Vermont Legislature SmartTranscripts:

[Alyssa Black (Chair)]: Good morning everyone, this is House Healthcare, it is Thursday April 2 and we have in with us this morning and thank you so much for joining us Doctor. Richard Page, who is the Dean of the College of Medicine. And honestly, I, in all my years in the healthcare committee, I don't think we've ever had anyone in from our medical college. So we thank you so much for coming in.

[Richard L. Page, MD (Dean, UVM Larner College of Medicine)]: It's my pleasure. I think I've gotten to be there once or twice. I know I've been on the Senate side as well. But it's really, it's my pleasure to be with you.

[Alyssa Black (Chair)]: Yeah. You know, we have this bill around primary care and we've been sort of delving a little bit deeper into the our system of primary care in the state, in The US, our challenges, our workforce challenges, and just sort of incentivizing or trying to incentivize providers to go into primary care. And it occurred to me that we really know very little about medical education. And we also have in later tomorrow, I think the Dean or the program director for the residency, the family medicine residency program.

[Richard L. Page, MD (Dean, UVM Larner College of Medicine)]: That's Gordian Powers. Yeah, I saw that you've invited him. I think that's great.

[Brian Cina (Member)]: Since How you

[Richard L. Page, MD (Dean, UVM Larner College of Medicine)]: are we doing in terms of time? I've got about maybe five minutes. I might be able to kind of bring people up to speed as to who I am and my perspective, the perspective I bring as Dean, and also I can give a few comments about the bill. Is it okay if I just lead off a little bit?

[Alyssa Black (Chair)]: Absolutely, lead off, and you have as much time as you need.

[Richard L. Page, MD (Dean, UVM Larner College of Medicine)]: Great, well, you very much. Again, my name is Richard Page. I'm Dean of the Larner College of Medicine at the University of Vermont. Soon after Marlene Trump, our president, arrived, I was also named Chief Medical Affairs Officer for UVM. And in a lot of ways, that's just codifying what I already do, that is as a senior leader of UVM and the physician senior leader participating in activities within the university and representing the university as appropriate. I want to just emphasize, it gets confusing because right down the hall for me is UVM Medical Center, which is part of the UVM Health System. The university and UVM Health are separate five zero one(three) organizations. So there was a time when the dean was responsible for the hospital, as well as the activities there, as well as the college. Over the last more than twenty five years, those are separate roles. Although, clearly, we're both the largest entities in health care in the state, and we work closely together. I'm providing my testimony to you in my role as I mentioned, a practicing cardiologist and working closely with the UVM health system, but I'm speaking on behalf of the Larner College of Medicine. At the outset, I wanna share with you that I, and I believe all of us, are absolutely committed to accessible, affordable, high quality healthcare for every Vermonter. That includes primary care, as well as specialized care and hospitalized care. Our citizens deserve the best possible care, and I'm absolutely committed, as I know you all are, to those fundamental principles. Are Vermonters deserve it. Our role in the college is to help provide doctors who are going to be practicing in the state. And right now, we're focusing on primary care. And in addition to education, I do want to mention that we're studying what we're doing. If you think about it, Vermont being the second most rural state or the most rural state in the country, and the second oldest state in the country, we've gotta be able to assess how we're providing care, make sure it's the highest quality, most affordable, accessible care we can possibly provide and study that. And along those lines, I wanna mention that we bring in major grants, including that are both often related to care, such as rural addiction through HRSA, but also the Northern New England Clinical and Translational Grant, which is a big grant that we share right now with Maine, as well as a Health Services Research Center and the Northeast Rural Health Research Center. That second, rural health research center is actually led by a relatively recent recruit that we brought over from Maine, bringing federal money in for us to provide care and study care here in Vermont. The last time I was with you all, I was actually on behalf with Randy Holcomb, speaking about the importance of the Cancer Center, which I do want to emphasize, even though we have not with tight budgets, we've earned nothing but support, have not been able to get financial support. That's okay. I just want you all to recognize that cancer care is critical for primary care, and we are absolutely committed to our patients throughout the state, every one of our 14 counties being able to access high level care where they are. We bring them to the medical center only when needed and then support them. And at the end of the day, terms of maintaining a workforce that is able to practice at the highest level as a primary care provider anywhere and have job satisfaction, lower burnout, the fact that they are one call away from an academic system that's committed to Vermont is really a high value entity for primary care. Now, I wanna share with you a little bit and some statistics around the Vermont workforce. Thirty two percent of all physicians in Vermont either were educated at the Larner College of Medicine or were trained in residency at the medical center. And if you look at primary care providers, 38% either were educated in my college or were trained, and some of them and or were trained at the UVM Medical Center. In our curriculum from day one, our students see patients, and we integrate our first year students from the very beginning and throughout into primary care opportunities in developing a primary care pipeline. I should mention we recently recruited a director of rural medicine within the Office of Medical Education, who's specifically gonna help us focus on providing a rural healthcare experience to our students. And we're talking about developing a rural track where students come in and are accepted to a track where they specifically are part of a pathway to rural primary care. I wanna mention the Area Health Education Center or AHEC. I'm gonna be using the term AHEC for the next minute or two, but this is a grant. We have three AHEC centers. The major one is associated with the Larner College of Medicine. These are funded by HRSA and are committed to supporting programs for students, trainees, and practicing primary care providers. I believe Anne Morris has provided testimony to this committee. Doctor. Morris is Associate Dean for Primary Care. I have an Associate Dean who specifically focuses on primary care, and she's also our AHEC Director. And through AHEC, we make sure and are committed to our most rural and disadvantaged communities gain exposure and access to healthcare providers. We have an AHEC scholars program. And actually seventy nine percent of our students are touched by that program sometime during their medical school, and actually thirty nine percent. So two out of five of our students, when they graduate, have a special lanyard that designates them as having been an AHEP scholar with specific experience in and around primary care. We're following this, and those who went through that program have twice the likelihood of practice going into a permanent practice in primary care.

[Alyssa Black (Chair)]: Would you mind interruption with a question? Because I think Leslie has a question. Thank you, Doctor. Leslie Goldman. I'm just clarifying.

[Leslie Goldman (Member)]: When we looked at our budget, there was a line that we were asked to support AHIC. And so that was coming out of the general fund, but what I'm hearing you say is that it's all funded by a HRSA grant. So I'm just trying to understand that dynamic.

[Richard L. Page, MD (Dean, UVM Larner College of Medicine)]: Great, thank you for allowing me to clarify. It is funded by HRSA, but critically dependent on matching funds from the state and hospitals.

[Alyssa Black (Chair)]: As a

[Richard L. Page, MD (Dean, UVM Larner College of Medicine)]: matter of fact, if we don't get that, we can't draw down the federal dollars. So thank you very much for that clarification. I'll actually address the AHEC kind of the line items that frankly, we're delighted have received some support, but actually in part are related to this bill we're discussing today. I do wanna mention that we're really proud that thirty six percent of our patients who graduated from, who matched this last month, are going into primary care specialties. That includes a total of 42, with 10 to family medicine, 20 to internal medicine, 10 to pediatrics, and two to medicine and peds combined. I should mention that a lot of us consider OB and psychiatry to be primary care specialties as well. And those were also very well represented, actually with nine patients going into OB, and I think about the same number going into psychiatry this year.

[Alyssa Black (Chair)]: Can I just clarify? So batch day, I know, was just last week or whenever it was. So you're saying that thirty I think you said thirty six percent?

[Richard L. Page, MD (Dean, UVM Larner College of Medicine)]: Thirty six percent of

[Francis “Topper” McFaun (Vice Chair)]: our students.

[Alyssa Black (Chair)]: Thirty six percent of your graduates, your MDs

[Richard L. Page, MD (Dean, UVM Larner College of Medicine)]: Of matching, yes.

