Vermont Legislature SmartTranscripts:

[Speaker 0]: Hi, welcome everyone to 02:30 on April 2. And we heard on Jen did a walkthrough this morning on S-one hundred eighty nine. And so we have our first few witnesses in, and I think we're going to start off with Mike Fisher, the health care advocate. So if you remember, this is the service reduction notifications and things like that.

[Mike Fisher (Office of the Health Care Advocate)]: Notice of service reduction. Hi, I'm Mike Fisher.

[Speaker 0]: Happy to spend

[Mike Fisher (Office of the Health Care Advocate)]: a few minutes with you talking about this issue and s 199.

[Speaker 0]: 189?

[Leslie Goldman (Member)]: 159. I'm sorry.

[Mike Fisher (Office of the Health Care Advocate)]: 189. Yeah. Thank you. The the chair has apologized for a number of times for for the language that went into a bill last year that set us up for this, and I wanna push back on that. I actually think it has proven to be and at the time, there were dynamics playing out in the in the community. We don't need to go back into that that that motivated this. I I wasn't sure it was worth all that much, but I've come to believe that having a regulatory process to maneuver through notice of service, you know, service reductions is actually really important, particularly at this time. You know, hospitals under the current rules, under the current dynamics, have developed revenue strategies about how to balance their budgets and, you know, where to increase revenues and where not to focus on increasing revenues. And so no fault of the nobody's fault, but we have, over the years, developed dynamics where we have hospitals that maybe are getting much of their revenue or they or have significant revenue coming from outpatient procedures or things like orthopedics. And maybe they haven't put as much focus on things like inpatient or birthing. So here we are today with a so that's status quo. That's what's happening to vetting. And and and now we have this year's hospital budget guidance that calls for a negative 1% growth, and that's after inflation. Right? So it's more than negative 1%. And from the health care ethics perspective, that is a modest step in the right direction, and we are going to need to continue.

[Speaker 0]: I know you're not the board, but could you you are a party to the board. Could you, for education purposes, could you advise us of, the note the, budget guidance when it took place? Because it just took place this week.

[Mike Fisher (Office of the Health Care Advocate)]: The board took its final vote on Monday. Monday. Monday. This week. So it's been in draft form for a while, and there's been a lot of push and pull. And the because, as you know, the board doesn't negotiate. They don't have the ability to to deliberate any other way than publish, and so there's been quite a bit of discussions about it and and multiple factors. But one piece of it that I'm focused on right now is the overall growth is negative 3%, and the commercial rate increase increase is negative 1%. Boy, there's a confusing concept. Mhmm.

[Leslie Goldman (Member)]: So for both hospitals and a commercial?

[Mike Fisher (Office of the Health Care Advocate)]: Yes. And and my point is, okay. That's real.

[Devon Green (Vermont Association of Hospitals and Health Systems)]: Sorry, just actual, not commercial.

[Leslie Goldman (Member)]: Oh, Okay, I thought I heard you say. Sorry.

[Mike Fisher (Office of the Health Care Advocate)]: Commercial revenue for hospitals.

[Leslie Goldman (Member)]: Commercial revenue for hospitals.

[Jen (Legislative Counsel)]: Let's get that. Yes.

[Mike Fisher (Office of the Health Care Advocate)]: And then the next point I was going to make is, from the health care advocates' perspective, in order to get to a place where we

[Speaker 0]: need to

[Mike Fisher (Office of the Health Care Advocate)]: be ultimately, we are going to continue to push forward. We believe that there needs to be a number of more years of negative growth rates. My point is there's going to be a lot of financial pressure on hospitals coming at us. And in that context of both how we how hospitals raise their revenue and negative financial pressure, how do hospitals make reasonable decisions? How do they make decisions about how to meet the hospital budget guidance? And, so then switching to the community hat or the even the region hat, how do we make sure that through that process, we do a good job of maintaining the things that we absolutely need in not only at the hospital, but in the region. And so I'm just coming all around to saying, I think, I am convinced that a, a regulatory process makes sense in this space, that we ask hospitals to go through a number steps before they make a decision to reduce a service.

[Allen "Penny" Demar (Member)]: Are we anticipating a lot of that? I am.

[Mike Fisher (Office of the Health Care Advocate)]: And the reason? Because of what I just described about a negative growth rate, because we don't have anybody to play the bill. Mean, you and I have had this conversation a few times. I I I like to say this, and I wanna say it again. I'm the conservative one here. Think? I I I think the prospect of us spending spending money that we don't have is dangerous and will lead to insolvency. And so so I am gonna stand down a little bit. I you know, there's been a lot of conversation in the senate about who should do what, should it be at a what should live at AHS, and what should live at the board. And, and and I sort of, in the senate, took a little bit of a outside of that role of, like, this is important, and it should be done well. It should be done transparently and and with good notice to the communities, and and should be done well. Informed. Informed by the what's going on in the region, informed by the impacts on the finances of the health care system, informed by quality considerations, transportation considerations. There's kind of a lot to consider.

[Karen Lueders (Member)]: I bet this is a stretch. Do you think in any way this would help the whole idea of regionalization?

[Mike Fisher (Office of the Health Care Advocate)]: Well, I think it comes in the context of regionalization discussions. And so, you know, parallel to this is transformation work that's going on from AHS, work engagement with that hospitals have had around how they need to transform. And and a lot of that conversation has been around sort of considering the regional impact. And so I I guess I think that these decisions need to be really must be considered in the context of the regional needs. So I I I ultimately think that where the senate came down is not bad. It it is definitely a step forward to ask hospitals to require hospitals to be doing a a public process. That's an improvement. And it is absolutely a step forward to be requiring AHS to consider consider the advisability and to to nonbinding recommend to make a recommendation to say something about it given their role in transformation. And the bill in front of you leaves the alternate decision with the Green Mountain Care book. I think that you could one could flesh out some of the factors that AHS would consider as it's making this recommendation. There there's a place that I think is light on some details, and I know that the board has suggested a number of different factors. I think the ones I just mentioned and maybe some more about what what should be considered in in this decision. But it but from my perspective, it's important that there be transparency. It's important that the the community has an opportunity to give input. And and and I think it's vitally important that AHS has a role in, you know, a public role, an official role in making a recommendation, and that we still need somebody to make a decision. And and I think the Green Mountain Care Board is is a good place to do that.

[Speaker 0]: Okay, so in the bill currently, things that AHS shall consider. Where are you?

[Emily Brown (Green Mountain Care Board)]: I think

[Speaker 0]: on page two. Starting on 13.

[Mike Fisher (Office of the Health Care Advocate)]: Consistency with statewide healthcare delivery

[Speaker 0]: plan established. Analyze the reduction for consistency with the statewide plan once established, which is again not due until 2028. The first report on it is not due, but ultimately is it 2029 that it has to be developed? I think the first one

[Jen (Legislative Counsel)]: is due to you in January 2028. Right.

[Speaker 0]: Okay. The full statewide plan is due to us in 2028. So they have to analyze it to see if it's consistent with the statewide plan, which doesn't help with this interim two years. They're supposed to consider what the community how the community responded and then make a recommendation. So really, only thing that they're really assessing before the statewide plan is whether or not the community was in an uproar or not.

