Vermont Legislature SmartTranscripts:

[Alyssa Black (Chair)]: Good morning everyone, this is House Healthcare. It is May 1, Happy May Day everybody. We have a little bit more additional testimony on 01/1997, and then we're going to have committee discussion. Before we got going with that, though, I wanted we very briefly talked about this yesterday, right before when we were ending. And I wanted to let everybody know, because I know the committee is really interested in S-sixty four. So if you recall, Ashley Berliner had come in from AHS, because we had asked the question during committee about whether or not it would require a state plan amendment for Medicaid coverage if we wanted to ensure that there was Medicaid coverage for it. Ledger Council is working with DivaAHS right now to figure out whether or not we need to have some additional language in there for coverage under Medicaid and what that would look like. Jen's going to be working on that. And we have it on our agenda on Tuesday afternoon next week for markup committee discussion around it and possible implode. So I just wanted to give everybody an update on that bill, because we know that it needs to go to gun laws also. So we want to deal with that as quickly as we possibly can. So turning back to 01/1997, we have Sarah Dudley with us. And we're really happy that you joined us. Get your thoughts on the bill. And I think specifically we had asked, because we keep going through kind of iterations of how primary care works and the different models. And we keep talking about direct primary care, and I figured, hey, let's get direct primary care in here and see how they work. And also, we've heard a lot around blueprints and practices. We hear a lot from practices that participate in the blueprint, but not practices that don't participate in the blueprint and trying to get some understanding of why that may or may not be. So we really, really appreciate your perspective and joining us on this.

[Sarah Dudley, FNP (TruePath Wellness)]: Yes, thank you. Haven't done this before, so just bear with me a little bit. Sarah Dudley, I'm a family nurse practitioner, and I thought I would just tell you a little bit about my history and how I got to the concierge or the direct primary care model, and then, yeah, answer questions. So I have been doing this for twenty five years now. I've been working as a nurse practitioner in primary care roles, mostly in Chittenden County since 2001. And I started in internal medicine at UVM and one of the given healthcare clinics for like nine ish years. Mark Levine's office was right next to mine, so just name drop that. He and I go way He taught me a lot. And I left there to join Thomas Chittenden and crossed paths in my years there with both Hannah Raven and Rick Dooley, stayed there for probably about ten years, decided was kind of done with primary care, which many reasons we can talk about, transitioned into some urgent care work and that happened to just line up with the pandemic about six months later. So that was a lot. Stayed there for about four years and then was just probably done with healthcare at that time and was gonna walk away, had many other dreams of ways to make money. But luckily I have a pretty supportive family and they sat me down and were like, what do you still like about healthcare? What do you not like about healthcare? Why would you just go stock grocery store shelves at night, which was on my list of things to do. Or maybe be a microflower farmer,

[Alyssa Black (Chair)]: I had a lot of plans. But

[Sarah Dudley, FNP (TruePath Wellness)]: my husband said, What do you And I said, I really like the stories, I like the connections. I came to being a nurse practitioner about four years out of undergrad nursing school. So I came into this as being a nurse and wanting to care for people. And so he just said, just go do that. And I think from probably some of your other testimony, I'm like, in this current healthcare delivery model, the current reimbursement model, I can't, I can't do that. I can't deliver the care the way that I wanna care. I can't connect with my patients the way I really like to connect with them. But I also knew because way back at the beginning of my career, I was part of the committee that got our Nurse Practice Act changed so that nurse practitioners could have full autonomous practice in the state of Vermont. I don't think really any of us did much with that. I didn't do anything with it for twenty years. So my husband's like, just started my own practice, which is crazy. But that's like how we got to there. So for the past, so this is coming into my fourth year. My practice is TruePath Wellness. It is in Essex Junction, Vermont. I don't know what you'd 100% label it. I guess initially my thought was more concierge, but now people talk more direct primary care. Honestly can't tell you all the intricacies that make it different. But the bottom line is I tell my patients, I don't bill insurance for my services. I don't bill insurance for my time anymore. I work for you. I don't work for UVM. I don't work for Blue Cross Blue Shield. I don't work for Aetna or United. I work for my patients. They pay either a monthly, fee or they get a discount if they pay annually. And that's it. I'm on call for them, text me, email, come see me. There's no co pays, there's no other hidden anything. If they have health insurance, then that is what they would utilize for any lab work, any other specialty care, any imaging testing. But their relationship with me is, just with me and they cover that. I guess that's that kinda sums it up. It's wonderful. It took it took a while. You know? It's I love it.

[Alyssa Black (Chair)]: Can you can you, like, expand about why it's wonderful? Like, what do you feel well that you didn't feel before, I guess?

[Sarah Dudley, FNP (TruePath Wellness)]: Yes. I think, I mean, not to tell be negative and tell you all the things that you've probably heard from other testimony. Walking out of Thomas Chittenden towards the end of that, that was looking at 80 to 100 patients a week, scheduled every fifteen minutes, out for months. I'm behind, you're half an hour behind within the first hour of the day. And so just that rush, that go, go, go, just putting a lot of band aids on problems, not really, at least I felt this way personally, can't, I don't wanna speak for everybody, but not really having the time to dig in and solve things with patients to do really, really true preventive care, just felt rushed. Urgent care, I knew for me personally, wasn't going to be a long term choice, but I needed to pivot and just take a break and try something else. Urgent care ER care, if there's a plus as a provider, it's as close as you get to kind of walking in, punching in a clock and doing your work and going home, right? Nothing follows you outside of that. So that is a nice feature, but limited connection. And towards the end of that, the expectation was every six minutes. So at least I had 15 in primary care, then I had six in urgent care. And I just was like on this hamster wheel, I guess. And then through the pandemic, I really saw a lot of things coming into the urgent care setting. They just didn't need to be there. I guess I would say that even without the pandemic, lots of people utilizing urgent care that I think if they had a true easily accessible relationship with the primary care, they wouldn't be there. You don't need to sit for two hours in the lobby with a urinary tract infection. You don't need to bring your kid in that's having an asthma attack after soccer practice and sit in an urgent care lobby for two and a half hours. I don't think, I think if you had, those are things in my primary care practice I would have taken care of all day long, but people just couldn't access them and they couldn't get to them. Lots of college students overflowing into the ER and the urgent care that I didn't really need to be there, but they didn't have any place else to go. So I don't know, I saw that as a pain point, I wasn't feeling ethically congruent in the way I was having to be forced to practice care anymore. And so, yeah, this was my thought of trying it a little different, I guess, if that helps. Yeah, sorry.

[Brian Cina (Member)]: Okay, fine. Yeah, my eye hurts ironically. It's dry today. It's today for some reason, so it just keeps curving. I think it's allergies. So I'm not crying, I might in a minute though, but I'm wondering how much So you've opened a private practice, and I also have a private practice, I'm a clinical social worker. So sounds like you have a private practice that doesn't accept insurance, but does private pay. And I'm curious, how does that work? Do you have a fee schedule? Is it sliding scale based on the need? Is it based on the problem? How do you make ends meet? What is your sort of, whatever you're comfortable sharing about your business model, what's not proprietary or whatever?

