Vermont Legislature SmartTranscripts:

[Theresa Wood (Chair)]: Okay, good morning everyone. Welcome

[Jubilee McGill (Member)]: to Wednesday.

[Theresa Wood (Chair)]: We will be starting off the day with some of our reporting that was due according to last year's budget bill around nursing homes, section E306B. And really, this is in response to the several years of EFR, extraordinary financial relief, and really wanting to have a better understanding of that, of ownership, of facilities, of process being used. So there were a bunch of questions that we asked in the that the general assembly asked the department to respond to. And rather than submitting a report, we said do a presentation. So we do like from time to time to relieve people of submitting reports, especially on things that are evolving in nature. So Commissioner Bowen is here. Welcome Doctor. Bowen.

[Dr. Bowen (Commissioner)]: We did submit a report, two reports. Are you above and beyond? Yeah, and we partnered with Diva and Jamie Mooney is here and she's going to walk you through the reports and Angela and I are here to answer questions or to flesh out any areas where there's operational and I'm not too much to make some.

[Theresa Wood (Chair)]: Okay, I must need to refresh or something because I don't see Nothing

[Dr. Bowen (Commissioner)]: on my schedule.

[Jubilee McGill (Member)]: Well, didn't post anything for today.

[Theresa Wood (Chair)]: Okay. All right. So why don't you walk us through what you've submitted? And we're just gonna do a brief round of introductions because Jamie, I think this is the first time you've been, before our committee. So I'm Theresa Wood. I'm from Waterbury, and I also serve Bolton, Bules Gore, and Huntington.

[Daniel Noyes (Clerk)]: Good morning. I'm Dan Noyes. I represent Wilkett, Hyde Park, Johnson, and Belvidere.

[Eric Maguire (Member)]: Hi. Good morning. Eric Maguire representing Robin City. Good morning. Doug Bishop representing Colchester. Morning.

[Zon Eastes (Member)]: My name is Eastes representing Guilford and Kernan.

[Jubilee McGill (Member)]: I am Jubilee McGill, and I represent Trickport, Norbury, New Haven and Wey Garofano.

[Golrang “Rey” Garofano (Vice Chair)]: Garofano. I represent Essex and Essex Junction.

[Jubilee McGill (Member)]: No worries, Member's Committee Assistant.

[Theresa Wood (Chair)]: And we go right around the room.

[Jubilee McGill (Member)]: Hi, Eric Maguire, work for NMR, and we represent the HCA.

[Dr. Bowen (Commissioner)]: Jill Cohen, Commissioner Galen, nice to meet you, Jean.

[Jubilee McGill (Member)]: I

[Theresa Wood (Chair)]: represent Cole. Hey, representative Cole at Hartford. Great. Okay, Jamie, you have the floor. And I'm thinking committee members, we might be able to see this on the

[Dr. Bowen (Commissioner)]: It's in the report section.

[Theresa Wood (Chair)]: In our report. Okay, thank you.

[Jubilee McGill (Member)]: I just lost Wi Fi for a second.

[Theresa Wood (Chair)]: Okay. It's in our report section. Jamie, the floor is yours.

[Jamie Mooney (Director of Rate Setting, Department of Vermont Health Access)]: Thank you. So I'm Jamie Mooney. I'm the director of the division of rate setting at Department of Remote Health Access. And would it be okay if I share the report right now as I walk through it so it's easier to understand?

[Theresa Wood (Chair)]: Of course.

[Jamie Mooney (Director of Rate Setting, Department of Vermont Health Access)]: Okay, one second. Okay. Is everyone able to see the report?

[Theresa Wood (Chair)]: We can't see what you have on the screen. No. I mean, it's pretty small. If you can make it bigger. Are those just links that you're gonna go to? You Okay.

[Jamie Mooney (Director of Rate Setting, Department of Vermont Health Access)]: Yeah. So this is just the table content section to make it easier to go through the report and we tied it out to each legislative section number in

[Dr. Bowen (Commissioner)]: the Okay. Yeah.

[Theresa Wood (Chair)]: So members, is under Diva. Don't look under Dale. It's under Diva in our reports section. Okay, go ahead, Jamie.

[Jamie Mooney (Director of Rate Setting, Department of Vermont Health Access)]: Yep. So the first tab that we have here is the nursing facility information. So this lists the 33 Medicaid participating nursing homes in Vermont, and we also included the three nursing homes that do not participate in Medicaid. However, they won't be included in the Medicaid related information, the data that was requested, but we did put them down here on the report. We just don't have as much information on them. So on this tab, it goes through their ownership type, the average length of stay for short stay, which is under ninety days, and long stay, which is over ninety days. The breakout of this is we have 23 facilities that are for profit. We have six facilities that are not for profit, and we have three facilities that are not for profit related to a hospital. And then the one facility that is a government state facility. Some pilots. Oh, go ahead.

[Jubilee McGill (Member)]: Jamie, are you okay with

[Theresa Wood (Chair)]: us asking questions as we go along or would you like to No. Hold Okay. When you say average lay of stay less than ninety days, is that indicative of rehab or because guess some rehab is more than ninety days, but is that just purely a day breakdown? So, somebody could have been admitted and it might not have been rehab and it was just purely a number of days?

[Jamie Mooney (Director of Rate Setting, Department of Vermont Health Access)]: Yes, that's my understanding. I don't know, Angela, do you happen to know? I did get this information from Dale. My understanding is just the short term stay for residents versus how long the average day is for a longer term resident.

[Angela Smith-Dieng (DAIL)]: Yes, that's correct. Thank you.

[Jamie Mooney (Director of Rate Setting, Department of Vermont Health Access)]: Some highlights here is for the short term stay, the range is twenty seven days to fifty six days, but most facilities stay around the thirty five, forty five days, which is consistent with the post acute rehab stays. And then the long stays are one hundred and sixty seven days to three twenty nine. So longer stays reflect facilities with a higher share of the permanent long term residents.

[Theresa Wood (Chair)]: And do we know what proportion of each facility they reserve for shorter stay versus longer stay? I'm presuming it's up to the facility, but I know that it's a financial consideration as well. Do we know what percentage of each facility is reserved for short term versus long term?

[Dr. Bowen (Commissioner)]: I'm going to say it's usually somewhere around 10%, but the license for both can be flexible.

[Theresa Wood (Chair)]: It's fluid.

[Angela Smith-Dieng (DAIL)]: If I can add to that, this is Angela Smith Jang. As Doctor. Rowan said, most facilities, the beds are licensed for both Medicare and Medicaid, so they could be used for short term or long term. It's up to the facility how they determine, that mix. You can kind of get a sense of how many are used for short term or long term based on the payer mix, which that's another tab in the report that Jamie will show you. What is also important to note too, though, is if someone arrives in a nursing home for a short term rehab and then decides to stay, they can stay in that bed. That is, that is their right. So you will see people in, a bed short term and then just transition into long term.

[Dr. Bowen (Commissioner)]: Not uncommon.

[Theresa Wood (Chair)]: Thank you.

[Angela Smith-Dieng (DAIL)]: Okay, I don't know if

[Jamie Mooney (Director of Rate Setting, Department of Vermont Health Access)]: there's any more questions on this tab before I move on to the owner information. Any others?

[Dr. Bowen (Commissioner)]: It's just on our page. Mean, we don't have this.

[Theresa Wood (Chair)]: I know, I'm just going to say that's not in the report that I'm looking at.

[Dr. Bowen (Commissioner)]: So I think you added this tab after, I think, so you can forward down an updated version.

[Jubilee McGill (Member)]: I just have a question for the length of space. Like I know, Helen Porter also has a memory care board. And so those are kind of longer stays. Are these, like the longer stays, are those an average of all of the stays facility, in or is it different programs?

[Dr. Bowen (Commissioner)]: I don't think it's pulled out by the specialty care. I'm not sure that they necessarily stay longer. Many go into long term care stay. They're alive. Yeah,

[Theresa Wood (Chair)]: go ahead.

[Daniel Noyes (Clerk)]: Do you track any individuals who come in for rehab or for short term stays that move on to res care? Like do they go into- Lower level care. Yeah, lower level of care, but still needing-

[Dr. Bowen (Commissioner)]: From rehab and also folks who are on long term might do that, between a bolus person or some other option that they have an ERC level three, for example, in those settings. I'm not sure we have the data here specifically for that, Jamie. No, I do not. Angela, do you know if we have it? And if not, is it gettable?

[Angela Smith-Dieng (DAIL)]: I think we'd have to determine exactly what we're looking for. We do, I don't know that we'd have to like dig in individual files, I think, to be able to get that. We could take a look at it.

[Theresa Wood (Chair)]: I I think one of the things is probably helpful for you to know. So in addition to our concerns about EFR, we are also thinking about future planning and thinking about sort of the continuum of services, as I know you all do at Dale as well. Sort of the flow between levels of care is one of those important points, both from nursing facility to res care and vice versa. And it would be helpful to know what kind of data the industry keeps about that. It might not be something you have at the state level at this point in time. But part of our inquiry is about really because it's a big chunk of money we're spending here, and we really want to understand it better and ensure that we're making the right kind of decisions when it comes to where we focus our resources. And so I think trying to figure out all of that is, this is sort of like one piece of it, but I just thought it might be helpful for you to have a bigger picture of what we're really grappling with.