[Mike Fisher (Office of the Health Care Advocate)]: And I guess that's what I'm saying that if the committee thinks that we need the agency that's doing I mean, I I'm put it more directly. The agency is involved in coming up with a plan and evaluating, I hope, I sure hope, or I believe, you know, quality implications, transportation, you know, impacts, costs to the system. And, again, I don't I I know that Jess Holmes and maybe, Emily Brown, a little bit later this afternoon, will go into some more detail about the factors that need to be covered. I I just read that and thought that was one place that I thought was a little light on some details that the committee could consider.

[Speaker 0]: Jen, would you mind see, Ryan. Would you remind us Act 167 by Acting No. 51 or 54 or 51, what were the timelines around hospital transformation? There's the Wyman report, and then it went to

[Jen (Legislative Counsel)]: think of the, maybe all of the timelines that were actually enacted sixty seven-fifty five, were certain reporting that you had to get that was in 2023 largely and then Act 51 provision that amended Act 67 did not completely have timelines in it. It just authorized AHS to start working, authorized or directed them to start working

[Speaker 0]: Thanks. Brian, do you want to ask your question? You

[Brian Cina (Member)]: had said something about the community, they're assessing the community's reaction to the service reduction. What if a healthcare institution reduced a service and the community didn't care, but it's something that anyone who was studying demographics would understand was about to be important. You know

[Mike Fisher (Office of the Health Care Advocate)]: what I mean?

[Brian Cina (Member)]: So where is there, like, a way to safeguard something from being cut even if the community doesn't care if there's if there's evidence that they're going to care next year, once it's gone, realize they what's about to happen. Like, you know, there's going to be this vast spree of pregnancies or births or something, and, you know, like this outbreak of birth, you know, and we're gonna need, like, more places to have babies or, you know, that there's gonna be, like

[Mike Fisher (Office of the Health Care Advocate)]: Then we'll need schools and teachers.

[Emily Brown (Green Mountain Care Board)]: How's this?

[Mike Fisher (Office of the Health Care Advocate)]: I I think that's a good point. I think I I guess, essentially, what comes to my mind is an experience that happened this summer whenever it happened with Rutland's proposal to eliminate the inpatient pediatric unit. And, boy, if you didn't attend to any of those hearings, it's worth checking in on them. The pediatric provider community showed up in force with passionate testimony, passionate perspective about the needs of their communities, the needs of being able to care for kids in the communities. And, you know, hey. I I wanna recognize there may be times that things have to be done that are gonna be hard. But, you it just feels vitally important to me that we make sure that people have a voice to be heard before those decisions are made.

[Jen (Legislative Counsel)]: Thanks, Debra. So

[Karen Lueders (Member)]: I was going to bring that up. So obviously, community and I don't want to sound disrespectful. Know I don't. I've been here for five minutes. I don't think that just touching on what Brian said, I mean, community, unless you dive deep and look at all of the hospital statistics, if that's the right word, how many kids are seen at Rutland, of course, any community's going to worry about transportation. I mean, I know just to have my kids tested for allergies, it was a two hour trip. Yeah. And I get that. I get it. And I was thankful that I could do that. And I know a lot of parents can't take a day because that's a day. But for a hospital that keep the pediatric unit, when they don't see enough kids. Right. I like, that needs to be remedied. Right.

[Mike Fisher (Office of the Health Care Advocate)]: I I wanna I wanna rerun the tape a little bit. That's why I don't think I said or I don't want to say that decisions are contingent on support from the community or something like that. We need to hear from members of the community. We need to be informed by the community and the experts in the community. And I don't know, ultimately, whether it would have been or would be a good decision to close the Rutland inpatient pediatric unit. I felt really concerned that there hadn't been a good process leading up to it. But at the end of the day, there's a question of, how much utilization is happening there and whether it can be staffed and staffed you know, there's a lot of other considerations. And so, I'm just suggesting that there should be required inputs

[Jen (Legislative Counsel)]: Oh, absolutely.

[Mike Fisher (Office of the Health Care Advocate)]: Before the decision is made. Yeah. Not necessarily that any of those inputs should trump Yeah. Decision.

[Speaker 0]: Makes that final I think that's what we're trying to figure out.

[Karen Lueders (Member)]: Yeah. Oh, so it's not the Green Mountain Care Board.

[Mike Fisher (Office of the Health Care Advocate)]: Well, currently it's

[Speaker 0]: currently is the Green Mountain Care Board. Well, yeah. Well, so why? Wait. Hold up. I've got lots of questions, and I'm going in order. Do you wanna finish balance? Because Perfect. Your question. So I want you to continue. And then I've got Allen, and then I've got Karen, and then I got Brian.

[Mike Fisher (Office of the Health Care Advocate)]: Yeah. It's hard. I mean, I think I think that there's been a lot of dispute, you know, about who who should carry it. And, honestly, from where I'm sitting, nobody wants to own it. I think everyone is afraid of being the one to make the decision. And from where I'm sitting, someone needs to be in the role for making the decision. And as much as I know that I understand why the board has has not wanted to do it and and and why the board has argued that AHS was in a better position to do it. I also feel a great deal of confidence that the board will run a transparent process where people have an opportunity to weigh in. And and man, we have tasked AHS with transformation, and we've given them funding to do it, and they're in the middle of it. And so it makes absolutely no sense to me that these considerations don't have the

[Francis "Topper" McFaun (Vice Chair)]: real from that.

[Allen "Penny" Demar (Member)]: Allen? You answered some of it, but I don't know of any community that when you have a public hearing is going to say, oh, yeah, I think we ought to give up this service. I don't know of any that wants to give up any program to the hospital. If a hospital is losing money there, they do it anyway. So you go against the will of the people. Yeah. And you and the Green Mountain Care Board willing to make that decision.

[Mike Fisher (Office of the Health Care Advocate)]: Well, I don't know what decisions that we'll agree about Well,

[Allen "Penny" Demar (Member)]: to what extent? What if it's a lack of doctors in a certain area of the hospital and they're losing money, but it's a very crucial part of the hospital? And all of sudden, hospital says, don't, we'll just go away with it because we can't find help. I can see a lot of issues with this. And I think personally, it would lead to closing of hospitals. I hate to say that.

[Mike Fisher (Office of the Health Care Advocate)]: Your points are well taken. This is hard.

[Karen Lueders (Member)]: Karen? First of all, I think it is good to have a procedure because I feel like some things were closed and eliminated without process, and maybe not for the right reasons or the right drivers. I did hear about with the pediatric in hospital, sort of like doing heart surgery. If you don't do an IV on an infant enough times, you're not really expert enough to provide a network. So I think every metric should be taken into account, including the community. My question is for Jen. When I read this bill, I

[Devon Green (Vermont Association of Hospitals and Health Systems)]: don't really see, and maybe it's

[Karen Lueders (Member)]: in front, where Green Mountain Care Board does have the ultimate authority to make the decision. It's like the hospital

[Jen (Legislative Counsel)]: They have

[Leslie Goldman (Member)]: The hospital does, really. The hospital makes, yes.

[Karen Lueders (Member)]: And then Green Mountain Care supervises what the hospital has decided after going through a process. That The care board is authorized to make changes to budget

[Jen (Legislative Counsel)]: to reflect the elimination or reduction.

[Mike Fisher (Office of the Health Care Advocate)]: Okay, my bad. Thank you.

