Vermont Legislature SmartTranscripts:

[Speaker 0]: Good morning. It is Wednesday, April 22, and we have returned to s 189. Kind of indicated last week after committee discussion that we were sort of starting over from the beginning a little bit. So we're having testimony from a lot of people who have testified before. But I think that think that after we went through it last week, I think the committee maybe has a better idea of what we're actually looking at and can make better decisions if we hear things again. So that's what we're doing today. So we're going to start with Your schedule has changed a little bit. Doctor. McCoy, are you guys testifying together? One and then

[Leslie Goldman (Member)]: the other. Okay. Well, whoever would like to come up first. Okay.

[Speaker 0]: And introduce yourself to us. She's good. Yep. Okay. Right there. Ms. Houghton?

[Dr. Anna McCloy]: Good morning, Chair Black, members of the committee, and interested community partners. My name is Anna McCloy. I'm a board certified pediatrician. I have practiced primary care in pediatrics at community health centers of the Rutland region, newborn medicine and pediatric hospitalist medicine at Rutland Regional Medical Center for the last thirteen years. I was born and raised here in Vermont. I attended medical school at the Larner College of Medicine at the University of Vermont. And after residency, I returned to the state to practice. I'm a parent of two children, ages 12 and 15. In the last year, I have been part of a medical team and community affected by service line reduction, which is what brings me here today to share my experience. As a pediatrician, a mother and a Vermonter, I have a vested interest in Bill S-one 189. I'm grateful for the opportunity to share my experience of Rutland Regional Medical Center's reduction of pediatric service line over the last six months. My motivation to testify here today is threefold. First, I hope that sharing my experience will help us all work together to preserve safe, appropriate, sustainable healthcare for Vermont's children, no matter where they live in our state. We must uphold five standards of care and do what is within our collective power to help all Vermont's children grow up to be healthy and to reach their greatest potential. Second, I wish to emphasize the importance of independent, objective, third party oversight of hospital service line reduction. And lastly, I would like to help spare other communities, patients, and healthcare teams the experience that we have had with our service line reduction in Rutland. On 10/29/2025, Rutland Regional Medical Center's leadership abruptly announced that they would close the pediatric inpatient unit in mid December, two months later. The decision was announced without collaboration nor warning given to the pediatric hospitalist team or staff. This decision was made without transparency and without thoughtful planning. There was not a transition plan or an alternative model of care in development, and we were headed into the winter viral season. This created chaos and exhaustion for our broader pediatric hospitalist team. It sowed fear among patients, their families, our staff, and community members. It seeded significant mistrust of the hospital leadership. In early November, Rutland Regional Medical Center submitted their proposal of service line reduction of inpatient pediatrics to the Green Mountain Care Board. The Green Mountain Care Board provided a professional, transparent public engagement process that yielded over 300 well informed insightful letters from community members and medical staff opposing the proposal. The GMCB hearings facilitated critical thought, an objective look at the data provided, and a discussion of the impacts of this closure that the impacts of this closure would have on our community and our state. The process brought to light RRMC's ability to effectively justify or articulate clear reasoning for their proposal, casting doubt on their motives. It gave those doing the work, our pediatric team, a voice and a forum to correct misinformation and mischaracterizations of our service line that RRMC had spun to fit their agenda. In mid December, the Rutland Regional Medical Center leadership team rescinded their proposal to the Green Mountain Care Board oversight process in the eleventh hour, stating that they would now pursue the closure under a new AHS framework. With this action, they were able to avoid the Green Mountain Care Board's regulatory determination. Media headlines at the time misleadingly stated that RRMC would no longer close pediatrics despite their explicitly stated goal to do so. This further relieved the hospital leadership and their proposal from scrutiny. Our team is not naive to the complexities of health care delivery. We understand that the health care landscape is ever evolving and that change is inevitable. The absence of a formal process, lack of hospital accountability to a regulatory body, and hospitals obstruction, meaningful collaboration with those who do the work every day, who care for patients, have made this a trying experience at best. Our Women and Children's Unit has a culture of excellence, resilience, and the innovation required for a rural health care setting. It is a safe, evidence based, child friendly medical care environment built over decades. I want to make the point that it has taken Rutland Regional Medical Center very little time to dismantle this essential service with no reasonable alternative established. As predicted in the fall, many of our most specialized, highly trained staff have resigned due to the destabilization of our unit. As resources and support have been callously withdrawn from the Department of Pediatrics, the burden of managing our sickest and most vulnerable pediatric patients through a busy viral winter season has fell entirely on the pediatric nurses, respiratory therapists, support staff, and pediatric hospitalists. It simply did not have to unfold this way. Welcoming a medical care team to the process with an openness to medical expertise, creativity and problem solving could have yielded more success early on. Solutions are often found in the middle ground. The Vermont Agency of Human Services has stated that it aims to strengthen the rural healthcare workforce, increase access to timely care, improve quality and reduce cost. Closures like ours function in opposition to those goals and will contribute to a system of healthcare inequity. We have seen this year with both the closure of the Copley Birthing Center and RRMC's pediatric inpatient unit, that service lines that don't generate significant revenue for a hospital are easy targets for reduction. We cannot abandon accessible healthcare for entire demographics, women and children. In the absence of an inpatient pediatric unit in Rutland, there will be increased transfers to tertiary care two hours away. This will further disadvantage low income, under resourced and vulnerable populations. Mothers will disproportionately miss work, have to arrange additional childcare, secure lodging, carry the mental load of managing their children's illness far from home and away from their support networks. Patient transports, increased emergency room use, delayed care, and increased use of tertiary care hospitals will mean higher costs extended across our state health care system and for all Vermonters. I can empathize with the idea that taking ownership of an oversight or regulation of a hospital service line reduction is not an appealing venture, but it is an indispensable piece of Vermont's health care puzzle. It is cumbersome, nuanced, and at times heart wrenching, but it is of tremendous ethical importance. Our experience demonstrates the essential nature of independent third party review of hospital service line reduction proposals. Our example highlights the inability of a hospital leadership and of a hospital board of directors to objectively evaluate and effectively administrate a service line reduction. The RRMC Board of Directors has not engaged with us despite our outreach. They cannot provide the level of scrutiny that would be required for such a process. With a unanimous vote for the reduction, they have effectively been a rubber stamp for RRMC's agenda. It is understandable they are not at the bedside, and they do not see what will be lost. I have learned many hard lessons during the last six months, the hardest of which is that what is right may not always prevail. That being said, have to try our hardest and do better than what has happened in Rutland. Exceptional and accessible health care is valuable. I know that service line reductions will happen, but to the best of our ability, the process must be collaborative, thorough, respectful, equitable, and with oversight. We do fear that if recommendations are non binding, that hospitals will not choose to follow them. In honing this legislation, you have the opportunity to protect the current and future generations of Vermonters. Thank you so much for taking this testimony as you work through Bill S-one 189. It is our privilege as pediatricians to be able to use our knowledge, agency, training and position to advocate for children and families in our own community and throughout Vermont. Thank you so much for your time this morning. Thank you.