[Alyssa Black (Chair)]: Have matched into

[Francis “Topper” McFaun (Vice Chair)]: Primary care.

[Brian Cina (Member)]: Primary care.

[Alyssa Black (Chair)]: Primary care residency programs. Somewhere, not necessarily at UVM, but somewhere.

[Richard L. Page, MD (Dean, UVM Larner College of Medicine)]: Right, no, in general.

[Alyssa Black (Chair)]: In general, okay, great. Yes, yes. Thank you. One more question, Doctor,

[Francis “Topper” McFaun (Vice Chair)]: thanks for coming in. How many of those that you're talking about are Vermont young women and young men?

[Richard L. Page, MD (Dean, UVM Larner College of Medicine)]: I don't have that number for you. I can tell you generally a quarter of our class is UVM or Vermont state residents. So I think my bet is it would skew. I can find that number, I suppose, but I don't know that offhand.

[Francis “Topper” McFaun (Vice Chair)]: Thank you.

[Richard L. Page, MD (Dean, UVM Larner College of Medicine)]: You bet. Final thing I'll just say about AHEC. First of all, one way or another, I don't know if through this committee, the placement grant helping bring doctors into the state was funded again this year, thank you, over a period of time, I'm not sure exactly, we have 62 physicians over the last five years actually who came through associated with AHEC recruitment. The educational loan repayment plan was funded this year, little bit less than what was requested, but it was funded significantly. The AHEC support grant, which is split among the three AHEC's, actually was not funded this year. And that really is useful for my goal is to be having contact with middle high school students, really developing a pipeline within our state to take care of patients in our state. And the last thing about AHEC I'll mention is there's a line on page 10 of the bill we're discussing today, Which removes the sunset of the AHEC Scholars Loan Incentive Program. This to remind you, this gives in state tuition to third and fourth year students who then can train anywhere, but they are committed to coming back to Vermont for a year to year payback for them to have that received as a scholarship. Otherwise, it's become a loan. And we're really excited about this. The first time I ever spoke with legislators in the state was soon after I arrived when this was just getting started. And I would love for it I think it was a five year program. We really should not sunset that. And that's in a line in this bill. And one way or another, we should continue that. That's a way for these students to be have the opportunity to take away some debt, which helps them choose primary care, frankly, because primary care doesn't pay as well as some other specialties, and for them to be committed to come back to Vermont. So just to summarize, we are committed with you to developing the workforce in primary and specialty care for our state. We're committed to having our primary care physicians wanna stay in the state. We're committed to access, affordability, and high quality. And now this in my eighth year, and this is the last job I'm ever gonna have, More and more, I I like to think of myself as a Vermonter. I'm I'm told I need a few more generations to really have pages be Vermonters, but but I'm tremendously, grateful for the opportunity to visit with you all and to serve as dean of the single college of medicine in the state. If you like, I can shift. If there are any questions, I'm happy to take them. Otherwise, I can shift to just my perspective this bill, keeping in mind I'm speaking as member of the university, dean of the Larner College of Medicine, where I don't control the healthcare system and how it operates locally or statewide.

[Alyssa Black (Chair)]: Let's see if we have any questions. I know I have a couple before we shift to the bill. Okay. No other questions. So I guess I'll go ahead. So I've been thinking a lot lately about sort of the hierarchical structure within medicine. And would you agree that there is? I guess I should ask you that.

[Richard L. Page, MD (Dean, UVM Larner College of Medicine)]: Yeah, without knowing exactly what you mean, I can't say anything, But yes, there certainly are hierarchies in terms of the faculty. There are professors, associate professors, assistant professors. I'm not sure which hierarchy you're referring to.

[Alyssa Black (Chair)]: I think I'm more referring to how we've gotten to the point of a hierarchy within various specialties. Would you agree that there are some specialties that have more allure than others?

[Richard L. Page, MD (Dean, UVM Larner College of Medicine)]: It depends how you put it. I mean, me, in some ways you can put primary care as the highest of all because of the mission and the breadth of their care. If you're referring to payment, and I can't say it's just, but if I'm participating in the hiring of a neurosurgeon versus a primary care doctor, the benchmark is different in what they're paid. Yep. In a just world, would that be the case? I can't really comment, but it's the way the world is. In terms of hierarchy of how competitive specialties are, there's no question about that. For example, I mentioned neurosurgery, I mentioned orthopedics. Nationwide, and I don't know whether it's related to them being paid more or what, but nationwide, those are very competitive specialties. So for example, if you're not top in your class, you're not even getting an interview for those. Nationwide, there are opportunities for primary care that are available to anybody in any level of their class. Now, we don't graduate anybody. Every class is going have the top, most competitive, highest grades and scores, and less. And nobody's going to leave our college without being a well qualified future physician. But to answer your question, you're specifically going after which is more attractive, there definitely are more competitive specialties than others. Primary care, geriatrics, even infectious disease. Pediatrics has become less competitive. One of the things that I like about the commitment that we're making in educating and providing opportunity and exposure to primary care, and the commitment that we all are talking about is how can we support primary care physicians. We need to make it as doable as possible for those who are called to that specialty. That's why the payback, the scholarship, I don't want someone feeling like I've got $200,000 in loans, I can pay it off faster doing one specialty versus another. But that often plays in people's minds. I will tell you, though, as I'm celebrating the matches of our students, knowing that some of them have significant debt, what inspires me is how many of our students choose specialties like peds, like family medicine, and then subsequently specialize in geriatrics. Even though they've got debt, they're following, they're in medicine for the right reason, and they're following their heart.

[Alyssa Black (Chair)]: Oh, how much The other thing that we've sort of been learning about a little bit is sort of the federal funding of medical education and where federal dollars are invested. So of all the federal funds that Larner College of Medicine would be receiving for various things, how much of those funds are specifically grant funds

[Richard L. Page, MD (Dean, UVM Larner College of Medicine)]: facilities there? Almost entirely grant funds from one way or another. The federal funding, we receive some state funding, and we're appreciative of that. That comes from the appropriation that comes to UVM. But the federal funds that we draw down based, in the college, are based almost exclusively on grants that we write. So, we'll write for HRSA, we'll write to NIH. Some of these grants, and likewise, foundation grants, as well as federal, are around specific programs, often for community outreach and even care. But the majority of our funding we get $100,000,000 at the Larner College of Medicine in extramural grant support for research. So that's research grants.

[Alyssa Black (Chair)]: I think that's what I was trying to extrapolate a little bit is of all of your grant funding, like as a total, how much of that federal grant funding is specifically tied to grants that support the medical education and encouraging the workforce within primary care, as opposed to things like research?

[Francis “Topper” McFaun (Vice Chair)]: Yeah,

[Richard L. Page, MD (Dean, UVM Larner College of Medicine)]: almost all of it's research related. The HRSA grants are kind of a combination, but those are all things we write for. AHEC is not a huge amount of money by any means. There is a significant amount going to the rural addiction through HRSA. We'll go for any grants that are out there. But most of the grants, the vast majority are for research grants. The research grants that we're obtaining though, span the spectrum. You know, we have people studying the individual neuron and capillary relationship of blood flow that will end up having an impact on dementia. But we also have, for example, a grant that is an NIH grant studying how you follow cancer chemotherapy neurologic side effects using an app on your iPhone, that is a beautiful grant for our state, because we're able to reach out to the rural community. But the vast majority of what we receive are research grants. And the research grants are very among primary care and general, but it's not exactly the way you're describing. The one area I do want to mention is the federal money that supports residencies. That's, again, I'm not responsible for the residencies, but the because residents are employees of the medical center. And as I made clear, we're separate entities. Although they're within departments that are shared with the medical center and the college. And those federal funds, they've gone up a little bit, mostly in primary care, which is great in terms of, don't know whether the committee is familiar with the caps on residency positions. Every hospital is given a certain amount of, of positions that are federally paid for, and any new positions are what's called over the cap. And and we're about 70 positions over the cap, which means there's no federal funding, it's purely the residents are paid by the medical center. I am aware of the fact that our residency is planning is in in the process of going from six to seven, per year, which means at any one time, instead of having 18, we'll have 21 residents in the residency program. And that is actually over the cap. So that's being funded by the hospital. But it's a good thing, and I'm glad they're doing that. And keep in mind that the residents do play a useful role in terms of primary care as well. There is almost a residency's almost like an apprentice program, in that you're learning at the side, and you're doing as you're learning. So that's another place where the pipeline we're educating the medical students in the college, and then the medical center is training them for them to then go out and practice medicine.