[Dr. Bowen (Commissioner)]: Yes, go ahead. So that's not a surprise to us, but that's where you're at. I just want to say that we're also in that same place. I'm thinking we might be able to get that data from the receivers like the residential care homes and where are folks coming from to them, and we will look for that. The whole plan around stabilization and sustainability that we're working on that we classified to entail, and we're now in the engagement phase of that. So we've been meeting, we've had our kickoff and then we even had our first work group which was on staff end of supply there as a driver of some of the challenges. But we're looking at the continuum. We're acutely aware, as you are, that we need the whole continuum. We're We're very close to capacity in our nursing home system and have to plan for that. But it wasn't for, more people are in our home and community based system that are being served and are being served in a nursing home or the highest level of one sort of acuity of that system. And if it wasn't for a system that Vermont has built, I think in some ways uniquely, we would have maxed out already in our self giving the ADHD. So it's as important to look at the whole continuum as it is to just look at places where we're particularly stretched right now. If we don't have the whole continuum, we're 100% in agreement. If we don't have the whole continuum, we won't be prepared as we go and look forward, five and ten years forward. We need the now and we need the five year point and be ready for what we're looking at in terms of the demographics in terms of ten years.

[Theresa Wood (Chair)]: And I think, Commissioner, referenced workforce. And I think that one of the things that is critical is when we think about workforce, we have to think about not only the workforce for the highest end of the system of care, but the home and community based side of the system of care. And those direct support workers are at the lowest end of the pay scale and doing those ones in the community, particular at the lowest end of the pay scale and needing to have a positive impact on trying to keep people in that field and trying to help them be able to stay in that field. So just wanting to make sure that we're thinking about, and I heard you say that, the whole continuum and workforce is across the whole continuum.

[Dr. Bowen (Commissioner)]: And thank you for that. Appreciate that. Just one of the things that I just want to highlight also, in terms of going up and down sort of the public health triangle, that people tend to go up, in other words from more independence to more acuity, and don't come down always where there's opportunity to come down. And so we are paying some close attention to that now to see what is blocking people from being able to come down the track and go when they can. So it should be bidirectional.

[Theresa Wood (Chair)]: Thank you. And Jamie, we don't have this chart and this spreadsheet. Oh, we do now?

[Daniel Noyes (Clerk)]: Yes, we do.

[Theresa Wood (Chair)]: Oh, okay. Thank you. Just got it. All right. Thank you so much. Because it's hard for us honestly to see all the little numbers up on the screen. We can look at it on our own things here. Thank I think we can move to the next one.

[Jamie Mooney (Director of Rate Setting, Department of Vermont Health Access)]: Okay. Perfect. So the next one is the owner contact information. So we gave you the owner contact information for the 33 Medicaid participating facilities. We did not give the emails and stuff as this was public. So we do have here the, if contact information for each facility, it can be provided upon request as we do have that information with us.

[Theresa Wood (Chair)]: Thank you. That's helpful. Obviously, we are also trying to understand We realize there's pressures on this industry, but we also realize that the majority of them are being held with for profit organizations. And the decisions that for profit organizations make about care. I know they have to meet licensing requirements, but we've heard some not very good stories, I have to say, about a few of these facilities and withholding of medications and things like that. So I think that this is sort of the beginnings. I wanna be transparent about this. People are probably aware of the private equity bill that passed out of the house earlier, and it was slated to have a long term care component. And we knew that we had asked for this report. So we took that out, but that doesn't mean that it's not going to reappear next year. So I just feel like I want people to understand where the possibilities lie on this. Thank you. Keep going, Jamie.

[Jamie Mooney (Director of Rate Setting, Department of Vermont Health Access)]: Okay. So the next one is the payer mix, where it breaks out between Vermont Medicaid, out of state Medicaid, self pay Medicare, other managed care, hospice, VA, and then other. And then I do have the reporting period end date as some facilities don't submit their census at the same time. So just to give you an idea of when we get that information. So for this one, twenty six out of 33 of the facilities, which is 79%, derive 60% or more revenue from the Medicaid, from Vermont Medicaid. Medicare is the secondary payer, which typically reimburses at a higher rate, which ranges from zero to 22. Higher Medicare shares provide some revenue flexibility as well. And then commercial insurance is very minimal. It's usually around zero to 3% commercial insurance revenue within the facilities. And we do have that facilities with 80% of Vermont Medicaid dependency have almost, just for the committee to understand, no revenue buffer in a sense. So if Medicaid rates are not covering the actual costs, they don't have the other revenue to help offer that. Does anyone have any questions on this tab?

[Theresa Wood (Chair)]: Only that I guess I'm a little surprised that Medicare isn't a little bit higher proportion given the amount of rehab that takes place, which is usually funded by Medicare.

[Dr. Bowen (Commissioner)]: But it's a small percentage of the total.

[Theresa Wood (Chair)]: Of the total number of days. Yeah. Anybody else have any other questions? Thank you. Oh, go ahead.

[Doug Bishop (Member)]: Just quickly. I was just wondering, what are some of the factors that are involved in regards to the Vermont Medicaid reimbursement? Like you got I can't see it from looks like Mission Care of Bennington is receiving their percentage is ninety two percent, whereas there's one in Cedar Hill with twenty eight percent. What factors into that?

[Theresa Wood (Chair)]: Mission care is a specialty organization.

[Doug Bishop (Member)]: Is that what it is, is exact specialties and- Care

[Dr. Bowen (Commissioner)]: is built specifically for complex care, deserved population. Others will choose whether what percentage of Medicaid versus commercial. Jim, you have anything further?

[Theresa Wood (Chair)]: Pay a very high rate

[Dr. Bowen (Commissioner)]: to Mission Care. Oh yeah. Well, the rates for Mission Care also can be rates that others tap into and some of them do have complex care services and beds. For specific beds, Commissioner, is that what you're saying? Yeah, well, they don't have the It could be, again, life insurance is not different, it's whether they meet the criteria for the higher rate depending on the complexity of the case. At Mission Care, they all are, except for the ones who were their legacy and chosen to stay and are still there. Though any of the new folks that came in and said Mission Care are open for the complex care. They seem to criteria be for that higher level of reimbursement. Jamie, anything further there to clarify that?

[Jamie Mooney (Director of Rate Setting, Department of Vermont Health Access)]: Yeah, I did wanna add that what you're saying, Commissioner, too, is that other facilities are able to get special rates like Mission Care. So the higher Vermont usage is actually other facilities that have been utilizing that. So one is Maple Lane, who uses our behavioral rates quite often, and then they're at eighty five percent, Crescent Manor's eighty three percent, and they have the Huntington's unit that also has special rates. So yes, I would agree.

[Theresa Wood (Chair)]: Gotcha. Go ahead, Representative Noyes.

[Daniel Noyes (Clerk)]: I just also wonder about the transition from self pay to Medicaid, like the spend down. It's more of just a question I'm thinking about is like, how many people go in with money, total spend down all their money and then transition to Medicaid? Don't really need an answer. I'm just something I wonder about.

[Dr. Bowen (Commissioner)]: Yeah.

[Daniel Noyes (Clerk)]: As people haven't really thought about how they're gonna pay for their long term care, Well, or maybe they

[Dr. Bowen (Commissioner)]: there's plenty that happened or they're coming in in that situation and have to be assessed for eligibility for Medicaid. There is some period of, if you've applied for the Medicaid and you haven't heard back yet, then it be a red track period. I believe that red track period is getting smaller based on federal requirements for the nursing home. For a period of not getting paid, they need to be assured that there will be a retroactive payment. Eligibility is based on, as you know, your finances, but also based on the acuity. So Medicare will pull that once the rehab is not actually, can appeal and try to make that work, but for those who come in on Medicare and need to stay in long term, they run into, they could run into that situation where they're not Medicaid eligible or not yet Medicaid eligible and that's where there needs to be effort to either either spend down or get that application in. So that transition that you were talking about earlier, which is how do you go from rehab to long term care is a place where what are you talking about that might come up?

[Daniel Noyes (Clerk)]: I know we just hear all those ads on the radio that they can protect your assets from nursing homes. And I'm just wondering like how many people actually come in?

[Dr. Bowen (Commissioner)]: Yeah, I mean, there's also the look back all Yeah. Of So yeah.

[Daniel Noyes (Clerk)]: Which is what, five years?

[Dr. Bowen (Commissioner)]: Yeah, is it, Jamie, is that changed at all? So for the five year look back for long term care Medicaid eligibility?

[Jamie Mooney (Director of Rate Setting, Department of Vermont Health Access)]: Not that I'm aware of, but I don't 100% know the answer to that.

[Theresa Wood (Chair)]: Yeah, I don't think it

[Dr. Bowen (Commissioner)]: has. No.

[Theresa Wood (Chair)]: Okay. Thank you. Let's move on to this next table.

