Vermont Legislature SmartTranscripts:

[Brian Cina (Member)]: If you want, I can get you hot water.

[Alyssa Black (Chair)]: There's a whole service committee here. Welcome back, everybody. So Jessica Holmes from the Fremont and Care Board joining us. What's your perspective on 01/1989 again? I know we've had I don't think you were here the

[Allen "Penny" Demar (Member)]: first time.

[Devin Green (Vermont Association of Hospitals and Health Systems)]: I wasn't in here the

[Jessica Holmes (Green Mountain Care Board Member)]: first time. So this is my first time here. I was over on the House I mean, the Senate side. So yes, well, thank you. So for the record, my name is Jessica Holmes, and I'm one of the Green Mountain Care Board members. And thank you for the invitation to testify this morning on S-one Hundred 89. I actually thought maybe what would be most helpful is for me to respond to what I think is your decision tree. So I think the very big first question that you're all facing is, does there need to be a state decision maker, an up down entity that serves as the final arbiter of proposed service line changes? So my answer, and I hope it's yours, is yes. State oversight over hospital service line reductions and eliminations, and I say reductions and eliminations, I'll get to that in a second, is critical. If we want to actually ensure access to care is preserved in the state, There needs to be an entity giving the up or down vote on service line changes, a decision maker who is evaluating the impact of the proposed change on access, cost and quality across the entire system. Unfortunately, I think if hospitals are left to decide on their own, even if there's a non binding recommendation out there, if ultimately the decision is theirs, their decisions will be based on the impact to their hospital, to their bottom line, not to the system as a whole. Given the fragility of the health care company, and I think you all know about the financial headwinds facing our hospitals, we are going to expect more service line closures. They are coming. I think without state oversight, what we're going to end up with potentially is care deserts emerging for your family, your friends and your neighbors. I think we could see more closures of birthing centers. Think about how that's going to play out. How will the closing of more birthing centers impact the cost of care? How is it going to impact infant and maternal mortality rates in the state? How is it going to impact our ability as a state to attract young families to the state if we have more and more closures of birthing centers? So a state entity needs to take that holistic system wide view and intervene when necessary. We support a public process. I think a community open meeting or a hearing is important, and we support that. I just don't think it's enough to ensure adequate access. It's necessary, but it's not sufficient. I think you can look back. The Copley community had plenty of opportunity to comment. They closed birthing. It might have been the right decision. We don't know because there was never that system wide analysis. So closure may have saved Copley money, but it may have actually increased the quality of the system. First, now delivered at UVM that were delivered at cheaper Copley before. This shows up in higher premiums and higher property taxes. You've heard about Rutland's pediatric unit. So closing Rutland's pediatric unit may actually have saved Rutland money, but it likely would have added costs to the system to the extent that those acute pediatric patients would have been transferred to UVM. The hospital's plan did not actually include an assessment of the local EMS capacity to make those transfers in a timely way. It did not include data to show that UVM could readily accept almost all or all of those pediatric patients. It didn't include an assessment of the additional cost to the patient or to the system of that ambulance transfer to Burlington or being cared for at UVM instead of Rutland. So as a board member, I can tell you that if I had been forced to vote that day, I would have voted no to that closure. And closure might have been the right decision. I don't know, because some of the financial analysis that was presented was problematic. It raised questions. Some of the volume data that was presented raised questions for me. There was no data actually that suggested that quality was actually compromised. There was anecdotes, no data. And most importantly, there was no system wide analysis on the cost, the access or the quality implications of that decision. We actually asked for an assessment from AHS, but we didn't get one. Without that analysis, I could not, in good conscience, approve the closure of a pediatric inpatient unit, one of only a few in the state, without a full understanding of the consequences to the patients and to the system. Frankly, I would have said no, but come back when there's a thorough analysis, when we know what the systematic impact is. In academic terms, this is like a revise and resubmit. The pediatric closure would have been a hard decision. It would be a hard decision. Most service line decisions are going to be hard decisions. I think Jill testified to this. This is really hard work. Making these decisions is hard for the hospitals. The hospitals don't want to close the service that's provided to their community. For any entity that is actually charged with this decision making authority, it's going to be hard. The Green Mountain Care Board, I want to say this, as somebody who's sat on the Green Mountain Care Board for twelve years, We do not shy away from hard decisions or even unpopular decisions sometimes. We make them all the time. But to make them, we actually need the right information. And in this case, in these service line cases, we do not have the right information, nor do we have the resources to get it. That's the reality. That was the situation we faced in that moment, in that hearing. We didn't have full information of the system wide impact. So who does? Well, to make these decisions, a state review of service line changes is about ensuring that one hospital's financial decisions do not negatively impact the access, cost and quality everywhere else in the system. AHS, this is not going to be a popular opinion here with Jill, but AHS is actually uniquely qualified to make that system wide assessment. In fact, the legislature has already entrusted this work to AHS. If you go back and look at Acts 51 and Acts 68, you charged AHS to lead the development of a statewide health care delivery system strategic plan, it's static or dynamic. They've been charged to develop that plan. They've been charged to coordinate transformation planning across providers and regions to assess the impact of individual hospital transformation decisions on costs, premiums, access and health outcomes, and to track whether those decisions collectively move Vermont toward lower costs, improve quality, reduce inequities and increase access to services. AHS is supposed to be driving this transformation, actually not reacting to hospital suggested transformation. So I would ask the committee to consider this. If you knew you were the final decision maker on service line changes, wouldn't you have a really strong incentive to ensure that the analysis underlying that decision was thorough and credible? Positioning AHS as the final authority on service line changes better ensures that the hospital transformation work and the statewide strategic plan are developed with the highest level of rigor and accountability. The legislature has already provided AHS with the resources to do this work. Think there's I get asked, I think there's about $4,000,000 in state funding for transformation alone this year. This federal Rural Health Transformation Program, $1,000,000,000 is coming to AHS over five years to lead transformation. There's millions of dollars allocated to this. I think there's at least I saw $1,150,000 or so allocated to hiring a vendor to gather and study data that will inform hospital and regional transformation planning, to provide modeling. This is exact words from the Rural Health Transformation Application. To provide modeling to assess the impacts of proposed reforms on cost, quality, access and sustainability across Vermont's hospitals. That's exactly the modeling that's needed to make these decisions about whether a proposed service line change at one hospital harms access, cost, sustainability or quality in the system. We don't have the analytic capacity to do that. We don't have millions of dollars to hire a contractor. AHS has also planned to allocate a couple of million dollars to building this strategic plan that will, and I quote, provide a roadmap for health care delivery system reform and ensure a coordinated, data driven approach to organizing and sustaining Vermont's health care delivery system statewide. AHS is building the roadmap. They're building the plan, whether it's static or dynamic. We've already tasked them with designing the strategic plan to optimize where hospital services and other services should be provided. And now they have millions of federal dollars to do it. They're also in the plan, in the Rural Health Transformation Plan, they're allocating $150,000,027,000,000 dollars to support grants, to help health care providers in adopting tactical regional care strategies that will shift appropriate services from hospitals to non hospital settings and create regional hospital services or centers of excellence. So they're going to be giving grants out to move care around. To responsibly award those grants, AHS is going to have to do the analysis to decide where those centers of excellence should be. That's what you're providing the grants for, to move the care and help those hospitals move that care. So it seems to me that they have the resources and they have the responsibility to be deciding where services are, what transformation efforts are worth funding and where those centers of excellence should be. That's exactly what the original introduced S-one 189 does. It asks AHS to make a decision about a proposed hospital service line closure or reduction. I want to add one more thing about, I think, why AHS is really important to be the up down decision maker here. They're a payer. That's come up. And that matters because many of the essential low margin services were seen on the chopping block: dialysis, birthing, primary care, pediatrics, mental health. These are the ones that we've seen on the chopping block so far. They all depend really heavily on Medicaid for financing. So if AHS does the analysis and determines that preserving access to certain services is necessary, Doing so may require a targeted increase in Medicaid reimbursement, a stabilization grant, an enhanced payment in the Medicaid global budget. Something programmatic is a programmatic response. They're uniquely positioned to take those actions. So as originally introduced in the Senate, S-one 189 aligns actually decision making authority with existing statutory responsibility and the resources to make those decisions. AHS is responsible for hospital and system wide transformation, the statewide delivery system strategy, Medicaid, and they actually have oversight over large portions of the care continuum, long term care and mental health. So AHS can and should decide if a service line change is optimal for the system. Green Mountain Care Board has a role. We regulate hospital budgets. We can and we should perform the regulatory function of adjusting a hospital's budget once a proposed service line change is reviewed and approved by AHS. I want to add another reason why AHS should have the thumbs up or down rather than the Green Mountain Care Board. It would be an incredible waste of taxpayer dollars to have the Green Mountain Care Board duplicate the expenses associated with trying to figure out whether or not this is a good decision or not. If we're the decision makers, we're going to want to do our own analysis. We're going to have our own questions to be asked and answered. So it would be silly and a waste of resources to actually duplicate this process for both AHS and the Green Mountain Care Board. AHS is already doing it. It would also be pretty counterproductive for the Green Mountain Care Board to come in and second guess AHS's strategic planning and transformation decisions. So what happens? Let's think of a scenario. Hospitals, AHS, and other health care providers are working. They're expending huge resources on a vision for our delivery system. And they're working hard to develop a regional transformation plan, only to have the Green Mountain Care Board come in at the eleventh hour and chart a different path through a separate process. It doesn't really make sense, and it's a waste of resources. AHS is leading transformation. They always have been. They've been statutorily assigned that task, so deciding where service lines are is a critical part of that responsibility. I know that there's been some other lingering concerns about elimination reduction. Should it be elimination and reduction of services or just elimination? I actually think that AHS needs to review both. If it's only elimination, a hospital can slowly reduce until the service is effectively gone. Would call that death by a million cuts or thousand cuts, right? You can go from six inpatient beds to four, to two, to one. And then the notification happens when you go from one to zero. It's effectively gone by the time that that notification is made. I did hear the suggestion that a board resolution should be the determining factor. What if the closure is not brought before the board, and it doesn't qualify? By the board, I mean the hospital board. So having a hospital board resolution to dictate whether or not a notification has to be made, there may be services that are cut without board approval. So I would worry about that. I think some of the issues that I heard raised earlier were around timing. As I look at the language in the bill, I do think the timing is a bit unclear. And actually, frankly, I don't think there's enough time to do the work needed. So I saw sixty days. I think hospitals need to notify the relevant parties long before that, ninety, one hundred and twenty days. I'm not sure what the right amount is. If AHS has this test, then I would suggest AHS could opine on that. But I do think that sixty days is a shorter period. That was a really tight period for the type of analysis that needed to be done for us to evaluate it. I also might add language on page one, lines 13 to 17, that puts honestly some of the onus on the hospital to take a first pass at assessing the system wide cost, quality and access implications. So for example, in the Rutland case, it would have been really nice to see them attempt to make an assessment of what is the additional cost going to be to families in our community that are now faced with a transfer to UVM. What would that EMS cost be? What would be the delta on the cost per day for that pediatric stay up at UVM versus Roblin? I think that the public hearing should be scheduled at the time of the notification. But honestly, again, no less than ninety days before a plan is closure. I think there needs to be time for the community to respond.