[Alyssa Black (Chair)]: Thank you. I have one last question. This is more of a philosophical question, I think. You had said, of course, primary care doesn't pay as well. And that is the truth. I mean, we know that. I think we've accepted that it's become truth and that we don't question why it's like that. And of course, we know there's dozens and dozens of reasons of how we've gotten to this point to include like the investments that we make, the education, residencies, and I mean, you just talked about federal grant funding and where that goes. So as policymakers, which we are, it's actually a little scary to think about, sitting around this table, what can we as the legislature do in our limited sphere to start changing the narrative so that twenty years from now, the dean won't have to say, well, of course, primary care doesn't pay as well.

[Richard L. Page, MD (Dean, UVM Larner College of Medicine)]: Yeah, it's a great philosophical question. There, you know, a lot of it goes back to doing procedures have been paid at a different level than seeing patients in clinic. That We right or could talk about that forever. We could also talk about the fact it takes nine years to become a neurosurgeon, as opposed to three years to become a family medicine doc, And, or a cardiac surgeon, for example. The, the, we're not gonna change that right now. And, and one thing that I, I worry about in this bill is two things I just want to mention in terms of, while I think it is well intentioned, we need to be careful about the consequences that might come from it. I read the qual- talk about quality, I want a high quality doctor. How do you define that? It's really not very clear in the bill. And I can tell you that every physician is subject to quality measures already. So we would be adding an extra burden to the physician and their practice if we're not consistent with other quality metrics. Because as a practicing physician, filling out the boxes, by definition, is taking you away from being face to face the patient. That's one concern. The other concern is, I haven't done all the math, but the cost of this would be significant. And just as a citizen of the state, I'm wondering where it would come from. And that's something for you all and others to work out. But I'm not seeing any, whether it's specialist or hospital, that is flush with finances right now. There were, as you all know, as we all know, finances are really tight right now. The from my perspective, the key is I'd love, you know, twenty years from now, I'd love a world that simplified these things. But for now, to shift finances from one area to another, I just think we need to understand how we do that and what the ramifications would be. I do really want to emphasize to you the. The value of having world class care in Vermont. I've heard it say, can we afford this? We can't afford not to do it in my mind. I have patients, rich and poor. My wealthier patients can go to Boston, can go to other places, can take off time to be in another state. So it becomes an equity issue for others who don't have that privilege. I would also mention that even if our patients do get to go to another state to get that care, they'll end up, we'll end up paying for it, potentially at further cost and certainly at further difficulty for the family. And basically if we're not able to provide world class care here with the commitment for patients to be able to go back and be at home and live a productive life within our state, those who won't get care will only come back sicker. And we'd be doing a disservice to our the patients in the state. So, one of the things that obviously attracted me to be here at the state is, the basically the world class care and commitment we have to primary care being as good as anybody else's. And again, affordable, accessible, and high quality. I'm completely there with you. Complemented by having a world class academic medical center and having world class specialty care when our patients need it.

[Alyssa Black (Chair)]: Can you give concrete or singular example of something that you would consider to be world class care that if we were not investing in it, we wouldn't have here in Vermont? You give us an example of something or

[Richard L. Page, MD (Dean, UVM Larner College of Medicine)]: A a seizure seizure or T therapy, chimeric something therapy. It is an immune type therapy for cancer. And for some cancers, it is state of the art. It will make a decision as to whether someone lives or dies. It costs a significant amount of money. I'm not gonna give you the amount. It's eye popping. It ought to be paid, and actually, if you do it right, it's paid by Medicare. And for the cost of it, CAR T therapy is something that those with privilege can go to Boston for. Those without privilege would not get it and would not have the opportunity to potentially survive from their cancer. We're doing this as an outpatient as much as possible. It started as all inpatient because you have to make the compound specifically for that patient's cancer, then that gets infused back into them. Form these CAR T cells and this immune therapy. It can make the difference between life and death. And that's just one example. I'd love to show you all around what our doctors do when I say our doctors, because they are dually employed. They're employed by the medical center, they're employed by the college and university. But that's just one example.

[Alyssa Black (Chair)]: Do we know how many of these therapies UVM does? And does Dartmouth do this?

[Richard L. Page, MD (Dean, UVM Larner College of Medicine)]: Do you know the best person to give that response would be Randy Holcomb, who could give you the numbers. Randy is this cancer center director that I recruited four years ago. And, but that's just one example. But we could give you those numbers and actually it's, it makes the difference between having nothing. And the other thing that I'll mention is, if you don't do CAR T therapy, you go through further courses of chemotherapy. Further courses of toxic chemotherapy, the patient often, most of the time, will not survive. The cost of that is baked into the hospital system. You're not gonna turn patients away, and you're gonna give them chemotherapy that's standard of care, which per dose is less, but the overall cost for their care ends up being significant, if not equal.

[Alyssa Black (Chair)]: What was his name, I'm sorry?

[Richard L. Page, MD (Dean, UVM Larner College of Medicine)]: Randall Holcomb, H O L C O M B. He's a cancer center director. And he's been back and forth typically with me just about every year, Wendy, right? As we've been making the case for cancer center designation. And when I say that if you have two minutes, we're going longer than I think you want it, the Cancer Center designation by the National Cancer Institute, the NIH, will provide better care to Vermont. Because it provides not just grant money for research, but it elevates the level of care for every Vermonter. And the leverage on that investment once we get that grant to bring in further support for our clinical service, first and foremost, patients come first, but also for research and education. The other thing I will mention since we're talking dollars is economic impact. I mentioned research, and we get about $50,000,000 from the National Institutes of Health, NIH, annually in our college.

[Alyssa Black (Chair)]: I'm sorry,

[Richard L. Page, MD (Dean, UVM Larner College of Medicine)]: how much? It's estimated, I'm sorry.

[Alyssa Black (Chair)]: How much was that?

[Richard L. Page, MD (Dean, UVM Larner College of Medicine)]: $5.00, 50.

[Alyssa Black (Chair)]: $5.00.

[Richard L. Page, MD (Dean, UVM Larner College of Medicine)]: 50,000,000 Most of that money goes to pay the salaries of faculty, and more than that, the technicians that are working on the research. It's good paying jobs. The estimate is that for every dollar that the NIH brings in, it adds 2 and a half to the local economy, because this is outside money coming in, supporting people working in. So that translates to about $125,000,000 just for our NIH extramural funding. And at the end of the day, I think we can all agree we need more people being having good jobs, being supported, more money coming from the outside to shore up the health system in our state. Because as I said at the outset, we're a relatively old state. The demographics are working against us. And we're all committed to providing care that's successful, affordable and high quality.

[Alyssa Black (Chair)]: We had really both come and justify it. Okay. Yeah. I can take it out. Brian, did

[Francis “Topper” McFaun (Vice Chair)]: you want to go?

[Brian Cina (Member)]: Yeah, a minute ago, a few minutes ago, you said something about, you were talking about, you were comparing the chimeric therapy with conventional chemotherapy, and you were saying that the patient who gets the conventional chemotherapy costs a lot of money, and the outcomes aren't always so great, but then there's this other therapy available that we don't always provide. What did you say the barrier was, why we wouldn't choose the thing that maybe costs more but works versus something that costs a lot and doesn't work?