[Jamie Mooney (Director of Rate Setting, Department of Vermont Health Access)]: So this next table is the employee to contracted traveler ratio and contracted traveler positions. So we have a large range of reliance. We have from nearly 0% at the Mayo to 70.76% at Berry Gardens of using travelers. So facilities above the 40% traveler share, there's 11 out of 33 that are above that. And at five facilities, the contract travelers actually exceed the permanent nursing staff. We're seeing that it's across all the positions, RN, LPN, and nurse aides. 22 out of 33 facilities are using them across all three levels. We do have, in addition to that, 10 facilities that are just using it at LPN and nurse aides and not the RN level.

[Theresa Wood (Chair)]: So a question for you. Those facilities are using a high rate of contracted. How many of those facilities have received EFR payments?

[Jamie Mooney (Director of Rate Setting, Department of Vermont Health Access)]: A number of them, absolutely. We did see a correlation. I could dig into that more and provide that for you as a follow-up.

[Theresa Wood (Chair)]: Absolutely. I mean, this is part of the problem. They pay their own staff and only going by a couple that I see here by their local reputation type of care. So, yeah, we definitely would want to know of those with the correlation between percentage of travelers and receipt of EFR. And I know that the department's been working with these facilities to reduce that, but this is actually pretty shocking to see in some places where the contracted travelers exceed the employee count.

[Daniel Noyes (Clerk)]: In the national average, 5% or 10?

[Dr. Bowen (Commissioner)]: Somewhere around 56%. But it has come down here.

[Golrang “Rey” Garofano (Vice Chair)]: I mean,

[Dr. Bowen (Commissioner)]: it was higher nationally also.

[Theresa Wood (Chair)]: And I just noticed that this is as of 2024. So, when will you have 2025 information?

[Jamie Mooney (Director of Rate Setting, Department of Vermont Health Access)]: We should have that at the May.

[Theresa Wood (Chair)]: Okay. So, it'd be great if you could update this for us at the

[Daniel Noyes (Clerk)]: May.

[Theresa Wood (Chair)]: So that we could see that in particular, this particular start. The other thing

[Golrang “Rey” Garofano (Vice Chair)]: that this makes me think about is just the morale at those facilities, having contractors that are in and out, you know, not outnumbering the people. So it just makes me feel like we have a

[Dr. Bowen (Commissioner)]: lot of work to do around this.

[Daniel Noyes (Clerk)]: Yeah, we do.

[Dr. Bowen (Commissioner)]: It's actually different in different facilities. I've been to many of them. I've talked to the travelers, I've talked to the pharmacist about, I've asked the travelers why they don't stay. They feel like Many of the travelers are in two different phases of their life. They're either early in their careers, this is an opportunity, or maybe they want to settle down, and others sort of empty that spirit than where they sit now, because they're a champ, just how to see the world and how it is profitable for them to do that. So that's why they continue to stay. Even if they come back a few times, depending on the organization itself and the way in which they, and how long the travelers stay, because some have longer runs and some have shorter runs. Obviously the longer runs the better, because then they can integrate more and just see a better morale. If it's rapid turnover, you're constantly needing to address and get people up to speed and have to deal the teams.

[Zon Eastes (Member)]: The

[Dr. Bowen (Commissioner)]: reason for why some are doing better than others with permanence there is multifactorial. So it's not just about the salary although if they are able to pay them more that's obviously helpful, but it's also is there health in the area that they, is it something that they can afford if they were to settle down as opposed to working like that? There's many factors about what the region of the area is, where the work will take place.

[Theresa Wood (Chair)]: Yeah, think that's true. But I also think that they need perhaps an incentive to move. It'd be helpful to see, we can compare. We say there's been progress. So hopefully we'll be able to see that when we see the 25 numbers when this gets updated to see progress. And at some point in time, we need to say we're serious and we're not We, the global we, I'm not highlighting Dale, I'm just saying. We need to say that we're serious. Unless you make some progress on reducing that. Because I'm seeing some very high ratios in places that are close by to places that have almost nothing in terms of contract. But their payer mix is also different. And I think that's just It's an interesting This data is helping us to think, I think, a little bit more deeply with actual data than not just hearing the stories that we hear.

[Dr. Bowen (Commissioner)]: What sustainability would look like and how to accomplish that. And some of the nursing homes, like some of the hospitals have looked at having available housing for people. Yeah.

[Theresa Wood (Chair)]: And how long and how many times you get a bite at the apple in terms of EFR, when you're not making progress on reducing the number of travelers. At some point in time, I think we need to Just to remind

[Dr. Bowen (Commissioner)]: you, Joe, that if they do get EFR, they have to submit a sustainment plan. So they have to Yeah.

[Theresa Wood (Chair)]: So it'd be interesting to hear how many folks are actually That sustainability plan involves reducing the number of travelers and increasing staff, and how many of those are achieving them, having a plan and achieving it, and the elements of that plan are obviously all really important.

[Dr. Bowen (Commissioner)]: Okay.

[Theresa Wood (Chair)]: Other questions? I felt like I monopolized that conversation. Sorry.

[Doug Bishop (Member)]: Was gonna ask you something quick. Do do you have the numbers of, like, what is the the maximum staffing capacity needed at each location? Like, you're showing the the the numbers between travelers and and contracted contracted travelers and the employee count. But what what's the level of what's the number needed to staff that facility at capacity? More or less, they are do I use 10 more than five supplies?

[Theresa Wood (Chair)]: Are you talking about like vacancy rates? Do they have high vacancy rates?

[Doug Bishop (Member)]: So there's the I'm just gonna take the first one. Bel Air. It's maximum or staffing is we need a 100 people.

[Dr. Bowen (Commissioner)]: Right. So based on a community, you're making Yeah. Or a bed to have, etcetera, etcetera. Do you have that, Jamie?

[Jamie Mooney (Director of Rate Setting, Department of Vermont Health Access)]: I do not have that. I don't know. Does Dale have that

[Dr. Bowen (Commissioner)]: somewhere? Dale might have that. Angela, we might need to check with Pam on that, but we can see if we can get that. Maybe Pam will get it to you.

[Zon Eastes (Member)]: I

[Theresa Wood (Chair)]: am trying to understand the tab. So I get contracted staff as a percent of the total nursing staff. And when it says nursing staff, is that meaning RN, LPN and nurse aides when it says nursing staff, is it all levels of nursing?

[Jamie Mooney (Director of Rate Setting, Department of Vermont Health Access)]: Correct. So yeah, RN, LPN, nurse aid. Correct. That's under the rate setting nursing category.

[Theresa Wood (Chair)]: Okay. Then help me, I'm just gonna, because it's at the top of the page. So at Bel Air, four point five two percent of the nursing staff are contracted. Am interpreting that correctly?

[Jamie Mooney (Director of Rate Setting, Department of Vermont Health Access)]: Correct, yes. So four point five two percent of all the nursing staff is contract staff.

[Theresa Wood (Chair)]: Okay. And then employee as a percentage of total nursing staff. I don't really understand what that means.

[Jamie Mooney (Director of Rate Setting, Department of Vermont Health Access)]: So that is looking at the other end, 95.48% are permanent staff, not agency of the total staff.

[Theresa Wood (Chair)]: That's just getting that's just the financial. Okay, that's just a calculation. Okay. Okay. Permanent staff. Yeah, I just I know reading if you add those two together, it's a

[Dr. Bowen (Commissioner)]: 100%.

[Theresa Wood (Chair)]: Okay. Okay. I was thinking it had something to do with total staff, but it's not total staff. It's just nursing staff.

[Jamie Mooney (Director of Rate Setting, Department of Vermont Health Access)]: Right. Yes. I can understand the confusion though.

[Theresa Wood (Chair)]: Gotcha. Okay. Thank you. Are there any other questions on this tab? Is that Noyes? Do you have questions? No. Oh, okay.

[Golrang “Rey” Garofano (Vice Chair)]: I actually have a question.

[Theresa Wood (Chair)]: Okay, representative. Some of the

[Golrang “Rey” Garofano (Vice Chair)]: line items only have contracted traveler job titles that are LPN.

[Brenda Steady (Member)]: So I

[Jamie Mooney (Director of Rate Setting, Department of Vermont Health Access)]: wonder,

[Golrang “Rey” Garofano (Vice Chair)]: and this might be a question for Dale, what determines who they contract out for? Because obviously, an LPN is more cost effective than an RN to contract out. Their level of pay might be different. So I'm just trying to understand.

[Dr. Bowen (Commissioner)]: Well, I mean, there are certain requirements for what level they would need. But to your point, if need a certain number of licenses, there's enough human license, but if you need the RM skill set. So that would be, at the facility, determining what your needs are and where your vacancies are. If you're particularly having difficulty hiring LPNs and you need them, either because it helps in your mix to have the license, but you don't need the RN level, maybe you have sufficient, then you're going to be looking for. Right, so the mix of course, RN, LPN and LNA is very much a part of how the director of nursing and the nursing team is working all the time to make sure they meet regulatory requirements and then they can balance where there could be cost efficiencies associated with it while staying within compliance safety.

[Theresa Wood (Chair)]: Thank you. And I just want to be clear about when we if you can give us when you give us the updated data from 2025, if you can highlight which of these facilities also received EFR payments on one or more occasions, that would be helpful. Absolutely. Okay, let's move to the next tab.