[Karen Lueders (Member)]: And I

[Jessica Holmes (Green Mountain Care Board Member)]: would also say, if AHS is deemed the final decision maker, I don't think a closure should happen, obviously, then until a full analysis is done. And I'm not sure in the timing and the current bill whether that's I think there's some vagaries there. I also think the bill is vague on what type of analysis should be done by AHS, whether it's for a non binding recommendation or whether it's for an actual binding decision. I think more explicit language needs to be added to the bill on page two, lines 14 to 21. My suggestion would be some language that says, prior to approving any reduction or elimination of a hospital service line, AHS shall conduct a comprehensive analysis demonstrating the following. First thing would be alignment with statewide strategy. The proposed change is consistent, making sure that the proposed change is consistent with health care delivery system strategic plan, the community health needs assessment, and or ongoing hospital and transformation efforts. Second thing is we should understand what the impact is on the total cost of care. So there should be a quantifiable assessment of the impact on the cost of care for the patients at the hospital and the broader hospital system, health care system. Should be an assessment on the impact on access to care. So a quantifiable assessment of changes in access to care, including travel time, service availability, and whether those alternative sites that are proposed actually have the sufficient capacity to receive all the patients that are going to be coming their way. And what's going to happen to the wait times and the access at the hospital that's going to be receiving these patients? I think there should be an assessment on the quality of care, including whether or not the alternative sites of care provide care that's of equal or higher quality. We should be worrying about population outcomes. So there should be an impact on population health, including whether reduced access actually delays care and may adversely affect morbidity and mortality. Probably should be some look at network adequacy to make sure that this is not going to compromise network adequacy standards. Patient transportation and transfer capacity and evaluation of the adequacy of patient transfer and transportation system, including understanding whether EMS has the capacity to actually take on those additional transfers and potentially the disproportionate impact on low income populations that don't have reliable transportation. And then finally, I do think that there should be an assessment of the consideration of alternatives. We heard about alternatives this morning. There should be a demonstration that all reasonable access preserving alternatives have been considered and where feasible, exhausted, including but not limited to Medicaid payment adjustments, stabilization funding, service sharing arrangements and other collaborative or transformational strategies. I understand there may be some questions about what happened watching some testimony about what happens after an AHS decision is made or somebody, a decision maker's decision is made to keep a service line that a hospital wanted to close. I think that was a question raised. Are there ways to improve the financial sustainability of that service line that the hospital wanted to close? And I think there's two approaches here. One that's actually been mentioned a bit. First, AHS can do an analysis of the Medicaid payments. Is the Medicaid reimbursement adequately covering the cost of delivering that care? If not, AHS has, and with help from the legislature through budgets, has the power, has the lever to adjust payment. If they deem this as a service that needs to stay in that community, that should be the first step. Particularly if this is a predominantly Medicaid financed service, look at the reimbursements. Is it covering the cost of care? In the Rutland case, as you've heard, we asked in the hearing to Rutland, did you reach out to AHS to explore the potential for enhanced Medicaid payments? They have not. That should happen before anything else starts. Predominantly, in this case, primary payer. When it comes to the Green Mountain Care Board for hospital budget review, we also have authorities to adjust budgets to report, one, if there's been an increase in Medicaid revenue allocated to preserve that service, we can adjust the budget. That would come over from AHS, but we can then adjust the budget accordingly. If there are still concerns about sustainability, the board can look at commercial This payment will be a little bit easier as we migrate to reference based pricing. For example, we could allow a targeted rate increase on a low margin service if AHS or the decision making body, but I would argue AHS decides this must be a service safe in that community, we can titrate commercial rates. We can target that. That is something that we can do. Global budgets are also another mechanism to help ensure that adequate funding for a prescribed portfolio of services is available. So in other words, there are ways that both AHS and Agreement and Care Board can adjust revenues to make services more financially sustainable. But that should happen after the critical review that this service should be preserved in that community, and that the implications of that service retention or potentially service reduction have been really fully analyzed in a system wide view. And my last point, I think, is just it's a very, very minor one. But in the bill that was written and sent over from the Senate, and I think Emily Brown testified to this, I would eliminate item three on page five. I'm not sure why DFR suddenly is playing a role in monitoring service line decisions after. It just seemed like it came out of nowhere. I'm sure there was a reason for that at the time. But as I'm looking at it now, I don't see the reason for it. So I might strip that line.

[Devin Green (Vermont Association of Hospitals and Health Systems)]: Those are my thoughts.

