Member)]: can find your testimony?

[Eric Covey (VNAs of Vermont)]: Yes, it's Eric Covey.

[Mike Fisher (Chief Health Care Advocate)]: Oh yeah, yeah, thank you. Yeah, thank you. Doctor?

[Unidentified Committee Member]: I'm just gonna give an example. If I thought that huge drug repository, if I felt wrong, felt strongly that that should not be cut.

[Rep. Brian Cina (Member)]: Yes. I don't rank that as a five.

[Rep. Alyssa Black (Chair)]: Yep, so you do it from two, you do it That's one of your five. Not cutting is one. Not cutting is

[Rep. Brian Cina (Member)]: Locking the cut counts is a priority because it's an investment if it's not a cut. See, I get her a I get that. I'm

[Unidentified Committee Member]: just trying to When you got your it's different than that.

[Rep. Alyssa Black (Chair)]: Did change, yeah. I'm just going go back to what Lori said, we are in a very, very, very tough budget here. And I'm not going to send something to house appropriations that just says, We love everything, because we do love everything. Mean, every single thing on this list, almost everything on this list, is important. And we're here to make these hard decisions.

[Eric Covey (VNAs of Vermont)]: I know, there's some hard decisions. Do we know maybe or how it could affect the rural healthcare transformation affects what we do and say here?

[Rep. Alyssa Black (Chair)]: I don't believe anything other than what the administration, AHS, has given to us as reasons of we think that rural health transformation will be a new program within this, this does not affect any of that money that will be spent.

[Eric Covey (VNAs of Vermont)]: It'd be hard to believe, dollars 193,000,000 won't be

[Mike Fisher (Chief Health Care Advocate)]: seen. Okay,

[Rep. Alyssa Black (Chair)]: we'll be seeing. We've had several presentations around rural health transformation. It's important for people to remember that money cannot be used, just bash the bill, something that's already there. That's not what it's for. For transformation, which we still don't have a definition of.

[Rep. Brian Cina (Member)]: But could we mean anything, yes.

[Rep. Alyssa Black (Chair)]: Any other questions. So we'll do this tomorrow.

[Rep. Brian Cina (Member)]: Thank you.

[Rep. Daisy Berbeco (Ranking Member)]: If anybody has questions in the meantime and needs help with their translating their priorities into recommendations,

[Rep. Alyssa Black (Chair)]: let me know, call me.

[Rep. Brian Cina (Member)]: You know what I would recommend or request, even though I don't feel like I need this, it might be good for us, is when it's time to vote, if one of our leaders like you, whoever's leading the process, restates the process to us one last time after this discussion so it's really clear, you know what I mean? Because I think I get it, but I still think it would be nice for us as a group to start off with like, okay, everyone, here's your ballot, here's the column, here's how it works. Well,

[Rep. Daisy Berbeco (Ranking Member)]: you should, I'm going to suggest that when you come here to vote, you have your rankings already done. Don't sit and do them in committee. That's not

[Rep. Brian Cina (Member)]: how mean I'm not to make repeat the ballot accurately. So I'm just saying explaining to us how to fill out the thing when it's distributed would be useful. Even though I think I know what I'm doing, I think it might help us to just have someone be like, ready, everyone? I

[Rep. Daisy Berbeco (Ranking Member)]: also just say, Sash is not on this

[Rep. Brian Cina (Member)]: So

[Rep. Daisy Berbeco (Ranking Member)]: I want to be clear that you're I mean, have an idea, but we're missing one important one. We're gonna print them another one, though.

[Rep. Alyssa Black (Chair)]: Is there a dollar amount?

[Rep. Daisy Berbeco (Ranking Member)]: Can I ask a question? We going Nolan, are you gonna get any additional numbers on some of these outstanding matches? And if you're not, then we can print.

[Rep. Alyssa Black (Chair)]: But if you are, we should wait.

[Nolan Langweil (Joint Fiscal Office analyst)]: I don't think I'll have answers for tomorrow. There are small correctional that I would recommend making.

[Rep. Daisy Berbeco (Ranking Member)]: Okay, so then Daisy, I updated everything.

[Rep. Alyssa Black (Chair)]: We're not going finish this until 01:00 tomorrow.

[Rep. Brian Cina (Member)]: So we can think about it in

[Rep. Daisy Berbeco (Ranking Member)]: the morning.

[Rep. Alyssa Black (Chair)]: So we won't print anything until 12:00. So you get a fresh coffee at noon. Okay? And I do want to say that I think that one thing that I would like to have a discussion tomorrow around this increasing co pay, and maybe we can have a policy discussion with the committee about that. Alright, so I think we're done for the day.

[Unidentified Committee Member]: Is Sash

[Eric Covey (VNAs of Vermont)]: going to be on

[Rep. Alyssa Black (Chair)]: the Sash will be on new We the new can go off of live, thank you everybody.