[Sarah Dudley, FNP (TruePath Wellness)]: Right. I don't Maybe there should be some that's proprietary. Have no Medical provider first right, business person second, I am learning that. I didn't have any prior business ownership. Well, we did own an ice cream truck briefly as a family, but outside of that. So do, I have like, I have an individual, so I have a rate if you're an individual, I have a rate, like an adult individual fee, I have a family fee, I have a couples rate, I have a pediatric rate and I have like a college student rate. They're all a little bit different, probably according to my husband who now is helping with anything that's not medical, I think it's about probably $140 $150 a person is what we collect per month when you average out, some pay more, some pay less. I don't necessarily have a sliding scale. I have some clients that have started with me and then money might get tight or they might've been using an HSA or FSA or something that kind of runs out. And at the end of the day, I am here to care for people. So we don't immediately boot anybody over that. There's usually a discussion around a payment plan or lowering the fee for six months and then getting them restarted. If that helps you, yeah, that's kind of it. The only full discount is if you pay for the whole year upfront. I ask that they stay for six months just because a lot of that initial work in establishing with a new patient and a new primary care is done in those first few months. I'm looking at your prior records, I'm getting to know you, you're getting to know me. So it's not ideal to be turning over a new person, they come for a month and then they leave type of scenario, but we don't force that, if that makes sense.

[Brian Cina (Member)]: Yeah, so it's like a monthly membership fee, so to speak, or a monthly plans fee and that covers all of their primary care that might be needed? Or is that just the base and then depending on their usage, there might be additional fees?

[Sarah Dudley, FNP (TruePath Wellness)]: I tell them that's anything I can do for you in the office So that, you know, that I have control over. Right? So if it's so and I don't charge upcharge on usage. That kinda shakes out. You know? You have some people that are coming every month. They might have something going on, and I might see them every week. I have some people that just wanna know that I'm there. They come once or twice a year. So when you even all that, I don't I don't get into the weeds on how often people show up. That's yeah.

[Brian Cina (Member)]: Because I I don't mean to over ask, but I'm just trying to understand the finance of it a little more, because that's something we are looking at in the healthcare system. Does the fee include basic diagnostic tests, or is every diagnostic test different? Because I know some diagnostic, I'm not a doctor or a nurse, so I don't do diagnostic tests like this, but I know that, so forgive me if I get it wrong, but I know some things you can do in your office, like my previous providers, urine things, they can go in the back and take your urine and put drops in it, then it tells them. And then there's other things, they take your spit and ship it to a lab, and then it comes back with your cortisol level or whatever. So I'm curious, and I might have messed those things up. But when it comes to testing, is it the things you do in office are covered and the ones you ship, they pay for? Because I know with my chiropractor, when he had to ship it somewhere, I had to pay for it. When it was in the office, I didn't because it was covered or it was I don't know how he did it, but basically, it was when it got shipped somewhere that I had to pay, so.

[Sarah Dudley, FNP (TruePath Wellness)]: Yeah, I have similar, right? So I'm trying to think of what I do in the office. I run a basic urine screen in the office for free. I incur a little bit of a cost for ordering some lab supplies to do that, but it's built into the overhead. I do rapid strep tests on-site, those are included. If we're just taking off, not to get all medical, skin tag, if I'm taking off, doing simple skin procedures that we don't need to send out for biopsy, those are included. If it has to go out because could this be cancerous or precancerous or we don't know, then that would go to the lab and the patient would be billed a lab fee directly from the lab, right? From UVM's lab or Quest's lab or that type of stuff. So they get all their office visits, anything you give the normal doctor's office, I do EKGs, onset urine testing, stitching, lancing cysts, taking skin things off, freezing things off. What else do we do? I have a body composition scanner. So if we're working on weight loss and building muscle mass decreasing visceral fat, they can come in every month and run through that, that's included. I know, I think that's probably it. Work with And then if things, yeah, if things go out, then they would just incur the lab bill. I do have a cash based lab contract that's very reasonable. So for my patients that are either uninsured or have high deductibles, instead of sending out them getting a $600 lab bill, they have some pretty complete panels that can come back for about $150 But they know I'm gonna bill them additionally for those because I get billed for those. So that's not under their monthly fee.

[Brian Cina (Member)]: I appreciate the details, because it just gives us a better sense of the scale of expenses that go into primary care. That, when you are doing it on your own, you don't have this institution behind you and the infrastructure to support it, then you really do, it really does show you this. It lays out the real cost of it in a very more tangible way to me, to hear one person sitting in an office has all this equipment, and they can provide only so much for that 100 and something a month. And then beyond that, you have to utilize other pieces of the healthcare system, and that's why it costs more. So I just think it helps us understand the cost of healthcare more to hear the details from you.

[Sarah Dudley, FNP (TruePath Wellness)]: What do wanna say? Yeah, it took a little bit to figure out what the price point had to be to rent the building and have the basic equipment. I have one staff member and then I actually just brought on another nurse practitioner student that worked with me for the past year is gonna start building a panel and coming on. So I have to factor that in. Yeah, but there are ways, there are things like I say, the cash based lab. I use a lot of the independent imaging places for patients that are gonna incur out of pocket costs. They're cheaper for diagnostic imaging, open MRI. Have, yeah, you can kind of create networks to keep costs down as best you can and still provide good care.

[Brian Cina (Member)]: I'm curious how much I don't need to ask so many questions.

[Leslie Goldman (Member)]: It's not well, Brian.

[Brian Cina (Member)]: It is well.

[Alyssa Black (Chair)]: I've got like five based on what you've asked. And

[Brian Cina (Member)]: I'll stop with this one. Let other people ask yours because it's probably going be similar stuff. But how much is an MRI cost for one of your patients? Because I know that tends to be one of the more historically expensive

[Sarah Dudley, FNP (TruePath Wellness)]: diagnosis. I can't say 100%, right? Because I'm not billing them. I think it depends with contrast, without contrast. I would say between $800 and $1,100 at Vermont open MRI.

[Brian Cina (Member)]: That seems cheaper than it used to be.

[Sarah Dudley, FNP (TruePath Wellness)]: If paying cash. Yeah. And they can get an x-ray for maybe about $50 ultrasound in the few hundreds. Again, cash based. I don't see that money. I just want to make that clear. This is just me trying to if I have patients with full coverage, no deductible, they just, whatever, didn't just go wherever, we just send it out. But if we're trying to navigate people through a system that are high deductible or no insurance, I've just seen

[Alyssa Black (Chair)]: Well, you

[Brian Cina (Member)]: have patients who have insurance come see you, they only use the insurance for the other stuff? Yes, yes. Oh, wow.