[Jen (Legislative Counsel)]: And under current law of agreement, your board does not make the final decision. They are authorized to modify the budget and they are authorized to take other actions as necessary, they do not have necessarily the decision making authority over which service lines are continuing or not. It depends on the extent of their hospital budget order authority.

[Speaker 0]: So in 01/2026 we said that AHS was supposed to make the decision or

[Jen (Legislative Counsel)]: No, so in

[Leslie Goldman (Member)]: What did we do in in Which last is what would be replaced with this. You see the language that it struck.

[Jen (Legislative Counsel)]: A hospital has to provide notice, explain the rationale. The board is authorized, may evaluate the post reduction or elimination for consistency with the Safeway Healthcare Delivery Strategic Plan once established in community needs assessment and may modify the hospital's budget and take such additional actions as the board deems appropriate to preserve access to necessary services. That's it. Then anything that was part of transformation is not part the.

[Mike Fisher (Office of the Health Care Advocate)]: So thank you. I was misreading it. I'll say Yes.

[Jen (Legislative Counsel)]: Yes. Are of this incident on s one eighty nine. Yeah. Various parties, various roles.

[Mike Fisher (Office of the Health Care Advocate)]: I'll say again from my perspective that I do think a decision maker has to weigh in.

[Jen (Legislative Counsel)]: Who should that be?

[Mike Fisher (Office of the Health Care Advocate)]: And I ultimately think that the Green Mountain Care Board is shouldn't well-to-do that, and I understand why they don't want to. But

[Lori Houghton (Member)]: Brian?

[Francis "Topper" McFaun (Vice Chair)]: The

[Brian Cina (Member)]: I'm wondering about the possibility of the Green Mountain Care Board being responsible but not solely responsible. I know we've had this debate before about when there's one person who's not designated and who does it, but I feel like it's Could it be possible to ask them to take the lead, but to get legislative oversight? Or maybe it's the AHS and the legislature, both have to weigh in on Green Mountain Care Board's recommendations, we're not dumping it in their lap, we're taking some responsibility. But then there's this extra piece that I just want to throw out there, which is how do you force someone to provide a service? What if the hospital or the healthcare system just cannot afford to provide it anymore and does not have providers? Would you be going to start arresting doctors and forcing them to work in labor units or whatever, work in mental health units if they don't want to. How do we make people provide the service? They're stopping.

[Mike Fisher (Office of the Health Care Advocate)]: These are big challenges, and it goes to this concept that we have I mean, do we have a plan?

[Brian Cina (Member)]: And I guess what I would say, though, is asking that, but I think that the answer might be something like, what if if it does come back to the legislature, we do have the power to say, we'll we'll pay you twice as much to provide this thing. We can incentivize it. I feel like we don't have the It would be unethical or wrong for us to force people to do something, but we can make the deal so sweet that they can't say no.

[Jen (Legislative Counsel)]: But if you don't want the confidence.

[Brian Cina (Member)]: We would need that from the Green Mountain Care Board. What I'm saying is they would make a recommendation, maybe. Maybe it's not all in their lab. I'm not saying I have an answer. I'm just throwing out these questions to hear from the witnesses, what they think. But in the end, if the Green Mountain Care Board and AHS are looking at our healthcare system and determining that this is a pivotal piece, or it's going to be a pivotal piece that we're about to lose, I think that should come to us and we should take further testimony and then decide, are we gonna try to save this piece of the healthcare system? And if so, how far are we willing to go? And that could mean paying more, it could mean,

[Jen (Legislative Counsel)]: I don't know.

[Mike Fisher (Office of the Health Care Advocate)]: Let me just say, so again, this is really tricky. We've tasked AHS with doing the analysis and with coming up with a plan ultimately. And and, hey. Hospitals are doing what they can, but they're trying to figure out how to run their own shop, how to and make it work for them and their community. And and we this sort of goes to the regional thing. And we need to make sure that the individual hospital decisions fit within the region's needs, that people have access to the care that they need within a reasonable distance. And and so I do think we we have we have two parties who have different skill sets or different tasks in this system. I think AHS has taken on and been assigned by the legislature, to do the planning piece, to be informed about the impacts on the system. And we have the Agreement on Board with a, you know, a good public process.

[Speaker 0]: I'm gonna go with Leslie. Did you have a question, Leslie? And then I'll go back to Allen. No. More just I mean,

[Leslie Goldman (Member)]: about the difference between the Green Mountain Care Board and AHS. And Green Mountain Care Board, and you've mentioned this a number of times, transparency, they have to operate with open meeting law. AHS does not. And there's a lot that goes on there that is just unknown. And that's why I think the Green Mountain Care Board as perhaps the final arbiter is going to be most available to people in the community and statewide. And they have the statewide vision the Humanitarian Care Board does, maybe once the strategic plan is done, then AHS will. I'm not sure. We don't hear about that. We don't hear too much about AHS. We hear a lot more from the Humanitarian Care Board. That's what I'd like to know about is the transparency and that we can depend on that information to be accessible. We can watch meetings. It's there. It's available to communities. AHS, it's not. And yes, we've tasked them with stuff, but

[Mike Fisher (Office of the Health Care Advocate)]: Can I can I just add sort of

[Speaker 0]: But I actually wanted to ask Jen a question? But

[Mike Fisher (Office of the Health Care Advocate)]: And I have a question. K. The witness asked questions. We've made a lot of plans. I've been around for a lot of planning efforts. Is it going to be is this plan going to drive policy? Will it have will it have a real influence over decision making? And I don't know the answer to that. But whenever I hear about a new planning effort, I I think, boy, we've made some great plans in our day that have sat on the shelf. Yeah. And I guess I am hopeful or I think I hope this isn't yet another one of those. I hope this is one that actually drives decision making.

[Speaker 0]: When is the last time We focused and said, come up with a plan, and the plan has come to fruition.

[Francis "Topper" McFaun (Vice Chair)]: Sorry, don't have to laugh.

[Speaker 0]: No. I guess maybe we should define what a plan is because to me, a plan isn't a concept. A plan is here's the plan and we follow the plan. I guess what I'm saying is when's the last time we came up with a plan and followed the plan?

[Leslie Goldman (Member)]: That's what made

[Speaker 0]: me a plan.

[Brian Cina (Member)]: Like a fire drill maybe.

[Leslie Goldman (Member)]: I mean, Act 167 was a plan that got executed by the Green Men Care Board, which helped us a lot. And it helped the system a lot. So now we're moving on from that. And the statewide strategic delivery plan was

[Speaker 0]: essentially saying, here's what we need, where we need it. Maybe. Oh, I thought Jen was convulsing because I was getting it all wrong. You were straightening your wrist.

[Brian Cina (Member)]: I don't feel like we've completed any of other plans though. I feel like we start them and then we were like, never mind, let's do this other thing. And then we start them and then we're like, never mind, we're gonna do this other thing. It's like the house never gets finished being built Well,

[Speaker 0]: is that okay, though? I mean, sometimes we I recall think that's the problem and the problem that showed up this year was we put in where they have to consider the plan, but there's no plan yet. So what are they supposed to consider? And then when they asked, what do you want us to do? They said, we don't know. We haven't come up with a plan yet. And then it seemed they just either. I mean, in a nutshell, am I sort of talking about kind of what happened this year? And and it Nobody wanted to make a

[Francis "Topper" McFaun (Vice Chair)]: decision. And further,

[Mike Fisher (Office of the Health Care Advocate)]: make, you know, make a plan for what the landscape's gonna look like in '28. The landscape's gonna look different. I mean, we can make some predictions about what it's gonna look like.