[Speaker 0]: Can actually have a seat. Leslie, you have a question?

[Leslie Goldman (Member)]: I do.

[Leslie Goldman (Member)]: Thank you so much. And I was hoping you could submit your testimony to talk to them and then we could review it again, which I appreciate lot. And thank you so much for this work. It's really important that I'm someone who cares a lot about process. So I think that whole thing was a process failure. So that's what this bill is about, is about process. One of the things that came up was the use of the pediatric unit and maintaining quality. And we spend a lot of time talking about money, but I don't know if I think we talk enough about quality. So I was wondering what your thoughts are about staffing a unit with intermittent use. Does that make sense? Is that question?

[Dr. Anna McCloy]: I think so. So let's see. I'm gonna refer to times before this service line reduction was put in place. Because since that time, I think the dwindling resources and support for the unit has

[Daisy Berbeco (Ranking Member)]: compromised But

[Dr. Anna McCloy]: prior to that, I think that we had a relatively creative way of using the unit. So the pediatric unit, the women and children's unit, it's called, many publications, it's listed as a five bed unit, but it's actually four beds because we don't put two patients in one room anymore. That's sort of gone by the wayside. So four rooms that are available for pediatric patients. And then there is another side of the unit that is used for mother baby care. So separate from our birthing center, after a mother gives birth, the couplet, mother, baby, family, come down the hall to the women and children's unit and postpartum care takes place. So the nurses on the women and children's unit, they take care of mother baby couplets and they take care of pediatric patients. And so historically, there have been times that rooms, they're intermittently empty or not all are full at the same time. And those rooms have historically been used for off service patients. So for example, like a postoperative joint patient or somebody who had another day procedure. And our nurses have been cross trained to cover those. Typically, was orthopedic, typically orthopedics, sometimes surgical. But I think there's quality and value in that because you have a set of nurses that's cross trained over multiple specialties and they can be a boost to multiple services if one maybe doesn't have inpatients that day. Does that answer the question? Sort of? Okay. Okay.

[Leslie Goldman (Member)]: I don't think I was very articulate, but thank you. Sure. Yeah.

[Speaker 0]: You spoke about dwindling resources and the process that took place in Rutland has destabilized the workforce. I keep thinking of how in this bill, how do we thread this so that there is a collaborative process that is allowed to take place without a Okay, I can't think of another term, so I'm going to use this term like rats fleeing a sinking ship. Yeah. Okay. That's I mean,

[Francis McFaun (Vice Chair)]: how do

[Speaker 0]: we how do we allow for a public process? How do we allow for a collaborative process that won't destabilize, that will lead to people saying, I got to get out now because this is going down. Right, but

[Dr. Anna McCloy]: yeah. Yeah. So when Rutland Regional announced the closure at the October, it felt like felt like a bomb was dropped out of nowhere. We know that that decision didn't happen overnight. And so one of the systems failures, process failures leading to this was that the pediatric team wasn't brought in when these conversations first started happening. As I mentioned, I do think most of the time solution is found in the middle ground. And I think if all parties had been at the table and able to listen to each other's expertise, that we may have been able to find a compromise that would have allowed us to preserve some staff who have some really high level skills and really specialty training in pediatrics. Rutland is a rural area. And so when we lose those staff and this program goes, don't know that we will ever be able to get it back. I don't know that it would ever be needed or welcomed. But if we had started from the beginning as part of the conversation and we had been at the table, I think we would have been able to come up with a middle ground. And in fact, since this has all started, we proposed a number of middle ground ideas that have not been really welcomed or engaged with.

[Francis McFaun (Vice Chair)]: Do you know how much the pediatrics services or the administration estimated to lose on pediatrics?

[Dr. Merri Fox]: I'd like to speak to this a little bit as well.

[Speaker 0]: Record. Absolutely. Name is Doctor.

[Dr. Merri Fox]: Rebecca. I'm a board certified pediatrician. I also do outpatient pediatric care for community health, and I'm one of the pediatric hospitals at Redmond Regional Medical Center. So again, that covers newborn care, emergency consults, as well as inpatient pediatrics. One of the things the hospital has presented this package to both their board and then us when they announced the service line reduction of significant fund loss. I think one of the things that we discovered at the Green Mountain Care Board meeting was that their numbers may not have entirely reflective of how the unit functions as a whole. As my colleague, Doctor. McFaun alluded to, our costs encompass both postpartum care for mothers and infants, as well as the pediatrics beds and as well as like off service patients that we take. And so the numbers that were presented did not include the care for the postpartum couplets for for the income side of peace or the off service patients. And then the costs that they estimated included like both facility costs and staffing costs for the entire unit, not just the pediatric portion of the unit. So I think in many ways, we are actually an incredibly cost effective unit. We have a very unique arrangement in Rutland where the cost for the physician care is mostly burdened by our community health federally qualified health center, and the hospital just pays us a daily stipend. And we are incredibly cost effective. An entire year of all five of my partners is less than one other physician for a full time benefit package. So for that perspective, we're incredibly cost effective, and we've come up with a very unique arrangement. Obviously, staffing side of things for nurses, especially with fluctuating capacity as we tend to do, we tend to be a much fuller capacity in the winter and have lower capacity in the summer when their children are less sick from respiratory illness, is a little bit challenging. But we have, Stephanie said, we proposed several middle grounds to have more of those flex spaces where we could admit more of those so called off service patients when our pediatric volume is lower. And we have essentially been, for lack of a better word, screaming into the void. We've sent emails. We've requested meetings, and we're not hearing from the hospital leadership. They've repeatedly declined meetings with us to find that middle ground to make it a cost effective unit.

[Francis McFaun (Vice Chair)]: So in cost effective, do you think you'd make money on pediatrics then?

[Dr. Merri Fox]: I think there's a path where we could make money. And I think pediatric care is challenging. Medicare and Medicaid reimburse less for pediatric service than they do for adult services, which is a national problem for pediatrics. One of the things that came up at the Green Mountain Care Board is that the hospital is not asked for an increase in reimbursement for inpatient pediatric states in ten years. So there's been no push to increase the reimbursement they could receive for that. And then we had a plan to decrease expenditures by combining both the postpartum, the labor and delivery, the pediatrics floor to make the nursing staff much more cost effective. That would have been the plan in place up until the October announcement, and it's still pretty unclear to us why that plan changed so suddenly.