[Jessica Holmes (Green Mountain Care Board Member)]: Wow. I'm gonna bring them

[Alyssa Black (Chair)]: to Leslie.

[Jessica Holmes (Green Mountain Care Board Member)]: Just bring them you.

[Alyssa Black (Chair)]: Leslie's question, which is can you submit to us?

[Jessica Holmes (Green Mountain Care Board Member)]: I would be happy to submit that.

[Alyssa Black (Chair)]: I really like that. Yeah. Okay. Any questions? I just have one, I think. Okay, I'll ask one more. So I've mentioned it here today, the timeline. It's way too short. It's way too compressed. And there are too many things happening all at once, which frankly does not solve any I keep going back to what is the problem we're trying to solve. So does this solve that problem? No, it wasn't. There's not in place a system before this happens to allow for all of the things that you just talked about that you're going to send us in writing, for those types of things that happened. I think back to the Fremont and Care Boards with public hearing on this Rutland coming in and the questions that all of you were asking that were not able really to be answered. And I just feel like that is the kind of thing that should be happening well before this, as far as the board is concerned, asking those pertinent financial questions. So if we created the space for this prior to any kind of public process, because once something becomes public, we know what happens. If we allow this sort of collaborative space, what role would you see the Green Mountain

[Allen "Penny" Demar (Member)]: View

[Alyssa Black (Chair)]: Award in playing in that? What things should you be considering yourself with or would be willing to provide input on?

[Jessica Holmes (Green Mountain Care Board Member)]: I think that's a great question. And as I

[Devin Green (Vermont Association of Hospitals and Health Systems)]: was listening to you this morning, I

[Jessica Holmes (Green Mountain Care Board Member)]: was thinking it would be nice if there was a space prior to a public hearing or public comment period, where frankly, AHS and the hospitals could work collaboratively in figuring out some of that and also ensuring that the hospitals are working collaboratively with the folks from their orbits that need to be consulted. I think where there could be some to try and start to do that system wide impact. So I think that there is some space in there. They're doing transformation planning. They're leading transformation planning. They have these analytics contractors about to come on board to do much of this system wide analysis. If there was an earlier discussion between the hospitals and AHS, I think where the Green Mountain Care Board could slot in there is our hospital finance team has a lot of experience looking at hospital financials. Some of those questions that emerged at the hearing probably could have been asked and answered if there had been some dialogue, perhaps, between our hospital finance staff in these earlier conversations. There might be a role there for some good questions from our hospital finance team. Any other questions for Jessica?

[Karen Lueders (Member)]: Have a question. I

[Jessica Holmes (Green Mountain Care Board Member)]: understand the public notation, but this affects more than just the people who are responding to this. If you had someone like the Chamber of Commerce come in and just say, How this really affects the people that would move into this area, there was no pediatric there. It involves so many more people that we don't even think of at the time that we're doing this. I don't know how you involve other people who have Well, one of the things I can tell you from sitting on the board for a very long time is we do get letters. If you open up a public comment period and you open up a portal So for example, if this did land in AHS's court, they could have a portal. Once it's decided the time has come, now we're having a public comment period about this process. We're going public with this. We've done some due diligence before. This looks like something we do need to move out into the public sphere and gain some public perspective on. You can have an online portal. And as a Green Mountain Care Board member, I can tell you, I read all the letters. I can tell you my colleagues read all the letters. We would read letters from the Chamber of Commerce. We read hundreds of letters. It shapes your perspective. It's really, really important. It helps you ask better questions. Don't know if you all felt this, but I felt like my questions were much better informed by having the stories and the inside knowledge from the doctors who were working boots on the ground. And so having a public comment does help the decision maker make better decisions. And the public comment period is open to everybody so that member of commerce could submit a letter just as a doctor, just as a patient, just as the parent could. So having opportunity, at least we read all those letters. I can promise you we do. I think there's a forum to make them aware of how the community itself is impacted. I've read a lot of the letters, and they do act from people who won't be impacted. So they're very If there was I mean, part of the process could be soliciting input from important stakeholders. I mean, of just receiving, but it could be soliciting. I don't know how you legislate soliciting.

[Karen Lueders (Member)]: I know.

[Jessica Holmes (Green Mountain Care Board Member)]: But I'm just saying there could be a process by which there are clear stakeholders whose input is necessary. Who don't know what their stakeholders yet. Yes. Jessica. I'm curious, and you may not be the right one to ask, Do you feel that the hospital boards, as they are now, give I mean, are they a good representation of all people involved? Should there be a change? Maybe even at I would say that I think board governance is a challenge and is a problem. And I say that from two hats. I sat on a hospital board prior to sitting on the Green Mountain Care Board. And the information that I received as a decision maker, as a trustee was filtered. I know that because then when I went on the Green Mountain Care Board, I received much different information and different perspective. And so I think that it's interesting if you were to ask trustees, it would be an interesting question to ask trustees they felt. Did they feel fully informed when UVM made the decision about primary care dialysis, mental health? Did they feel like they had adequate voice in those conversations? I don't know the answer to that, but it would be an interesting question to ask the board members at the hospitals for whom the services were cut. So I don't know the answer. All I can say is from my own personal experience, having sat on a hospital board a long time ago, I didn't fully realize how filtered the information was until I got to a different place in the healthcare system and realized, oh, I didn't understand. I wasn't getting the full picture.

[Karen Lueders (Member)]: I don't know if that helps.

[Alyssa Black (Chair)]: A board and board governance exists for that entity. It doesn't exist for the system as a whole. And we talked about that with Blue Cross Blue Shield's board.

[Jessica Holmes (Green Mountain Care Board Member)]: They were fiduciary responsibility to their hospital. Right.

[Alyssa Black (Chair)]: Any other questions? I'm still trying to get more of the tables.

[Francis McFaun (Vice Chair)]: Was it your suggestion that before a hospital eliminates analysis not only of internal, but also how it fits into the statewide system?

[Jessica Holmes (Green Mountain Care Board Member)]: Well, no, what was saying was I think I called it a first pass. So I recognize fully that a hospital doesn't have all of the data that, for example, AHS would have on the system wide look. They don't have the analytics capacity. They don't have a big contractor lined up to do a system wide analysis. But there's some questions that they could have asked and answered, in the Rutland case, for example. I'll give you the the easiest one. There's a cost per day for a stay in the hospital at UVM and at Rutland. Price transparency. We have price transparency files. That is not a difficult data point to gather. Understanding how much is it going to cost for that patient to travel in an ambulance on average from Rutland to UVM. Simple, small bits of information just to understand what is the cost impact going to be to the patients in their community. I don't think that they can do the full system wide assessment. I absolutely don't. First pass, look at it. And we didn't see any of that, really, in the analysis that we received. So my suggestion was just be really nice if hospitals could actually look a little bit externally and see what are going to be implications of this decision that I'm making here for my hospital? What are the implications for my patients and my community in terms of cost, quality, access? Are they going to be able to actually Is the hospital that I'm sending my patients to actually going to receive to be able to receive those patients? At what cost? And what implications is it going to have for the wait times at that receiving hospital?

[Francis McFaun (Vice Chair)]: Without the full transformation plan in place, it'd be difficult to say, well, they can go to Springfield or they can go to Bennington. Transportation costs, you know, in Barrytown, they did something interesting that they purchased not a full fledged ambulance, but more of an SUV designed to transport patients. And the cost is half of what it would be in the ambulance. Plus, it doesn't need to be banned by two paramedics. So that's just an example of the

[Daisy Berbeco (Ranking Member)]: And I think there's

[Jessica Holmes (Green Mountain Care Board Member)]: some really exciting work that's being done actually by AHS, the Rural Health Transformation Fund, around mobile integrated care. There's going to be some real transformation efforts that are happening that are underway that might actually inform some of the needs here. Again, that's why I point to they are doing that work. They have a fuller picture. We don't have all that sight line into all of those other transformation efforts. They should be involved in this decision. And I do believe it needs to be up or down because I do think that the state has to see these service line changes coming. Actually, if you look at the transformation, you saw the presentation last week, a lot of the transformation plans involve evaluations of service lines. They're anticipating they're coming.