[Jamie Mooney (Director of Rate Setting, Department of Vermont Health Access)]: So, the next tab is the number of requests the Division of Rights Setting received for nursing facilities. So I just wanna say like state fiscal year, we have 20. They weren't 20 complete requests. So I'll go through that quickly as well. So for state fiscal year '25, all five of those were complete requests. We granted five of them, so they were all granted. In state fiscal year 'twenty three, we had 12 requests. One of them was actually incomplete. We never heard back from them. Therefore, there was really only 11 complete requests of which they were all granted. In '24, there were 20 requests. Eight of them, they withdrew the application and resubmitted. And then one of them was also incomplete, so really that's 11 complete requests again. And eight were granted, three of those were denied. And then in state fiscal year '25, we had nine requests, Three of them were incomplete. So really we had six complete requests of which all of those were granted.

[Dr. Bowen (Commissioner)]: Can you speak to '26 because there is some continual good news as you see the numbers of requests going down?

[Jamie Mooney (Director of Rate Setting, Department of Vermont Health Access)]: Yes. So as of today, for state fiscal year '26, we've had four requests. One was incomplete, one was denied, and two were currently pending Division of Rate Settings review. So it has decreased, but we're still not at the end of the state fiscal year. So we're not 100% sure how much will come in, but as of right now, we've only had four and two are pending and the other two are not one complete. Thank

[Theresa Wood (Chair)]: you. Thank you, Jamie. So in your update to this report, if you can extend this, we perhaps didn't ask the exact right question in the budget bill last year. So the detail that you just provided, the number of incomplete, the number of withdrawn or whatever, and then the ones that were the total number that were actually approved would be helpful. Because if we were just going this, we would say, oh, well, 20 received and 20 didn't receive. So that would be really helpful. Represent Bishop and then Rep. Zonn Mcgill.

[Doug Bishop (Member)]: Another data point that I'm curious about and the curiosity arises because I believe the Green Mountain Nursing Home in Colchester, which has since closed, may have received EFR. So I'm curious of applicants, what we know, applicants who were denied, applicants who were approved, those that withdrew. Are there other instances of closure?

[Jamie Mooney (Director of Rate Setting, Department of Vermont Health Access)]: That is the only one that has occurred with an EFR request denied or approved.

[Zon Eastes (Member)]: Thank you.

[Theresa Wood (Chair)]: That was my question. Somebody told me this. I think it might have been you, Commissioner Bohm, but I'm not positive. But that they some have to portion or all or whatever of that EFR.

[Jamie Mooney (Director of Rate Setting, Department of Vermont Health Access)]: Is that correct? That is correct. Yes. We've worked with them to get recoupments for that EFR. Absolutely.

[Dr. Bowen (Commissioner)]: Remember the purpose of the EFR is to prevent the closure.

[Theresa Wood (Chair)]: Closure, right.

[Jubilee McGill (Member)]: What happens to that money when

[Golrang “Rey” Garofano (Vice Chair)]: it comes back?

[Jubilee McGill (Member)]: I mean, we have to cut a lot of things from our budget recommendations order to So be able to do I'm just wondering what happens with leftover money or if someone doesn't ultimately Well,

[Dr. Bowen (Commissioner)]: right now it wouldn't be left over because we don't know what the need will be as we continue through the school year at the end. We

[Theresa Wood (Chair)]: get an annual closeout report on choices for care that comes to us. And so it would go back into the choices for care account. And then as the commissioner just said, at the end of the year, there's a closeout process with any pending expenses that we know we need to pay or accounted for. And then there's legislative language about 1% and all of that kind of stuff. But it does come back into choices for care. It doesn't just kind of go to some bottom line somewhere. Yeah. Go ahead, Jefferson.

[Doug Bishop (Member)]: I'll follow-up on the Green Mountain nursing home. Is that recoupment complete? Or if not, do we believe it to be on track and coming back in the way

[Daniel Noyes (Clerk)]: that we expect or hope?

[Dr. Bowen (Commissioner)]: It's a Jamie question.

[Jamie Mooney (Director of Rate Setting, Department of Vermont Health Access)]: Yes. So the way that rate setting works with recruitment is we let Game well know that we want full recruitment. So as soon as they get paid, we recoup it. So that has been underway. They did have a rate update. So I do need to reach out to make sure that we're complete in the recruitment. But my understanding is we're absolutely on track. I know at this point we've recouped at least 90% of it.

[Zon Eastes (Member)]: You.

[Theresa Wood (Chair)]: Go ahead, representative.

[Doug Bishop (Member)]: With all the increase in EFR requests, is there enough fiscal stability in place that will prevent possible future closures or any type of service disruptions?

[Dr. Bowen (Commissioner)]: So it's a reduction, you said it increases.

[Doug Bishop (Member)]: Yeah, but even still there was that increase with '22 and it seems it's not coming down to the pre pandemic levels, but they're still Are you are you asking more or less

[Theresa Wood (Chair)]: Were you successful in preventing closures?

[Dr. Bowen (Commissioner)]: Yes, we were successful in preventing closures. Think they were saying that none of the other ones we got in person at closing in on here, but that we're at two pending right now is, I can't speak to the whole year again because we're not there, but we are entering April and we have fewer bus lanes than we might have expected at any time, but sometimes this comes out of the agency again, so we just have to wait and see. But is it effective in helping? So yes, in the more immediate, because when they're, when there's a very the value fiscal evaluation that happens before they're approved for EFR, you can't just ask for everything because it would be easier if we have more money. It has to be that you're in fairly better circumstances and the infusion does get them back on track. To your point though, Chair Wood, if you want to know whether did that work to the extent that they're more stable now or do they need EFR again? I know that when I looked at some of this data during the pandemic, I think it was a different world. So it was harder for them at that time and they didn't pass the level of occupancy either or even were trying to maintain. But it does seem to have that effect that it gets them out of the woods that won't be able to operate, we would have to close the place. And for Queen Mountain, they had expected to continue and they reached a point where they just couldn't. So the analysis and the conversations and the assessments that were provided were yes, they were at risk, but that this should work and at some point it just did. But of course you have to recoup those funds. They're there for that particular reason and if they're not being used for their case they can be used. Anything to add to that, Jamie?

[Jamie Mooney (Director of Rate Setting, Department of Vermont Health Access)]: Yeah, I did wanna add too, because I know looking at this, the increase, right? Like it jumped from '22 to '23, just to give perspective on how the rates are set in regard, especially to the traveling nurses, that in 'twenty three, so the nursing homes fiscal year 'twenty three, their traveling staff increased the usage, The cost is about three times more expensive than having a permanent staff. So in their fiscal year '23, they had a huge cost increase, but the way the rates work is they were paid off of their fiscal year twenty one costs, which haven't weren't caught up at that point with the new costs. So that's why we're seeing such a large increase from 'twenty two, 'twenty three. And one suspected reason though, there's many factors, unfortunately, in the rates, is that the drop here could be that on 07/01/2025, the nursing rate got rebased to fiscal year 2023 costs, which is now including the contract staff that wasn't included previously?

[Daniel Noyes (Clerk)]: So re, go ahead. Rebasing includes the contracted staff rate.

[Dr. Bowen (Commissioner)]: It's the rates, the nursing rates. Do you want to explain that For to the rates for permanent staff and travel, that be different?

[Jamie Mooney (Director of Rate Setting, Department of Vermont Health Access)]: No, so it's all lumped into the nursing category of the rate. But in 'twenty one, nursing homes didn't have as high as usage for nursing, traveling nurses. And we know that the traveling nurses for nursing home to pay the hourly rate is actually higher about, I think we found three times higher than if they were to pay an hourly first salary employee. So their costs increased significantly in their fiscal year '23, which just recently got captured July 2025 in the REIT.

[Theresa Wood (Chair)]: So is another way to put that is that, so when you rebase the rates, they're now based upon what the higher expenses were, and so the rates went up. And when did they come back when did they come back down ever?

[Dr. Bowen (Commissioner)]: Well, when did the rates have come back down? Well, no. Just like the patients.

[Theresa Wood (Chair)]: Yeah, that was a conceptual theoretical comment. People fools, right. That being said, every

[Dr. Bowen (Commissioner)]: two years the nursing gets rebased and every four years it's a pro rebased then beyond nursing. So there are some recommendations in the EFR report, the other one, because there were two reports, that have proposals that looked at the frequency of the rebasing to get it as close perhaps to reality as one could.

[Theresa Wood (Chair)]: Right, right, of course. And I think we will probably spend a bit more time on this whole rebasing and understanding the regulatory framework around this a little bit more in-depth at another time. I think we're seeing a reduction in the number of EFRs because the rebasing has occurred and their rates are higher, so they don't Based upon having those contractual employees. So it's almost like a little bit of a vicious circle that they're rewarded for having contracted staff, which is not really the incentive that we're wanting to have.

[Dr. Bowen (Commissioner)]: Yeah, mean, there are complications to that. And why we're so cautious to say we're glad to see that it's low at this point in the year, but we just don't know what the next few months will bring in terms of the pressures. So we'll see, but we do think that the reduction is as expected related to the rebates and-

[Daniel Noyes (Clerk)]: You said how much more travelers were than regular staff, but I couldn't understand what you said. So I'm trying to hear what that percentage was.