[Francis McFaun (Vice Chair)]: Do you think that if, the hospital had brought you in earlier in the collaborative process Mhmm. That some staff would still say, oh, I see the handwriting on the wall, I'm gonna get out? Yeah. So even if they had the process

[Speaker 0]: Yes.

[Francis McFaun (Vice Chair)]: Some staff may leave.

[Dr. Anna McCloy]: Yes. I do think that's true. Again, though, if we are talking about a service line reduction as opposed to an elimination. Yep. So I think it would be expected that you would lose some staff if we were reducing the service, reducing some staff, reducing some rooms, but not losing all of it. That would have been

[Dr. Merri Fox]: a middle ground that we would have accepted. I think as the teenagers that I take care of would say right now, the vibes are bad. The staff who work there, the very talented staffs, respiratory therapists, LNAs, the nurses, they're very afraid that they will very suddenly not have a job. And these are talented people with families and careers and houses to think about. So they are sort of making backup plans as you know, who would blame them. Because still to this point, it's not clear whether we will have a pediatric unit in a week, in a month, in a year. And so I think that has led to a significant loss of staff and skills that would not have happened had this been more of a collaborative process.

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

[Speaker 0]: Thinking back to and I could be wrong here, I don't actually know what ended up happening with it. But Rutland, we were doing a certificate of need bill last year. And if I recall, Rutland was building like a whole new L and D maternity. So that was yeah. Are they still doing that?

[Dr. Anna McCloy]: No, that was the plan that Doctor. Mary Fox was referring to that had been in discussion and planning phases and even construction meetings all the way up, at least through the summertime. And then all of a sudden, the meeting stopped happening. No communication. And and then a couple months later, the announcement. So it that the intent of that unit was going to be like a redo, like a redesign that did put the two departments together, pediatrics and labor and delivery postpartum. And so that was in effect a little bit of a middle ground. Yeah.

[Dr. Merri Fox]: Yeah. And I think it is important to say that we have labor and delivery as one spot, postpartum and pediatrics is another spot. And the way safe staffing works in a hospital is you have to have a minimum number of nurses on a unit if there is a patient there. So you have to have one nurse who could take care of the patient and then potentially even another nurse to respond to an emergency. If someone came in in labor and an emergent situation, there has to be a second nurse there. And the same is true for the other side too. If there was a code situation, there cannot just be one nurse. So with two units, we're talking to minimum staffing of one nursing. And so the plan had been, and pediatrics was very much involved in this plan, to create one combined unit so we would have more flexible staffing options and being able to reduce some of that expenditure. And as you alluded to, like, funding was set aside for that. The plan was to start construction, and then all of a sudden, that stopped. And then three months later, we had this sort of surprise announcement that we were not a part of or privy to.

[Speaker 0]: You you also said that you're essentially contracted. Is it a contracted hospitalist, I'm assuming? Yes. Yep. Does Rutland Regional just pay you a lump sum? Who bills for your services? Does Rutland or do you?

[Dr. Anna McCloy]: Rutland Regional bills for the services provided in the hospital. And it's a combined payment between community health and Rutland Regional. So we are community health employees. And as a group, we are contracted hospitalists to the hospital. And it's a bit of a unique arrangement. I think it's a pretty creative arrangement for a rural health care format. Because if we are working at the hospital and we have time, if we finish our hospital work or we're between things at the hospital, we can come back to the clinic and see outpatients. And so we're a little bit back and forth sometimes during the day.

[Speaker 0]: I guess I'm just I mean, if you're if you're an inpatient, you have obviously your hospital inpatient stuff, the facility, and then you have every provider that sees you then has their own charge. We see who bills for that physician charge? Do you or does Rutland Regional?

[Dr. Merri Fox]: The way it works is we submit all of our claims, the hospital will bill for all of our service that we provide and get reimbursed from the insurance companies and the hospital pays a daily stipend to community health. Which is passed through to us. Got it. Thank you. Thank you.

[Speaker 0]: So any other questions for Doctor. McCloy? Did you You were testifying as well. I'm assuming you have something else. Do you want to switch spots? Sure. Would be

[Dr. Anna McCloy]: Doctor. McCloyde as well. Okay.

[Dr. Merri Fox]: My apologies. So some of

[Speaker 0]: the questions you were asking was going to

[Dr. Merri Fox]: be to some of the pieces that I really wanted to address today, sort of what has happened after the announcement of the closure in at the October. I grew up in Vermont and I trained in Vermont and my goal has been to stay in Vermont. I'm very invested in the health care and the health care landscape of Vermont. As Doctor. McCoy has said, the pediatric unit is sort of a critical piece to the healthcare landscape in the state of Vermont. The ability for the hospital to close it without regulation, think, is sort of a terrifying use case for what hospitals across the state may sort of have to come to the next few years as we think about hard decisions in healthcare. We know healthcare in Vermont is not affordable, I and think it is going to take some creative solutions to reduce the expenditure for the state as a whole. I think no one in the state would like our health care to be worse, but it may have to be different. And we think, we really appreciate the AHS's work to sort of thoughtfully reconsider all of these sort of options and where health care dollars are most effective. The hospital and all hospitals in the state really sort of have to look at their budget to see where they are financially feasible. But I do not think that always takes into account the cost to the state as a whole. One of the strong arguments we've made when they'd announced this closure is that we are, by losing the ability to admit children locally, we are increasing burdens to the family. As Doctor. McLeod mentioned, it is not equitable to have to drive two or three hours to receive inpatient pediatric care for your children. And the burden to the system in general is longer wait times in the ED, something we all work hard to avoid. The increased use of transportation services for ambulance, specialized ambulance, often for sick children who may have high respiratory support needs, things we could manage in the hospital now, but that are challenging to transport just because of the risk that children could get so much sicker. And a transport is not a benign process, both for the patients, for the families, and for the cost. And then we all know that tertiary health care centers do have higher costs as much less expensive to the state to the state health insurance system to receive care at a small community hospital. Doctor. McFaun had mentioned that losing staff is not something that is easily replaced. And I think when these service line reductions are announced,

[Speaker 0]: is,

[Dr. Merri Fox]: is a lot of self creates a pressure, as we had sort of talked about, to find another job, to attain financial security. And I think these are skills that have built and culture that have been built over decades that will not be easily got back. So it's not something that you can do as a test case for any service line reduction to say, what will happen if we reduce this? What will the cost be? Will the reduction in cost be? Because it's not something you can say, we've changed our mind and we're going to go back because that will be a much more challenging process to renew something than it is something to continue. I'm very concerned about how the hospital has handled this. I think there is a lot of desire for hospitals to be able to self regulate. We would like everyone to have the best intentions. I think our very specific experience has shown that that has not necessarily been the case that hospitals, Rutland Regional Medical Center has not been able to sort of collaborate both with the public based on the public commentary and the pediatricians who are most deeply involved in this work to make a decision that's best for the community and not necessarily a decision that's best for their bottom line. So I think, you know, House Bill 189 is very important because it does sort of that process to have oversight. I think, and someone who has the bigger picture in mind to say what's best for the state, what's best for this town is is critical to maintaining sort of that future of health care in a way that we can make it cost effective.