[Alyssa Black (Chair)]: I'm going to ask you, and I'm actually going to ask Jill as well from the side, because I forgot to ask you. So if we envision a process where there is a process, a space for collaboration, I'm calling it, do you think that there might need to be some level of confidentiality or exemption

[Devin Green (Vermont Association of Hospitals and Health Systems)]: from public records

[Jessica Holmes (Green Mountain Care Board Member)]: I think they'll ring up in the early stages of evaluating a service line adjustment. Yes, I do. I think there's reason and value in that.

[Alyssa Black (Chair)]: I should have asked you the same thing.

[Jill Olson (Agency of Human Services – Medicaid)]: Joel Olson, I'm a Medicaid Health Station Director. Yes, I actually think I referenced that in my testimony.

[Alyssa Black (Chair)]: Oh, okay. Sorry. I missed it. Okay, thank you. Thanks, Jessica.

[Karen Lueders (Member)]: Thank you.

[Alyssa Black (Chair)]: If we keep taking testimony, we could have all of the board members each commit to that. Okay. Give Dave a try this time. Hi. Morning. Looking for your thoughts on everything we've been

[Devin Green (Vermont Association of Hospitals and Health Systems)]: talking about. Sure. There's Yes. Devin Green, Vermont Association of Hospitals and Health Systems. I'm going to try to of coalesce around things that we're agreeing on. I think we can all agree that the current process is bad, and we don't want it. So we're there. And I do really like the idea of an initial confidential process. Because what I've heard most from the state when these things have happened is, wow, I wish that we had the ability to come in and try to help and avoid all of this. Because there are real ramifications when this goes public of people leaving their jobs and community upheaval and that sort of thing. So I would love to create a sequence of events and have that first part be a confidential opportunity for the hospital to approach the state and say, This is what we're thinking. And then the state to be able to pull its levers and say, Okay, we can do this, or, We can do that, or, Actually, we agree with you and you should go forward with this. That really is the sort of up and down process right there without being an up and down process. Because what I've really been struggling with is if the state can't pull any levers, but they say, No, don't close this, what do we do? We don't know what to do. And we are in a moment of, There is no plan. The plan doesn't come out until 2028. And so we really need a clear process forward on how to make these changes because the affordability actions are happening now.

[Alyssa Black (Chair)]: Which plan comes out in '28? We've got so many plans.

[Devin Green (Vermont Association of Hospitals and Health Systems)]: The statewide strategic plan from Ag sixty eight. I hope I got that name right.

[Jessica Holmes (Green Mountain Care Board Member)]: I butchered it before. I know.

[Alyssa Black (Chair)]: How about hospital transformation? When are we supposed to be wrapping up that?

[Devin Green (Vermont Association of Hospitals and Health Systems)]: I mean, I think that is all within because part of what you're looking at is the statewide it's not just hospital transformation. You're looking at the statewide plan. Are there non hospital services that can take over for this? And so I think that's where there's so much uncertainty right now. And we could really use uncertainty going forward. And so this could just be an interim process until we get to that plan. But whatever it is, I really like the idea of something that happens beforehand, where the state is able to weigh in and pull all those levers that member Holmes just named. Because both AHS and the Green Medicare board have a lot of levers to pull. The other piece I really advocate for is clarity around how this process will work. I think I hear a lot of confusion from members about, well, you know, I have a psychiatric unit, and I have teen bed I have adolescent beds, and we don't have a lot of adolescents right now, but we do have adults coming in. Can we turn over those beds and use them for adult beds? Is that considered reducing the beds? Do we have to go to the Green Mountain Care Board on this issue? The reduction piece, I hear what Ter Holmes is saying about this sort of reducing, reducing, reducing. But I I think more often than that space is what hospitals do are they flex beds and services, and they react to volume, and they need to change people's schedules according to what providers are available and that sort of thing. And so we need that flexibility without having to go through a whole process to get approval for it. We would like the process so we would like the process to only go towards the elimination of services. We would also like the process to only apply to the permanent elimination of services. So we have scenarios where a neurologist has left. It's gonna take two to three years to get another neurologist in. We're not ending that service, but the service is not gonna be available. And we don't wanna have to go through a whole regulatory process around it when we're intending to keep that service and neurology going. Then, as I mentioned, specify a timeline with discrete sequential steps. So work with policymakers. See if there's anything that can be done there. And then step two, if the policymakers say, yes, great. We have things that we can do. We can fix this. We don't want this service to go away. Let's keep it. Great. No one needs to be the wiser necessarily, and you know we don't have providers leaving. We don't have, the turmoil in the community. Step two. So if the state says no, there's nothing we can really do, step two, or if the state says, Actually, this is what we're thinking also, and we want you to go forward with this, step two is the public notice process and the public engagement process. And we do think that those are valuable pieces. Our hospitals have not necessarily engaged well in these public processes. We want to do better, and so we support having the public notice and the public engagement process in place. Again, this is just highlighting the opportunity for the state to help, and the public notification engagement process will remain the same. The other piece that's in here is the there's language around the green and and another thing I wanna point out is hospitals are going to have to make things affordable. The Green Mountain Care Board will ensure that affordability. So it's not like we're gonna cut all the low hanging fruit and keep all those savings and be so much more profitable off of that. What's going to happen is if things are cut, the Green Mountain Care Board will rebase our budgets and then hopefully see that affordability go towards our premiums. Or if the Green Mountain Care Board decides that we should be investing more in our primary care or those sorts of services, they can do that as well. There's one piece in here that says the Green Mountain Care Board may determine that hospitals should return funding fever monitors, which I don't think is a thing. And so I would just ask that that be removed and that we keep the reflected in health insurance premiums or reinvest in primary care, prevention, or other service fees.

[Jessica Holmes (Green Mountain Care Board Member)]: I

[Devin Green (Vermont Association of Hospitals and Health Systems)]: just don't know. I think that's what you're talking about.

[Alyssa Black (Chair)]: Yeah. Ahead, Allen.

[Allen "Penny" Demar (Member)]: I I see you say hospitals must first notify policymakers. So are you saying if a hospital intention is to, eliminate a service, they go to first thing they do is go to the AAS, a h s j f Yeah. First. Okay? And that would be an confidentiality thing. Yes. And between the two, they would agree to

[Jessica Holmes (Green Mountain Care Board Member)]: go to the public?

[Devin Green (Vermont Association of Hospitals and Health Systems)]: I think so what can happen is hospital bill policymakers. The policymakers say, actually, we have some Medicaid funding that we can increase, or we have some commercial rates that we can increase, and we can help you

[Allen "Penny" Demar (Member)]: out with can resolve it.

[Devin Green (Vermont Association of Hospitals and Health Systems)]: They can help resolve it before Right.

[Allen "Penny" Demar (Member)]: You're okay with that?

[Devin Green (Vermont Association of Hospitals and Health Systems)]: I'm okay with that.

[Karen Lueders (Member)]: I'm

[Brian Cina (Member)]: trying to understand how would it work to notify policy makers to see if the state can help before notifying the public. I'm guessing there's other processes that already exist in state government where receivers of state money have the ability to talk with the state before being public to minimize harm on the public if it can be, and I don't know if that already exists for hospitals or anyone else has examples, but I'm wondering how that might look here. How would that process work?

[Devin Green (Vermont Association of Hospitals and Health Systems)]: There's hoping Jen, Carby. But I could look at other processes too and see if those are available.

[Brian Cina (Member)]: I'm sure if I sat here, I could think of one somewhere, but I figured I'd ask. In healthcare, there was already such a process. And then the other thing is listening to all the testimony, it feels like people, everyone acknowledges the problem. There are some disagreements around who should be responsible for what. I'm curious where hospital and healthcare systems stand on the issue of who should be doing the financial analysis piece of like what we heard about before decisions are made, we should have numbers and understand. It was more than that. It was transportation, disparate impacts on different populations. So where does the hospital stand on who's best positioned to do that kind of social and economic analysis before decisions are made by anyone around the reduction or closure of services to hospitals?