[Speaker 0]: That's why I'm like, it's okay to not Yeah. And to the plan.

[Mike Fisher (Office of the Health Care Advocate)]: That it has to be iterative. Long as you're

[Brian Cina (Member)]: Yep.

[Speaker 0]: Adapting and learning and

[Brian Cina (Member)]: Maybe we should call

[Speaker 0]: it something different, man.

[Leslie Goldman (Member)]: Well, depends on the unintended consequences of what comes out of this at some point.

[Speaker 0]: Allen, did you have a question? Well, I don't know.

[Allen "Penny" Demar (Member)]: The hospital's nonprofit, they are a business. They run it according to how everybody's telling them how to run it. So they're losing money in a certain area. They can't make that judgment of if we're gonna stay afloat and we're gonna keep making money, we do not need to provide this service. And all these other agencies gotta get involved and say, Oh no, you go to the public. Public's not gonna wanna close nothing down. Think we're opening up a whole can of worms there. It's their business. If this was your private business, you make those decisions. If you're not making money, you're gonna get rid of that service.

[Speaker 0]: Can I ask a question, which is exactly what I'm thinking about, which is exactly what you said? I mean, let's be realistic. If a hospital is losing money on a service and they're making money on a service, which service do you think they're going to cut? They're not going to cut the one that's making money. They're going to make the one losing money. And I think that the decision making last year when we did Act 68 and we put this in here was that the board would be able to look at that cut and make determinations on we see that you're struggling in this area. We're allowing you to increase your revenue here so that you could keep that service. To which I was thinking my question to you, you said maybe we should be coming up with more more things that AHS would need to

[Mike Fisher (Office of the Health Care Advocate)]: Factors to evaluate.

[Speaker 0]: One of my frustrations in this year's and what happened with Rutland is it's very clear that that is a service that is incredibly important to that community. However, it's also a service that is losing money because you have to staff it, it's not full all the time. If it's your child, you want that there. And I totally get the importance of that. But one thing that was never asked, Rutland Regional is on a global budget with Medicaid and these were pediatric beds. And why was AHS not saying, let's help you sustain these beds because it's important to the community to think about what they pay on a global budget for those beds. And so, you know, we had asked the Green Mountain Care Board and their role in revenue setting, rate setting, whatever they do with hospitals in the commercial space, maybe we should be asking AHS as their because they are the payer of Medicaid, maybe we should be making in here that they must consider the rates that Medicaid is paying for these and their decisions need to be made on that as well.

[Jen (Legislative Counsel)]: Got it.

[Mike Fisher (Office of the Health Care Advocate)]: I mean, I think that's there's some sense to what you just said. I guess I think the Medicaid global budget's brand spanking new. But going forward, we have that dynamic. But all of this reminds me, going to Allen's question, of what I started with, a recognition that I think today hospitals care that they're making it. If they're getting paid two times as much for this as they're getting paid for that, they're both very important in their community. It's okay. They're making it. And as financial pressure happens, if we see I mean, from my perspective, we need hospitals in the community to do certain things that hospitals are positioned to do. And if they have been, you know, fault of years of negotiated rates, you know, they are not getting paid well for some things that we really need them to do, it would be a real loss to the community to not do the adjustment to the rates, which we're not positioned to do right now. You know, I think once we have record based pricing, I think there'll be some opportunities to make some I hope there'll be some opportunities to make some adjustments. But that that we that we have to be really careful that we don't lose the things we need the most in the community. Even if it makes perfect sense for the hospital that's looking at where they're losing money today.

[Speaker 0]: Trying to make the point that the reductions that we have seen consistently, I don't think it's any coincidence that they are services that are heavily Medicaid dependent. Half of the children in the state have Doctor. Dinosaur. And a huge percentage of pregnant women are covered under Doctor. Dinosaur. We have birthing centers. We have pediatric inpatient beds. We have psychiatric beds at Anyways, topper, go ahead. You can go ahead because I'm getting feisty. Feisty, know. Know, it's getting towards the end of the week. I'm just speaking for myself. But

[Francis "Topper" McFaun (Vice Chair)]: if we establish a global budget, That global budget, and it's made up the proper way, where people have input and the needs of the community, all that stuff is folded into the plan. What you have to do with the global budget is you have to fund it and keep it funded. That's what we're not doing. And if you do that, it'll work. Because you know upfront how much money you're gonna need to do the things that the community is saying, showing you that they need. So if you do it, that was part of twenty years ago, a global budget and can tell you right now it didn't work. I thought we were starting it pretty well when we did Catamount Health, because then everybody had insurance. We don't follow through on things that have been well planned and with the funding that's needed, there's always something else that comes in and sidetracks it without finishing it, know, taking a look at really what happened. A perfect example of this, and I know people may not want to know about this, but in Rochester, New York, there was an experiment that was done on type of universal healthcare, and it worked. And then people got greedy and wanted more money for themselves. The project was working, people were being taken care and I'm just convinced that that's the way to go. I have felt that way for years, that the way to go is to develop a world of budget and follow it, and make sure that people are covered. If you do that, you think the problem is solved.

[Mike Fisher (Office of the Health Care Advocate)]: Only we'd listen for twenty years.

[Speaker 0]: Yes, I know.

[Brian Cina (Member)]: Well, it's not too late.

[Speaker 0]: You make an amazing point, I hadn't thought about, which is, AHS is already coming up with global budgets and presumably they're coming up with global hospital budgets based upon the services that the hospital provides and the needs of the community.

[Francis "Topper" McFaun (Vice Chair)]: Okay.

[Speaker 0]: We all set with Can I just finish? Can I make

[Lori Houghton (Member)]: one comment? We spent all last year doing this whole thing on certificate of need, and moving some of these services out of the hospital. And I look at the low hanging fruit that I know hospitals want to get out of their dialysis, birthing centers. I know that those are not money making places, but why isn't anyone looking at setting these up outside of the hospitals? I mean, why do we do all of that for not? If we realize that they're probably not making the hospitals any money, we're worried about the fiscal solvency of a hospital, and we have these certificate of needs that nobody's acting on, why isn't the hospital helping to facilitate moving some of these services out of a hospital? I just, why do we do all this and then nothing

[Mike Fisher (Office of the Health Care Advocate)]: happens with any of it?

[Lori Houghton (Member)]: That's my ten minutes that I worked on.

[Francis "Topper" McFaun (Vice Chair)]: Let me tell you another little story, because you talked about dialysis. Prior, dialysis was done in the hospital. If you've been out to New Hampshire now, where the bus there goes, because I brought Con Holger down there all the time, they're making money.

[Speaker 0]: Yes. They're not hurting.

[Francis "Topper" McFaun (Vice Chair)]: So the system you set up has to be, there has to be some independence in that system too. There's ways to do this. I'm hoping that what the chair was talking about comes to fruition. You know, many, many years ago we said, I'll give you another example, of where we screwed up and we shouldn't have. Because now it's costing us more money. Autistic people. And we said, I remember I'm standing there and I remember the words being said, all of these services are going to be provided to you locally instead of you have to come down to Brandon. Well, we didn't do that. Look the mess we're in now. And, you know, we're trying to crawl our way out of this hole that we're We're doing some good things, don't get me wrong.

