Vermont Legislature SmartTranscripts:

[Sharon Gutman (Physical Therapist and Owner, The Rehab Gym)]: We need to get moving.

[Sen. Ann Cummings (Chair, Senate Finance)]: Today, this is Senate Finance. This is April 8, and we are going back take testimony. We did the walk through of h eight eighty five eighty five, which is the somewhat comprehensive insurance reform bill, which is I think really like three bills or at least three bills put together. So we're gonna start and we have Emma Paradis, one up. Yeah. We just tell us your name, who you represent, and then what's your word as your voice?

[Speaker 2]: Wonderful. Thank you. Good afternoon, Randy. My name's Emma Paradise, and I'm the co director of Common Good Vermont. And I think it's my first time in this committee, so thanks for having Really appreciate the opportunity to testify under five eighty five.

[Emma Paradis (Co-Director, Common Good Vermont)]: Specifically, I'll be speaking to the health insurance governance provisions and Expanding Access Association Health Plans, all pieces. And just since this is my first Committed Committee, CommonDebt Vermont is a statewide program of United Way of Northwest Vermont, and we're dedicated to uniting, strengthening, and advocating for Vermont's nonprofit sector. And also, as of January 2025, we also became a member association representing over 200 nonprofits across the state. So just to start, I'd like to speak to the health insurance governance provision that would require representatives of the public, which would be individuals appointed by partisan elected officials to serve on certain nonprofit boards. And I did send a letter to the committee that I chaired with the House Health Care Committee with more thoughts on this, but overall, we are just concerned that opening up the door to government intervention into the governance of independent non profits could really have serious implications for the sector at large. And this could include housing and human service organizations, those who are delivering other programs through state funded programs. And we're just really encouraged exploring other options that achieve the same goals around transparency and accountability that are not at odds with core governance structures, but notfits. Moving on, I really want to focus my time on association health plans. Common Good is deeply invested in ensuring that health insurance markets are accessible, affordable, and equitable for nonprofits that rely on stable benefits to recruit and retain staff. And in the face of rapidly rising health care prices, AHPs could really provide much needed relief to nonprofit employers and expand benefits to employees. We do approach this with often, though. We definitely support the expansion, but we do feel it's important that there are appropriate guardrails in. For context, as I said, we're a member association. Most of our members are small organizations. 55% have really small budgets under 500,000. Maybe small teams, four to five staff, probably not the primary demographic for an association plan, but as most don't currently offer a health insurance benefit. But this could be a way to get those smaller organizations to provide health insurance benefits. About 37% of our members are mid sized, 500,000 to about 5,000,000 in revenue annually, and have more employees and probably are more likely to offer health insurance already, but they could find real significant cost savings potentially through AAPs. And then a small portion of our members are over 5,000,000 and many of these already offer pretty robust benefits, but could also save up through this program. But regardless of size, managing health insurance cost is really a top priority for Vermont nonprofits. For those who do provide insurance, it is a driving cost. We do biennial wages and benefits survey for nonprofits in Vermont as well as the partners in New Hampshire and Maine. And in Vermont, in 2024, 94% reported premium increases, and that compared to 52% in 2022. So really dramatic. And these increases were absorbed by employer and employee of the like, sometimes with the higher deductible or sometimes with decreased coverage, but they really didn't have to make changes to benefits in order to keep offering coverage at all. And so we're really concerned that after seeing years of growth in the number of organizations offering benefits, in 2024 we actually saw a 2% decrease from 2022. So, concern that this is a trend that fewer non profit employers will be offering benefits. And for those who don't offer health insurance due to the cost being a barrier, this can make recruitment and retention really challenging. We're seeing more organizations look for alternative arrangements like ICHRAs, but also expiration of ACA subsidy like oh, ICHRAs. An n word for me. Yes. Mhmm. Sure. Courtney? Can you

[Sen. Ann Cummings (Chair, Senate Finance)]: It can be gold. Oh my gosh. I I

[Michael Landsberg (Athletic Trainer, The Rehab Gym)]: I get it.

[Emma Paradis (Co-Director, Common Good Vermont)]: I got it. Yeah. But What do they do? It it's an alternative to, oh my gosh.

[Sen. Ann Cummings (Chair, Senate Finance)]: Is it I?

[Emma Paradis (Co-Director, Common Good Vermont)]: ICHRA, insurance management. My gosh, I'm so sorry. I can look that up. ICHRA. And

[Sen. Ann Cummings (Chair, Senate Finance)]: it's an individual coverage health reimbursement.

[Sharon Gutman (Physical Therapist and Owner, The Rehab Gym)]: Thank

[Emma Paradis (Co-Director, Common Good Vermont)]: you. We'll a

[Sen. Ann Cummings (Chair, Senate Finance)]: briefing on what does it money.