[Devin Green (Vermont Association of Hospitals and Health Systems)]: So a couple of things there. I think first, we would wanna understand the extent of the analysis that's being done. And I hear competing interests. So we hear, you need to save the state money. You also can't make an individual Vermonter pay more money at another hospital. And that is a little bit of a tug of war, because what we also hear is we will become more affordable if we increase volumes in certain areas and they become more efficient. So I think we need to be If we're going to specify an analysis, I think we need to be really clear about what the goal is and then let the analysis float from there.

[Brian Cina (Member)]: What the goal of the?

[Devin Green (Vermont Association of Hospitals and Health Systems)]: What you're looking for. Are you looking for statewide affordability? Are you looking for What is your ultimate decision making point?

[Brian Cina (Member)]: Do you think it's impossible for us to come to a place where we could have like five goals and they all work together? Or is it going to be that we're going to have to choose affordability over access or choose quality over cost or something like that?

[Devin Green (Vermont Association of Hospitals and Health Systems)]: I think we should keep quality, access, affordability top of mind always, but I don't think you're ever going to get all three of them at once.

[Brian Cina (Member)]: That feels like a very honest answer, thank you.

[Jessica Holmes (Green Mountain Care Board Member)]: It's bad though, yeah.

[Allen "Penny" Demar (Member)]: Getting back to my question when those two parties meet and all of a sudden Ah says, oh, we don't have any funds and they're not gonna be available. Talk about up and down. Who's gonna have the ultimate authority to say we're eliminating this or you're not?

[Devin Green (Vermont Association of Hospitals and Health Systems)]: Then I think the hospital has the ultimate authority to close the service. If the state is unable to help, I don't understand where the hospital would be able to continue keeping the service going.

[Brian Cina (Member)]: Thanks.

[Karen Lueders (Member)]: Any other questions for Devin? Right. You. You. Okay.

[Alyssa Black (Chair)]: So I guess with our remaining time, so first of all, thank you, everybody. I was sort of hoping that, mean, I was just like, well, let's start all over from the beginning. And after our discussion last week, I think that this is really fruitful. You all brought your A game today. Good job. I just think our questions were so much more well informed and had more thought behind when you're first seeing it.

[Daisy Berbeco (Ranking Member)]: So I guess I

[Alyssa Black (Chair)]: would like to get a feel from the committee on where we go with this bill from here. Also thoughts on whether or not anyone feels like there's more people we need to talk to, if we need some more information to be able to make informed decisions, and then how we navigate going forward with changes that we decide to make. So looking for thoughts. I don't

[Brian Cina (Member)]: know if this came up yet, I admit that I've missed some, a few meetings, but I'm curious if there's any examples of how this is handled in other states we might learn from.

[Jessica Holmes (Green Mountain Care Board Member)]: Devin, you want

[Karen Lueders (Member)]: to chime in?

[Jessica Holmes (Green Mountain Care Board Member)]: Yeah, sure. Devin, greetings from us. Massachusetts has the notification

[Jill Olson (Agency of Human Services – Medicaid)]: piece, but they do not have final authority.

[Brian Cina (Member)]: Who doesn't have final authority?

[Jessica Holmes (Green Mountain Care Board Member)]: Massachusetts, the state of Massachusetts has a notice provision public process piece.

[Brian Cina (Member)]: But the hospitals have the freedom to practice business without state interference or whatever, however you want to frame it. Maybe that's hard. That's a little. But there's no state that has a regulatory body like the County Care Board that is controlling costs or involved with it? Is there any other state that has that kind of a regulatory body working with formal agencies in a state like Human Services to make decisions?

[Jessica Holmes (Green Mountain Care Board Member)]: There are a number of laws around

[Devin Green (Vermont Association of Hospitals and Health Systems)]: closure of services.

[Jessica Holmes (Green Mountain Care Board Member)]: You know about the mechanism for if the state says you can't close it.

[Jill Olson (Agency of Human Services – Medicaid)]: What I typically have seen

[Jessica Holmes (Green Mountain Care Board Member)]: is an analysis of things close.

[Brian Cina (Member)]: Mean, it's helpful to hear though, that there's an analysis, but inevitably if the business can't stay open, it can't. Or if it can't continue to provide a service because the business itself may not

[Karen Lueders (Member)]: close. Daisy? My

[Daisy Berbeco (Ranking Member)]: thoughts or feelings about the bill haven't changed since last week, and

[Jessica Holmes (Green Mountain Care Board Member)]: I feel really clear that AHS should be,

[Daisy Berbeco (Ranking Member)]: put back in as required to approve any reduction or elimination of services. Think Jessica really articulated the reasons that I feel that's necessary quite well. And then I think we should, before removing that piece at the end of page four, I want to understand that better, why does Cina have that in there, about the board adjusting the hospital's budget, which may include directing any savings to Vermonters to address affordability concerns. I want to understand what the intent was there. And then the final piece, a few people have brought up about involving EFR. And I don't think we've heard from DFR, but it seems like everyone we've heard from agrees that that's not necessary.

[Alyssa Black (Chair)]: Jen, do you have any insight on where this all came from in

[Jessica Holmes (Green Mountain Care Board Member)]: the Senate that you could bear with The part about returning to Vermont or Does everybody get a shout?

[Alyssa Black (Chair)]: Do you know where the DRR fee stayed from?

[Jen Carbee (Legislative Counsel)]: That's from last year. It's existed a lot, it was in the context of Ag1's Direct 68. I think it was paralleling some language around limitation of reference based pricing, but

[Alyssa Black (Chair)]: I don't

[Jen Carbee (Legislative Counsel)]: I recall the think it was this committee that added it, but I don't recall the reason. I agree,

[Karen Lueders (Member)]: it seems less connected to

[Jen Carbee (Legislative Counsel)]: this piece than to the reference based pricing. Yeah. I'm sorry, I missed the whole that it's

[Alyssa Black (Chair)]: not underlined. So they're getting rid of decrease and just putting reduction or elimination.

[Jen Carbee (Legislative Counsel)]: Well, was really a tune to reflect the changes in the underlying statute that the bill was proposed.

[Alyssa Black (Chair)]: Excuse me, Ruth. So I still am actually hung up on I can't even get past line seven on this though on page one. Do we have a definition of what a service identity is? Yeah, there's the intentionally. And then just a service. And thank you, Devin, because I'm sitting here looking at Massachusetts's law. And they have a reduction in essential services. I'm wondering how they define essential. Maybe we can kind of look into that. I'm going to call some people from around the room if they

[Jessica Holmes (Green Mountain Care Board Member)]: I'm a friend? Yes. I actually asked, I anticipate question might come up, and I asked our staff if they had pulled together and they were working on the notice of service line reduction, we were thinking about essential services, so I can share with you the list that they pulled together: emergency and observation services, primary care, preventive and wellness services and chronic disease management, including patient education, prenatal care, pregnancy, maternal newborn care, before and after birth, obstetrics and labor and delivery, sexual delivery, mental health and substance use disorder services, including behavioral health treatment, this includes counseling and psychotherapy, rehabilitative and habilitative services and devices, services and devices to help people with injury, disability, or chronic conditions gain or recover mental and physical skills, including OT, PT, pulmonary and cardiac rehab, dialysis, short term hospital stay, and pediatric services. And this was pulled from the American Hospital Association had put a list together, eight or ten years ago of central services people with the rural communities, so there was part of that list. Some of it was pulled from the work that AHS' contractor, RHRC, had done, and then also from the 10 essential health benefits. So that is what I have. Can forward that to you if that's helpful, but

[Alyssa Black (Chair)]: I don't. Great. And Jill, as part of the rural health transformation wasn't the first step What they did was getting together and just deciding whether essential services.