[Alyssa Black (Chair)]: It's

[Sarah Dudley, FNP (TruePath Wellness)]: probably, I trying to think about this as I was driving in. Maybe

[Alyssa Black (Chair)]: this

[Sarah Dudley, FNP (TruePath Wellness)]: will answer some other questions. So my Yes, I'd say at least half the patients They're well insured per whatever standards, Vermont standards are national standards, but they work with me for, I think the biggest, for access, they're gonna call me that day and they're gonna hear from me in an hour, they're always gonna get the same provider. Those are the big things I hear. I spend time with them. Every office visit's a minimum of a half an hour. Most are an hour. You come in, we go right to the room. You're not waiting in a lobby with five other people because I'm behind, I just don't book that way, I don't schedule that way, which also decreases my cortisol level to just be chill. Yeah, so I think it was, I have patients that can just pay for this as an extra service because they want this type of care and they want this access and they want it individualized. I have patients with high deductibles and it's cheaper for them to know if they just pay this every month and they have to come to the doctor however many times, they're not gonna get any more bills. There's no surprise bill coming in the mail because they haven't met their deductible. And then I have a handful of, I have a lot of self employed people that don't, just do not choose to buy insurance and either save for that differently or however they do that. And then they know at least all their preventive screen, all their basic primary care stuff is covered and they sort out the rest, I guess.

[Alyssa Black (Chair)]: Yeah. You answered some of my questions. I'm very curious who you serve. You kind of touched on that, but how do you market your services to people? And I'm thinking about the volume of people that you see and how much control you have over that, and that must be a huge factor in your ability to really treat people and do less administrative work. Can you speak to that a little bit?

[Sarah Dudley, FNP (TruePath Wellness)]: Yeah. So I initially was marketing myself under the concept of this is just kinda like back to basics healthcare, right? Thinking of when I lived in the Midwest and I saw Doctor. Dunn in his little house down the road and he saw me and all my siblings and like, just was very simple. And that was kind of my initial mindset. If I can just cut all this other stuff out and really just have good solid relationships with my patients was what I wanted. After attending a few business networking meetings, because also like, this is the only way I get paid, right? I need patients to want to buy into this model. It's premium Now is what we would call it. That was the word I was encouraged to use. You're not basic, this is premium, full access primary care. Even though in my mind, it's the way we used to, the way I used to always get it, right? I don't know, but So that's how I market. Yeah, you get access, you get an individualized relationship, get as much time as you need.

[Alyssa Black (Chair)]: You know? People finding you word-of-mouth or are you advertising?

[Sarah Dudley, FNP (TruePath Wellness)]: I haven't done any I have a social media account and some social media following and mostly word-of-mouth. I haven't done any real formal advertising. Yeah, just other friends in the healthcare community, my prior colleagues in urgent care, when somebody comes through that doesn't have a PCP or they're like, well, you to see somebody. I get referrals that way a fair amount. They're like, you should go work with Sarah. She's great. You're gonna get this. Then you get one person and that's good. And then they tell their neighbor and then their neighbor and then you get the wife. The wife always brings the husband. It's rare that I get the husband that brings the wife, but that So can then you get the family. Yeah, I guess if that helps.

[Alyssa Black (Chair)]: I'm just wondering what your panel size is. Also wondering, because you said that your patients have direct access to you, even your cell phone number. I'm wondering if you find with that accessibility that people abuse that.

[Sarah Dudley, FNP (TruePath Wellness)]: That's a good question. And that was some of the constructive feedback, you could call it, that I had from other providers in medicine when I was kind of like, I might do this. Yeah, that you would get people might abuse that and they don't. I don't know how it just My thinking on why is because they know me personally, so it's not just like calling in a random after hours on call line, right? They know, oh, is this worth waking Sarah up for? So I think there's a little bit of that feeling and I'm gonna be there tomorrow and I'm gonna be there next day and I was available all day. So there's not this urgency of I've already left four messages and nobody's getting back to me and so I have to keep calling like that. That's the best I can say. I mean, I do get emergent calls when they're warranted and that's part of the deal, But I no. I think it's very mutual respect that I don't know why, but The panel size, that was also something that was like, right now I think I'm in the mid 2 hundreds. I might expand to about 300 and that's probably it. And I have another provider that she's new, so she's gonna be slowly kind of moving on. I don't know that she'll manage as many as I do. I think we're gonna just kind of feel that out as she goes. Heard I listened to some of the other testimony from other providers. To put it in perspective, when I left Thomas Chittenden, had 1,600 on my panel, which is a lot. And so I was like, even if I, I even want a quarter of that this way. You couldn't do it.

[Alyssa Black (Chair)]: Actually, can I ask you that? Because we've had a lot of testimony on this before. I don't want to When you were at Thomas Chittenden, were they under the CPS model of One Care? Think that started after me. After you.

[Sarah Dudley, FNP (TruePath Wellness)]: Because I don't think that they are that Well, I know that went away just recently, right? But I think they did have a period where they were able to not have as many on everybody's panels. When did I leave there? We were in the blueprint or that stuff was at least starting. My daughter was born in 2018, if that puts it in when that stuff was going on, 16, right in. So I don't think One Care was a thing. And that was an especially they'd had some providers that had retired, Hannah, they started Richmond Family PACT, there had been a little bit of turnover and so those of us that were left were absorbing panels, so I think that gave us all a little more than they probably carry now.

[Alyssa Black (Chair)]: Do you have an electronic health record?

[Sarah Dudley, FNP (TruePath Wellness)]: I do, yes, yeah.

[Alyssa Black (Chair)]: Do, okay.

[Leslie Goldman (Member)]: Can you say which one?

[Sarah Dudley, FNP (TruePath Wellness)]: It used to be called Karyo, now it is Debra. I did some research, priced things out, that's good. I have access to Epic. I use Vital, I use it for my immunization registry.

[Alyssa Black (Chair)]: So plugged in there. Yeah. I'm on your website, and I think it's really interesting that you have a small business thing. I do. Yes. Plus, you know, I have a business in Essex Junction, and I cannot afford insurance for my employees. I might get a So I

[Sarah Dudley, FNP (TruePath Wellness)]: started this and that kind of How do I want to say all this? So I didn't anticipate that need, right? I kind of thought there are definitely individuals out there that are having trouble getting into their primary care or they've moved to Vermont and they can't find a primary care and I'm doing all this primary care in six minute visits in an urgent care,

[Allen “Penny” Demar (Member)]: which is

[Sarah Dudley, FNP (TruePath Wellness)]: not appropriate. There has to be a different way to do this. And so as I started that up, then I realized, well, I should probably have a student plan. So have a handful of UVM students and St. Mike's students that see me when they're here during the school year, because it's just easier access than the student healthcare center. Some of them are on chronic medications, I do a fair amount of mental health stuff for them, so that's a good fit. And then I had some small business owners approach me that similarly, right? They have four, I have one that I think now maybe they have six employees, I had one with three, I had one where I used to do 10, but now they've gotten more employees, so then they did get a health insurance plan, so they've kind of moved off of me. But that's what they've said, Hey, we can't give you a full health insurance plan, but we can cover the cost for you to work with Sarah. And so, yeah, I don't know. Again, wasn't a need I anticipated, but it was there and it's been a good relationship.

[Alyssa Black (Chair)]: So we've talked a lot in here around my vice chair is going to start shaking next to me around quality and value and measures. And I'm wondering, and I'm not asking you to comment on quality measures or outcomes. I'm wondering to you as a provider in sort of an alternative practice financial model, what has been most valuable to you personally as a provider? What have you valued about this?