[Speaker 0]: I know.

[Francis "Topper" McFaun (Vice Chair)]: Some good things are going on, communities are being created now, etcetera, etcetera, but we should have just done what we said we were going to do and you wouldn't have this problem that we have now. You have people aging out, they can't take care of these kids, and there's no place for the kids to go.

[Mike Fisher (Office of the Health Care Advocate)]: It is one thing to say theoretically that it would be less expensive to serve this need outside of the hospital. There needs to be a place to go. There needs to be there needs to be facilities. There needs to be services set up, and that significantly, we don't have that. And that might and and it to some degree, there may be a timing aspect to that. It just might take a minute. You guys have hearing euphoria for five minutes, here for ten minutes. Might take twenty five minutes. Might take

[Francis "Topper" McFaun (Vice Chair)]: hospital for what it was meant to be used, Swan.

[Speaker 0]: Exactly. I have a question, and I'm saving it for our next guest. No, I never write anything down, but I write this down. Thank you.

[Jen (Legislative Counsel)]: Thank you.

[Speaker 0]: Thank you. Afternoon. Hot seat there.

[Devon Green (Vermont Association of Hospitals and Health Systems)]: I know. Feeling feisty?

[Speaker 0]: Has a question written down for me?

[Devon Green (Vermont Association of Hospitals and Health Systems)]: Evan Green, Vermont Association of Hospitals and Health Systems. And do we wanna start with my testimony or is that right in the okay. VAL supports s one eighty nine, the senate version of the bill. We understand where the legislature was coming from last year and the response to the elimination of services that the UVM Health Network did at that time. We think that this bill addresses those concerns while not leaving us in a totally unpredictable spot. So we are in a little bit of no man's land where we don't have a plan, and we do have these financial pressures on us. I will admit that. What this bill does is, and the main complaint I heard last year was the UVM Health Network did this, and they didn't They went public. They didn't give us a heads up. No one was notified. They did it immediately, and we were unable to weigh in. I think this ensures that hospitals will notify all the relevant parties, so AHS, Green Mountain Care Board, their own delegation, all the policymakers who could actually keep that service in the community are going to be notified before anything happens. I think that piece is really important. It actually does give us some process so that if So if the agency of human services said, Wait a second, we need to think about how Medicaid funds this service, they have the ability to do that. I think it also provides a process for the community to weigh in, going to the health care advocates concerned. It does provide notification on the website and the ability for the community to weigh in, which I think is really important. I think it takes care of those two things. I think the important thing to remember also is that there's not a huge incentive for hospitals to reduce services with the way the Green Mountain Care Board is proceeding under this. If a hospital cuts a service and that saves money, we already have in the hospital budget guidance that hospital's budget will be rebased based on that cut in the service. So it's not like the hospital will necessarily keep the money that it saves unless it can make a case agreement with their board that it makes sense for them to keep some of that money. So there's no big incentive We have these budget pressures, but the budget pressure is going to remain regardless of if a service is cut. Because even if it's cut, it's still the same budget on those services. Does that make sense to both? Okay. So I think for the sort of imperfect point that we're in, where there is no plan, this fulfills the need that we have over the next couple of years, where the public is notified and has a chance to respond, policymakers are notified and have a chance to respond, and then ultimately, the hospital can move forward with reducing or eliminating that service if necessary, instead of ending up in this process where, again, as Representative Cina said, I'm not sure what happens. Maybe rates can be raised, but if we are told that the hospital needs to keep that service and nothing changes, I'm not sure what happens from there. And that is really destabilizing. And so I think this sets up a good process going forward, understanding that we need to come up with a plan by 2028.

[Speaker 0]: Any other recommendations that AHS shall consider when coming up with their non binding? Think this does What is the difference between just a recommendation? This is what I want to ask Jen. I mean, by nature of the word recommendation, that's just a recommendation. It's always non binding. Why is non binding?

[Jen (Legislative Counsel)]: There was concern about whether anything was supposed to

[Speaker 0]: be done with it. So it

[Jen (Legislative Counsel)]: was being clear that it was not done.

[Speaker 0]: Okay. Another, where we have to put in a dictionary definition of what

[Devon Green (Vermont Association of Hospitals and Health Systems)]: recommendation is. It does say consider the community's response and the impact of the proposal on the necessary care and services in the hospital service area. So it's not just necessarily considering the community's response. I think it's also considering that. The one thing I would change is in the last paragraph On page five, subsection three, it talks about authorized reduction or elimination of hospital services.

[Leslie Goldman (Member)]: What line?

[Devon Green (Vermont Association of Hospitals and Health Systems)]: Sorry. Line five. Okay. And I would I would want to eliminate authorize at this time, given that

[Jen (Legislative Counsel)]: And they circle back on my back.

[Devon Green (Vermont Association of Hospitals and Health Systems)]: Yeah. Okay. Good.

[Speaker 0]: I'm not red. It's not on line. Okay. So that would be my recommendation. Is that a non binding recommendation? It is a non binding recommendation. Any questions for Debra?

[Brian Cina (Member)]: I know because Debra has answered the questions that were said earlier.

[Speaker 0]: Sort of to Topper's point, and Wendy Critchlow. So, we've seen a million charts and graphs, And we know that hospitals, that the increase in our healthcare spending is mainly going to Oh gosh, you're going to hate this.

[Devon Green (Vermont Association of Hospitals and Health Systems)]: Late on me.

[Speaker 0]: Have outpatient hospital, we have inpatient hospital. And we've seen a nice little trajectory in inpatient hospital. We have not seen this. However, outpatient hospital we've seen. Okay. So, in the service reductions that we've seen, Actually, some of the also contract things that we've seen. They seem to be in the inpatient space. So my question is, what are hospitals doing? Where are hospitals investing their resources? I mean, this gets back to sort of tougher with the brand and training school and we're going to do it in the community. We have these plans, but we never actually invest in insuring these. So where are hospitals investing their money? Are they investing in improving inpatient services or are they investing in improving outpatient services?

[Devon Green (Vermont Association of Hospitals and Health Systems)]: I mean, I think they're looking for operational efficiencies at this point. I don't think there's a whole lot of investment necessarily happening. I think if you look at things like our I'm going to forget the term for this, but our plant age or our building age, we're one of the oldest in the country because we have foregone those investments largely. So I think we are doing things like bringing in Dartmouth and UVM patients back into our inpatient unit, and that's a lower cost for the patient. That's opening up access in those hospitals. We are trying to create efficiencies on every level. And I think there is investment in the outpatient space, because more and more services can be done on an outpatient basis, and we know that that's what people tend to prefer. They don't want to spend the night in the hospital if they don't have to. So, in terms of investment, again, I would say we're looking at trying to reduce costs as much as possible in this moment. And that's what we're going to keep doing going forward.

[Speaker 0]: Yes, Tucker.

[Francis "Topper" McFaun (Vice Chair)]: That may be good for you to be on the dock, because of a big institution, Central Long Hospital or Springfield Hospital, they may not be able to do that.

[Devon Green (Vermont Association of Hospitals and Health Systems)]: I think they are doing it, I think the smaller hospitals are doing a lot of that work. If you look at Gifford, they are taking patients from Dartmouth and UBM to patients who still need inpatient care, but they don't need it in that higher cost setting. They're bringing those patients back to the community, they're staying at their community hospital, and that lowers the cost of care for everyone. It's better for the patient. I think the smaller hospitals are sharing services, they are really trying to do a lot.