[Jamie Mooney (Director of Rate Setting, Department of Vermont Health Access)]: Oh, so yeah, the contract nursing staff costs we found are approximately three times more per hour than the employee.

[Daniel Noyes (Clerk)]: Three times more per hour. Correct.

[Dr. Bowen (Commissioner)]: Yeah.

[Theresa Wood (Chair)]: It's a perverse incentive that we've got going on in this system, I have to say. And I realize it's a phenomena that was created in large part due to COVID. And I have this little bit of foreboding sense that it is not something our regulatory structure has caught up with. And it sounds like you are looking at that. Is that right? Or

[Jamie Mooney (Director of Rate Setting, Department of Vermont Health Access)]: Yes, we are looking at the rebasing. That is part of, like the commissioner said, the proposal to see if there's, it would make sense to change the way we rebase, especially nursing. Correct.

[Theresa Wood (Chair)]: Yeah. I mean, it is what's happening is people are being rewarded for using more contracted nursing staff and and at a perverse rate of three times what they're paying their other staff. And that's a structural problem that we need to address. Represent Garofano. I have

[Golrang “Rey” Garofano (Vice Chair)]: a really dense question, and forgive the dense nature of this. Do we know if these nursing homes paid permanent staff like double, if not triple? Is it just the fact that the staff does not exist? I mean, do we not have local nurses that will take double with benefits a secure job that is permanent? You know what I mean? It's like, are people just not available and we have to

[Dr. Bowen (Commissioner)]: bring people in? There's a lot. We have a workforce shortage across the board, but seeing it here as well in Vermont. There are fewer people, fewer people coming into these fields, fewer people to work, many different types of jobs, course, many different types of sectors here. You have an affordability crisis. There's many, many factors that pressure why they can't hire. They would prefer to hire permanent staff. The travelers is not, there's no reward for the organization to hire travelers. It is a pressure on them on their costs. They would prefer to hire permanent staff and they can't get them and then they go to travel. But those who are choosing to be permanent staff, they have reasons why they're not being travelers. They're in different places in their life, they have families, they like the camaraderie, they like the stability of having a permanent job, they like the benefits and to be able to prepare for their future in a different way than the travelers. And there are more people coming back because we did drop from like 30 something to 25. So it is in terms of the percentage of use. There is more and it's efforts and it's in nursing home by nursing home, some struggle more than other nursing homes. What we're looking for where we can learn from best practices, where are there folks who have fewer travelers and what do they do differently. And like I said, some of them were looking at housing or being able to have housing for some of the staff. Others had the ability to increase some of the salaries. Others were looking at different types of schedules, twelve hour shift or contributing to pre. There's all different kinds of ways that nursing homes are looking at their models to try to address it. What we want to do as part of our SNS plan or this stabilization and sustainability plan is to find those best practices and elevate that and get that across the board. That's some of the work that we are doing through that process. By bringing people in and engaging, we're having conversations that are interested in terms of what's working for some and why it may or may not work.

[Theresa Wood (Chair)]: Yeah, go ahead, representative.

[Zon Eastes (Member)]: I'm looking at the report on 2025 and I see two listings from the same nursing home. I wonder if someone could just speak to that about what

[Dr. Bowen (Commissioner)]: Yeah, it could have crossed fiscal year. But Jamie, do you wanna explain that?

[Jamie Mooney (Director of Rate Setting, Department of Vermont Health Access)]: Yeah, that's exactly what happened. They requested the EFR in 'twenty four for their 'twenty four fiscal year. But by the time we were able to actually issue the EFR, it wasn't until.

[Zon Eastes (Member)]: I see. Thank you.

[Jamie Mooney (Director of Rate Setting, Department of Vermont Health Access)]: Yeah, absolutely.

[Theresa Wood (Chair)]: Okay. Yeah, why we move to that, let's move to that. Okay. No, no, weren't jumping ahead. That's good. That's fine. We were ready to move.

[Jamie Mooney (Director of Rate Setting, Department of Vermont Health Access)]: So I broke it up into fiscal year twenty twenty three, twenty twenty four, 2025. And this goes into the facility name, the type of control, the amount received, the reason why it was requested, and then the reason why we awarded the EFR. The difference here to note is the tab six was within the state fiscal year they requested, and then tab seven, eight, and nine are depending on when they actually received it. That's why it's

[Dr. Bowen (Commissioner)]: a little bit off with that.

[Jamie Mooney (Director of Rate Setting, Department of Vermont Health Access)]: For state fiscal year 2023, dollars 8,809,093 was awarded. So $8,000,809.93 across nine awards, which had eight facilities. So this again had another one that overlapped because of the timing.

[Zon Eastes (Member)]: I see

[Theresa Wood (Chair)]: in the reasons, it's pretty much the same reasons all the way down through. Yeah. What when when when we say, like, cash needs or we, say things about financial viability. How do you define things like urgent cash needs? And I guess, what are the things that you look at when you make a decision to approve an EFR payment?

[Jamie Mooney (Director of Rate Setting, Department of Vermont Health Access)]: Yep, absolutely. So one thing to note, just so the committee knows, when we get an EFR application, we do a thorough, I would even call audit, where we're looking at their balance sheet, their income statement. We're looking at what their AP is at the moment, what their AR is, so their accounts payable, accounts receivable. We are looking at when they tell us the reason is staffing, then we're digging into their staffing to making sure what they're saying is actually true, what we can see. They're saying their rate decreased, then we're looking to see if their rate actually did decrease and why it decreased. We check to see, are they capped in an area, like indirect or resident care that is causing this financial situation? So when we say urgent cash need, we'll see that on their balance sheet, they don't have a lot of cash in the bank, which is absolutely a concern. We'll also see that maybe they have minimal cash in the bank, but then also have accounts payable that are 500,000 and they have their staffing contract telling them that they'll pull staff if they don't pay them. So we've had situations like that come in, and of course we verify to make sure what they're saying is actually the truth because we know sometimes people want to express what's going on, but it might be a little bit exaggeration. So we at rate setting make sure that everything they're saying makes sense based off all their financial information.

[Theresa Wood (Chair)]: Go ahead, Representative Steady.

[Brenda Steady (Member)]: Just out of curiosity, how often do agencies have audits? Is there, like, every few years or just so they can, like like like, our town, like, have to have regular audits so they can see where the cash is coming in, cash is going out. Often do nursing homes or any organizations in this, well, nursing homes have to have an audit?

[Jamie Mooney (Director of Rate Setting, Department of Vermont Health Access)]: So a nursing home, when they report to rate setting, we require them to have audited financial statements from an independent auditing firm. And then on top of that, we then reviewaudit at this point, all of their cost reports every year. So we're going through making sure there's no increases and decreases. If there is large increases, know why, because obviously we need to make sure that's allowable per our rules per CMS. So then when we get the EFR as well, we're digging into that and comparing it to our most recent information to see where increases were and what they're saying. Does that answer the question? It did. Thank you. Absolutely.

[Theresa Wood (Chair)]: Jamie, you talked about the balance sheets. You also look at P and L statements?

[Jamie Mooney (Director of Rate Setting, Department of Vermont Health Access)]: Yes, absolutely.

[Theresa Wood (Chair)]: And do you do any analysis of I guess I would say real estate costs. So lease slash mortgage kind of payments. And is there any differential or anything that you consider? I guess, is there a range of what you might consider to be normal cost per square foot or however it's measured?

[Jamie Mooney (Director of Rate Setting, Department of Vermont Health Access)]: So good question. I don't know if we have a normal range per se, but we absolutely do look at that. We've seen where leases have increased. And we know that the owner of the property, the owner of the operations of the nursing home is also the owner of the property, which then at that point, we take that into consideration absolutely for EFR and would take that out of the calculation that they might've had, because understandably Medicaid isn't gonna pay for that. So we do absolutely look at the property. I know another big one that's come up too is like distributions. We also look at that as well. So we do try to do a very thorough review to make sure we're only paying for the items that are important for the homes to stay open.

[Theresa Wood (Chair)]: And do you know out of the facilities that are owned, how many of the actually of the real estate is owned by real estate investment trusts?

[Jamie Mooney (Director of Rate Setting, Department of Vermont Health Access)]: I don't know off the top of my head, but I can definitely dig in to see if we have that information and provide that in follow-up.

[Jubilee McGill (Member)]: Reps. Anne B. You wouldn't have to go back through all the years, but even just like 2025, it would be useful to see kind of like request amount requested versus what was paid. I know you kind of get was requested and was awarded. Like I just see under my local one, they requested financial distress due to Medicaid reimbursement shortfalls, high per diem costs, excessive management, home office, and related party fees, contract nursing costs increase, and billing collection issues, risk of closure without relief. And then for what you were awarded, it was to cover estimated losses on Medicaid services, ensuring continued operation and quality residents. So I'm guessing not all of that was covered. Some of that, I know related party fees can actually be a red flag for some financial issues. But yeah, I'm just wondering kind of what are these all of our nursing homes requested and what are we actually covering when we give this?

[Dr. Bowen (Commissioner)]: If anything else were done, that's something that they get. Jamie, we should have that, right?

[Jamie Mooney (Director of Rate Setting, Department of Vermont Health Access)]: We do. If you would like, I can update '23, '24 and '25, 1 to include the amount requested.