[Speaker 0]: Any questions? Can you I don't want to get your last name incorrect. It It's Mary Fox. Mary Fox.

[Dr. Merri Fox]: M E R R I F O X. Yes. Yes. Like a happy woodland creature. I'm just saying,

[Speaker 0]: if I was a pediatrician for my kids, I'm like, I'm going go out. Wendy, do you have

[Wendy Critchlow (Member)]: a question? I do have a question. In this process right here, how would you picture this? So first you have the public announcement. And you said that when when Robin did that, got a lot of feedback. That Yeah, so I

[Dr. Merri Fox]: think it was very powerful, actually. And I think maybe the letters are still publicly available. When they announced their closure to the Green Mountain Care Board, it created like a public comment period. And we had over 300 community letters from families, from people who'd worked on the unit, to patients who'd been cared for there, to just concerned community members who were very eloquent in stating the impact this would have on their lives or the importance of the unit that they had experienced throughout their lives and the concerns for the future if

[Speaker 0]: it were to close. So it

[Dr. Merri Fox]: was quite a powerful public response.

[Karen Lueders (Member)]: And I would assume that it would be. My

[Wendy Critchlow (Member)]: what concerns me is that you're not gonna get people that are like, oh, yes. This is a great idea. Close. You know? So I'm wondering what this first step is actually gonna achieve. Like what do you mean first step?

[Dr. Merri Fox]: Public notice. The public notice period?

[Wendy Critchlow (Member)]: Yeah. What do you want it to achieve?

[Dr. Merri Fox]: I think there are I think you can gauge how much a community cares about a specific issue by how profound the response is.

[Speaker 0]: And

[Dr. Merri Fox]: so I think, you know, there may be service lines that people that will impact a small number of people, and then there are going to be service lines that impact a large number of people. So I think the public comment period is a nice way to sort of gauge how profoundly the communities will be impacted. Because my assumption is with pediatrics, you're not going

[Wendy Critchlow (Member)]: to know you need it until you need it.

[Dr. Merri Fox]: That's the hope. Yeah. We hope most kids will never need us.

[Wendy Critchlow (Member)]: Whereas dialysis, if you're going three days a week, you know, and they decide to close that, you're like, that that impacts my life on a daily basis. I just wonder how effective this portion of this bill is going to be. That's all I have to say. Can I expand on that a

[Leslie Goldman (Member)]: little Yes, please? Because the one thing

[Speaker 0]: that I've taken away from this bill is we've set this process in motion, but aren't we missing a step in the beginning? I mean, you both have talked about how you were willing, that there was no collaboration, that there was no work to possibly come up with additional things. And that's actually missing from this bill.

[Dr. Merri Fox]: I think sort of we're all dancing around this, like that's probably the most powerful piece is that we are for mantras, we're hearty, we're creative, we are duct tape and bag balm. So like, we can often come up with solutions that are really creative. And so I think I don't know how you regulate getting all stakeholders involved. Do think to some extent the public is a stakeholder, but I think the people who are actually working on the units or who are working on the service line, I think they may have the most creative ideas to prevent service line reductions or eliminations and making it more profitable.

[Speaker 0]: Yeah. I don't think that we could possibly legislate collaboration.

[Leslie Goldman (Member)]: But I

[Speaker 0]: think we could create a space for it.

[Dr. Anna McCloy]: I just wanted to add that also think that piece of it is so important because nobody cares about our patients more than us, except their parents, more than us. We know them. We interface with them. Many of them, especially kids with chronic illness, every week of our existence. Multiple times a week, on our days off, overnights, in snowstorms, whenever. We're invested with these families. So nobody is going to want to problem solve this harder than the pediatricians. But we were never given a chance.

[Speaker 0]: Yes, go ahead. Thank you. So

[Daisy Berbeco (Ranking Member)]: I'm a firm believer that the

[Karen Lueders (Member)]: community should have a voice, and of course, you as well. I'm wondering how the financial aspect is learned for everybody involved because, of course, the community is going to not be comfortable with this. And I see your side. There's a lot to learn. We have a lot to learn. And I just feel that very, all those little intricate pieces that the hospital is aware of, but their financial hardships and what we're trying to accomplish within the state. That also needs to be learned on every level. I think the financial piece

[Dr. Merri Fox]: is very complicated. I think even people who are in it day to day may struggle with all the nuances of it. I do think thinking of this as from a regulatory standpoint and where we can mandate government oversight, which I know that's like a scary word for some people. I think the Green Mountain Care Board meeting that we had in December was actually really powerful because there were some very thoughtful, smart people on that meeting thinking about the financial pieces of this and sort of pointing out the points where, you know, the expenditure data may not have been completely correct and where the intake, like the reimbursement data may not have been correct. And then all, even in that moment where we were talking about the potential foreclosure, there was brainstorming happening about how to make it more financially feasible. So I do think just even in that one regulatory piece that we saw, it was incredibly powerful for thinking about how cost effective we can make our service lines. So I do think there's a real role for that in some regulatory oversight.

[Francis McFaun (Vice Chair)]: Do you regularly come up with suggestions on how you can make services, more cost efficient?

[Speaker 0]: Do do I? Well,

[Francis McFaun (Vice Chair)]: the staffs. So you said that in the collaboration period that they could come up with ideas. Should you be doing that on a daily basis or weekly basis?

[Dr. Merri Fox]: Actually, I think we've really tried to do that over the past few months. We've repeatedly asked for meetings with hospital administration to sort of come up with a model to make it more cost effective. And we actually have not been allowed to have a meeting with hospital administration since October.

[Francis McFaun (Vice Chair)]: But not not prior to when you were operating. There was

[Speaker 0]: no no

[Francis McFaun (Vice Chair)]: notice that they were gonna close pediatrics.

[Dr. Merri Fox]: Correct. And we do we do have we do have monthly pediatric section meetings where we talk about budget to some extent and unit use. To my knowledge, I've never had administrator to be at those meetings.

[Speaker 0]: I

[Francis McFaun (Vice Chair)]: think it changes, hospital to hospital about the communication between the administration and the staff.

[Dr. Merri Fox]: I would say actually the communication at Rutland Regional Medical Center has been unprecedented in my experience, how bad it has been over the past several months.

[Francis McFaun (Vice Chair)]: It seemed that those doctor that testified the other day from Randolph. Yes, thank you. They seem to collaborate more with their staff. And I don't know if that's common amongst hospitals, but that certainly would be helpful.

[Dr. Merri Fox]: My past experience with other hospitals, it's been more common.