[Jessica Holmes (Green Mountain Care Board Member)]: So

[Jill Olson (Agency of Human Services – Medicaid)]: we did as part of transformation. Hospital I work on both.

[Alyssa Black (Chair)]: That might transform.

[Jill Olson (Agency of Human Services – Medicaid)]: Yeah, so yes. So there was a sort of what services need to be local, regional and statewide. And I'm just listening to this list. What I think we need to also be clear about some of those things don't necessarily need be provided by a hospital. And so you're really talking here by hospital. And I'm not sure that's the Listening to

[Jessica Holmes (Green Mountain Care Board Member)]: that list, I'm not sure I would say those were all must be a hospital services.

[Alyssa Black (Chair)]: But if we said a hospital essential service or a essential service from a hospital, I have been watching the tippy basketball thing all day.

[Devin Green (Vermont Association of Hospitals and Health Systems)]: I'm nervous about it.

[Jill Olson (Agency of Human Services – Medicaid)]: I certainly think that there is room to think through what a definition. I

[Jessica Holmes (Green Mountain Care Board Member)]: just wanted to add to that. Do think that, example, primary care is not hospital necessary, but it could be a community. All of primary care is actually owned by the hospital and the hospital's decision to eliminate primary care where there's no alternative would be problematic.

[Brian Cina (Member)]: Brian? Sometimes it's easier to ask what's not something than what is, and in this case that was a really long list and I'm wondering what would not be an essential service that a hospital provides, like the cafeteria,

[Alyssa Black (Chair)]: the

[Brian Cina (Member)]: patients. What would be a not essential service? I can't think of an example of anything a hospital does that isn't essential to someone. Maybe plastic surgery, but do they really do that for cosmetic reasons? I mean, that is essential for people's mental health if they have an accident and it's preparing their body. I see a hand.

[Devin Green (Vermont Association of Hospitals and Health Systems)]: I actually think that list

[Jessica Holmes (Green Mountain Care Board Member)]: is quite small given all the services that hospitals provide. So I think that list is a good start.

[Brian Cina (Member)]: You mean you think there's things missing?

[Jessica Holmes (Green Mountain Care Board Member)]: I don't know, I think that list is a good, I

[Devin Green (Vermont Association of Hospitals and Health Systems)]: would need to look at it more, but

[Jill Olson (Agency of Human Services – Medicaid)]: I think that is helpful.

[Alyssa Black (Chair)]: I keep going back to what problem are we trying to solve. And I don't think we're, there is, there doesn't seem to be a problem of eliminating services, hospitals eliminating services of say,

[Karen Lueders (Member)]: neurology,

[Alyssa Black (Chair)]: Other than in the instance where they can't find a neurologist, because when we're talking about the essential services, we're really talking about the low reimbursed services. And that's when they're making decisions based on financial, which was the original intent in 01/2026 or Act 68. Do you remember that it was directed that if they were eliminating services in order to be compliant with their budgets. So I don't know, that list of essential services seemed really to hit all the places where we have seen where the problem is. And what problem are we trying to solve?

[Jessica Holmes (Green Mountain Care Board Member)]: You can always

[Daisy Berbeco (Ranking Member)]: do that. I didn't raise my hand, but I

[Alyssa Black (Chair)]: really Oh, had a

[Jessica Holmes (Green Mountain Care Board Member)]: okay. And this is just, this is just,

[Alyssa Black (Chair)]: holding around on my head.

[Jessica Holmes (Green Mountain Care Board Member)]: I don't remember. I don't know. Going back to the boards that represent the hospitals, could there be a little reform there where with the rural health transformation, making sure that knowing that we need Green Mountain Care, we need somebody from the hospital, maybe somebody that represents pediatrics, whoever is really closely affiliated with the hospital, going through any transfer, making sure everyone's represented. And then you just have orderly or monthly meetings and everything is always in the know.

[Alyssa Black (Chair)]: Are you talking about the hospital boards that would get into the state appointing board members.

[Jessica Holmes (Green Mountain Care Board Member)]: If you recall the event you remember two weeks ago?

[Alyssa Black (Chair)]: I do. What was that? That was a shield.

[Jessica Holmes (Green Mountain Care Board Member)]: We don't want to.

[Alyssa Black (Chair)]: The governor appointing two board members. And we have to remember that these are independent, solely their own businesses, nonprofits.

[Brian Cina (Member)]: So it was the insurance company, and we did it though. Yes. Since then. Yeah.

[Daisy Berbeco (Ranking Member)]: You all set? Daisy? So we're talking about services. What is a service? Is it this line seven essential service? Is there a reason not to just have AHS, BOSS, and CareBoard get together and give us that list? And then add a definition to the bill.

[Alyssa Black (Chair)]: It's a great question.

[Daisy Berbeco (Ranking Member)]: Because I know there's technical stuff, right?

[Jessica Holmes (Green Mountain Care Board Member)]: Like some services, CMS,

[Daisy Berbeco (Ranking Member)]: they are essential services by CMS, and you can't screw up the waiver by omitting any of them.

[Alyssa Black (Chair)]: And those folks would all know that stuff. It leads me to a question I have for the committee, which is whichever direction we decide we want to go, is everybody okay with me getting these stakeholders together to hammer out? You know, if we're talking about things like what's an essential service and coming up with a definition. If we're talking about things like, is there a process before the process? Would everybody be okay with me gathering the folks together and them hammering out something? Okay, good. Which is coming to your point.

[Jessica Holmes (Green Mountain Care Board Member)]: Yeah. So I have a question for Jill, if that's okay. Sure. After listening to Jess's testimony, which was pretty clear, I'm not sure I quite understand. I'm hearing you say AHS does not want it up or down, but I'm not understanding why.

[Jill Olson (Agency of Human Services – Medicaid)]: Jill Wilson, Medicaid and hospice instructors. I think I said this in my testimony that I think we believe that the levers, but we don't want to add a sort of new specific tool in the toolbox. We want to use the tools we have.

[Jessica Holmes (Green Mountain Care Board Member)]: But that's not a tool, that's a decision.

[Jill Olson (Agency of Human Services – Medicaid)]: I may not be able to satisfy your question. Our position is that we do not want to add an explicit up or down vote to the process. We would like to have more opportunities to work with hospitals and advance some of these decisions. So I think there's a lot of agreement actually that I'm hearing. And then the other piece that we haven't talked about that much today is we also have this sort of transformation role where we're doing all this consultation and then sort of trying to, the idea of regulating a decision we're hoping to make or a plan we're hoping to build. But on the up or down, we just do not support adding another extra school. I think partly, I think Devin's also got at it a little bit, which is if we say no and we don't change anything, and then we met Karen, the board doesn't change anything in their budget, so what happens next? What's the remedy then shot on the situation? So we're not trying create a new regulatory process to govern this. We just don't support that. We do support transformation, the analytics, the public process, the ability to have more confrontation in advance, and then consider the levers we do have, including the monetary levers.

[Jessica Holmes (Green Mountain Care Board Member)]: But if I understand Brian's question, was if the state's unable to help, so you don't have any tools or levers or whatever, then ultimately it's up to the hospital aside. And that would be okay, but I'm still trying to understand your but I guess you don't have a way to say that.

[Karen Lueders (Member)]: I

[Francis McFaun (Vice Chair)]: don't think the hospitals decide just overnight that we're going to eliminate this service. No. There's a lot of the time to see discussions with the administration staff, hopefully with the board, although we heard that that may not be

[Alyssa Black (Chair)]: as good. Can I tell you the impetus for what happened in s one twenty six?

[Allen "Penny" Demar (Member)]: Sure.

[Alyssa Black (Chair)]: UVM received a budget guidance from the Green Mountain Care Board and overnight announced that they were closing dialysis across the state, they were closing a primary care practice in Wastefield, that they were shutting down immediately. I think they gave thirty days notice to the Department of Mental Health that they were exposing eight inpatient psychiatric beds. They eliminated a bunch of other stuff. And it was just all done with no notification to anybody.