[Richard L. Page, MD (Dean, UVM Larner College of Medicine)]: Well, it actually, the barrier was overcome. In partnership with the medical center, the acceptance was that we would, and we do provide this care. So that was two or three years ago now, and it's happening, and we are providing that. That's just one example of how we're able to provide great care for our patients with the expectation that they can go home sooner, be cared for locally as much as possible, but having that here in the state cannot be underemphasized. Those with privilege and wealth can get it in Boston. Those who don't have that and can't take, their caregivers can't take off time to move in for a few days in another state won't receive that. And at the end of the day, no question, we need to be smart about our finances, we need to provide great care, and that's what we're all wrestling with and how we manage that.

[Francis “Topper” McFaun (Vice Chair)]: Tucker, I'm a little bit confused. You just answered a question about you provided here. And then I think, correct me if I'm wrong, I think you just said, if you got money, you can go to Boston and get it. If you don't, you're not gonna get it.

[Brian Cina (Member)]: Think what doctor-

[Richard L. Page, MD (Dean, UVM Larner College of Medicine)]: No, we did not provide that. What we're doing is by having a high level of care, and this is just one example of many, where you, since we are providing this care, allows for Vermonters to have high quality, equitable care.

[Jen Carvey (Office of Legislative Counsel)]: Prior to the academic medical center providing CAR T people had to go to Boston to get it. But now that we're doing it here, anyone can receive it here. Yeah,

[Richard L. Page, MD (Dean, UVM Larner College of Medicine)]: sorry if I was unclear on that.

[Brian Cina (Member)]: Yeah, thank you. Is there any other treatment that is currently available that bears barriers in the way of people receiving a hearing that we could change, Like, similar to this example of CAR T therapy. Yeah. Is there any other any other emerging technology or therapy or treatment that people aren't able to get in Vermont unless they're privileged and they travel out of state? I

[Richard L. Page, MD (Dean, UVM Larner College of Medicine)]: wouldn't have all the answers to that. Not that I'm aware of. I will mention that we have cardiac surgery here. We have pediatric specialties here. We have neurosurgery here. If we didn't have an academic center, we would not have those in the state. And we're fortunate to have those things here. So if that's answering your question, there are some things we don't do here. We do not do cardiac transplant here, because we don't have enough people in the state to maintain a program like that. And it's not that it's too expensive. Frankly, if you're not doing 20 heart transplants a year, you shouldn't be doing them at all. And so we have some things we do not do here. We do not have pediatric cardiac surgery. We have adult cardiac surgery, but we have very good relationships. So there are some things we shouldn't do and we don't do here.

[Brian Cina (Member)]: The- It's out- Oh, sorry.

[Richard L. Page, MD (Dean, UVM Larner College of Medicine)]: But we do here is frankly something we can all be proud of, that we're able to provide the level of care that we do. And it's because of, frankly, the partnership of the academic, you know, the College of Medicine and the Academic Medical Center. And again, getting back to primary care, if I were a primary care doctor, I'd wanna be able to call UVM Health and get an immediate consult, which we give them, take the patient when we need, support them to give all the care they can locally, is a betterment of the doctor's practice and the patient.

[Brian Cina (Member)]: So when a person, what I'm hearing is that there's some medical practices or procedures or treatments that it doesn't make sense for us to offer them locally because of because we don't have the scale of need to justify investment and maintaining the infrastructure for those things. However, we have connections to regional providers that people are referred to.

[Richard L. Page, MD (Dean, UVM Larner College of Medicine)]: You got that absolutely right.

[Jen Carvey (Office of Legislative Counsel)]: All

[Richard L. Page, MD (Dean, UVM Larner College of Medicine)]: right. For the quaternary, they say, certain quaternary practices that require so much infrastructure and require the volume. You don't wanna go to a pediatric cardiac surgeon who doesn't have enough to do. You wanna go to one who did that procedure yesterday and the day before. And that's why those things need to be centralized in some frankly, cities and states than we have. At the same time, there so much care that we are able to give here that we really can be proud of and frankly, I believe our citizens deserve.

[Leslie Goldman (Member)]: Leslie. Thank you again, Doctor. Page. I heard that you increased your family medicine slots by one, is that right from like five to six? That's

[Richard L. Page, MD (Dean, UVM Larner College of Medicine)]: what I am told, yes.

[Leslie Goldman (Member)]: Okay, But the new one is not supported by federal funding, is that right?

[Richard L. Page, MD (Dean, UVM Larner College of Medicine)]: Right. You may have seen that recently there has been some openings of new residency spots. Basically, once a hospital has its residency spots, the federal government has what's called a cap.

[Leslie Goldman (Member)]: Okay. And then if I may ask, yeah, if I may ask, I'm sorry, I know we're running out of time. I just wonder what made you decide one and not three, or do you ever think of adding more and more?

[Richard L. Page, MD (Dean, UVM Larner College of Medicine)]: Great question. I don't have the answer to that. I'd emphasize, I mentioned that as a step in the right direction. But those are hospital employees. Doctor. Powers is gonna be talking with you. He's a residency program director, and he can speak to that. To increase the resident compliment is all, is when you're, when the federal government isn't going to give you any more money is always a tough decision. I'm actually impressed that we're, our hospital is looking at that and selectively increasing some of those positions, because they are bearing the full cost of the salary for that individual.

[Leslie Goldman (Member)]: Okay. So it's really about funding those slots internally rather than getting federal support.

[Richard L. Page, MD (Dean, UVM Larner College of Medicine)]: Right. And the other thing that limits the number of spots in any case, any place is the number of faculty and clinical opportunities available. Okay. I just emphasize that for a state our size, it's pretty impressive that we have as many residency spots, and we even have a medical school, which is something we can be proud of.

[Leslie Goldman (Member)]: I've always been amazed by that. So six slots seems to be about the right number is what I'm hearing you say.

[Richard L. Page, MD (Dean, UVM Larner College of Medicine)]: Right, it was and now we're going to I'm told we've gone to seven.

[Leslie Goldman (Member)]: Okay, so six to seven. Okay, thank you. Yep. Thank you. Really valuable information.

[Alyssa Black (Chair)]: Really appreciate you joining us this morning. Just thank you very much.

[Richard L. Page, MD (Dean, UVM Larner College of Medicine)]: It's a privilege to get to talk with you. Thanks for all you do. These are, I can't imagine sitting in that room working through the decisions you have to make and thank you for your service.

[Alyssa Black (Chair)]: Thank you, thank you Doctor. Peehawks. Have

[Richard L. Page, MD (Dean, UVM Larner College of Medicine)]: a great day.

[Alyssa Black (Chair)]: We're gonna do, moving on, S163, which I I didn't know it was days and days ago, so you might have forgotten what it is. We're gonna move on to that. I have it listed as markup impossible vote. I ask Jen if you want to help me. I always feel like I'm setting you up. The answer was

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

[Alyssa Black (Chair)]: Setting the stage for legislative council. I was going

[Jen Carvey (Office of Legislative Counsel)]: to ask

[Alyssa Black (Chair)]: Jen to work on some changes to include physician assistance. She's going to walk us through the changes, committee discussion. I did want to mention that the reason I waited for today was because if you recall, the Board of Medical Practice was meeting yesterday. And they did send us some comment, which is posted on our webpage. Very brief. Brief, and which sort of reiterates what Doctor. Greenberg kind of said, even though he was not representing the board at that time, he was making sort of personal comments.

[Brian Cina (Member)]: Can someone say what it says? So that anyone watching knows, if

[Alyssa Black (Chair)]: you'd Yes. Like me to read The board has convened and unanimously approved the following statement. Overall, the Board was opposed to transitioning attending coverage for inpatients to advanced practice providers. We have significant concerns about practitioners with less training and experience and the potential safety and quality ramifications. The board did fully support the team approach of care that includes physicians. If the bill were to proceed, we would recommend treating PAs and APRNs similarly. I have a hard time at work. We would also recommend a minimum level of inpatient hospital experience, similar to APRN transition care policy that requires two thousand four hundred hours and twenty four months of practice for initial licensure. I would be more than happy to join the committee to further explain the thought process and rationale of this statement.