[Speaker 0]: So that's a really ignorant question.

[Dr. Merri Fox]: Yes. There's no ignorant question.

[Speaker 0]: Well, no, you talked about like some of the solutions that you've come up with or proposed. Mean, pediatrics. Why do we have to have I mean, I understand that there's got to be some sort of specialized beds, but would pediatrics or maternal and couplet. Does that require specialized?

[Dr. Anna McCloy]: It does. Services? Services. It requires specialized skill sets. I'll use that word. Because in pediatrics, there's such rapid growth of the person and change in physiology during that time that every age group has their own normal vital ranges and every medication is based on their weight versus like a set dose. So in terms of managing a respiratory illness dehydration or situation or something, then those nurses are highly trained and attuned to those specific parameters, whether it's vitals or doses or weights or whatever. I think they also have special skills around managing different ages and developmental needs. And so I do think that those are our specialty skill sets. And for postpartum care, I'm not an obstetrician, but the postpartum period is a very vulnerable period. And so having nurses that can recognize early when something is going awry is very important. But our postpartum care nurses also do newborns, so they can take care

[Dr. Merri Fox]: of them as a couple. Yeah, I would strongly agree with that. We work really hard to keep a space that is calm and quiet and minimize trauma to children in the rooms where they're staying because being in a hospital is a really scary experience for anyone, but especially if you're two years old and you don't understand what's happening. And so keeping them calm and helping them feel safe does help them recover faster. So having them in a unit where we can sort of monitor that environment and then also minimize the risk of harm based on what is in the room, what equipment we keep. I don't know if anyone's ever taken care of a toddler. They can get into things very quickly. So we have very safe spaces, and it's much easier to bring an adult into a child safe space and specific space than it is to bring a child into an adult space that may not be set up for them.

[Speaker 0]: Great. Thank you. Thank you. You're both Right. Or your chest will be easy. Great. Chill.

[Jill Olson (AHS Medicaid and Health Systems Director)]: Morning. I'm Jill Olson. I am the Medicaid and Health Systems Director for the Agency of Human Services. You've heard from us before on this bill, and I think my understanding is you sort of want to, now that you've heard from everybody,

[Karen Lueders (Member)]: you kind of want to

[Jill Olson (AHS Medicaid and Health Systems Director)]: do another lap of understanding where everyone's coming from now that you've more grounded in the issues. So that's how I understand what you're hoping to get from me today. So I'm not going to say anything substantially different from what I said the last time I testified. But I do want to start here, which is that this is a lot to grapple with. We are making hard decisions in Vermont because we have competing priorities. It is always in health care hard to adjust lower costs, increase access, maintain quality. Those three things, we want all of those things, but they do not always work together. Sometimes they move in different directions. And that is why we have challenges like the case you were just hearing about when hospitals are faced with decisions about their budgets. It's really hard because we also want premiums to be lower. We want health care costs to be lower. So we want things to be less expensive, but we don't want any less of it any place. That is why this stuff is so hard because we all hold all of those things in our head at the same time, all of those desires. And so I think where we're trying to get to, where the agency is trying to get to is a place where we have the adequate process that we need. Because I do think everybody felt pretty surprised by, particularly by what happened in the Rutland circumstance. We were surprised, too. So we do want to have some process. And I think there's pretty broad agreement on that. But I just want to be really clear. We had some changes to, but generally supported the bill as it came out of the Senate because it actually does not create an up down regulatory process. We do not think that we should have an up down regulatory process. So I just want to say that really clearly. Up down? I mean a process where we say, yes, you can or no, you can't close that service. We have our role, just to remind everybody you heard from our transformation team, I think it was last week. So we have a really close role with the hospitals. We're providing technical assistance. We're providing analytics. We're going to have more analytic capacity in the coming months. And so we have this consultative, very close role. Actually, I would say we're actually not an independent third party at all in these circumstances because we're spending so much time working closely with hospitals. But just backing up. So in the bill, it does now, I think we've talked about that it may have some sequencing problems that we need to sort out and timing problems, which we would be happy to help try to figure those out. But we generally supported the bill as it came out of the Senate. We would probably suggest focusing on service eliminations, not reductions. We would suggest really making sure that we're talking about things that are happening because the hospitals are making a decision, rather than something like we're seeing circumstances where they just cannot recruit to to a specialty. I don't think we want to have a lot of process around something that is probably not changeable in any way. We do agree that we need a public process. There needs to be not a surprise, and there needs to be some work, especially to make sure we all understand if there are disputes about what are the facts on the ground, that there's an opportunity to get that straight. Chair Black, I think you talked a little bit earlier about, is there also opportunity and there isn't now for confidential work, but before something is announced? Because it does have these ripple effects when there's something really significant being considered. AHS totally caught off guard by the Russians. We were. Didn't find out the same day. We all found out at the same time. Yes, we all found out at the same time.

[Speaker 0]: We did

[Jill Olson (AHS Medicaid and Health Systems Director)]: not have a pretty warning. Yeah. Yeah. And I think everybody I think the hospital agrees with that, too. I think we've all I mean, what is helpful is you pass language last year. We quickly had a test case, and we all figured out that it actually, the law that was passed is not really functioning as we So had here we are again. That's the way this, we all know, that's the way things work sometimes.

[Leslie Goldman (Member)]: For the record, what was that law?

[Jill Olson (AHS Medicaid and Health Systems Director)]: It was Act 68.

[Speaker 0]: It's the service line reductions at Yeah, Green

[Jill Olson (AHS Medicaid and Health Systems Director)]: you passed legislation last year that created a process where the Green Mountain Care Board had the final approval and we have authority This is what's on the books now, right? The Green Mountain Care Board has final approval authority. And we, AHS, if something is part of a transformation plan, it's essentially exempted from the process. So this was not in a transformation plan. It isn't currently in a transformation plan either. So I think the other thing that we sometimes, as I've listened to the discussion on this, we're not always bearing in mind is that there are various regulatory, I would say, carrots and sticks in place in other parts of legislation. So I think a fair question that hospitals are asking us about certain services is whether there's room for Medicaid increases. I think that's a really fair question. That's a budget conversation. It's not really a It belongs in the environment, but I think it belongs in a different part of the conversation. So that's a really fair question they're asking that I think we all need to grapple with because a Medicaid increase is something that costs money. So it's a budget decision. If we do an increase for one thing, what are we going to spend less money? That's kind of where we are in a tight budget environment. So some of these other levers already exist. They just don't exist. So what I think we want to do is use the levers we have rather than create a special sort of focused up down type of process. The Green Manager Board obviously has tremendous amount of authority as well in terms of nudging hospitals in one direction or another, or shopping. They have quite a bit of authority. As we just looking to see if I had any other introductory comments I wanted to make. Daisy's got to clarify. Oh, I'm sorry. Yes?