[Emma Paradis (Co-Director, Common Good Vermont)]: Okay, keep going. Apologies. In both cases, though, the expiration of the Affordable Care Act subsidies are also going to have an impact both on employers who may see more employees taking advantage of plans or employees who rely to those plans that no longer can take advantage of them. So no matter where you stand, health insurance costs are really hurting our workforce, forcing skilled, mission driven workers to choose between a career supporting healthy communities and their family's health. So Common Good sees expanding access to association plans as a real opportunity with the potential to provide affordable benefits and predictability to nonprofits and their employees in the face of a program system. There's also the potential to reduce the administrative burdens for small organizations through a shared system. And we have seen other state associations were part of the national council of nonprofit networks. There's associations like us in other states, and they have seen real cost savings. Together South Carolina is our South Carolina counterpart, and one of their members shares that in 2022, we joined the South Carolina Association health plan, saving $50,000 annually while gaining access to high quality benefits alongside nonprofits across South Carolina. This collaboration has strengthened our ability to support our team while keeping cost manager As early adopters of Together South Carolina AHP, we're proud to show how nonprofits can leverage collective strength to create lasting impact for our teams and our communities. So that's one example, obviously, a different situation in Vermont. But we also just wanna urge a little bit of caution that we do wanna make sure that we are protecting against adverse selection, ensuring that fair market competition is still in place, avoid situations where Vermonters are segmented, and maybe uneven risk pools that may cause unwanted consequences for some and benefits for other. And so we just have to consider how association plans will impact the quality of benefits organizations and nonprofit employers receive, and also how those not covered through an association health plan would suffer the impact, as well as for markets at large. There are also questions about what cost savings will be achievable. Be frank, Vermont has a small size and different demographics than other states, but I think, well, by no means a silver bullet, AHP is far the best chance we have at bringing down health care costs in the short term for nonprofit employers employees. And I think we can mitigate and manage risks while still moving forward. So with these considerations in mind, Common Good would recommend clear guidance and disclosure requirements to ensure nonprofits understand the difference between different options available to them, require annual reporting on AHP enrollment premiums and benefit design, ensure parity in essential health benefits so that nonprofit workers are not offered coverage. And tonight, we would really urge the committee to consider moving the effective date for AHP to no later than 01/01/2027 in house health care. From the original bill, it was pushed back to 2028 with a report from DFR. And we just employers really need relief now. And while Commen feels ready to put the ground on you to stand up the program, we will need assurance that AHP's will feel loud before investing the time and resources into development and implementation. And so we see these recommendations as key to creating conditions that support the successful and responsible expansion of AHP's while mitigating unintended consequences. With the proper guardrails in place, we're optimistic that this exposed expansion of AHP's could provide much needed relief to Vermont's nonprofit workforce, and we support the committee we would support the committee moving forward this revision of the bill as responsible. Okay.

[Sharon Gutman (Physical Therapist and Owner, The Rehab Gym)]: Thank you. Thank you.

[Sen. Ann Cummings (Chair, Senate Finance)]: Committee, any questions? Thank you for Yeah. We've taken testimony on any of these at all. I like what we're doing

[Speaker 2]: now. Okay.

[Sen. Ann Cummings (Chair, Senate Finance)]: Did have an initial walk through the building. Yeah. Okay. Just gathering information. Okay. I don't see

[Sharon Gutman (Physical Therapist and Owner, The Rehab Gym)]: the question, so thank you. Thank you. K. Jessica Bartos.