[Brian Cina (Member)]: Thank you.

[Alyssa Black (Chair)]: I'm sorry, I'd to reach out to Debra, who I see is over in Denver, and I realize I'm putting you on spot, and maybe we can wait till Jen does walk through, but if you could maybe sort of reiterate the protocols that because I think you spoke to that before about each hospital has certain protocols for this type of thing. And I think that's kind of what they're getting at here. But I'm gonna let you think on that while Jen does walk through.

[Jen Carvey (Office of Legislative Counsel)]: Hey, good morning. Jen Carvey from the Office of Legislative Counsel. So this is s one sixty three. It's currently titled an act relating to the role of advanced practice registered nurses in hospital care, although I proposed a name change for the bill at the end of the amendment. So this is a strike all amendment, and I've shown markup what the changes would be. And really, it's just adding physician assistants throughout everywhere APRNs were added. And so you'll see I've added in a definition of physician assistant as a individual licensed under the applicable licensure chapter in title 26. For the patient's bill of rights, everywhere it says physician and APRN, put physician assistant after physician just because

[Alyssa Black (Chair)]: it seemed to

[Jen Carvey (Office of Legislative Counsel)]: flow better. So if every patient would have an attending physician, physician assistant, or APRN, and adding that throughout. So attending the right to obtain information from the provider coordinating their care, so adding in physician assistant, right to know the name of the attending, adding in physician assistant, right to receive information necessary to give informed consent, adding in physician assistant, right to know the identity and professional status, and which physician, adding in physician assistant, APRN, other practitioner is primarily responsible for the patient's care, continuity of care, and right to be informed by the attending physician, physician assistant, or APRN as continuing health care requirements following discharge. And then adding in physician assistants as far as, who may be subject to disciplinary action for failure to comply with any provision of this section. It could be basis for disciplinary action against a physician under either physician chapter, physician assistant or APRN and, having a complaint filed with the Board of Medical Practice or OPR. And then for license requirements, for this is for hospital license requirements and the, minimum standards that a hospital must meet. All patients admitted must be under the care of a physician, adding in physician assistant or APRN professional case records compiled for all patients and signed by the attending and adding in physician assistant. And then for the title, I suggested an act relating to the role advanced practice providers in hospital care. I don't know if that's, an acceptable term or we could say advanced practice registered nurses and physician assistants if the committee approves. The AP, the AP patient, advanced practice practitioners.

[Alyssa Black (Chair)]: Provider is what I sounds like we're

[Jen Carvey (Office of Legislative Counsel)]: trying to look this up, but we can use whatever term people want or use the full name of

[Alyssa Black (Chair)]: the It's confusing that Insurers are called providers like that. I was always not really looking.

[Jen Carvey (Office of Legislative Counsel)]: I don't think insurers are considered providers. Facilities are considered.

[Francis “Topper” McFaun (Vice Chair)]: They're payers.

[Alyssa Black (Chair)]: Payers. I don't know. Keep using APP lately. It seems to be the new

[Brian Cina (Member)]: Yeah. It's APP.

[Jen Carvey (Office of Legislative Counsel)]: It's not changing statute.

[Alyssa Black (Chair)]: It's changing the title. That well, maybe I'm dyslexic. Are they always messing up APRN or ARNP and something like that?

[Brian Cina (Member)]: ARNP. Yeah.

[Alyssa Black (Chair)]: Alright. So, those are the markup changes. Had Jen, go ahead and do that in light of our discussion that we had about last week on this and the testimony that we had received. I will say that I've met with we would be amending the Senate's version, and I have met with the chair of the relevant committee, and as an individual, she's generally in favor, so I don't think that our, I mean, depending on what our committee, obviously they can make decisions. Didn't think that there were any concerns with this. Leslie, did you have a question? Probably for Jen, more for you. Okay. Discussion. There's a conflict, it seems, between what the Board of Medicine is saying and what the hospitals are doing. And I'm trying to understand how we think about that concept. Yeah, I mean, that was sort of, that's the decision before us is, we heard from the hospitals that this is actually permanent practice. We heard from the board of medical practice that you don't want it, but it's still current practice. So it seems to be where do we, you know, what decision are we really making here? I mean, to me, we're just frankly codifying current practice. This doesn't need to be codified. I mean, don't have an opinion. I mean, I do have an opinion, but I'm biased. So that's weird, right?

[Brian Cina (Member)]: It's okay. As long as you're acknowledging your bias, what's your opinion? What's your opinion of?

[Alyssa Black (Chair)]: But I don't get the conflict. I think these are decisions that we have to weigh within our I'm thinking about more testimony, or maybe there isn't any. Maybe it's just we decide. Is there any more tests? Is there anyone that you would like to hear from? Would you like to hear from the board again? I mean, think the statement's clear. I think we need to hear from hospitals because that's about current practice. I think that's the issue for me is that conflict between current practice and the board. Because we had OPR who supports it. Yeah. And I will say that the board said that they support with rigorous protocols and training and things like that. So maybe we should hear more from the hospitals that actually are doing this, what their protocols are for, unless Devin can get it right off the tip of her. I guess the struggle for me is if they're raising an issue for potential safety, what do we need to ensure for safety? And if the APRN process, you put that in

[Richard L. Page, MD (Dean, UVM Larner College of Medicine)]: the

[Alyssa Black (Chair)]: bill, we just say we support hospital decision making, or whatever it is that we know that patients are going to be that the safety is addressed. We do have, currently in APRNs, three years of supervise, may practice independently. We have that, that's already

[Jen Carvey (Office of Legislative Counsel)]: statute. That's the statute just to make sure that we are And

[Alyssa Black (Chair)]: we already have a statute that physician assistants must work, must have a collaborative agreement. But no specific hours or training. Is it that they have to

[Jen Carvey (Office of Legislative Counsel)]: have So I wanna step on the APRN piece for a moment. It is an APRN with twenty four hours and twenty four months and twenty four hundred hours of licensed active advanced nurse nursing practice in an initial role in population focus or fewer than twelve months and sixteen hours for any additional role in population focus has to have a formal agreement with a collaborating provider. And then I think once they satisfy those requirements, they are able to allow to engage in solo practice.

[Alyssa Black (Chair)]: Okay. So it would seem as

[Jen Carvey (Office of Legislative Counsel)]: though any numbers Those numbers that the board is giving are the are the numbers for APRNs. Okay. To be clear, two year two years and two thousand four hundred hours. Then an additional twelve months and fifteen hours for additional role and population focus. So if

[Alyssa Black (Chair)]: an APRN is being employed currently in an inpatient setting practicing on their own, they've met by virtue of their license the two thousand four hundred hours in twenty four months practice. Does that come in to go for cracking? Guess it's just what OPR will license. They have done that, that they have documentation.

[Francis “Topper” McFaun (Vice Chair)]: I

[Alyssa Black (Chair)]: have questions from Brian and Houghton.

[Jen Carvey (Office of Legislative Counsel)]: It's not entirely clear just from the statute. The statute is on transition to practice. It's not entirely clear sort of what they have to file where and with whom, but I I imagine the board of nursing has a documentation process that they can look at if there's a Is

[Alyssa Black (Chair)]: there any similar provision around physician assistants that they have to have supervising for a certain development and they can be

[Jen Carvey (Office of Legislative Counsel)]: They are not permitted to practice without a collaborating physician agreement. There is no transition to solo practice or physician assistants. Yeah, I guess what I

[Alyssa Black (Chair)]: mean is, is there a directly active licensure, is there a supervision and then they can go to a collaborative after so many hours? Or is it straight from Don't.