[Francis McFaun (Vice Chair)]: Well, I'm not saying notification. What I'm saying is they didn't just say, you know what? Tomorrow morning, we're gonna cancel all these services. Had internal you don't think they had internal discussions on whether or not they could afford to have these services?

[Alyssa Black (Chair)]: I don't think we ever got a clear picture on

[Francis McFaun (Vice Chair)]: the You United might not have, but inside the hospital, when Rutland decided to close pediatrics, they had some in-depth discussions on whether or not they were losing money, what could they do to make money. When Mr. Leffler testified at UVM, there are internal reports and analysis to do on how can we be more effective. So I believe that the hospitals are trying to make those decisions based on facts and analysis. I like the bill as it's written. I believe the hospitals should have the authority. I like the notification. I can see the timelines being adjusted to a little bit more. And in the end, I think it's the hospital's decision to close or eliminate a service.

[Brian Cina (Member)]: Okay. I see a hand. I think of a witness from earlier. Yeah.

[Karen Lueders (Member)]: One of the things we asked when we made this decision, because it felt very absolutely with all of us, was sort of that reasoning why, and it, I think, still is a little unclear to us how they got to that reasoning. More I put it in my opinion here was that it was directly in response to the Green Mountain Food Board's regulation of the invasion of our farm harvesting crisis causing a rapid budget shortfall. And so I think sometimes hospitals will make these decisions that feel almost reactionary to regulatory oversight and not necessarily about communities.

[Jessica Holmes (Green Mountain Care Board Member)]: Wendy, very quickly, in essential services, anything you have to go

[Karen Lueders (Member)]: into the hospital. You don't need a list.

[Jessica Holmes (Green Mountain Care Board Member)]: The second is this bill is fine, but it has absolutely no teeth at all. And I was really on the fence about the up and down thing. But if in the end it just becomes a hostile making this decision, then why bother? I

[Brian Cina (Member)]: would respond to that by saying, the community knowing what's happening allows people to make personal choices to cope with that. And that's my biggest concern, is not trying to meddle with business decisions that happen, but really empowering the public to be able to plan, to be able to figure things out, and also to be able to organize that communities can organize and pressure hospitals or organize and solve problems as a community that people in a room in an old historic building may not be able to solve. I think that the value of the bill is community engagement and adding transparency and not having a situation. I'm not accusing UBM of this, but it appeared when that happened as if it was some kind of reaction. You know? Like like, I think your point is valid. Behind the scenes, people are probably always talking about how to sustain these things and knew where the weak points were. But I think to have the morning after, whatever it was, this dramatic announcement about service cuts that caused panic around the state and communities, that is what we're trying to prevent here. That's really what we're trying to prevent here. We're not solving the bigger picture issue of system

[Jessica Holmes (Green Mountain Care Board Member)]: And I think you're assuming that everyone that's coming to the table in this bill is gonna be a good actor. And I think that we have that knee jerk reaction because of what did happen. So that's the reason that I'm a little skeptical.

[Brian Cina (Member)]: What are you skeptical about?

[Jessica Holmes (Green Mountain Care Board Member)]: I'm just skeptical that we'll go through all of this process when the end result is just going to be what the hospital intends.

[Lori Houghton (Member)]: Lori? I agree with Brian, and that, and everything you said. In my own words, I would say

[Jill Olson (Agency of Human Services – Medicaid)]: Be careful.

[Karen Lueders (Member)]: I know.

[Lori Houghton (Member)]: We don't usually do that before

[Daisy Berbeco (Ranking Member)]: crying, but

[Lori Houghton (Member)]: I think the power of the public is really strong. And I think we've seen that over and over in these conversations about whatever it is in the state that we are trying to change because our systems are caving in on themselves. I I like the bill as is. I think we need to enhance Section two and the Agency of Human Services shall. A lot of the suggestions that Jill and others said specifically, I want to see the transformation plans in here and access quality costs and effect on the system that Jessica said. I think if we beef that up, put the timeline in, do the confidentiality piece, I think this is a step further than we did in the last bill, because I think this encourages more analysis to get to the whole system of care.

[Jessica Holmes (Green Mountain Care Board Member)]: Hold on one sec.

[Alyssa Black (Chair)]: You said in section two. Section two

[Lori Houghton (Member)]: is I meant it for in page

[Karen Lueders (Member)]: two. Page

[Jessica Holmes (Green Mountain Care Board Member)]: two.

[Alyssa Black (Chair)]: Two. So

[Lori Houghton (Member)]: you were recommending There were a lot of conversations around and I think Jill's going to send us her stuff. We're going to get Jessica's. I want to see that enhanced. A strong part of me wants to say that, yes, AHS should have an up and down. But these are businesses, unfortunately. And the businesses and the partners with all of the data at hand, which hopefully will be much more enhanced, needs to make a collective decision

[Daisy Berbeco (Ranking Member)]: with the public.

[Allen "Penny" Demar (Member)]: Allen? I'm old school. I look at the hospitals as a business. If I own I that would do what it takes to make it success. And I would compromise, but the ultimate decision should be mine. I own that business. I would check-in this case if it was a hospital, I would try to get all parties involved and see what the best decision and maybe some ideas of how I could continue serving that business and not losing my shirt. And the public should be involved because it's a hospital. It should be involved If they cannot come to a compromise, there's no finances to help them out, it's got to be up to the business owner or the hospital to make their decision.

[Karen Lueders (Member)]: Karen? Well, in thinking we're about that not thinking systemically, we're not thinking of the entire state, we're not thinking of the impact your business is having on an essential business statewide. And I think that's what transformation is accepting. So I just wanted to note So

[Allen "Penny" Demar (Member)]: I should go under to save the rest of

[Karen Lueders (Member)]: No, I'm just noting the project, the annotation.

[Jessica Holmes (Green Mountain Care Board Member)]: No, I know.

[Karen Lueders (Member)]: And so it's not quite the same as business. Yet, nevertheless, there are COPS restrictions. So if the final arbiter here is agency of human services, but they have nothing to give, and they're saying to the hospital, you must be in the red, you must keep this, I don't think that would happen. I would think they would say, we think this is important, we've analysed it, we don't see how we can financially support it. Therefore, in a way, the hospital, that end result might end up closing that service, it's been looked at very, very far.

[Allen "Penny" Demar (Member)]: And that's what the point I was getting at.

[Karen Lueders (Member)]: Yeah, no, I mean, I'm just talking it through, not saying this is a right or wrong. But I guess I am in support of until we have that real transformational plan and that's the work that's going on, I'm in support of having clarity on a process and then a decision, And I think there's some really compelling reasons to have the agency community service to be that decision maker. But once we have a plan, maybe that process evolves. But we're sort of in between. And then the other thing is I do think reduction is an important consideration, not just the intentional closure. And I think if there is some flexibility, a pediatric bed away, and we don't have kids, I don't know, if there's some in house flexibility that could just be run by the hospital, run it by the regulator, well that's great, because it's important to have those real life practicalities taken into account. But anyways, that's kind of where I'm headed at the moment. I'm going

[Alyssa Black (Chair)]: to ask Allen a question, but before I do, I'm just going to tell Devin, yes, I know what a hospital is, and I know this isn't but this is just illustrative purposes. Allen, what if Northwest Medical Center came out tomorrow and said, We're closing our emergency department. We're a business and we're not making any money on it.

[Allen "Penny" Demar (Member)]: Right now, they can do that, right?

[Alyssa Black (Chair)]: Well,

[Daisy Berbeco (Ranking Member)]: so. Almost.

[Allen "Penny" Demar (Member)]: Almost, yeah, okay.