[Sarah Dudley, FNP (TruePath Wellness)]: Oh my gosh. That's a good question. I think the relationships with patients, I really feel like I make a difference again. And I think there was a good eight to ten year chunk of the middle of my twenty five years of this where I was like, what are we doing? I don't feel that way anymore. My patients are, yeah, they're appreciative, they're very thankful. I have time to be like, why maybe this, you know, this hair loss supplement might not work. Why maybe you don't really need to still be on that sleeping pill because there's all this other stuff we can work on. I just I don't know. It's yeah. I think being able to feel like I'm actually really the care I'm providing is congruent with, like, the care that I would want for me and my family. So I think that's been the biggest benefit. Yeah.

[Alyssa Black (Chair)]: Brian, more questions. I have some to Oh, can I go to Leslie and just Of

[Brian Cina (Member)]: course, of course? Ahead.

[Leslie Goldman (Member)]: You, Sarah. I'm Leslie Goldman. I'm a retired family nurse practitioner, so I'm totally fascinated by your life because I lived your previous life, but not your current life. And I'm looking at your website too. And I'm curious, and a lot of my questions have been answered with sort of the day to day operations, fascinating. How do you deal with emergencies or patients admitted to the hospital? What's your interaction in that world? If you could just talk about that a little bit.

[Sarah Dudley, FNP (TruePath Wellness)]: Yeah, I I have what do they call it? What am I with UVM? Community provider access or something, right? So it's similar to kind of how I had it at Thomas Chittenden. What do I want to say to explain this? The use of hospitalists kind of changed that for all of us in primary care. I don't know, it was ten, fifteen years ago or something like that when that came on. So if I have a patient that's admitted to the hospital, then they get an assumption under the care of either that specialty provider, they get absorbed on the hospitalist service and they just communicate directly with me like they would have previously, right? They send me notes, they call me, I'm probably in better, I am in better touch, I'm not probably 100% in better touch with my patients than I would have previously because I only have a couple 100 of them and I

[Leslie Goldman (Member)]: I was just looking at the number before they're

[Sarah Dudley, FNP (TruePath Wellness)]: going to the hospital, so I know that this is what's coming on or we've Yeah. Yeah, I guess if that helps you out.

[Leslie Goldman (Member)]: Communicate that. But you coordinate care once they're discharged so they come back to you and whatever. I'm looking at your website and you say apply, apply. So what does that mean? Does that mean some you take and some you don't? Like, what's the criteria as you move through that?

[Sarah Dudley, FNP (TruePath Wellness)]: I know that's interesting feedback. Don't know about apply. That word was probably just put on there without thinking a lot of it. There have only probably been two or three people that I have just had to say, I don't know that this will be the best fit, that you have a lot of needs that are something that at the time as a one person practice, I probably can't support. And so usually there is always, everybody gets scheduled for kind of a meet and greet, you get half an hour, we sit down, let's just talk about what your expectations are and what I can provide, and are we gonna be a good fit? And also probably there's 10 or so people after that meeting that are like, this probably isn't for totally fine. I'd rather know that upfront, right? And vice versa, there's been a few, the one I'm thinking of off the top of my head, which is I wish I could have, but she needed some IV medications and home things. And I just was, you would be better served at a clinic that's larger, that's got the full blueprint really that you guys offer. There are definitely pluses, there are a lot of pluses to that. Yeah. So that's more of, I think what that is, that's really, or people filling that out and not really looking at the whole website so they don't know that we are a cache base, that is one of my husband's first things when he answers the phone and they're asking if we're taking new patients, he'll say, We are, have you had a chance to review our information? We do work different from a traditional practice. So we preface that discussion before, yeah.

[Leslie Goldman (Member)]: Where do you get your collegiality feeding your professional self?

[Sarah Dudley, FNP (TruePath Wellness)]: I know, that is, yeah, no, I know that's a good point. I definitely, I am still in touch with prior providers I used to work with, Rick Dooley and I get together and you guys have met him, think. Precepting this nurse practitioner student was great. And then where I am now, I still have a, what would I call them? I have a contract with the broader world retreat, that's where I'm covering today, I do so many hours a month for them. I've cut that down as my private practice gets bigger, but they need help and I enjoy the collegiality of it. And I like, and it's good. It's just good experience, good mental health experience for me. I also contract with River Rock, which is an intensive outpatient treatment program in Burlington for substance abuse. And I do their medical coverage if they need it. So if they have clients that do not have a local PCP or don't have a PCP at all, maybe they've come out of rehab out of state and then they're now back here, the program will cover my subscription fee while the patients are there and then they access me for primary care. So I have interaction with their counseling staff and social workers and their director. Down here at the retreat, I'm on the medical consult service very, very minimally, but there's five other nurse practitioners with myself down here, so that's a good fit to come down once a month.

[Leslie Goldman (Member)]: You go on vacation and what happens to your patients when you go on vacation?

[Sarah Dudley, FNP (TruePath Wellness)]: I did just go on vacation and you know what the beauty of it is? I can just go when I wanna go. That's a self employed thing though. But how's my patient on vacation? So, so far, I haven't been I'm still reachable. We warn them, right? Hey, this week, we're not going to be available for on-site visits. If you need anything now that you can think of, please reach out. We will answer emails, phone calls, text messages, but our response might be delayed. And then for now I have Emily, that's part of that, who's allowing the practice to keep growing. And so she cross covered for anybody that needed to be seen in the office. And before Emily, I had one of my prior colleagues in urgent care who's now in dermatology covered. Nobody needed her, but she was there in case there was somebody who really had to have her come in.

[Leslie Goldman (Member)]: Do you have a contract with her or is it just a mutual

[Sarah Dudley, FNP (TruePath Wellness)]: That was a one time mutual thing, but Emily and I do have a contract. Yes.

[Alyssa Black (Chair)]: Well, yeah. Got it. Yeah. Shoulder owned contracts.

[Sarah Dudley, FNP (TruePath Wellness)]: So, yeah, there's probably a way to make a bigger call group. I don't know. I haven't sorted that out yet, but the need hasn't been huge. Your backup luckily, legally, there's an emergency room within so many miles in Vermont and urgent care with so many miles. And so there's no patient abandonment issues. They can always access that, but

[Alyssa Black (Chair)]: Thank you. Do you do home visits ever?

[Sarah Dudley, FNP (TruePath Wellness)]: I do, yeah. Some new babies. I have a few patients that are in assisted living and I'll go visit once a month, earlier if they need me, but I'll just check-in.

[Karen Lueders (Member)]: You

[Brian Cina (Member)]: said that you provide a premium level of care, that's what you would call it. You know, are there any providers out there who offer a premium level of care and accept insurance for other patients? Do you know providers who are offering a premium track in addition to accepting insurance?

[Alyssa Black (Chair)]: I

[Sarah Dudley, FNP (TruePath Wellness)]: that still looks I think that's what that MDVIP kind of chain model is. I don't know 100, but I do think that is happening, yes, where you can pay they will still bill your insurance, but if you pay an extra membership fee or you pay something on top of that, that would get you more priority care or maybe a different level of access. Don't quote me 100% because I don't know.