[Francis "Topper" McFaun (Vice Chair)]: Some of them are. I know some of them are up in the north part of the city, But I just really felt that the solution to the hospitalist dilemma is to start off with where they are now, at the highest cost that they are now, and then develop global budgets. You can smile about it, think that's the way to go. And then then you what you've done is you've said to the hospital, you need $10 to run this show? Okay. You're gonna get it. And they run the show for $10. Yeah. Not 11 or $10.50. They can run it for less, but they can't go over this, the $10. I think that would solve the problem, and they'd stay in business.

[Devon Green (Vermont Association of Hospitals and Health Systems)]: I agree. We want to move towards global budgets, and you did that last year in act one sixty seven. And but on the other hand, we do have an affordability problem, and I understand that the legislature, the agreement, and care board Vermonters want hospitals to be as efficient as possible before we institute those global budgets. And that's what we're working on now. I do think the sort of process of global budgets would necessitate a process of looking at what hospitals are keeping and letting go in terms of services because you don't want well, I don't wanna get into it. Let me think about that statement more. I'm going down a totally hypothetical road at this moment. Agree with you on the global budget piece.

[Speaker 0]: I'll say that.

[Francis "Topper" McFaun (Vice Chair)]: So,

[Leslie Goldman (Member)]: I don't know if I'll be very articulate, but when I look at my 90s, the highest paid people in our small hospitals are orthopedic surgeons. So how do we think about that? Because every small hospital wants to have an orthopedic surgery service line because that's how they stay afloat. I'm having trouble with that because then the less remunerative service lines, pediatrics, psych, primary care, whatever, gets thrown under the bus. And I don't know how to think about that. And I'd like to know how hospitals are thinking about that. And I know you're doing your transformation work and it's not for public and whatever, but how do we I think the orthopedic service lines may be keeping places afloat that maybe shouldn't be. And that worries me. So I won't be specific, but I just don't see how we're supporting what we want since we've been spending all this time on primary care. How do we move from an inpatient orthopedic surgery center all over the state to primary care, which is what we need all over the state? And I'm curious to know how we do that.

[Devon Green (Vermont Association of Hospitals and Health Systems)]: Yeah. And I think we've been struggling with this for a long time because the fee for service world, it sort of rewards Yes.

[Leslie Goldman (Member)]: That worth of come up before.

[Devon Green (Vermont Association of Hospitals and Health Systems)]: But right now, we're focused on affordability. And I think moving into reference based pricing and global budgets, that's the opportunity to tackle that issue. If the Green Mountain Care Board is setting the rate for orthopedic surgeons, they may lower that rate and increase the rate for giving birth not giving birth, not getting paid for giving birth, for birthing services.

[Leslie Goldman (Member)]: Yeah, you are.

[Francis "Topper" McFaun (Vice Chair)]: I'm not

[Speaker 0]: getting paid. That's stupid. So

[Devon Green (Vermont Association of Hospitals and Health Systems)]: I think the hope is that the reference based pricing will help smooth that out a little bit. And then the opportunity with global budgets is if a hospital understands that it is working within a budget, then it can really focus on those essential services for its community instead of chasing the fee for service model. But likely, the fee for service model for orthopedic surgery isn't going to change. I don't imagine. Mean, can

[Leslie Goldman (Member)]: we imagine that's going to be included in

[Devon Green (Vermont Association of Hospitals and Health Systems)]: a global budget if Medicare was playing? But that's obviously up in the

[Speaker 0]: air with the A. D. Model. Just, Daisy has a question, but do hospitals know on a micro level how much that one orthopedic surgery costs to provide that care or say, how much does one birth per birth, Do all of our hospitals have an analysis of exactly what it costs to provide a care? How much does it cost to provide an abdominal CT? How much does it cost to provide? Do we have that? That's not the chargemaster, right?

[Devon Green (Vermont Association of Hospitals and Health Systems)]: It's not the chargemaster. I will check and get back to you on this.

[Speaker 0]: I'm just wondering how the Green Mountain Care Board is ever going to be able to set reference based pricing to incentivize the kind of care that we need once AHS finishes the statewide strategic plan if hospitals don't even know how much it costs to provide that care in the first place? Well, must know. I mean, we know what they're paying with because

[Leslie Goldman (Member)]: they're budgets. I mean, their budgets. They must have that information. I mean, maybe not every knee replacement costs exactly the same and every moment at one place, but they must have an idea. I mean, they're charging.

[Speaker 0]: Well, that's what I'm wondering is if we get that data.

[Devon Green (Vermont Association of Hospitals and Health Systems)]: Our critical access hospitals are at cost. They have a cost report.

[Speaker 0]: Okay. Daisy? How often do hospitals do community health needs assessment? Every three years. Can you tell us a little bit about what's contained in there?

[Devon Green (Vermont Association of Hospitals and Health Systems)]: Delving back into my memory, I believe it has the needs of the community. The surveys are done within the community to figure out what the needs are. And some of those are done at, like, town meeting day. Those surveys are given out, that sort of thing. And then a prioritization of those surveys once they come back, and then a plan for how the hospital either can or cannot meet those needs.

[Speaker 0]: And is it personal, individual health needs, or is it community wide health, like economic needs?

[Devon Green (Vermont Association of Hospitals and Health Systems)]: Yeah, that's a good question. I'd have to go back and look at the surveys that are done. I'm not sure. I would have to go back and look at that. And I can certainly check the web I can give you the website where all the community health needs assessments are.

[Speaker 0]: I Google it too. The first page of the bill refers to that. And

[Emily Brown (Green Mountain Care Board)]: I realized we never really dug into it.

[Devon Green (Vermont Association of Hospitals and Health Systems)]: Yeah. Yeah. So they're really they're There's a lot of good information in there.

[Karen Lueders (Member)]: All right, I might end it. So reference based pricing, would the Green Mountain Care Board would that

[Speaker 0]: be across the state, or would that be a possibility? I don't know.

[Karen Lueders (Member)]: Because it hasn't Well, I'm worried if one hospital, like we've seen it, charges more for service to make up for the loss somewhere else. I mean, how could that not be really bad if it's just the same?

[Devon Green (Vermont Association of Hospitals and Health Systems)]: Right. That's the peer. My understanding is that the Green Mountain Care Board has said that it will take into consideration different types of hospitals. But the Green Mountain Care Board is here so they can talk a little bit more about their reference based pricing work.

[Speaker 0]: Let me ask Diane. I feel like reference based pricing is in my head all the time, and I can't remember if it's other conversations. Have we had an update from the Green Mountain Care Board? And when I say the Green Mountain Care Board, I mean Elena. Have we had an update from Elena on reference based pricing yet, or were we saving it? Diane Lynn for Green Mountain Care Board. When the reference date's update was due was in February 15, we turned in the report in Elena, that somebody came in to give you an update on where that was. And we had that update? Yes. Okay. Feels like a long time. It does. I'll read you through. I'm looking at Act 68 at some point and how they're because it's all in development right now. No more questions for Debra I just have one last one. Didn't even write it down. I was going to say two. I think, if I'm not mistaken, I think that March 15, there was a report due on hospital transformation from the hospitals to AHS. Has that been delivered? And have we seen that?