[Alyssa Black (Chair)]: They wouldn't be

[Allen "Penny" Demar (Member)]: able to They fill it got to collaborate with the AHS. Yes, okay. And maybe even the Green Mountain Care Board, and come to a solution to keep that hospital open, maybe financially or whatever. And maybe they'll say, okay, you've got to cut this service out, you've to cut this service, but it's a group effort. But if it fails, it's going to be up to the hospital to make that decision. So if Ah says, you're going to stay open, but we don't have no funds, what happens then?

[Brian Cina (Member)]: We force the workers to work for free.

[Jill Olson (Agency of Human Services – Medicaid)]: We don't need to settle. You don't need to

[Alyssa Black (Chair)]: doesn't have an emergency department, and it's too bad so sad you guys just need

[Devin Green (Vermont Association of Hospitals and Health Systems)]: to drive an extra 30 miles to

[Allen "Penny" Demar (Member)]: We we don't want that to happen. That's why this bill is here. Right? We want we want us.

[Alyssa Black (Chair)]: Well, we want we want some oversight in just summarily dismissing services.

[Allen "Penny" Demar (Member)]: But I can't give you oversight if I must say, you can't do this or you you know, but I'm not giving you any money for it.

[Alyssa Black (Chair)]: What if you're raising the cost of care for the rest of the entire state?

[Allen "Penny" Demar (Member)]: I think you're going to be in trouble anyway.

[Daisy Berbeco (Ranking Member)]: Daisy? And then Leslie. I was just going to say that we heard that one of the reasons is if you have this request that your hospital wants to close, Green Mountain Care Board might have a solution. They have a piece of the pie, and it's the funding pie. And then, AHS has the Medicaid funding piece of the pie, which is a significant one. So just getting them all in the room together to try and save those services is fundamental. It feels like right now, it's just the hospitals deciding without having that conversation and all of the information, like Jessica noted, that hospitals

[Allen "Penny" Demar (Member)]: I agree with that. Think Devin said it, I asked her, Are you agreeing with AAHS to continue the conversation? And I added maybe the Greek Mountain Care Board to get to a solution before there's any major decisions being made.

[Alyssa Black (Chair)]: I also just want to remind everybody that every hospital in our state is a nonprofit, which means that they are afforded many, many Tax. Tax Because they serve essential services in the community. Leslie? Yeah, I

[Jessica Holmes (Green Mountain Care Board Member)]: think that's really important to me is that we talk about how schools of business and yes, they have a bottom line. And yes, they're nonprofits and they need a margin in order to sustain. But they also provide a public good that goes beyond other businesses. And I think that public good is really crucial to understanding the whole system so that if something happens in Rutland, it is going to affect everything. And that there does need to be an entity that is aware of that and is going to make a decision about how that is going to unfold.

[Leslie Goldman (Member)]: So I just need to go beyond, I think Karen said it well, beyond the idea that a hospital is just a business and only cares about its own bottom line. I think we need to go beyond that. And I think that this bill starts doing that. But if there's no ultimate decision maker, then I agree with Wendy, then there's no point to the bill. So that's sort of where I'm thinking about our hospital system. I'm going to say it again, I'll probably say it many more times, 10,000,000 went to Springfield Hospital when it went bankrupt. Public money. So it's not a basic business. It has access to resources that other businesses don't. And it has responsibilities that other businesses don't.

[Jessica Holmes (Green Mountain Care Board Member)]: So I think we need to think about that.

[Alyssa Black (Chair)]: Lori?

[Lori Houghton (Member)]: Yes, to everything everyone is saying. That's why this decision is so difficult, right? I think we have come a long way from giving Springfield $10,000,000 and even what happened with UVMMC. Jessica Holmes has been in this building since 2018, pushing for a hospital transformation and a system wide look. We're getting there. Do I wish it was moving faster? Yes, I do wish it was moving faster. I'm sorry, I missed testimony last week. I'm going to read it this weekend. But that needs to happen faster. But that's what we're getting to. So I see this as another piece of that puzzle to ensure that all the levers are being used and all the groups are coming together to ensure that any decision a hospital is making about their services is looked at in the full, right? I do think Rutland did it a tiny bit. Maybe it wasn't right for that community, but they were like, this is where the people would go. That needs to be beefed up. And I love the idea that Jessica put in about, they need to have a first pass of like, how will this decision affect the system? I think we're getting to what everyone wants, except for that ultimate decision maker. And I don't think we should be making that decision.

[Jessica Holmes (Green Mountain Care Board Member)]: Oh, we should not. They should be.

[Lori Houghton (Member)]: Think I think it has to be a process. And there is no ultimate decision maker at this point in time. So here's what I

[Alyssa Black (Chair)]: think we should do, because we're finishing up now for the day. Let's table the ultimate decision. Let's just table that conversation. I keep thinking of this point of, is this bill doing anything right now? It's like a trip to Disney and you can fly, which is the old system we had, or you can get your whole family in a car and take a four day nightmare family car ride. And this is basically that nightmare family car ride. But I mean, ultimately, we're getting to Disney the same way. So we just need to decide if we can make the trip a little bit easier. So does everybody feel good about me getting all of the stakeholders in a room to come up with a clear, cohesive process that meets everyone's needs? I will probably, I'm thinking we need the hospitals, spas, we need Green Mountain Care Board, we need AHS, and for the public, I think that maybe the healthcare advocate's office should be party to this.

[Brian Cina (Member)]: I think so.

[Alyssa Black (Chair)]: Okay. I definitely think so. Everybody good with me getting four stakeholders together to hammer out that piece. Then we will table and make the ultimate decision on whether or not, once that's all done, whether we're going to make somebody give an up down.

[Brian Cina (Member)]: So you're saying that before you make a decision, you want to get the stakeholders together and see if they can have a compromise. Instead of a car ride or like the plane, maybe we build a bullet train

[Alyssa Black (Chair)]: or something

[Jessica Holmes (Green Mountain Care Board Member)]: like that.

[Alyssa Black (Chair)]: Or like we get like a special sprinter van. -Yeah. I

[Lori Houghton (Member)]: used to be the family that did the four day

[Jessica Holmes (Green Mountain Care Board Member)]: -Oh, okay.

[Lori Houghton (Member)]: -We're removing the line that you would put between your siblings. No one can touch you.

[Jessica Holmes (Green Mountain Care Board Member)]: We're removing those lines and we're all gonna sit in the back seat together.

[Jill Olson (Agency of Human Services – Medicaid)]: Do. It's both closer.

[Alyssa Black (Chair)]: I had a conversation with Jill Olson last week in which I described, you know, moving the lines and everybody getting along. Something that we know in this life in every single aspect from childhood through, and I'm not gonna use the word that I used with her in the conversation, but there's always going to be that one person that doesn't want to play nice. And I think we're trying to craft a process knowing that in life, there's always going to be a party that doesn't want to play nice. So let's try to do things where we force everyone to play nice. Line between the kids.

[Jessica Holmes (Green Mountain Care Board Member)]: So other than the arbitrary, downs, are going to also do a timeline on that first step that we're not talking about yet? Okay.

[Alyssa Black (Chair)]: So we'll do timeline. First step, we'll have them figure out what a service is.

[Jessica Holmes (Green Mountain Care Board Member)]: All the stuff on page two.

[Alyssa Black (Chair)]: All the stuff on page two. Yeah. That's essential. Oh god. Analytical. Yeah. Come up with something better There's a in number in section two. I wrote in the paper, this is dumb.

[Daisy Berbeco (Ranking Member)]: No offense to Ledonia Council.

[Alyssa Black (Chair)]: No, I think the Ledonia Council just writes what they're told to write.

[Brian Cina (Member)]: Okay,

[Alyssa Black (Chair)]: because I was looking at

[Brian Cina (Member)]: the agenda, we have important things to set up. So we're back after the floor, but we're not touching this.

[Jill Olson (Agency of Human Services – Medicaid)]: Okay, thank you.

[Daisy Berbeco (Ranking Member)]: Was a really helpful discussion everyone.

[Jill Olson (Agency of Human Services – Medicaid)]: Thank you.