[Jen Carvey (Office of Legislative Counsel)]: I don't think there's any kind of transitional. It just goes they just have to have a practice agreement. They can only engage in practice in the state if they are in a practice agreement with a physician.

[Alyssa Black (Chair)]: Okay. Brian, you have a question?

[Brian Cina (Member)]: Comment question. The comment was that it goes back to the why do we need to codify something that's already happening? And I would say that sometimes it's good to codify the current practice because it eliminates any question about it and it creates a consistent framework for people to follow. My question would be before we do that, just making sure that we're comfortable with, we meaning collectively we, like not just our committee, but like the people, whatever, are comfortable with the training and the protocols, etcetera, for having APPs doing the work of MDs or, you know.

[Alyssa Black (Chair)]: I think that's where the word surrogate came from, that I got stuck down to Doctor. Houghton, the idea and why they're against it is that APPs are seen as surrogates for MDs, for doctors. I mean, I was trying to figure out, he used that word, and I was just trying to understand it. I think that's what I would still be guaranteed.

[Brian Cina (Member)]: Don't think of it so much as surrogates. It's just another component of the healthcare system that is highly trained. Well, it's a

[Alyssa Black (Chair)]: surrogate because they don't have enough docs. So I think APPs have been needed in hospitals in order to function. And so that's good that they do that. But it's a need.

[Brian Cina (Member)]: It's almost like the APPs have been used to fulfill a need that the MDs aren't available to fulfill. And whether it was approved or not, it's become the practice.

[Alyssa Black (Chair)]: The standard of

[Brian Cina (Member)]: And yeah.

[Alyssa Black (Chair)]: And now the docs are against it. So that looks very confusing. When I have a tissue

[Brian Cina (Member)]: surgery It doesn't confuse me only because historically, my experience with MDs is that they want to maintain the hierarchy of the system, and it's not like a personal thing, it has to do with training, it has to do with all the training they go through. So there's concerns like, we have to do all this training and now people who are lesser trained are doing this thing, is that gonna undermine the system? So I get it, but the reality is the system's already functioning that way, and what are we gonna do? Yeah,

[Alyssa Black (Chair)]: I guess what I'm feeling, I'm struggling with this this Board of Medicine statement, I'm sorry, I think I've been jumping all over people, but they're not acknowledging the reality of what's needed to do this work because there aren't sufficient docs to do the work. So why not? It's confusing.

[Brian Cina (Member)]: I guess what I was going with it was maybe we need to hear from the hospitals or whoever what the what the trainings and protocols are to make sure that these providers are equipped to fulfill their duties. If we can confirm that, either we pass this or we add something to this that requires that or whatever, but I don't think we can pull the rug out from under the current practice without there being consequences.

[Alyssa Black (Chair)]: I don't think we should. I think we have to support all bias. I think we should support current practice because that's what's needed to

[Jen Carvey (Office of Legislative Counsel)]: run the system. One question that may be helpful to ask the hospital when you hear from them as well is whether they would expect to change their current protocols and requirements if you pass this legislation. It would be my expectation that they had put them in place because that's what they think is the most appropriate for the delivery of safe patient care in their facilities. But if there's something about this language that would change their requirements, you may want to know that before you pass the lunch.

[Alyssa Black (Chair)]: Thank you for making the point. I wanted to make the point that hospitals would not be doing this if they felt it was unsafe. Because don't forget, they have Alpacas.

[Brian Cina (Member)]: They have a lot at stake.

[Alyssa Black (Chair)]: Topper's been holding onto a question.

[Francis “Topper” McFaun (Vice Chair)]: It's been discussed, I would feel comfortable. I'm not going to be here, so. But I would recommend that you do discuss what Brian just said. You need to talk to the hospital. How do they do this to make sure that the patients are safe?

[Unidentified Committee Member]: Also adding to that is the consequences of doing the APRNs and the VAs. I think somebody I heard, there might have been a conflict there. Now, whether it was a pay issue or priority issue, I think I remember hearing something about doing the boat, or maybe it was

[Francis “Topper” McFaun (Vice Chair)]: a cost issue. One of those don't get as much training as the other. Well, know, but I

[Alyssa Black (Chair)]: think the bill was put forward by ATRNs, and as the bill evolved, I don't remember hearing any conflict between APRNs and PAs. I think it was just a matter of it was introduced because it was brought forward by APRN. Do we know

[Unidentified Committee Member]: if there might be some sort of a conflict?

[Alyssa Black (Chair)]: I think we've gotten tons of APRN emails saying this would be great if you did PAs too. And I don't think any PA of the

[Unidentified Committee Member]: No, I don't see a problem, but sometimes we pass things not knowing the consequences. That's why I brought it I

[Jen Carvey (Office of Legislative Counsel)]: think the testimony that I heard you received was largely, if you're going to do APRNs, there's no reason not to do, or you should do PAs. You you're hearing from the board of medical practice, they'd rather you didn't do either, but I think even that even the chair of the board, I think the testimony was if you're going to do one of the advanced practice practitioners or providers, you should do both.

[Alyssa Black (Chair)]: No reason not to do both.

[Francis “Topper” McFaun (Vice Chair)]: Is this any extra cost to the hospitals?

[Alyssa Black (Chair)]: No. This is current practice. And

[Jen Carvey (Office of Legislative Counsel)]: I think maybe it's helpful to to look at the language again, just to remember the context that this bill is in. So the context that this bill is addressing is the bill of rights for hospital patients and rights that patients have in the hospital as far as having an attending provider who is responsible for coordinating their care and who do you want to list as the types of providers they are entitled to have responsible for coordinating their care, rights to obtain information about their diagnosis, prognosis, provide be able to provide informed consent. But, basically, knowing who the provider is, who is and and getting complete information from the provider who is responsible for coordinating their care. And so I think the testimony that you've heard and that was heard at least as far as APRNs downstairs is that all three of these provider types, I think, are are often filling this role. And the question is, do you reflect that in the statutory language providing rights? Similarly, in the past it already in the hospital licensure statutes, the Department of Health can only issue a license when it determines that the applicant and hospital facilities meet certain standards. And the two relevant ones that currently mentioned physicians are that all patients admitted to the hospital shall be under the care of, and do you want it to be specifically a physician, which is current law, or do you want to say, or can it say that all patients that to be licensed, they can find that all patients admitted to the hospital are under the care of one of these provider types and that the one of these provider types is signing the medical records for the patient.

[Alyssa Black (Chair)]: Very helpful. Thank you. So I think what I'm hearing is that people would feel a little bit more comfortable if they heard from hospitals. Am I reading the room right? So that obviously isn't going to be today. Devin, do you think that you could at the most earliest convenience please have something hospital talk about and what their protocols are, hiring, all of that. Go ahead, Brian.

[Brian Cina (Member)]: Yeah, just want to clarify that it's not that I'm not comfortable today because of anything except what we just heard from the Board of Medical Practice, that that statement saying, what they said in that statement, I would like to hear the hospitals respond to that statement and reassure us that doing this is the right thing to do still, that's all.

[Alyssa Black (Chair)]: I agree. I think that's reasonable. Yeah. Alright. So that whole possible vote, not gonna vote on this today. Alright. Chen. Yes. Left is due. Moving on. S one eighty nine. S. We are gonna do a walk through of this bill.

[Brian Cina (Member)]: And then we have a break, right?

[Alyssa Black (Chair)]: We do have a break.

[Brian Cina (Member)]: I'll try to hold on.