[Jubilee McGill (Member)]: If you just did 2025, it would give us a good sense of kind of what folks are yeah. I don't think unless others want all the years.

[Dr. Bowen (Commissioner)]: That's relevant. Yeah. Yeah.

[Theresa Wood (Chair)]: I mean, I think '25 is fine because, I mean, we recognize there was a, post pandemic, there was a lot of stuff that we But can't really kind of consider

[Dr. Bowen (Commissioner)]: I think by the time we're at 2025, we should be starting to hopefully recover from that. Go ahead. I was just wondering if the department looks at kind of the balance sheets on it. Oh, it's got one of the ladybugs growing ratio. Oh, me or?

[Daniel Noyes (Clerk)]: No, I was just wondering, like when one of the facilities comes and says we could use some help, we look at their balance sheets. And I just wondered if the department has the capacity or looks at balance sheets to try to be pre active. Before they get to a point, I mean, I don't know, is there any ability to do that and try to figure out how to help on a smaller level instead of waiting for them to say, Sky is falling.

[Dr. Bowen (Commissioner)]: Let's see what Jamie says to that. Have some thoughts, go ahead.

[Jamie Mooney (Director of Rate Setting, Department of Vermont Health Access)]: That's a great question. We don't currently do that. But to answer that part, we don't currently do that. Do we have the capacity to do it? I would have to think about that more potentially, but I would need to think about how that would look. And is that something that rate setting would be able to determine just by looking at their financials?

[Dr. Bowen (Commissioner)]: I just They have to operate, the providers have to operate their model. They have to operate within their They have a responsibility to operate. The EFR is extraordinary. I know. Right? It's supposed to be extraordinary financial relief just so that they don't close if they really are going to be that close to closing because we would be in a difficult situation. Just losing money out was a big deal. As far as getting into their finance and operations, if it impacts operations, if it impacts quality, if it impacts access, then from the regulatory or from the survey and certification end of it, we will be seeing that. So you're saying what's our preventive strategy so that we can be helpful. So that's part of what we're trying to look at across the board. Keep in mind, folks all have requirements that come from CMS and from the state, but those are the drivers that have to keep them in a reasonable operating space in order to meet all of those criteria. So if you're running up against physical problems early and your operation is faltering, you're going to run afoul of that and you're not going to be able to do business. When we come in and see a quality issue, whether it's routine or there's a complaint or whatever, anything that's routine review is a proactive approach. When you've got a complaint and you're coming in, that's a responsive approach, but you're going to require them to ensure the quality and they will need to have operations that work in order for them to do that. That's all staffing and all the right. So from a regulatory and a quality perspective, this is constant. This is all the time in there. So it's not just know, E and R is the only time we're in the space and looking at the operation.

[Daniel Noyes (Clerk)]: Right, and I think about the capacity of your ability of licensing protection or long term care ombudsman to do this work, we're spending $14,000,000 on EFR, would a couple FTEs be able to get out in front of that and really reduce that down so that we're not getting to the point where we need EFR?

[Dr. Bowen (Commissioner)]: Yeah, I mean, very good questions. How do we prevent folks from getting to a place where they could end up closing? They don't want to close. So they're looking all the time in their operations as where the pressures are. We don't know how many of them figured out their model. When we go and we talk with them about their models, some of them being very innovative. Some of are really thinking this crew and the sustainability, some of the things that Chair Wood was talking about in terms of how you balance your payer mix, how much of it is rehab where there's a certain churn of return, how you balance your commercial and self pay versus paying. Some of them are really paying attention to that and doing that well and others less so.

[Daniel Noyes (Clerk)]: Is there a communication amongst all of them for best practices and maybe, I

[Dr. Bowen (Commissioner)]: don't know. Mean, I think Yeah, part of what the SFF plan is, is getting them in the room, the engagement right now is them talking about what's happening at their end and what was working at their end and what's not working at their end. So this is the beginning maybe of a process. Don't have necessarily well, have to say through like Helen Leiden and her group, they're very much on top of trainings and convenings, and so they do have opportunity through that collective to be having those kinds of conversations about what's working and what we need to do to sustain. We have regular contact with talent where we don't wait for a problem. We have regular meetings where we can be helpful in some of those projects.

[Theresa Wood (Chair)]: You know, some of the things, I guess, is to follow-up to represent McGill's question. When I see things like management fees and owner distributions reducing cash and urgent need to pay vendors in the same breath as owner distributions reducing cash. And I see in several of them low occupancy. And yet at the same time, I'm familiar with some people that we are sending out of state because nursing homes won't take them in Vermont, or for some reason, we're told that they don't have any beds available, which the data doesn't actually, at least the last time we saw it, support. So it's trying to weave a picture of how all of these things fit together. I appreciate, Jamie, the sort of level of detail that rate setting goes through when they're evaluating that. And I just am wondering, and I know that there's close relationships between Dale and rate setting because it really is sort of a combination of all of these things that need to be considered when a decision is made about whether to grant extraordinary financial relief. Like, I'm pretty sure taxpayers wouldn't be too keen on us giving out money for for profit organizations when the owner distributions were part of the issues that caused the cash payment and inability to pay vendor payments. That's where

[Jubilee McGill (Member)]: I think having the information- Having Occupancy while we're exiting people to the streets

[Dr. Bowen (Commissioner)]: today So on

[Theresa Wood (Chair)]: I think it is helpful for us to see the amount requested versus the amount received and to see where you've most likely taken into account some of those things that, you know, appear to be either excessive or not allowable from from a rate setting perspective.

[Jamie Mooney (Director of Rate Setting, Department of Vermont Health Access)]: Yep. Yeah. Yeah. I can update this one as well, like I said. So I'll add the column of amount requested, but I'll also go into more detail on what was actually allowed and what was taken into consideration. Because right, we do not pay for owner distributions. We look at management fees because if they're extremely high in causing this situation, we're not going to be paying for that portion of it. So absolutely, can go into more detail on the 2025.

[Theresa Wood (Chair)]: Yeah, and that's calling out a for profit organization, but we can see, Gifford got $4,000,000 hospital based organization. And that had to do with fees, some of that had to do with fees as well. So, don't want to I'm not really looking at for profit versus not for profit. I just am looking at the expenses that get charged to these facilities and how much of those we consider to be part of the business and how much of that is part of the public good and do Vermonters as taxpayers owe to be able to do that? Because when I look at some of these, I don't know, it gives me pause. I just will say it gives me pause. And we don't have all of the details that you all have. I realize that. And so appreciate the level of detail that you have provided here.

[Dr. Bowen (Commissioner)]: But we will definitely get some more of what you're asking for and to show, they may ask for lots of different things that isn't, This is something that they'll know. So really within the guardrails of what is allowable for our Medicaid. So it's not going to be what they ask for and often the amount is not what they ask for, so it's very carefully, carefully done. So this is older data than the Yeah, yeah, So we won't really want to have as much updated as we can get for you. But you also said the occupancy we have with empty beds, we have generated you empty beds at this point, to reiterate, and anyone who meets the criteria that's in the GA systems is offered. I know that would be a

[Jubilee McGill (Member)]: Can we get an update? Today is April 1, and I believe it's something like two sixty, two eighty people are being removed from the hotels today, including 42 children. And I happen to know of a few cases that it seems like would be within Dale's wheelhouse. I know one person who's bed bound and is suddenly trying to figure out how to live on the streets today. I know of a family with a disability with three children, one of who has disabilities, a breathing disorder, requires electricity for her breathing treatments to sustain life, going to the streets. And another person who the last time he was on shelter and had open heart surgery has created complex medical challenges, lifelong, was again being exited to the street. So I'm just wondering, has there been Yes, so much. Are you doing I'm just hoping we have a better experience in identifying places that are not the streets for these relief

[Dr. Bowen (Commissioner)]: Right, and some who've come into nursing homes, choose do so. Angela's on, I don't know if you wanted to say anything more there.

[Angela Smith-Dieng (DAIL)]: I just know that as of today, there are two choices for care participants who are likely being exited from GA and the case managers have worked with them on plans for their exit. I'm not aware of the cases that you're mentioning. So it would be great if you could share any of that information. Would connect with you all along on that. Well, online, but

[Dr. Bowen (Commissioner)]: I think she I

[Brenda Steady (Member)]: have question. So so seeing this questions on the balance sheet, should recipients of any awarded funds be required to engage in a third party CFO to come in and get their business back on track?

[Dr. Bowen (Commissioner)]: You mean like a receivership or something? Yeah, like Well, if necessary, but then you'll usually not. But initially, I

[Theresa Wood (Chair)]: was gonna say, the department has taken that step They the

[Dr. Bowen (Commissioner)]: have,

[Brenda Steady (Member)]: they have, that's it. That was the next question. Was there any mandate of the funds allotted to be assigned to these financial health and

[Theresa Wood (Chair)]: I fiscal can recall a couple of specific circumstances where the department's taken what they call receivership and they essentially, yeah, it's a legal process.

[Brenda Steady (Member)]: It's not good. It's not cost effective. No,

[Theresa Wood (Chair)]: no, no. It's necessary in some cases because of quality of care and financial issues. And so the department takes the steps that they need to in order to assure quality of care. So that has happened in the past. There

[Dr. Bowen (Commissioner)]: was some active mess right now. Yes, is. That's

[Brenda Steady (Member)]: good to know. Thank you.