[Daisy Berbeco (Ranking Member)]: Are you working with Rutland as part of the hospital transformation?

[Jill Olson (AHS Medicaid and Health Systems Director)]: Yes, there is. Yes, the transformation team is working with all the hospitals to create transformation plans.

[Daisy Berbeco (Ranking Member)]: And you were doing that during or previous It was all just that they closed the pediatrics,

[Jill Olson (AHS Medicaid and Health Systems Director)]: not notification to you. Well, to be fair, the transformation process, so Katie Carroll, who you've heard from last week, has only been in her role about seven months. She's been there just a little bit longer than me. And so I think there's been a lot there. Process has significantly developed really since September. And so I would say there wasn't that developed a process at the time that this all happened to be fair about sort of where we were at. So when we looked at the bill the last time,

[Speaker 0]: and this is literally the piece of

[Jill Olson (AHS Medicaid and Health Systems Director)]: paper I used the last time, so I'm looking at it again. And I do have some written words on the page if it's helpful to share them or to do some work outside this room on language. But we would suggest focusing the bill on So again, working from the Senate version, focusing on eliminations and making it really clear that I'm not sure if the intentionally eliminate, will be sort of clear in the future about how to interpret that. We might wanna consider something more like board resolution to close a service, something that's explicit that an organization has made a decision to change a service.

[Leslie Goldman (Member)]: Could you say that again? Sorry.

[Jill Olson (AHS Medicaid and Health Systems Director)]: So we want to make absolutely sure that we're not creating a lot of process around things that we can't change. Like if the hospital is unable to recruit a specialist, that service is going to have to go away if they're not able to recruit the right specialist. I don't think we want to create process around something that can't be adjusted. And so we really wanna focus it. It says intentionally, I'm just not sure that we're gonna understand what having been around a while. I have sometimes gone back two years later and said, what on earth did we mean when we said that? We knew what we meant at the time in the room, but do we know what it means two years later? And so we would suggest probably language that would focus on, like a board resolution to close the service, something that where the board has made an explicit decision. So we could make a suggestion about that.

[Daisy Berbeco (Ranking Member)]: Daisy? Would that prevent the situation that happened this time from happening again, where AHS was working closely with the hospital and they made a decision to close a unit without even notifying you.

[Jill Olson (AHS Medicaid and Health Systems Director)]: I think what would change that is the notification language that's in the bill. We strongly support adding the notification process so that there could not be yeah, absolutely. Because you said you didn't support a regulatory process. That's right. I don't support an up down regulatory where we give approval or denial, but I do absolutely support notification so that there is not a surprise in the way that there was and so that we have the opportunity to consider what they're doing, why and whether or not there's anything, if we want to change it, could be done to change it. Notification to HHS. HHS and the Green Bank Board. Yeah. And a public process. A public process. Of that. We totally support all of that. That's why I say we're supportive of the structure generally. I'm sorry if that was confusing.

[Speaker 0]: I'm just thinking about the Rutland situation. If there had been a process in front of all of this in which AHS was notified and could ask the questions like, have you worked with the providers? Have you, you know, what's going on with the affected people? And have you thought of alternatives? And to be able to ask all those sort of questions around the care and then a process where the Green Mountain Care Board could have done their, hey, you want to show us the numbers? Because what they did was they did that in a very public process and hadn't been given the numbers ahead of time.

[Jill Olson (AHS Medicaid and Health Systems Director)]: Yes, I think we were all a little thrown because there was a lot of work to do to make sense of the situation, and we didn't have time. And so, yes, again, I think this is something that hospitals are supporting also, the notification, some time. And then as I think you're starting to get at, is there even room for a process that could be confidential before it becomes a public conversation? I'm wondering, Leslie, I

[Speaker 0]: see you. Hold on one sec. I'm wondering if there is that time and stakeholders or the interested parties, I will call Green Mountain Care Board and AHS and the actual hospital people in the hospital, if there is a process in which everybody is having time to make thoughtful, clear, rational decisions, would that then provide

[Jill Olson (AHS Medicaid and Health Systems Director)]: a space where AHS could come in and rather than make a recommendation, give a up down? We do not support a situation where AHS becomes a regulator with an down. We do not support that. We do think that ultimately the hospitals need to make the final decisions. That's what this bill does as you have it. That's what we're supporting. I also will say again, we are so close to this with the transformation process that we're essentially regulating conversations that we've sort of had all along. So we're not very distant from it, and we don't have an apparatus in place. That is not the important part. I think the important part is that, no, we do not think ultimately we should have an up down. We do think we all should be considering the regulatory and budgetary levers that we have. Medicaid rates, other kinds of regulators, the Green Man Care Board regulation of hospitals. I do think that makes sense, and that's what we would use and consider. But I do not think we should be able to just say no, yes, or no. Do not think we want a situation where we're doing sort of a reverse CON, which is essentially what this is trying to be.

[Wendy Critchlow (Member)]: We do not support that. Leslie? Thank you. Yeah, I

[Leslie Goldman (Member)]: hear what you're saying about that. I know that we're focusing on Rutland, but last year, year before, lost talk of time, there was those psych bins. There's going to be more of these. Yeah, and then there was also losing primary care.

[Speaker 0]: And Don't forget to say dialysis.

[Leslie Goldman (Member)]: And dialysis. So I think this conversation applies way beyond Rutland, although I

[Jill Olson (AHS Medicaid and Health Systems Director)]: appreciate it. It absolutely does. So

[Leslie Goldman (Member)]: that's what I'm wondering about, having a process that is looking at the whole the state plan. You're in charge of that plan. Yes. So how does losing service lines or whatever get implicated in your use of the state plan? Because I think, well, if I'm understanding it right, you're the one creating it. And I would think that perhaps you would be the one to want to apply this kind of change to it. Or how does it fit together?

[Jill Olson (AHS Medicaid and Health Systems Director)]: Yep. So I think I've said this here before. I envision a strategic plan is a dynamic process because the environment keeps changing. So I don't think it's gonna sort of be like this static, do this, don't do that roadmap. So I think the transformation process is actually more what is building into the strategic plan. What services do we wanna have where? What should be regionalized? What needs to be local? What should be statewide? That's the sort of big conversation we're having. So we're absolutely doing that. And then yes, there are certain services that I think we need to pay special attention to. I actually haven't sort of gone through my, what would I do to this bill if I were to change it? I would keep it focused on some of these key services that are likely to be on the table for hospitals as their revenues are reduced, as their budgets are shrunk. So that's gonna be things that are important to us. But the challenge is many of the things that are important to us are also things that are not especially, that don't pay well for hospitals, mental health, inpatient mental health, the OB services, the dialysis. Some of these are things that are challenging for hospitals, primary care to provide. So I guess where I'm a little struck, if I could,

[Leslie Goldman (Member)]: is you don't want it up down, but you want to implement the strategic plan. And it seems to me that there's a conflict there. Well, because if someone's doing something that you don't think is consistent with your strategic plan, then you're taking away your voice in it.