[Alyssa Black (Chair)]: While Jen is pulling up this bill, I wanted to put something out there for the committee, which I don't think that I did, and I meant to do right after crossover. I've been struggling a little bit finding reporters of bills, and I think that we've had an uneven distribution of bills that have been reported, and I wanted to let the committee know that I'm going to be assigning reporters to bills, and it could be on any bill, And I wanted people to be aware that they could be called on at any time to record a bill. Could I

[Jen Carvey (Office of Legislative Counsel)]: think about that

[Alyssa Black (Chair)]: for a minute, if I may? It would be great if you make a decision about that, but it would be really great to have it more upstream so that because when you're a reporter you might listen to things a little bit differently than if you're just listening. So knowing ahead and blowing as soon as possible. I believe that the point is, is I'd like everybody to be thinking on every single bill as if they were reporting the bill. I

[Unidentified Committee Member]: disagree with all that. And First Okay. Of all, if I don't believe in the bill and I don't vote

[Francis “Topper” McFaun (Vice Chair)]: for it, I won't report.

[Alyssa Black (Chair)]: I I believe that I will be taking that into consideration. Does that mean that you're just gonna vote on it?

[Unidentified Committee Member]: I will know it, but I will say upfront, I do

[Francis “Topper” McFaun (Vice Chair)]: not report this bill I'm reporting.

[Alyssa Black (Chair)]: Getting added to your issue. The point is that we needed a more even distribution the labor in the committee, and that's all unattrenched.

[Brian Cina (Member)]: If you've chosen to do a bill you don't believe in, you could come up with a very creative way to present it that would report the bill itself, matter of fact, but embed all these little comments in it that undermine the bill. So you could use that position

[Unidentified Committee Member]: if you I wouldn't do that.

[Alyssa Black (Chair)]: We're all legal, we're all elected, and it's imperative that we all hold away. And that is my fault. Wait, why does a healthcare advocate one weigh in on? I like the shirt.

[Francis “Topper” McFaun (Vice Chair)]: I just want to say, a quote of Hudsonism, I remember him saying one time, I'm just Okay,

[Alyssa Black (Chair)]: moving on from that, Jen's now going to walk us through 189.

[Jen Carvey (Office of Legislative Counsel)]: Hey. Hello Eric. Switching gears here to s one eighty nine as passed by the senate. And this is an act relating to establishing a process for reducing or eliminating hospital services. It creates a new section in title 18.

[Alyssa Black (Chair)]: I'm sorry, Jen. We're oh, I thought you were asking for the donut. He just knows he'll never have to report any of these bills. Go ahead. Everybody's got 189. Let's go up. Thank you.

[Jen Carvey (Office of Legislative Counsel)]: 89, an act relating to establishing a process for reducing or eliminating hospital services. It adds a new section in title 18, but it actually also takes this language out of the existing section in title 18 that was added last year in act 68. So for those of you who were here last year, you may remember there was there was talk about creating kind of a process when a hospital wanted to reduce or eliminate a service. And you put that in or or in between downstairs and up here. You put a process in for notice and the Green Mountain Care Board could consider whether changes needed to be made to the budget of a hospital in light of a service reduction or elimination, and also just trying to make sure that people were not surprised given some recent experiences where people had been surprised by a hospital service reduction. So this would require that a hospital that proposes to intentionally reduce or eliminate any service and I'll pause for a minute on intentionally. This was a topic of discussion downstairs, but there were concerns about what would happen if a hospital had a provider leave and the provider was the department. And so at least for some time period, they're not able to offer that service or maybe choose not to start offering that service again, but they are not intentionally reducing or eliminating the service based on a provider leaving, retiring, moving on. So this is a hospital that's making a choice, hospital that is intentionally reducing or eliminating any service.

[Alyssa Black (Chair)]: Didn't she I mean, it's been a year. Didn't we deal with that whole situation in '26?

[Jen Carvey (Office of Legislative Counsel)]: That's what I'm saying. This is undoing that and doing something new. Oh, okay. So we're So you'll see where that language has struck in the next section.

[Alyssa Black (Chair)]: You have some hard on something coming in next year. Just been lying to us.

[Jen Carvey (Office of Legislative Counsel)]: I would say you'll certainly want to take testimony on this, but I don't think all of the, players in the process were happy with how it turned out. Okay. So the hospital that's closest to intentionally reduce or eliminate any service must provide a Notice of Intent to the Agency of Human Services, the Green Mountain Care Board, the Office of the Healthcare Advocate, and the members of the General Assembly who represent the hospital service area not less than sixty days prior to the proposed reduction or elimination. The Notice must explain the rationale for the proposed reduction or elimination and describe how it is consistent with the statewide healthcare delivery strategic plan once established and the hospital's most recent Community Health Needs Assessment conducted pursuant to both state and federal law. And some of this language is similar to or identical to language in the existing process. It's just setting up a different process. So they must provide a notice of intent to various entities, including the local legislators, post the notice of intent on the hospital's website beginning on or before the day on which they provide notice under subdivision one, Publish the notice in a newspaper of general circulation in the hospital service area within ten days after notice is provided pursuant to subdivision one. There was some discussion downstairs about publishing a newspaper being outdated, but we don't have a better mechanism yet or at least a generally agreed upon mechanism. So that's what's in here now. You can certainly make changes. A press release. Talk about alternatives. They must conduct a public engagement process, including holding one or more public hearings in the county in which the hospital is located and soliciting and responding to public comments regarding the proposed service reduction or elimination. The public engagement process may begin prior to providing the notice required in subdivision and shall continue for not less than thirty days following the notice. The hospital shall provide a summary of the community's response to the proposal, including the public comments received to the Agency of Human Services following the conclusion of the public engagement process. Then the Agency of Human Services must analyze each proposed service reduction or elimination for consistency with the statewide healthcare delivery strategic plan once established and the Community Health Needs Assessment, consider the community's response and the impact of the proposal on access to necessary care and services in the hospital service area, and provide nonbinding recommendations regarding the proposed reduction or elimination to the hospital, the Green Mountain Care Board and the public.

[Alyssa Black (Chair)]: I have a clarifying question. Yes. The statewide health delivery strategic plan, is there a goal when that will be done?

[Jen Carvey (Office of Legislative Counsel)]: I believe the first draft of the first iteration of that is due in January 2028.

[Alyssa Black (Chair)]: Okay.

[Jen Carvey (Office of Legislative Counsel)]: That was from act 68 of same S 126 last year.

[Alyssa Black (Chair)]: So that's a while out there. I think we're gonna get an update on that.

[Jen Carvey (Office of Legislative Counsel)]: If a hospital elects to proceed with reducing or eliminating a service after completing the process in subsection A, then within five business days after making the decision to proceed, the hospital must notify the Agency of Human Services to inform the agency's healthcare system transformation efforts and future versions of the strategic plan and the Green Mountain Care Board to enable the Board to review the impact on the hospital's budget. In section two, this is amending the board's hospital budget review statute. So this is breaking the language that was added last year, directing the hospital that proposes to reduce or eliminate a service in order to comply with the budget order to provide a notice of intent within not less than forty five days. This bill would have sixty days, But the notice is still explaining the rationale for the proposed reduction or elimination and describe how it is consistent with the statewide health care delivery strategic plan once established and the community health needs assessment. So some of these concepts have just moved over to the new statute. Under the current law that would be struck in this, the board may evaluate the proposed reduction or elimination for consistency with the strategic plan and community health needs assessment and may modify the hospital's budget or take additional actions as the board deems appropriate to preserve access to necessary services. And then I had to carve out for services that had been identified for reduction or elimination as part of the transformation efforts with the board and AHS. Instead

[Alyssa Black (Chair)]: But you say do have a question?