[Dr. Bowen (Commissioner)]: Well, is in the continuum. Yeah. Thanks.

[Theresa Wood (Chair)]: Sort of on this, so I was made aware of several folks who are on actually public guardianship that Dale has public guardianship for who were being discharged from hospitals and needed to go to a nursing facility. And they actually had to be placed out of state, some as far as way as Maine and New Jersey.

[Dr. Bowen (Commissioner)]: Well,

[Theresa Wood (Chair)]: I'm talking about they're there now.

[Dr. Bowen (Commissioner)]: Okay, so a couple of things on that. So yes, there are, and it's usually like border facilities. And if you're saying there are thing that might be a little barking board, usually it could mean that there's specialty, right? So it could be due to complexities. We have some specialty care in Vermont, not enough. So it could be based on what their special needs are that the facility has been supported. It could be because there was some reason why they weren't accepted. What we did at one point was sold many folks back into mission care, for example, because they can manage those complexities as they are. So if people are interested at this point in coming back, we do try to bring them back into Vermont, but it is necessary for us to have those relationships outside of Vermont because we have such a growing demographic and because our capacity, we're like over 90% built now, so we need to maintain those relationships. But the public guardians, they work very hard not to have them go out there. They have to travel.

[Theresa Wood (Chair)]: Yeah, I'm just trying to figure out how we maintain really our official role as somebody's guardian when they're several 100 miles away.

[Dr. Bowen (Commissioner)]: So there's not very many, not like a lot.

[Theresa Wood (Chair)]: No, no, I know.

[Dr. Bowen (Commissioner)]: Yeah, but in those circumstances they may travel, but they'll also be working with the individual and the family and see whether they want to stay there, in which case they would work on shifting their guardianship. Or do they want to come back and then work to bring them back? The guardians really press hard, I can tell you, to not have a scenario where they're so far away they can't reach out.

[Theresa Wood (Chair)]: Oh yeah, I realize the Guardians do, but it seemed to me like, you know, what I was hearing at least was they were being told there's no room at the inn.

[Dr. Bowen (Commissioner)]: Yeah, less so recently, because it definitely got popped and we really don't want that scenario. Of course, of course. Sometimes the theory of folks who were boarding in hospitals for a very long time, and it really had to do with what the bench armies were that couldn't easily be met. And then to relieve them of being a boarder in a hospital, The other option out of state was the one that's been selected. So there are circumstances that I'm familiar with where one or two times something like that happened. But in most cases, when the guardians say, this is gonna not be good for this, we honor that.

[Theresa Wood (Chair)]: Yeah, I mean, certainly understand the border states and the border facilities for sure. Just was like, when I heard Maine and New Jersey, I thought like, how do we maintain our role as a public guardian?

[Jubilee McGill (Member)]: Are there specific specialties or is it just like a supercharged, extra skilled kind of nursing Are there

[Dr. Bowen (Commissioner)]: So in Vermont, we have right now one facility that has ventilator capacity, for example. If they were exceeded there, they would have to go out. What we are doing through our lung transformation is trying to get a second facility with ventilation. We also have some who have ability for dialysis, but not enough. That's a part of

[Jubilee McGill (Member)]: our work.

[Dr. Bowen (Commissioner)]: Bariatric. So in some of these scenarios that might be why they're going out. I'm not saying the specific one, but in some that's why. And then we need another relationship Addison with and Eton Mons because we could reach capacity and do want to make sure that we have an option to assist identified between each. Okay.

[Theresa Wood (Chair)]: Other thoughts? You've gotten to the end of your tabs there. I just didn't know if there's anything from the report which is a little bit different than this data that you wanted to speak to.

[Jamie Mooney (Director of Rate Setting, Department of Vermont Health Access)]: So you're talking about the report from December, correct?

[Theresa Wood (Chair)]: Yes. Yeah.

[Jamie Mooney (Director of Rate Setting, Department of Vermont Health Access)]: So just a couple of things, I think, to note from that report is we do have proposals or thoughts that are being brought up during shareholder engagement. So some of the areas that we've already talked about was how we're rebasing, the timing of the rebasing. Another one that is big with EFR is that a lot of the smaller facilities are being capped. An example is they might have to have nursing staff, even though it's not really the CAPP, but they have the same type of cost that any other facility, but because they're smaller, their per diem is higher than the CAPP, so they're being capped. So one proposal is to look at it in peer groups for the CAPP so that they're all taken into consideration in the equity sense of things, instead of just based off of this is what your peer DM is. Another area is the step up process. For anyone who doesn't know the step up process, that is where we look at their property costs when they purchase a new facility and increase it based off of many factors in the rules. And there we would like to tweak the rules because currently sales are happening more than twelve years. Right now you have to own a property for twelve years so you can get a step up. We have so many sales right now that are happening that have not owned it for twelve years, so they're not getting a step up. So sometimes their property basis is back until, I mean, I think we have one back into the 2000s because it was sold multiple times. It wasn't eligible for step up, which is hindering the ownership and isn't necessarily enticing buyers to come in and purchase facilities with that. So we have that. There's areas we're working on currently. Is PDPM is a new acuity measure in the rates because CMS went from ROG IV to PDPM. We're noticing some ups and downs depending on providers for that. So we're going to be doing validation audits to make sure that what the providers are reporting as their case mix score is accurate and also helping them in education of how should they code things so that they are reporting it correctly. And then from there, the plan is to see where the PDPM scores lie, and if there's more issues to dig further and to understand what's going on and what's causing decreases. And then the other area is that we will be working with VHCA and nursing homes to help train and provide education for special rates, as there are plenty of facilities who have special rate residents that aren't applying for special rates, or they're just not taking special rate residents. We've heard feedback that it might be too complicated, might be too much. So really wanna dig into what's going on, why are the providers avoiding it, and try to figure out if there's a way to make it easier or just provide training that might help their understanding a bit better. So there's a few areas that we focus on in that report that could help the stability of nursing homes.

[Theresa Wood (Chair)]: So I think we're obviously interested in nursing homes being stable, but we're also interested in making sure that Vermonters aren't paying more than they should pay. And it's just interesting to hear what you talk about the acuity scores and the case mix, because we hear testimony that says, well, nursing homes are taking on older people that have higher needs. And so that doesn't seem logical then that their acuity scores would be going down. Is that what you said that some facilities are having lower acuity scores or whatever those initials are that you referred to?

[Jamie Mooney (Director of Rate Setting, Department of Vermont Health Access)]: Yes. So some of them have dropped. I will say there's a weird nuance here. We switched to PDPM. And the way we get this What was that again? PDPM? Oh boy, I'm not gonna remember. Patient Driven Payment Model. With that, the state has a contractor that helps us get that information from the providers, but not from the providers, we get it from the CMS itself, the scores reported. RUG IV previously, we got straight from the providers. So we didn't have it straight from CMS. So what rate setting is trying to figure out, is the PDPM increase and decrease related to the switch to ROG to PDPM? Or could it also include a factor of going from provider submitted versus getting it straight from CMS, and if they're actually recording it properly in the CMS model. There's multiple factors that we're trying to pinpoint what is the real cause here and what can we do going forward?

[Dr. Bowen (Commissioner)]: Sure.

[Theresa Wood (Chair)]: And what's your interaction with licensing and protection, the division of licensing that goes out and does the survey and certification inspections and reviews? And I'm presuming that they look at acuity and quality of care and all of those kinds of things. Is there any intersection? Yeah, I know.

[Dr. Bowen (Commissioner)]: I can know that commissioner.

[Theresa Wood (Chair)]: That everybody can go use that. I know. Because they have very specific things that they have to look at, and I'm just trying to figure out if the data that CMS has on Acuity is provided by the nursing homes directly to CMS, or if that's something that is a factor of the licensing survey and certification reporting that happens through Dale, Division of Licensing and Protection?

[Jamie Mooney (Director of Rate Setting, Department of Vermont Health Access)]: No, currently we don't necessarily, I mean, we have a relationship with DLP, but not around Acuity. Previously, the providers would submit it and then we would reach out to DLP to kind of look at it together and understand. But now that we're getting it from CMS directly, go through the contractor, which it's, rate settings work in the contractor as also Dale is too. So we do have contacts from both departments working with our contractor, but they're pulling it straight from CMS now. But I have not had conversations with DLP recently about the PDPM scores.

[Brenda Steady (Member)]: Representative Steady? The chart you showed, why would the for profits facilities have much lower numbers than the nonprofit? It kind of looks like mismanagement somewhere on the nonprofit side.

[Theresa Wood (Chair)]: Lower numbers for what? Managing.

[Brenda Steady (Member)]: The managing of the places.

[Theresa Wood (Chair)]: I'm sorry. You talking about the charts that we saw? Are you talking about

[Brenda Steady (Member)]: the payments received? Yeah. Why why wouldn't the for profits look like they're managed better? I guess that would be the question. Money wise. No? Am I asking? I

[Dr. Bowen (Commissioner)]: don't know.

[Brenda Steady (Member)]: They have lower numbers, I guess. I don't know.