[Jill Olson (AHS Medicaid and Health Systems Director)]: So again, I don't think we should have a specific process about up or down on hospital service lines. But I do think that both AHS and the Green Mountain Care Board have a fair amount of authority to either make a service more possible to provide or to move a hospital in a direction or another. But I know I do not support having a special service line reduction process. We don't support that. So let me go through this again. Karen's got a question. Sorry.

[Karen Lueders (Member)]: A couple of areas. One is when you talk about confining the bill just to elimination. I mean, there's more than one way to, as we've just

[Leslie Goldman (Member)]: sort of

[Karen Lueders (Member)]: described, to have a really important service compromised or undermined. Since you are doing the transformational work, it seems important in the interim until you come up with this dynamic, to really be able to weigh in and understand. It seems like having the set of eyes through the Green Mountain Care Board process was so important in this situation. So in the meantime, what if de facto service area is being so compromised that it disappears and the very highly qualified people that have been part of the culture for thirty years are no longer there.

[Jill Olson (AHS Medicaid and Health Systems Director)]: I think that's a fair question that we could further consider. One of the other suggestions we have for the bill is to limit, if you're going to have a process, to limit it to certain services, to some of the ones I've named, that we sort of know are at risk and likely to be considered. Because I also expect that our transformation team is going to pay special attention to those services as well. We know which things are at risk and which kinds of things. And so we really want to be thoughtful about where are things at risk and where do we think that it's not a good idea for them to close in places where they're at risk. What's not going to be possible, no matter what we do, is to not have pain as we shrink the system. That is not going to be possible. And I just think we all have to really get on board with that, because there is no way to make cuts, to reduce premiums, to do all this work, and also not have a system that is the same as the system we have today. And

[Karen Lueders (Member)]: I think the testimony we heard today acknowledges that.

[Jill Olson (AHS Medicaid and Health Systems Director)]: I think so too.

[Karen Lueders (Member)]: Yeah. But being a part of the meaningful conversation at the right time also seems like something we want to somehow encourage.

[Dr. Anna McCloy]: Agreed.

[Karen Lueders (Member)]: I'm looking at this board composition. It's heavily financial. Are some

[Leslie Goldman (Member)]: The Rutland Board. The Rutland Board.

[Jill Olson (AHS Medicaid and Health Systems Director)]: Oh, oh, oh, I understand.

[Speaker 0]: I don't where we're talking. I don't know

[Jill Olson (AHS Medicaid and Health Systems Director)]: if it's a paper in front of me.

[Karen Lueders (Member)]: And so there are some medical folks on that board, but anyways, how do we engender, encourage, because it seems like if we have this process, it's good, Human Services looking at it if we might care about something like it's more out in the open. But how do we encourage, if you can, that really important? People on the ground understand so much. Daisy,

[Speaker 0]: let's let Jill get through the You wanted to

[Jill Olson (AHS Medicaid and Health Systems Director)]: I just wanted to go through a few things.

[Speaker 0]: Let Daisy ask, then that, and then Leslie.

[Daisy Berbeco (Ranking Member)]: I think what I'm hearing is that and what I know from previous legislation and what we're trying to do with rural health transformation AHS has tremendous responsibility right now in an environment that is failing Vermonters. Yet, you're not asking for any authority. And I'm just racking my brain trying to think of how you're going to be successful in meeting those responsibilities with no authority.

[Jill Olson (AHS Medicaid and Health Systems Director)]: I think we have authority. Most important, we have our authority around budgets. That's a really important authority. Our Medicaid budget is a really important piece of authority that we already have. I think that's some of where we need to grapple with some of these questions, is in that space. But we are not asking for regulatory authority just to say no to hospital. I think we just don't agree on that point, whether or not that's a good idea or whether we should use the regulatory structures in place. I think that's the sort of the difference. But where I think we have broad agreement is on having a public process, on having notification process and having the opportunity to understand what's happening and weigh in before it's a done deal. I think we have broad agreement on that. We do not want to be surprised again, and we do want to know what's happening, and we do want an opportunity to weigh in and understand the implications. Absolutely. We want all of those things.

[Speaker 0]: AHS was caught off guard in October, which I'm still grappling with that because hospital transformation officially began, I think, in January with the hiring of a contractor who've been Yeah.

[Jill Olson (AHS Medicaid and Health Systems Director)]: It's developed over time.

[Speaker 0]: Yep. So I'm grappling with how they were caught off guard on something that they've been working on for. But let's hold that for a second. I'm sorry, I lost my train of thought.

[Jill Olson (AHS Medicaid and Health Systems Director)]: Okay, I'm sorry. That's okay. Why don't I go back to just my I'm gonna remind you what we said about the bill the last time

[Speaker 0]: I was here.

[Jill Olson (AHS Medicaid and Health Systems Director)]: So we I just have a question about that.

[Leslie Goldman (Member)]: When you were here previously, did you submit testimony at that time?

[Jill Olson (AHS Medicaid and Health Systems Director)]: I didn't submit specific language, but I have it now, and I'm happy to

[Speaker 0]: do We

[Jill Olson (AHS Medicaid and Health Systems Director)]: can follow-up with the actual language. I was trying to adjust it last night and so I'm in

[Wendy Critchlow (Member)]: a little trouble. Oh, great.

[Speaker 0]: So even though you were caught off guard, did AHS approach Rutland?

[Jill Olson (AHS Medicaid and Health Systems Director)]: Oh yeah, there's been lots of conversations.

[Speaker 0]: Let's talk about our Medicaid reimbursement because number one, these are pediatric beds, which means that the majority of the patients in these beds are going to be on Medicaid. You also have a global budget, I believe, with Rutland. They're So one of your was that a conversation saying, Oh, gee, Rutland, we don't want this to happen. Let's talk about raising how much we're paying you.

[Jill Olson (AHS Medicaid and Health Systems Director)]: No, I don't think we've gotten to that place yet. Do not think we've gotten to that place yet. There has been a tremendous amount of making sense of what is the proposal, whether we think the proposal is a good idea or not, whether we think it should happen or shouldn't happen. So there's been a lot of And really, the transformation team is actually focused on more is a broader conversation about how pediatric services are being delivered in the region. That's been the conversation to date.

[Leslie Goldman (Member)]: And is that a result of the closure?