[Jen Carvey (Office of Legislative Counsel)]: Board are you talking about? It's the Green Man Care Board. It's all the whole section is all about Green Man Care Board. So instead so that language is coming out. And instead, in addition to the new notice public engagement process and nonbinding recommendation from the agency of human services, Upon receipt of notification from a hospital pursuant to, the previous section that the hospital intends to reduce or eliminate a service following its completion of that public engagement process, the board shall review the impact of the reduction or elimination on the hospital's approved budget. And this would allow the board still to adjust the hospital's budget as necessary to reflect the elimination or reduction, which may include directing that any savings related to the reduction or elimination are returned to Vermonters to address affordability concerns or to payers to be reflected in health insurance premiums or are reinvested in primary care prevention and other community based services. And then the language we keep the language directing the Board in collaboration with the Department of Financial Regulation to monitor implementation of any authorized decrease authorized reduction or elimination of possible services to determine its benefits to Vermonters or the healthcare system or both. And it would take effect on passage. So as I mentioned at the outset, this is looking to kind of revise the process set up last year that has not been workable for all of the parties involved. I will invite you to hear from it.

[Alyssa Black (Chair)]: If people followed multiple different hospital service line reductions throughout the past year. There were some very public ones. And then, Leslie? I'm just curious.

[Jen Carvey (Office of Legislative Counsel)]: I don't even know how to word this question. Would hospitals ever already spend this money? How do hospitals use their money? I they I know they have cash on hand as a bank. But is there any way a hospital would get in a really bad spot because they may have used this money and then have to come

[Alyssa Black (Chair)]: Does that make any sense? I think that would sort of be more in the Green Mountain Care Board Hospital budget review process that you're thinking of?

[Jen Carvey (Office of Legislative Counsel)]: I'll

[Alyssa Black (Chair)]: give a couple examples of what this bill was sort of addressing. There was a budget enforcement for UVM Medical Center, I think it was UVMMC, And they cut several service lines. They cut some primary care in Central Vermont, closed a practice. They cut eight inpatient beds, was it? Psych beds. Psych beds at central Vermont Medical Center. We heard earlier today from the dean, they cut transplant. I'm trying to think of the word. I'm like, when is it when you take an organ and someone put it somewhere else? They cut their transplant services, so they did all these service line reductions. And I don't know if you followed, there was a lot of uproar about that within public. Then we did this bill last year that essentially said before you can just summarily cut services, you have to sort of have approval for it. And then this summer, you might know there was the situation with Rutland Regional who had proposed eliminating some of their inpatient pediatric beds and that went through a process. And this is actually sort of how I will be this is kind of why this bill is before us because there's not really a statewide plan as of yet and we're in this interim period before the statewide plan is implemented or imposed, presented,

[Francis “Topper” McFaun (Vice Chair)]: everybody

[Alyssa Black (Chair)]: sort of felt a little hamstrung around how do we decide if this is yes or no when we're not really dealing with anything. Bill is to try to address that sort of thing.

[Jen Carvey (Office of Legislative Counsel)]: So if someone said, Okay, I want to retire, you have to give 60 days. So that's why it says intentionally reduce, because if somebody is going to retire, that's not the hospital choosing to reduce a service that's happening to the hospitals. Right. So would they already have a fixed amount in the hospital for that service that's going to get yanked back, but maybe they already used that money as much? I think that would be part of their modification of a budget order with the Green Mountain Care Board, I think.

[Alyssa Black (Chair)]: But I looks like we don't think we'll have to deal testimony with on this. We'll hear from and we'll hear from the board, and and I think they'll be able to answer that question if you you just asked. So, just kind of a little background on the language. Do you have any other questions about it? Leslie, did So, you want I know this is focused on hospitals, but in my community, what was withdrawn was primary care. That was provided by an FQHC. There was enormous community of war and no response whatsoever from the FQHC or the hospital the hospital service area. So my question is, is there a way to think about this beyond hospitals when there are service line reductions by other health care providers, or is that too confusing to the topic? And I would get that, but I would like to see how we can protect communities through that way as well. I think we regulate hospitals, we don't regulate FQHC.

[Brian Cina (Member)]: On that note, it says hospital, hospital, hospital, but doesn't say health systems.

[Alyssa Black (Chair)]: And what do you mean? You mean because you say the Green Medicare Board regulates the hospitals. That's what you mean?

[Brian Cina (Member)]: They do regulate the health systems. So that's why I'm wondering if it's depends

[Jen Carvey (Office of Legislative Counsel)]: what you mean by health system.

[Alyssa Black (Chair)]: Are you talking about like networks? Yeah. Which are not called networks anymore?

[Brian Cina (Member)]: Yeah, exactly. Like for example, university, UVM Health is a hospital, it's a network of hospital and health facilities, and they are regulated by being not disabled, right?

[Francis “Topper” McFaun (Vice Chair)]: No, they're not.

[Jen Carvey (Office of Legislative Counsel)]: You put some provisions in around them last year.

[Brian Cina (Member)]: I thought we did with that hospital bill.

[Alyssa Black (Chair)]: We put in reporting around them, but not regulation I of think we have to regulate them through the hospitals.

[Jen Carvey (Office of Legislative Counsel)]: Right, you largely regulate them through the hospitals, but there is you did put some language, I think, in around budget, looking at their budgets.

[Brian Cina (Member)]: I guess the reason I brought it up is because Leslie's concern about this healthcare system in general and service reductions at different points in the system, that we might be able to monitor or mitigate it or whatever the word is through the hospitals, through the health systems of hospitals a little bit.

[Alyssa Black (Chair)]: I was very frustrated, I'll just say because I was really trying hard to get this addressed in my community through HS and there's no response whatsoever. And that was a real loss. And it's a rural poor community. I will also point out that every year, for the last few years, we've put one in budget to include this year for provider stabilization grants. Karen? This is

[Jen Carvey (Office of Legislative Counsel)]: just a concrete example that might illustrate the problem. I think Weitzfield had a primary care

[Alyssa Black (Chair)]: place affiliated with UVM, and it was closed, sort

[Jen Carvey (Office of Legislative Counsel)]: of similar to those beds. Would there be any oversight? My understanding is that this would be included in that because it is a service provided by When I said they

[Alyssa Black (Chair)]: closed their primary care practice, I was referring to Wakefield. Other than the distinction would be made if you're owned by a hospital or not. In that community, it's regulated by the hospital. Regulated, yeah. And your budgets are regulated. Top part.

[Francis “Topper” McFaun (Vice Chair)]: Jen, what was the rationale for using the term may as opposed On to if you page four, down the bottom, talks about if the hospital decides to reduce safe beds, then the Green Mountain Care Board may adjust for all staying focused, or they may include directing them to do certain things. Why was it may instead of shall?

[Jen Carvey (Office of Legislative Counsel)]: I mean, my understanding generally was to give the board authority, but not require them to, depending on the scope of the reduction or the hospital's proposed use of any savings that may not be necessary or appropriate to adjust their adjust their budget. Maybe something that, you know, they deal with in conversations with the hospital but doesn't require an official adjustment to the hospital budget order. But I don't know that there was much discussion about should that be a shall or a may.

[Francis “Topper” McFaun (Vice Chair)]: Because you've a big problem. It's something I'm not closing those beds. It's huge.

[Jen Carvey (Office of Legislative Counsel)]: So you may want to hear from the board about, I mean, generally, we talked the other day about concerns about, that was not this committee, talked to another committee about, but about the extent to which you allow the regulator to make their own decisions versus directing them and how they do or do not take actions.

[Alyssa Black (Chair)]: I suspect we're gonna hear

[Jen Carvey (Office of Legislative Counsel)]: Providing authority, but not directing action.

[Alyssa Black (Chair)]: Alright. Thank you, Jen. Thanks so much. So we're gonna take a break. How about we come back here in fifteen minutes at 11:20. I'm going to do math in my head.

[Francis “Topper” McFaun (Vice Chair)]: 20. Only ten minutes.

[Brian Cina (Member)]: According to the clocks, which are now different again

[Alyssa Black (Chair)]: You know, it's roughly about a six.

[Brian Cina (Member)]: The the clocks are every clock in this

[Unidentified Committee Member]: room

[Francis “Topper” McFaun (Vice Chair)]: says

[Alyssa Black (Chair)]: something