[Devon Green (Vermont Association of Hospitals and Health Systems)]: I have not seen it. And my understanding was there was the earlier report due in February from the hospitals to AHS, and then AHS was sort of combining a lot of those reports into this report on March 15, but I have not seen that yet.

[Mike Fisher (Office of the Health Care Advocate)]: Okay.

[Devon Green (Vermont Association of Hospitals and Health Systems)]: And I would add that

[Speaker 0]: We would love to see that on it. Yeah, we're in

[Devon Green (Vermont Association of Hospitals and Health Systems)]: a little bit of the funky position with the antitrust piece where we can't be in the middle of that, and the state needs to be.

[Jen (Legislative Counsel)]: Okay.

[Speaker 0]: Daisy, did you? Yeah. I'm curious, and sorry if I missed it, but are we doing anything with the rural health transformation to look at actual cost of care? Are we doing any cost analysis with those dollars?

[Devon Green (Vermont Association of Hospitals and Health Systems)]: I don't know. It sounds

[Speaker 0]: like you could.

[Devon Green (Vermont Association of Hospitals and Health Systems)]: I think that's a good question for AHS.

[Jen (Legislative Counsel)]: Thank you.

[Speaker 0]: Thanks, Devin. Thanks. You're actually kind of lucky that you're for last because I'm getting tired.

[Emily Brown (Green Mountain Care Board)]: Thank you for having me. Emily Brown, Green Mountain Care Board. And before I start, I do just want to say a big thank you to represent McFaun. I understand your last day is tomorrow, and I just want to thank you for your service. I've been in this committee in various roles for a while, and I just really want to thank you for what you've done for this committee and health care in the state. So thank you. Yeah. Okay. So to start, so the original version of this bill originally had the duty of approval of the transformation or sorry, of the reductions or eliminations with AHS. The Green Mountain Care Board supports the original version of this bill. The original version also still had the hospital, process where they had to, provide notice and the public engagement process. We think that's very important. So we're happy that that made it into the Senate passed version. But we do strongly support AHS having the requirement to approve any reduction or elimination. And there's a few reasons why that is. So as I think has been discussed, throughout this testimony, AHS currently, at this moment has the resources, and the duty to transform our health care system. They have the Rural Health Transformation Funds, which is going to amount to a billion dollars over five years. They are receiving transformation plans as we speak from hospitals. They are in charge of developing a statewide strategic plan. All of those things go to how is our system going to look? And they are the ones who are directing that work. The way that the law currently exists, not talking about the bill, but the existing law currently, has the Green Mountain Care Board looking at any service line reductions or eliminations. The first and last time we went through that process, it was quickly apparent that the board was operating in a vacuum of information. We did not have the resources, meaning the financial or the staff resources, to do the analysis that is required to truly understand the impacts of a service reduction or an elimination. Again, that has been a decision that was made by the legislature to give that authority, at least the regionalization, the transformation, as I talked about, to AHS. So by having the board do their own analysis, we're essentially operating in a silo and do not have the perspective or the benefit of having the perspective of what is the plan for the state. If the board was required to continue to approve or deny any service lines reductions, we will still be requesting information from AHS and asking for their input. We actually did that during the Rutland case, and we're not able to get any input or information from AHS to inform our decision. That's, to me, very problematic, not only for our decision making, but for the state as a whole. I don't think it's good for the board to be making a decision in isolation that could have huge ramifications and potentially be out of line with what AHS is planning for their transformation efforts. So we would recommend, that if the committee was willing for AHS to have, a positive requirement to make a decision around any reduction or elimination. So that's kind of where I wanted to start. As to the Senate passed version of this bill, as I said, we support, the notice provisions. Some points I wanted to make were about timing. So it's very clear at the beginning of the bill in subsection A around the hospital process and what they have to do. What was not clear to me is that once they're engaging in their public process, that the agency of human services shall and then there's requirements, analyze each proposed service reduction or elimination, consider the community's response, provide nonbinding recommendations. There is no definitive timeline of how that nonbinding recommendation is then feeding back or at all into the hospital's decision. The hospital is required to provide the notice sixty days before a closure. There's nothing that says that AHS has to finish their analysis or complete their analysis before then a hospital is making a decision to close. So I think just wanted to point that out that I think there could be I imagine this analysis is not a very quick thing to complete. So I just wanted to point out that it wasn't clear to me if that was the intent to have the hospital engage in their processes and then give AHS. And I think that it should be timed. I think it wouldn't be fair to hospitals for HS to have an open ended timeline to do analysis. I think there does need to be some timeliness there. But I think it's not clear in the language, and Jen, please correct me if I'm wrong, that that analysis will then be feeding into or informing the hospital's decision.

[Leslie Goldman (Member)]: What kind of timeline are you thinking?

[Emily Brown (Green Mountain Care Board)]: I don't have one in mind, and I am hesitant. I would want AHS, if they were the ones doing the analysis, so I wouldn't want to recommend something. But I just feel like that is kind of a missing piece here. And then the other thing I wanted to point out was there is this requirement for upon receipt of notification from the hospital. So that's the notification from the hospital that then is informing the board's budgetary decision. There's no assumption here that AHS's nonbinding recommendation will be informing the board's notice. So I'm just again, this is more of a timing issue. I think it's important that upon notice and receipt of AHS's non binding recommendation, if that is the language that is the preference of the committee, that those two things are informing the board's budgetary process, not just the notice from the hospital. And then one more recommendation as well. On page five of the bill, line four, This is existing language that requires the board to collaborate with DFR and monitor the implementation. I realized there was a strike of the word authorized. The board would recommend striking that whole section. We don't believe that collaboration with DFR as far as this function is really necessary or would really add value to this process. So that's our other recommendation for this bill.

[Speaker 0]: This thing that existing law says that the board am I reading that right? Because it's not underlying that that's existing. Correct. That's my understanding. Collaborations, DFR should monitor the implementation of any authorized hospital services to determine its benefit.

[Emily Brown (Green Mountain Care Board)]: DFR does not overstate costs now? It did not increase. Okay. Oh, right. Because that decrease was struck.

[Speaker 0]: Oh, Okay. So it makes a difference a little bit. Yeah.

[Emily Brown (Green Mountain Care Board)]: So the language as it says, any authorized reduction or elimination of hospital DFR does not oversee hospital services. And to my knowledge, and I'm happy to hear otherwise from DFR, determine its benefit to Vermont or the healthcare system. I think there's obviously language in here that talks about any budgetary decisions related to reductions or eliminations flowing through to insurance premiums, which we regulate through our rate review function. But we don't believe that this collaboration or requirement to collaborate with DFR is appropriate if this is the language that the committee intends to pass.

[Speaker 0]: Daisy, you seem to be pondering. Is that a coincidence?

[Lori Houghton (Member)]: I'm thinking if you did

[Speaker 0]: anything in May, did this?

[Jen (Legislative Counsel)]: Is there any reason?

[Speaker 0]: Oh, yeah. Yeah, we didn't like the DFR bill.

[Emily Brown (Green Mountain Care Board)]: As would change

[Speaker 0]: perhaps their need to or desire to collaborate with DFR. I don't think so. Go ahead, Brian.

[Brian Cina (Member)]: Did you have an opportunity to present these amendments to the Senate?