[Jill Olson (AHS Medicaid and Health Systems Director)]: As a result of the Yeah, we sort of entered the conversation because of that announcement. Because the thing that

[Leslie Goldman (Member)]: I wonder, if I may, I wonder wanted to finish, I'm sorry. It makes me wonder about the transformation process and how it's really integrated into what's really happening at the hospital level. Because you're doing all this work and closing the service line while theoretically over here, you're doing all this transformation work, and it doesn't sound like it's integrated at all.

[Jill Olson (AHS Medicaid and Health Systems Director)]: No, it's really challenging work, and there are competing priorities. That's the challenge. There are competing priorities about budget, access, cost, quality. There is a lot to consider. So the transformation team by itself does not cannot sort of make a budgetary call, but they can make recommendations.

[Leslie Goldman (Member)]: But I was just thinking of that conversation. Like, I'm not hearing that there was conversation with the transformation team and people in Rutland about what was going on in their thinking as they thought about their pediatric service Yeah,

[Jill Olson (AHS Medicaid and Health Systems Director)]: well, I think part of it too is that, again, there is no confidential process, Right? So once it's announced, it becomes a matter of it becomes a public conversation. That's where it starts. And that's where this one started, was it with a public announcement.

[Leslie Goldman (Member)]: No. I get that. But what I'm thinking about is more upstream in mean, I don't know that you need to legislate a confidential process, that there wasn't communication on any level between the transformation team and the relevant.

[Jill Olson (AHS Medicaid and Health Systems Director)]: Is that a I think representative of Black said, we can't it's hard to legislate collaboration. It is hard.

[Leslie Goldman (Member)]: It was just a miss. It was just that no one was included. It's just a little Okay.

[Speaker 0]: Let Jill finish up.

[Jill Olson (AHS Medicaid and Health Systems Director)]: Sorry. I astounded. So I said the last time was we wanted to focus on service elimination rather than reductions. That we wanted to focus on We recommended focusing this on particular service lines that I think we could talk about, ones people are especially worried about happening and need further evaluation. Totally support having a public engagement process run by the hospital and a notice process to Green Mountain Care Board and AHS. I think that's right. We are comfortable saying that the agency will analyze the reductions. I would say against transformation plans, we would make some adjustments here. The strategic plan, once it's developed or when it's not, I would say transformation plans rather than the needs assessment, which is what it says now in B on page two. And then we would provide the analysis rather than non binding recommendations. We could make that public and provide that to the Green Man and Care Board. I do think we need to talk about the sequencing and timing. So that's something we haven't made a proposal about that yet. We also, I think, want to look at, there's some language where it says consider the community's response and the impact of the proposal on, it says access to necessary care and services in the hospital service area. I actually think we would probably want to say access, cost, quality, the impact on the system. One of the things the transformation team looks at when a hospital is talking about either losing a service, not that they want to keep, or closing a service, is whether or not there's capacity anywhere else. Because sometimes there isn't capacity for another provider to take on that care. And so that actually, I think, is where we play an important role, not just looking at what the hospital is talking about, what happens in that service area, but do those people have anywhere to go outside? Even if they're willing to travel, is there capacity at the other hospitals? And that's more the regionalization conversation. Like what is gonna be a regional service? There has to be regional capacity if there's gonna be a regional service. And then, I think that was our last actual change. Yep, I think those were the sort of primary truths. I'm happy to submit to you, if it's helpful, what those words would actually look like. Oh, and we also had the language about the governing body making an official decision, formal decision. So I realize I'm not entirely satisfying you, and that this And I will say again, it's just incredibly challenging at heart. And it's a lot to balance. I think the

[Speaker 0]: thing I'm struggling with the most is, I mean, you say that you have a regulatory you have regulatory levers. Your regulatory levers the rates that you pay. Medicaid rates. That's your regulatory level.

[Jill Olson (AHS Medicaid and Health Systems Director)]: You have that lever too. That's something we work on together. The budget is something we work on together.

[Speaker 0]: Yes. Although we can't change that in thirty days. Neither can we necessarily. And yet in the case of Rutland, you didn't pull that lever.

[Jill Olson (AHS Medicaid and Health Systems Director)]: You have not pulled that lever. And it's just

[Speaker 0]: I mean, the absence And you don't want an updown. The absence of not making the decision and the decision to not use your regulatory lever, I mean, that is a decision in itself. If if by not making the decision, that is you have made your decision.

[Jill Olson (AHS Medicaid and Health Systems Director)]: Yeah.

[Speaker 0]: There's a rush song that has a lyric in it about Do

[Jill Olson (AHS Medicaid and Health Systems Director)]: you like Rush?

[Speaker 0]: No. Listen. It's just basically the do not I don't like Rush. Not make a decision is actually a decision. Do not use your regulatory tool. You have basically done that.

[Jill Olson (AHS Medicaid and Health Systems Director)]: Yes. So I'm gonna say again, it's that I don't think we wanna build a specific process that is outside of the tools that already exist, the budget tools that already exist and the authority that the Green Mountain Care Board already has. I do think the hospitals should continue to have their they should be able to make proposals, and then we should be grappling with them with the tools that exist. I'm saying I don't think we wanna create this new tool in the toolbox, which is why we support the Senate version. It does not do that. It creates the notice process. It creates a public process. We wanna have process. We wanna understand what's happening, and we wanna have time. Those are the things we want so that we can then consider using the tools that are in the toolbox. What I'm saying is I don't wanna create this, a very specific new tool, as you did last year, actually. Want you to change that.

[Wendy Critchlow (Member)]: I worry about this because I think the services we're talking about are the real well hanging fruit here. What will be eliminated is the non money making services. And if you are going to say, Okay, well, if you're going to eliminate that, then why don't we give you more Medicaid money? I just see this as turning into something that's going to be a monster.

[Jill Olson (AHS Medicaid and Health Systems Director)]: Yes. And we might not do that. We might decide that is not where we're going to devote our resources, because they are a finite resource. We are going to have to decide where we're Where

[Leslie Goldman (Member)]: they too are being.

[Jill Olson (AHS Medicaid and Health Systems Director)]: Oh, I see what you mean. Well

[Wendy Critchlow (Member)]: I don't see a strategy at all. I'm sorry.

[Jill Olson (AHS Medicaid and Health Systems Director)]: It's okay. Our position is to essentially work from the Senate bill and to use the authority we have. Or not, as you say, or not use it. You know what, I don't have a lot things to happen.

[Speaker 0]: All right. Thank you, Jennifer.

[Jill Olson (AHS Medicaid and Health Systems Director)]: Thank you very much.

[Leslie Goldman (Member)]: So you're going to sort of summarize some of

[Jill Olson (AHS Medicaid and Health Systems Director)]: Yeah, I'm going to just give you the version Okay, the I'll

[Speaker 0]: give you a version of the language. I'd like to take a fifteen minute break. Let's be back here at it's 10:15 now. Let's be back here at 10:30. And we have Jessica and then