[Jamie Mooney (Director of Rate Setting, Department of Vermont Health Access)]: Receiving Is one lower

[Brenda Steady (Member)]: managed better than the other?

[Dr. Bowen (Commissioner)]: I'm not sure we can get that managed better or not. Yeah. And for profit enough for some profit.

[Brenda Steady (Member)]: It just looks like the for profits are managed better, money wise. I don't know. It's hard to explain.

[Dr. Bowen (Commissioner)]: I'm trying

[Theresa Wood (Chair)]: to figure out how

[Brenda Steady (Member)]: The numbers were lower for the nonprofits. Lower than what?

[Theresa Wood (Chair)]: I know, you're not saying what numbers I are

[Brenda Steady (Member)]: don't know what I'm trying to say. It's just like the non the poor profits are managed better with the monies, but that's okay. Can They

[Jamie Mooney (Director of Rate Setting, Department of Vermont Health Access)]: received lower EFR, like their EFR amounts were less than some of the nonprofit EFR amounts that was received?

[Theresa Wood (Chair)]: Is that your question, Steady? Sure. I don't

[Zon Eastes (Member)]: think that's

[Dr. Bowen (Commissioner)]: It's not accurate.

[Zon Eastes (Member)]: It's not accurate, but yeah. No? It's quite a mix actually.

[Dr. Bowen (Commissioner)]: I can say that try to look at operations like for profits. We look at quality for profits, profit, so that we can understand what's happening, to understand is there a difference in where those differences are. Not every for profit is the same, some of the for profits are those small, privately owned, and others are more like the bigger, more corporate. So we also try to understand the difference between the corporate profits that are kind of small and individually owned.

[Brenda Steady (Member)]: So it could be the size Well of

[Dr. Bowen (Commissioner)]: it could be, and it could be, like if it's corporate and you know, then there is perhaps a different level of fee of funding to support or backlog. Do

[Brenda Steady (Member)]: they receive a statewide tax deduction? Do they receive a statewide tax deduction?

[Theresa Wood (Chair)]: Are you tired?

[Brenda Steady (Member)]: The facilities, the nonprofit or the profit, do they get a reduction in statewide?

[Dr. Bowen (Commissioner)]: Hospitals, many hospitals are non profit, so that is the tax section that I think you were talking about. It would be relevant for many of the ones listed here that

[Brenda Steady (Member)]: are tied to hospitals. This is new to me, so I

[Daniel Noyes (Clerk)]: don't know.

[Dr. Bowen (Commissioner)]: There's not that many left tied on hospitals. It's really interesting in secret fact that you're looking at that too, which ones are type of hospitals?

[Brenda Steady (Member)]: See I think I said

[Dr. Bowen (Commissioner)]: it was. Some who've pulled out fully and some who pulled out partially and just looking at those models as well, what the differences are. We're trying to find this every possible way to see where it's working better.

[Theresa Wood (Chair)]: Yeah, I appreciate that. And I think that there's obviously differences between the size

[Dr. Bowen (Commissioner)]: of the facility. Yeah, I didn't even know that.

[Theresa Wood (Chair)]: How many beds the overhead is spread over and all of those kinds of things. That's true. Think while each The mix of patients and their payments. How was cessation?

[Brenda Steady (Member)]: Excuse me. I was talking Oh, sorry.

[Theresa Wood (Chair)]: And I think that, you know, one of the things that we want to make sure that we're doing in evaluating this and evaluating any potential future regulatory change is not only the stability of the organizations that are covered under these rules, but also what Vermonters should be paying for when it comes to Medicaid rates and what we shouldn't be paying for. And I appreciate that you've highlighted some of those things in these charts and in your assessment of that. So I think we need to balance any potential regulatory change with both of those lenses, what Vermont should be paying for and the stability of the organization as obviously also being a goal, because we do need nursing facilities to be strong and healthy. And what's Vermont taxpayers role in that versus owners role in that. And so thank you. Thank you for all the work that went into putting this together. We appreciate that very much. And I think this is probably we'll be having other conversations about this same topic. And I'm glad to see that Kathleen Dannette has actually been able to retire, retire. I know she was at rate she's still hanging around at rate seven.

[Jamie Mooney (Director of Rate Setting, Department of Vermont Health Access)]: She's doing our EFRs. Yep. Now she's still here Hanging her.

[Dr. Bowen (Commissioner)]: She's done. She's the one she's done.

[Theresa Wood (Chair)]: Kathleen, Kathleen is, she won't let go. That's good. That's good. But you know, it's good to have some historical perspective too. Right?

[Jamie Mooney (Director of Rate Setting, Department of Vermont Health Access)]: Absolutely. I try to soak it in.

[Theresa Wood (Chair)]: Rupesh Steady, did you have a question?

[Brenda Steady (Member)]: Can you tell me what cessation is? Do people get dismissed or discharged? They have, they have to have a place to go, right?

[Dr. Bowen (Commissioner)]: You mean, would they be discharged without a place to Right, so,

[Brenda Steady (Member)]: so it's an involuntary discharge of a resident. So, but that can't happen, right? Because they have to have a place to go. Like when my brother said he was coming to move in with me, No, they he didn't. They told them he did, but they called me and they wouldn't let him just leave. So that doesn't happen, right? They have to have a

[Dr. Bowen (Commissioner)]: place. Need

[Jamie Mooney (Director of Rate Setting, Department of Vermont Health Access)]: to a discharge

[Dr. Bowen (Commissioner)]: plan if that's what you're saying, but yeah, I mean, there's

[Brenda Steady (Member)]: because it says under cessation that it's an involuntary discharge of a resident for nonpayment, safety issues, improved health.

[Dr. Bowen (Commissioner)]: The nonpayment

[Brenda Steady (Member)]: Or closure of a facility, but they would find a place for them, right?

[Dr. Bowen (Commissioner)]: Well, they would have the family have some responsibility for that. If they're not getting paid, see if they're not getting paid. I kind

[Brenda Steady (Member)]: of went off topic.

[Dr. Bowen (Commissioner)]: Yeah, there's certain things that would kick into place there, but if they're eligible for Medicaid, so the application process should go in, they should be able to do that through the nursing home should have support like social work support to be helping with that. Also SNC or a survey and certification will help if people need to have an eligibility assessment. So it's really important that they reach I

[Brenda Steady (Member)]: kind of went off.

[Daniel Noyes (Clerk)]: I don't

[Dr. Bowen (Commissioner)]: know if can reach out to survey and survey and ask these questions and get some help. But it's very important that the Medicaid applications go in if they are not going to be in a position to pay for the nursing home because ultimately they need some source of payment for the services that they're receiving. If they're getting charged at self pay, that can be very expensive. The family is agreeing to cover, and this happens when they run out of money. This is your earlier point that you raised in terms of what happens when somebody spends down their money. While they're spending down they could be getting applications in and be working on that, which is usually what happens.

[Theresa Wood (Chair)]: Thank you very much. And I think going forward, it's really I really do appreciate all the information both in this report and the charts that you just reviewed with us. It's very helpful for us to have a clearer picture of what we know and more importantly, what we don't know. And that's important as we go forward. And I think that while we, and I know you probably know this, Jamie, but nursing facilities are the only place in state government that get automatic increases of any kind and have annual increases. And I realize that's sort of a narrow focus for you, but we have to have a broader focus. We have to have a broader focus that also recognizes the need for home and community based services have all of the same kind of issues that we talked about this morning in different ways, but all of the same kinds of issues. And having that balance between what sort of, I guess I'm cautioning about increasing the potential for automatic increases for nursing facilities until we have something that is more comparable on the other side of the equation to ensure that community based services right now, we were fortunate enough to at least get a, they have to have a review every five years. Okay, every five years. What would nursing homes do if their review was every five years? That's what we have for community based services. And that was only after a long fight here in the legislature.

[Dr. Bowen (Commissioner)]: It's all over you, is there our interim to use?

[Theresa Wood (Chair)]: I'm just saying, yeah, but rate increases are not proposed by anybody in the administration for these services, except for nursing facilities. And so we just have to be careful about the balancing of home and community based services and skilled nursing services, recognizing we need both, all. So thank you again for all of the work that you put into this. It was very helpful. And sometimes when you're so good at providing information, that begets requests for more information. But I

[Dr. Bowen (Commissioner)]: being highlighted. So important.

[Theresa Wood (Chair)]: Yeah, it really is. It really is. Yeah. Thank you so much. Thank you. And thank you for being here in person, Commissioner. We appreciate your attention to this important

[Dr. Bowen (Commissioner)]: issue. It's very good.

[Theresa Wood (Chair)]: Okay, folks, we are going to take a twenty minute break, five after eleven.

[Dr. Bowen (Commissioner)]: What do

[Daniel Noyes (Clerk)]: we have at eleven?

[Theresa Wood (Chair)]: Committee discussion.

[Dr. Bowen (Commissioner)]: Yay. We're

[Theresa Wood (Chair)]: going to, yes, we'll be back here and be looking for updates for people who have things happening down in the Senate. If have a bill that's downstairs and you have had some activity there, report back to the committee about what's happening on those bills. And then be interested to see what people's reactions are to the information that we just talked about for almost two hours.