[Brian Cina (Member)]: No, will, I'm just curious.

[Sarah Dudley, FNP (TruePath Wellness)]: I was told also at one point, you're leaving money on the table. You could probably still bill insurance and do some of this care. And I just said no. It's like one or the other for me. I don't know how other providers, but if you were trying to keep a small, like your own small private primary care practice and do insurance, I don't know why you would do that. I would have just gone back to Thomas because it's so admin heavy and you got billers, you got coders, you've got a who knows if you're gonna get paid, if it can take ninety days, you ask them for $109 they send you 72. I don't know. I was just like, I wouldn't try to recreate that model on my own.

[Brian Cina (Member)]: Yeah, I hear you. Got to say as a private practice business person or whatever we are called, that it that there's something appealing to the idea of just not having to deal with all the administration that you don't have to deal with now. So that's why I was curious if people are kind of doing both and and expanding. The so the real the last real, like, question I want to ask you, I ask a lot to people, and you might see my committee react

[Alyssa Black (Chair)]: to the question,

[Brian Cina (Member)]: is how I'm trying to ask this is a serious question. How How is technology such as artificial intelligence play into your practice? Like, you integrating AI into practice the way other primary care physicians are starting to?

[Sarah Dudley, FNP (TruePath Wellness)]: Yes, just in like a little bit and more looking into that in the last month, honestly, trying to use AI, just feeling like I'm not as a human being totally left behind, right? Because in all areas of our life, think that's coming in. My electronic medical record now has it as an option, I can bring it in and do the whole AI Scribe thing. I do not use it that way, again, because of what my patients like, is a different practice, right? I take notes on a piece of paper. And I do have my computer to look things up, but I don't document usually while I'm in the visit. So I use that when I'm done as like an AI dictation tool, which is better than old fashioned like dictation that we used to do. It's better voice and it links some diagnoses and things for you, so that's nice. And then we started playing around a little bit with an agent to see if that could be something that helps checking in with some of my patients that, like I said, like maybe we're working on some weight loss exercise goals and maybe there's a way to have something like that doing some weekly checking in for people, but I haven't rolled any of that out. Oh, and social media and blog posts and like, I use AI for that.

[Brian Cina (Member)]: But you see, I'm hearing that you're currently using it a little bit, you're using the function in your medical record in a limited sense for dictation and note taking, and that it adds some enhanced features, but it might link in diagnosis and stuff, but it's all human reviewed. Then that you're using social media and all social media is AI, so you're acknowledging that. And then that you're considering experimenting with agentic AI for following up and stuff with people, but not necessarily providing care, but like supporting care,

[Legislative staff/analyst (unknown)]: like the kind of supportive

[Brian Cina (Member)]: coaching kind of stuff or reminders, things like that.

[Sarah Dudley, FNP (TruePath Wellness)]: Yes, that's a good summary. Yes, nothing Yeah, for actual it's good to learn new things. I don't want to be totally left behind to not use it at all, but it might not fit. I don't know. So we just started, I just paid for that at the beginning of the month to have that agentic AI to see what we can do with it.

[Alyssa Black (Chair)]: Any other questions? This has been absolutely terrific. We really, really thank you for joining us. Of course, you have the freedom to set your own schedule. Or you didn't miss three patients that you could have seen

[Sarah Dudley, FNP (TruePath Wellness)]: in I this didn't know, though. I could, can I make one other comment? Of course. Whereas I was listening to some of the other testimony in the S197, which I think wouldn't really affect me, but I think it's a good I think what you're trying to do is great, right? This is finding other ways to support primary care that get them off only the fee for service model. And my only other thing would be, I guess you asked what I liked about my practice, I'm trying to tie this back. Was reflecting on if the patient panels can be cut down, the admin can be cut down, the quality will just happen. I really, you just have like, we're just all the healthcare providers in Vermont are good people, we're here for a reason, they want to do the best that they can for their patients. So I think unburdening as much admin and external quality checks just to have the quality checks for the insurers or the pay years, it just would be very helpful for them. And then another kind of like side trickle down is as I'm been freed from some of that, I'm just more able to be more interactive in my community in a way that I could not when I was cranking out these patients. So I was reflecting on that, I hold talks on women's health. I've got a Men's Health May we're calling it and we're doing two free seminars on that. I've gone to gyms and talked to people. I've talked to other small business owners. It's important to me to also give back to my community. And I think you would get more primary care people doing that if they're nine to five or nine to eight wasn't such a grind, that they're sitting on this wealth of this information that could also be really helpful and could be disseminated out into the community at large if they were working differently. I don't know. That's my plug.

[Alyssa Black (Chair)]: Thank you for that thought. That's some Oh, now we have two questions. I just Nobody mentioned that before. I wanna underscore that you didn't mention any of those activities that you're doing in your community when I asked about marketing. And it just shows that you're genuinely there for your community. You're not looking at it as an opportunistic or business opportunity. So I just commend you for that.

[Sarah Dudley, FNP (TruePath Wellness)]: Oh, thank you. Yeah. No, that's one of my pillars was to just part of doing this, right? Was to get, provide the care that I wanted to provide to get a little bit more work life balance back for me and my family and to keep my patients healthy and keep my community healthy. And so that's, yeah, that's a little same with some social media stuff, right? There's lots of wellness influencers out there and a lot of the actual certified providers aren't on there, right? They don't have time, they don't have the need. For me, that does serve a little bit of a marketing purpose, but it's also getting to put good education out there and good information out there that I think needs to be heard and balance out some of the stuff. Right.

[Brian Cina (Member)]: Yeah. Just what you were just saying about the bringing it back to the bill and stuff. What are your thoughts about universal primary care? Like, what if there was a system of care where that would pay you a fee that's close enough or more the same as what you're currently accepting for patients, and there was less administrative burden, would accepting you people in a universal primary care program? And if you don't feel like that's the right match for you, how do you feel like that being an option for others based on your experience in other parts of the system of care?

[Alyssa Black (Chair)]: I think

[Sarah Dudley, FNP (TruePath Wellness)]: it could work. I think though, I don't know how you get there. Think there are a lot of roadblocks. Like I said, it'd have to be really well funded so that providers could get off of the chain and could just really maybe then they have seven fifty patients, right? They can cut their panels in half, you cut their admin work in half, don't have, the quality just happens, so the quality stuff gets away. Yeah, I would consider, I'm not a 100% against that. I think practicing this way though has ruined me, I won't go back to an insurance

[Alyssa Black (Chair)]: reimbursement. I

[Sarah Dudley, FNP (TruePath Wellness)]: can't, I can't do it. And that's also just having some autonomy in your schedule in your life, just as any other small business owner, right? This isn't for everybody, this way of practice. I'm on call a lot, I feel a bigger burden and sense of responsibility, but I have a lot of autonomy and I can work the way you wanna work. There's pros and cons.

[Brian Cina (Member)]: Like you said earlier, it brings back some of the best of the old fashioned way of practicing.

[Sarah Dudley, FNP (TruePath Wellness)]: Yes, but don't market yourself that way. I'm not basic.