[Emily Brown (Green Mountain Care Board)]: Yes. So in the Senate, we were asked at the beginning to testify several times, and we testified exactly how how I just testified that we supported AHS having the the role of approval or disapproval of production, the same thing I just said, correct.

[Brian Cina (Member)]: And they didn't do it? They did not do it. Yeah, I'm not going to ask you why it's not fair, but I am curious for us to know why they didn't do it if they were asked to do it by Green Mountain Care Board.

[Jen (Legislative Counsel)]: You should have your VHS.

[Speaker 0]: Yeah, I'm

[Mike Fisher (Office of the Health Care Advocate)]: asking you.

[Speaker 0]: I see Val has a question, but first of all, do you think you could have your suggestions and send them to us along with cc'ing our legislative council. I will do that again. Because you said it should be

[Devon Green (Vermont Association of Hospitals and Health Systems)]: in the letter, never end up in

[Speaker 0]: the late June. I have a question, then that was a question. You said, and I've been here long enough now, twenty minutes. I've been doing

[Jen (Legislative Counsel)]: this for twenty five minutes. And

[Speaker 0]: then my first minute and then my second minute and my third, I remember. One 167, Act 51, and you said that AHS has been given the resources, the appropriations, the positions to carry out the work that we've tasked them to do. And I'm particularly thinking about the hospital transformation plan. Let's leave the statewide strategic plan out of it. So, first gave the Green Mountain Care Board the resources to be able to commission the Windham Report. That was done. That was a process. And then it was passed on to AHS to not come up with a transformation plan, but to actually do transformation. Do you think that if given the resources, that we should move it back to the Green Mountain Care Board? So with the appropriate resources. Because you do affiliate hospitals. And this was about hospital transformation. Regulate hospital budgets. Hospital budgets, yeah, great. You have a role in the hospital budgets. And yet, we've sort of moved away like any ownership from the board of having influence on hospitals, which is what the transformation plan was supposed to be.

[Emily Brown (Green Mountain Care Board)]: So I can't That was before my time at the board. I can't speak to And that was a legislative decision. Just a few points. Where we are now. We have the Rural Health Transformation Fund money coming in. That's a huge amount of money that AHS has the authority, the spending authority over. So that is to encourage transformation, to enable transformation. AHS is also a payer, as was mentioned before. They have control over Medicaid payments. If we are wanting a well kind of rounded and kind of well informed decision making, I think it's important to have the people at the table doing it have different perspectives and various perspectives on that work. I think, again, if I look at AHS, the fact that they're a public payer, they're the ones kind of leading the Rural Health Transformation Fund work. It does make sense where we are now to have them lead this work. I can't speak to back when after act 167, there was a decision made to transfer that. I don't know if at this point in time, would make sense from an efficiency standpoint and a lot of points to move it back to the board. We are where we are. I think there's opportunity for us to work together on this stuff. This impacts our work. As far as who is directing and owning the work, I think it makes sense to be at AHS because of where we are right now. If we were having this conversation maybe four or five years ago, that answer might be different. But I just feel like where we are right now, makes sense to proceed as we are and have AHS doing the transformation work.

[Speaker 0]: I think Val had a question and then Karen just continuing to be frustrated in my twenty five minutes that I've been here. It seems as though every single bill is a decision making process over who's going to do what and who's going to work in collaboration with or consultation with. And it just feels, I don't know, it feels like the state of Vermont doesn't have a mechanism for putting out a plan and implementing a plan and moving forward with plans. I thought I was over being fixed. You don't need to comment on that. I guess I'm just It just feels like we have the same conversations over and over. Val?

[Karen Lueders (Member)]: Go back to page one. I just was hoping you could repeat.

[Emily Brown (Green Mountain Care Board)]: Yes. And I apologize for not having written. You

[Karen Lueders (Member)]: had mentioned a positive requirement of

[Emily Brown (Green Mountain Care Board)]: someone to do something. So what I was referring to is in the original version of the bill that was introduced in the Senate, there was a requirement for AHS to say yes or no if there was a reduction or elimination. So they had the duty to approve or deny any reduction or elimination. Currently, I think Jen read through some of the existing language. It's it's a bigger standard right now with the board. It goes through our process, and we may take action and take appropriate action as we deem necessary. The original Senate version had language that was essentially put the burden on AHS to make a decision around whether a service should be eliminated or reduced.

[Jen (Legislative Counsel)]: Go ahead, Karen.

[Karen Lueders (Member)]: I'm Chan Lee. I've only been here five seconds. And I'm Chan Lee, chair of vice chair. When I think of the Green Mountain Care Board, I think of an ex female that's, at this point in time functioning well, having the tools to function well, very clearly identified,

[Speaker 0]: and having expertise, all of it. And when I think of AHS,

[Karen Lueders (Member)]: what vulnerable entity there could possibly be the funnel or the conduit to take on its responsibility? It seems large and amorphous, and I don't have that same I

[Emily Brown (Green Mountain Care Board)]: don't know, when you say AHS, what? Yeah, so it's my understanding. I don't want to testify on behalf of That is definitely better suited to them. But they do have the director of health care reform. And the office of health care reform lies within AHS. So it's my understanding that that area is part of who's leading this work. But I would not I don't feel comfortable testifying. I'll do that for them. So that would be better suited to them. But you're clearly saying they should do it. And don't want you to speak for this either, but I Yes. So maybe I can give a little bit more depth to that answer. We are a staff of about 30, and we already have a very labor intensive hospital budget process. We have rate review. We have our ACO and CON review. We do a lot with very little, I would say, having experienced other departments and agencies in the state of Vermont. We are, I would say, a very high functioning entity at this point. I don't think with our current resources, financial and staff, that we could take on the transformation work full stop. I don't think we are equipped to do that right now. And we also have a board structure that is focused on regulatory type decisions. So again, transformation work is much more we do have a policy director, Elena. She's wonderful, but she informs our regulatory work. The transformation work is much more of a policy and kind of thought effort. So it's not that I think, could we do it? Yes. But we do not have the resources or the money. If you were going to require us to do even the service line analysis, and I think board member Holmes testified to in the Senate, we would need resources to do that analysis in a way that was actually meaningful and was giving the hospitals and the public the information they needed on why we were making our decision. I would view that analysis as duplicative of the work that AHS is doing because they're already looking at how do you regionalize services and care? Where should services go? That is already being done at AHS. So if you were going to just take this and put it with the board, that would largely be overlapping with what I understand the work that AHS is already doing. And I don't same to what Devin testified to. I haven't seen the transformation plan. So we don't even have a window into what is being discussed or planned. So again, it's more about where we are now. And I was trying to answer the chair's question. Right now, I would not recommend transferring. I hear what you're saying, but it's about resources. It's about staffing. It's about duplication, wanting things to be more cohesive, which I think we struggle with in this state sometimes, especially around health policy.

[Speaker 0]: Cohesive. That's the word that I was looking for. Okay.

[Emily Brown (Green Mountain Care Board)]: Thank you. Thank you so much. I appreciate it.

[Speaker 0]: I'm just looking at the agency of human services office of health care reform and their most recent health care system transformation. And I'm not sure if it would be useful maybe to have someone come in and review it with us. Yeah, I think we're going to get an update from them soon. Okay. Thank you. Thank you, bye. We can go off of live and we're back.