[Brian Cina (Member)]: Premium. New and premium.

[Alyssa Black (Chair)]: Are buzzwords. All right. Thank you so much for joining us. We really appreciate it. Fascinating. Thank you for your work in our community. Thank you. Alright, so I thought that we should probably spend the remainder of the morning, which is only down to thirty minutes now, talking about last night and sort of having some committee discussion around S197. I honestly think that we've probably taken all the kind of unofficial testimony that we're going to take on it. Obviously, if we start changing things around, then we will take input around language from various people that sit around here all day. But that's the end of our educational testimony on primary care. I feel like we've been talking about primary care for about two months, haven't we?

[Brian Cina (Member)]: And we have like a week left.

[Alyssa Black (Chair)]: And we have a week left. It's a good grounding.

[Leslie Goldman (Member)]: We have a

[Alyssa Black (Chair)]: week left, and we still have four bills. We have this bill, we have the bill, the S-one 190, which was around reference based pricing. S-one 189 will do also next week. Jen is working on language around the Remember, all the stakeholders were kind of coming together and coming up with a road. We were paving the road. That's all I'm saying. And then we'll do a six eighty four next Tuesday. So, yeah, all of this, my hope is to get it done by next Friday.

[Brian Cina (Member)]: Because then we have a week because then we have a week of floor stuff, so that's why

[Legislative staff/analyst (unknown)]: we have

[Brian Cina (Member)]: to get it out of committee next week. Otherwise, we're we're gonna fail.

[Alyssa Black (Chair)]: And let's not forget. We're gonna start seeing things coming

[Brian Cina (Member)]: back from the center. Yeah.

[Alyssa Black (Chair)]: And that's always like, we have to listen to something for ten minutes and find somebody to come in. So, I just want to get What were everyone's thoughts around last night? Anybody want to start?

[Sarah Dudley, FNP (TruePath Wellness)]: Can I ask a question first? Yep.

[Alyssa Black (Chair)]: Just to frame my thinking or contain it. Is this feedback intended to inform next steps on any piece of legislation or just in general? I think in general, I guess I wanted feedback on last night, feedback around actually all the testimony that we've been taking, what people's thoughts are, I mean, entertain. I'm going to ask the question, which I don't know if we can get the answer to today or consensus on the answer. But as I keep thinking about all of these bills, I just keep asking myself the question over and over again, which is where do we want to get to? I really feel like we need to define, and particularly this bill, I think we need to define what is it that we are trying to achieve. And I feel like if we can define what we're trying to achieve, and we have a clear goal in mind of what we want to get to, then I think we can start building in the build the path to get us to this end point. I think somebody said to me something to the extent of, let's decide where we're going to go on vacation, and then let's do a plan of how we're going to get there. So I'm looking for thoughts around what people have been thinking between last night and the last two months of testimony we've been taking and how your thinking may be evolving or changing and where are you thinking? What are you guys thinking about? I'll go first. Yes, please. I think last night really solidified to me that primary care is so invaluable. I heard the stories, and to me, it made it very important. I can't really wrap my head around the whole Blueprint thing quite yet, because I don't see how Vermont is paying for it, and the other half is not. I don't even know if those are the right numbers, I still think the claims tax is the way to go in this, and I don't know if that's even possible, but I just think half funding a plan that is so important, we're not there yet, that bothers me. I know that that's where we have to be. So that's where I am.

[Brian Cina (Member)]: I don't think it should come as a surprise to anyone, but I think the end goal should be, I think we should allow private equity to take over the whole healthcare system.

[Alyssa Black (Chair)]: Oh my god. And then have them all be AI providers, Yes, only

[Brian Cina (Member)]: premium AI. Seriously, I just want to make sure everyone's paying attention. I think I ultimately want us to provide healthcare to the public good. And I think that in the long term, it might take a long time to get there, would be a publicly financed system. And that I would like, I do have sympathy for all the other players involved. And so I'm not trying to seize the insurance companies and put them under government control or any dramatic action like that, but more like an incremental transition. And I think that what that would look like is so huge and gigantic and overwhelming to conceive that we can't possibly work on that quickly. So I would say that in the short term, that aiming for a piece like primary care, universal primary care, is achievable, and I think that if there was a way we could do a little bit more in this bill, besides ask the treasurer to talk to surrounding states about the possibility of a regional universal care healthcare system, that that would be good. That if we could look at the numbers But I think it's more than looking at the numbers, because it's like, the question isn't like, how much would it cost? It's what would it take? I think that's the question. What would it take for us to create a universal primary care system? I have heard ideas from stakeholders. I'm not going to name them right now, because I don't want to put anyone on the spot, but they're here and they want to say something they can. But there are stakeholders who talked about how we have components in place, like a blueprint, that could be used as a foundation. And so I think that's a compelling argument. Might we be able to create, and maybe it's voluntary too. I know if we can legally force all providers into some, that doesn't seem fair to say to providers, you have to be part of this one system of you can't be private pay, but we should make it so appealing that premium providers, like the one we just heard from, want to be part of it. We need to make it a universal primary care system that's so good that it outcompetes any other option. That's what I would like to say. The minimizing administrative burden, the absolute minimum we should figure out what the absolute minimum is and require that and nothing more. And it should be the easiest to get paid without fraud. And there's ways to make sure people aren't fraudulent. I just think that with education reform, that bill had, what, one hundred secondtions in it. Like, that's the wrong direction. Like, we should be simplifying it.

[Alyssa Black (Chair)]: I feel like, because I was just saying, you're gonna be for one hundred secondtions. I'm like, yeah, we're not doing it. No, everything as

[Brian Cina (Member)]: an example of the problem is like, we should be simplifying things. We should be simplifying it and boiling it down to the absolute essence of what it should be, which is the highest quality of care and the best possible working in clinical conditions for the patients and providers. Anyway, I could prattle on, that's my point, that I've said enough. Hopefully that gave other people time to think. Uh-huh,

[Leslie Goldman (Member)]: okay. Yeah. I don't like

[Wendy Critchlow (Member)]: wording my experience like this, but I still feel

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

[Karen Lueders (Member)]: to comment.

[Wendy Critchlow (Member)]: So I'm just gonna ramble. Would love to see obviously, I think we all would primary care physicians just be relieved of their burden, of the administrative burdens. That's obviously huge. Someone takes the time in their life to pursue a goal that they should actually be able to fulfill their dream and be that person. Like, I hope I'm a good one. I know you have to ask the case there. But physicians obviously want more time than their patients. And also, I do think, and I don't know, if we could look at neighboring states and possibly find a way to make ourselves attractive in ways that they could help us, that we could use New Hampshire or New York. I don't know if any of that's possible, but they have numbers. And they have stronger entities.

[Alyssa Black (Chair)]: You mean, like a regional collaboration? Is that what you're referring to? Can I look to Ledge Council, because I don't recall this, but I because there is a section in the bill around regionalization, sort of the treasurer should call the other treasurers? Did we do that at some point? Maybe Nolan would tell, no one's our historian often.

[Legislative Counsel (unknown name)]: So I'm Houghton, Licht City Council. I know this issue has been brought up a number of times about looking at collaborators stays with DH. Typically doesn't get very far because it involves giving up a lot of our own regulatory authority to determine what gets covered. And so I think that the past efforts, I'm not sure they've gone as far as a report, but others may remember something differently. Think once members recognize the limitations on our own authority with our federal government states, the interest has seemed to wane.

[Karen Lueders (Member)]: Is that fair? Thank you, Mr.

[Legislative staff/analyst (unknown)]: Chairman. Think it's both that, and I like the way Chai Samson put it in Senate Finance the other day, we're not a great dance partner.

[Alyssa Black (Chair)]: He would say something.

[Legislative staff/analyst (unknown)]: Would say something. We're more expensive than any other state that contemplates joining us, then we're gonna look at that person.

[Karen Lueders (Member)]: We just raised him. But I'm not sure, sorry, I'm not sure that

[Legislative staff/analyst (unknown)]: was the question was exactly about insurance. It sounded to me like you were talking more about racialization work. Well, this was in the context of access to access.

[Brian Cina (Member)]: Mean, I've been

[Wendy Critchlow (Member)]: We obviously need help. I just, being thrown into this committee, I mean, there's just so much going on. I find it hard to have a voice as one person here in any decisions because there's so much going on with AHS. I don't understand how we make decisions and be parallel with that process. That's confusing.

[Karen Lueders (Member)]: Karen. Yeah, there's just so much to assimilate, digest, sort through. Last night, a good number of people were asking for studies, let's understand how we could finance or stand up universal access to primary healthcare. That is a great place to start, since it's a very small part

[Alyssa Black (Chair)]: of what we spend now,

[Karen Lueders (Member)]: but a huge part of what actually gets delivered in terms of quality healthcare. There were some already existing models, Doctor Dean talked about Doctor Dinosaur, thirty years of access for everyone 18 years old and younger, as an existing, well established functional model. The People's Health and Wellness Clinic said, hey, we're, this what we do every day, we're like the best deal in town, could we strategize regionalizing that? Doctor. Son has his 5%, let's make a public utility concept and then there's the blueprint, which know has some nice qualities to its model. But when you think, somebody said you need a million for any of this to work, we don't have a million, so my question is what is the best

[Alyssa Black (Chair)]: we can People, sorry.

[Karen Lueders (Member)]: To be, perhaps scale, so what is the best we can do with all 700 whatever of us, so you know, 40 and falling, you know, it just seems to me every person in the state needs to participate, That includes the big groups because we're all in this together some people are really,

[Leslie Goldman (Member)]: some people are not living because they

[Karen Lueders (Member)]: don't have access to primary care and so it just seems we're all in it together, we should all want to be part of this solution together. So I love the idea of starting with universal access to primary health care, I just don't really accept what you feel about it. Think it's really important. And it will save, I do believe it will save the system money, but that's not the reason to do it. It's the reason just to get the quality health care for everyone. And everyone deserves it.

[Alyssa Black (Chair)]: I

[Francis McFaun (Vice Chair)]: think it's clear from the testimony we've heard here in committee and what we heard last night that primary care certainly helps people, saves lives, and ultimately saves money down the road with undiagnosed condition. The concern I have is moving too fast. There's a lot of times that we do legislation where we don't consider the unintended consequences. And I think that, you know, studying into this a little bit more, this isn't a drastic step on 01/1997 as far as I'm concerned. But I think we need to know what we're in for. You know, the hospitals are struggling this year based on, you know, some of the things that we did with the solvency of of, insurance. And now we have to adjust that because the hospitals are losing money. So, I'm concerned about moving too fast. In general, I am in favor of the bill. I am concerned about adding too much on top of it,

[Alyssa Black (Chair)]: moving forward. What about taking some things away?

[Francis McFaun (Vice Chair)]: I'm open to that. Or replace it. You have to be careful about the replace.

[Brian Cina (Member)]: Like taking out a study of one thing. You mean, that's what

[Alyssa Black (Chair)]: you're talking about. That's what I was thinking. Yeah. Oh, Daisy, and then Leslie. I loved the conversation last night and wish we could have heard more.

[Daisy Berbeco (Ranking Member)]: I think it was interesting. We didn't announce anywhere that I'm aware of that we were focusing on universal health care, and that came up really frequently, consistently. And people were intense about that call to action and also very specific about it. There were a lot of great minds in the room with actionable recommendations, both structural recommendations and input that I think some of them, we should take time to contemplate just how actionable we could be. I agree with Dave. Moving too fast is never a good thing. But I think we should have a directional focus for universal health, primary health care. And I've concluded it should be provider led because I think our providers our last witness really summed it up well when she was saying something about when we reduce administrative burden and panel size, quality follows that because you allow providers to do their jobs. And I think that also will naturally or hopefully heal some of the workforce challenges that we have. Vermont's going to be and someone said this last night that Vermont will be a more appealing place to work. So I think one of my favorite comments from last night was that universal primary health care is prevention for some of our deepest crises that we're all facing right now around loneliness, mental health, and addiction. It was just such a wonderful comment. And I also really appreciated the doctor who spoke about the importance of the link between primary care and population health. I thought that was brilliant. And I can't say enough about the quality of the comments that we had last night, and I hope that we can really do something with them. My recommendation would be that we empower a group to get together over the summer and continue that conversation that was started last evening. I love that you said provider led. I thought

[Leslie Goldman (Member)]: you were going

[Alyssa Black (Chair)]: to say you loved that I said something about quality. It should be though. Our providers have seen it all. They understand the financing cases, they understand the treatments, they understand the delivery setting. I'm thinking back to previous iterations around healthcare reform, and I'm wondering, did we let the providers of care lead on that, or did we let the payers of care lead us?

[Brian Cina (Member)]: You know what's ironic? We said that ACOs were provider led. We called the ACOs provider led, I remember this. And I was like, so the administrator couldn't provide, you know what I mean? So just putting it out there that ACOs were considered provider led.

[Leslie Goldman (Member)]: Leslie, so I thought last night was really interesting, but there were no surprises for me. It was a segment of an activated group in Vermont who are informed and wanna see a certain model. And it's a great model, except the devil's in the details. And we don't know that yet, which is what we're talking about, I think, going too fast. I worry that we don't have enough providers in our system to provide what they are dreaming of. So that's a huge problem, I think. Just to launch about it, 01/1997 is like four reports and basically not much else, although there is a per member per month kind of blueprint kind of discussion, but I still haven't been convinced, I think, that the blueprint has the capacity to do this, and I would need more understanding of that. I am very interested in the model presented by Doctor. Song and would like it to be on the table. Because I think if we just do more reports with the same model, we're just going to get, do the same thing, keep doing the same thing, expect a different result, that's dumb.

[Alyssa Black (Chair)]: You're talking about a common good fund?

[Leslie Goldman (Member)]: Common good fund. I think we should really explore that because it does change the process and we need to change how we I mean, and I said the other day, is this a payment reform bill or is it something else? And right now, a payment reform bill would be an interesting place to start if we Because it would support primary care. That's the whole point of it. You have that 5%, you distribute it to primary care practices, they do it from themselves the way that we've heard. So I am very interested if we decided I would support the IGES study that looked at payment models, that if we want to include the blueprint because that's what we got and they included it came from the Senate, but in comparison to other models out there, especially Doctor. Sahn's. And I think I'd like to see that included.

[Alyssa Black (Chair)]: I

[Allen “Penny” Demar (Member)]: think there's a lot of reports. You said four? Yeah, I thought there was more than that. Okay, I have concerns over the payment plan per month per member. It's leaving it up to anybody to say how much, and it scares me. There's a part in there about the age scale of your age and say what your per member cost would be. And I'd like to know the breakdown of the money collected and where it's going to go. Is it going to go to all health care? Is it going to Blueprint for Health? Are they going to go for administration fees? There's a lot of unanswered questions for me, but I do support primary care.

[Alyssa Black (Chair)]: You support just primary care or you support Well, I'd

[Allen “Penny” Demar (Member)]: the like to final. Universal primary care, yeah.

[Alyssa Black (Chair)]: So you don't want to build universal primary care in this bill, but you

[Allen “Penny” Demar (Member)]: I want to see the final draft here.

[Alyssa Black (Chair)]: The steps that it would take to get Okay, it I was just trying to discern another. Anybody else?

[Brian Cina (Member)]: I have a final comment after everyone.

[Karen Lueders (Member)]: Okay.

[Allen “Penny” Demar (Member)]: I've got one more comment.

[Alyssa Black (Chair)]: Yes, please.

[Allen “Penny” Demar (Member)]: Far as last night at Universal Healthcare, and I heard Daisy say there's some brilliant minds in that room, I wasn't one of them, okay? The point is, it's a great idea, But if Vermont thinks we can do it on our own, I don't know if we can do that.

[Karen Lueders (Member)]: I don't

[Alyssa Black (Chair)]: know if we heard anything about necessarily universal primary care. I thought we heard a lot about universal, not universal primary care, universal health care. I thought we heard a lot about universal health care in that people said, this is what we need, but we can't have that because that's a federal thing. Well, okay. Chittenden. Oh. Any other I was gonna say, I was gonna call you out and I'm say I'm like, I'm I'm

[Lori Houghton (Member)]: I'm I'm like, I believe in universal primary care. I am interested in the common fund. I don't know how to get there, and it's not easy, or we would have done it by now. I want to pass something.

[Leslie Goldman (Member)]: I don't

[Lori Houghton (Member)]: want to do studies. I want to do a study that lays out a

[Alyssa Black (Chair)]: plan. Which to my question, where do we want to go? Where is our destination? Where do we ultimately want to be? And then let's lay out a plan to get there with steps along the way. How does that feel to everyone? Yeah, I'm with Leslie and Lori on the Common Fund, and I would love Doctor. Song to come and work with a group of to say, if Vermont wants to go this direction, this is how you could get there. There's a bill in Massachusetts that I'm sure could be a good resource. So, how about, I'm just laying this on the table because I know people want to get out of here. How about we lay out the intent of the general assembly that we will achieve universal primary care by some future date, and then we go through the steps of who needs to do what to get a model in place, to figure out the funding in place. The thing I love about the common good is it doesn't spend a dime more than what we already It's not established. It's to just be direct. And it includes other payer stuff. Well, that's the thing, and to ensure that everyone is paying into it, and I'm not even just talking about insurers and payers. I'm talking about should employers who do not provide health coverage for their employees, should they be paying Intuit as well? But to set up a process where people are moving towards a place where what do we need to get to this final destination? Does that feel good for 01/1997?

[Leslie Goldman (Member)]: By a certain time, perfect.

[Alyssa Black (Chair)]: Well, we can discuss if we want to do a certain time. I just want to remind

[Leslie Goldman (Member)]: everybody that care about that

[Alyssa Black (Chair)]: because it could be '20 Well, I want the plan next year.

[Brian Cina (Member)]: I need by

[Alyssa Black (Chair)]: that in 01/2026, we laid out a plan by 2030 to have hospitals on global hospital budgets.

[Karen Lueders (Member)]: That's right. That's So,

[Alyssa Black (Chair)]: you know, we are not this is not unprecedented.

[Leslie Goldman (Member)]: So We need to set out a date. If we

[Brian Cina (Member)]: could have universal primary care and global hospital budgets in 2030.

[Leslie Goldman (Member)]: That would be cool.

[Brian Cina (Member)]: But I think we need the plan next year, because we need a plan to approve. Figure out how to get there. We don't tell them. Need a plan.

[Alyssa Black (Chair)]: Great. Everybody in agreement of working through on Yes. Alright. Dan, could you write that off for us? I was

[Karen Lueders (Member)]: joking. The

[Alyssa Black (Chair)]: comment I

[Brian Cina (Member)]: wanted to make that was a little more far fetched at the end is just that this idea that we need a million people in Vermont to make universal healthcare work, that's what we have heard, I think, and we don't have that yet. Maybe we can make universal primary care work, and then that will make Vermont more attractive, and then here's where everyone's going to gasp, and then we bring the Olympics to Vermont. And then maybe we can have a million people here in ten years and have universal healthcare, thank you.

[Alyssa Black (Chair)]: And I generated sports people in the I just want say to the committee, I'm sorry that I wasn't there last night. I actually had to attend another meeting for the speaker or I would have been. So I didn't want you to think that I just didn't show up. We can. It was actually Okay. Good. Better.

[Leslie Goldman (Member)]: So where are we considered debt by when do we need something out of this committee in order to make

[Alyssa Black (Chair)]: it through the process? My goal is Friday, we need to get out of

[Leslie Goldman (Member)]: this committee. Okay, that's very cool. And so I think a lot of us have

[Alyssa Black (Chair)]: committed to that goal. We're going be here on Zoom anyway, let's be honest. Honest to say, I'm

[Allen “Penny” Demar (Member)]: willing to do it.

[Leslie Goldman (Member)]: It's a thing for myself to get this out of committee. If it means late nights, if it means We will

[Alyssa Black (Chair)]: be working, we will not have short It doesn't have to be that committee next week. We will be in committee every opportunity that we're able

[Legislative staff/analyst (unknown)]: to have the next week.

[Leslie Goldman (Member)]: Because this is crucial. I mean, I think having the hearing really made it clear that it was crucial and that we need to respond, that we heard it, that we're presenting a plan. All plans change. Everything we know in legislation can change. We'll pass something now, establish the plan, and whatever happens next year gets revised or fixed, whatever, can't work, will work, who knows? But for right now, that's the Senate. I really think it's important we get something out. And for me, willing to do whatever it takes.

[Alyssa Black (Chair)]: Thank you, everybody. We're done. We'll see you back here on Tuesday. Actually, make sure you check the agenda over the weekend in case we could possibly do committee before four Yeah. Tuesday. I know. It's, like, at four, 10:00.

[Leslie Goldman (Member)]: Yeah. What it takes. Alright.

[Brian Cina (Member)]: I mean, that's what Zoom is for.

[Alyssa Black (Chair)]: I think so.