[Jessica Barbas (VP, Public Affairs, Planned Parenthood of Northern New England)]: Good afternoon. Hey, everyone. I'm Jessica Barbas. I am the vice president of public affairs for Planned Parenthood of Northern New England and the Planned Parenthood Vermont Action Fund. This is also my first time in this committee, this session, which is great. Glad to be here. Planned Parenthood of Northern New England, we serve over 14,000 Vermonters across our six health centers, as well as statewide through our telehealth program, and folks really turn to us for that compassionate, high quality, affordable, reproductive, and sexual health care, which includes wellness exams, birth control, STI testing, cancer screening. No one is turned away based on their ability to pay, about fifty six percent of our patients have low income, and we provide about 1,240,000.00 in free and discounted care annually in Vermont. The Planned Parenthood Vermont Action Fund is also the leading advocacy voice for that legally protected healthcare in our state. Vermont law has very strong protection, as you all know, related to our right for reproductive and sexual healthcare. However, rights do not guarantee our access to them. And many opponents of this critical healthcare have realized that legislative bans are uniquely unpopular with the vast majority of Americans, and so they have instead started using other tactics to restrict services like abortion. One of the ways that our federal government is overreaching into states like Vermont is by restricting funding, which then in turn restricts access to care. And they're also using other administrative tactics to influence and restrict access by questioning insurance coverage or billing practices. So we're really here today to oppose section 40 five-thirteen, which is that addition of gubernatorial appointees onto the health insurer board of directors. Here in Vermont, there are already multiple nonprofit bodies that are designated in statute that have gubernatorial appointees. Some of them are even in healthcare. But the key distinction between what Vermont has done in the past and this legislation is that the appointment tower exists because the organization is created or governed by law. This power does not extend all nonprofits. So there are certainly nonprofit councils, boards, or commissions that are created in statute and then assigned public duty. Vermont insurance companies are nonprofit, but they are not created in statute, and they are not arms of the executive branch. And this is a really important distinction for patient care, medical judgment, and public trust, right? Health insurance for, while they don't practice medicine, they ultimately determine what medicine is acceptable, affordable, and timely. And in a reproductive health setting, our rights mean little if we cannot access or afford timely and effective healthcare. So extending gubernatorial appointment power to nonprofits outside of this current scope is really unprecedented and raises some significant concerns for us at Planned Parenthood of Northern New England. Others can speak more to the legal risks related to like nonprofit entities becoming state actors, or the fiduciary duties, conflicts that may arise as a result of the gubernatorial appointment, but I'm really gonna focus in on this provision from a reproductive health perspective, where I think there are layered dangers that go even beyond that general nonprofit governance concern. So first and foremost, it politicizes our healthcare delivery. Nonprofit insurers play a critical role in enforcing coverage protections, benefit design, utilization management, and network policies directly determine access to reproductive healthcare. And board governance can shape how aggressively an insurer applies with or constrains those protections. So extending gubernatorial appointment power into this space risks politicizing coverage decisions that are meant to be neutral, evidence based and actuarial. And these risks could be felt even sharper in Vermont, where unlike in larger states, a very small number of corporations play an outsized role. So a decision made by this board could easily become market standard for the whole state. So if a governor can appoint board members, that power of those members can then be used to influence which services are offered or funded or to pressure leadership to end advocacy or policies that may decrease access to legally protected healthcare services. Nonprofit boards determine an organization's priorities, hiring, resource allocation, and viewpoints or advocacy speech. And political appointees on any nonprofit healthcare board could have a chilling effect on that speech or advocacy. And I think this is an important point for you all as our legislative body, right, is that a health insurance board can reshape reproductive healthcare access without removing a single benefit from statute, simply by changing how that coverage is administered. So examples of that could include a slower or a more discretionary appeal process, more aggressive pre authorization needed for abortion or gender affirming care, or even narrowing the definitions of what's medically necessary. We firmly believe that healthcare decisions need to be made by patients and their medical providers and not by politicians or political appointees. And having political appointees on any nonprofit healthcare board really opens up a pathway for those political influences to have an influence on medical judgment and practices. So this legislation would really create a new precedent for government oversight in an independent nonprofit healthcare entity. And if enacted, this framework could be used as a model by other states to further restrict access to reproductive and healthcare. So So if other states were to choose to adapt this model and require political appointees on their state insurers, for their hospital boards, for their local Planned Parenthood or other health clinic, they could essentially ban abortion or other forms of care without legislative accountability. So they won't need their state legislature to pass an abortion ban if they can work from the inside of these institutions to defend, restrict, or delay access to care. So, medical independence is really a safeguard for patient care throughout our entire system, from our health providers to our insurers, and once you politicize any part of that governance, you risk politicizing patient care. So,

[Sen. Ann Cummings (Chair, Senate Finance)]: Thank you. For your time. Okay, thank you. Questions? Committee? I think that was going to be How many members are on the board again? It's got balance. It says it can be no less than one sixth. Nine? Am I right in that? Have Courtney Harness, Blue Cross, and Blue Shield of Vermont. We have 12 members on board, so this would replace two of them. So nonmajority of board? No. It would be a sixth, not less than a sixth, Patrol said. So if they don't wanna remove two people, they'd have to go up to 15 members on the board. And I think even without a majority, it could

[Jessica Barbas (VP, Public Affairs, Planned Parenthood of Northern New England)]: have a chilling effect, right, if the board leadership is saying, what are those governor appointees going to think of this policy? I better, like, walk this back or self censor this before it even gets to a board.

[Sen. Ann Cummings (Chair, Senate Finance)]: Okay. It is a precedent. Okay. Okay. Other questions? Thank you. Okay. We're going on to Sharon Gutland. We have a chance to share.

[Sharon Gutman (Physical Therapist and Owner, The Rehab Gym)]: My colleague, Mike Glansberg, has a limited time. Could you go ahead of me and then I'll He go about is in two slots. He's on

[Sen. Ann Cummings (Chair, Senate Finance)]: Zoom. Okay. If we've got hand? We can put him up. You can have the comfortable chair. You can see without doing it in your neck and eating.

[Sharon Gutman (Physical Therapist and Owner, The Rehab Gym)]: All therapy. It's all good.

[Sen. Ann Cummings (Chair, Senate Finance)]: I have two new knees, and this is a good way to practice some functional exercise. And knocked it off the floor. Mr. Landsburg, welcome to Senate Finance. So we just ask that you introduce yourself, tell us who you're representing and the floor is yours.

[Michael Landsberg (Athletic Trainer, The Rehab Gym)]: Sure. Thank you very much for the time, Madam Chair and committee members. My name is Michael Landsberg. I'm an athletic trainer. I've been practicing athletic training in Vermont for thirty three years, and I work at the rehab gym along with Ms. Gutman. My biggest reason for being here today is, I guess, twofold. First and foremost, there's a misunderstanding, I think, in the public of who athletic trainers are. And I know that in the House when this was testified on, I did not testify, but there was a question as to, okay, why are athletic trainers included in this language here I alongside have

[Sen. Ann Cummings (Chair, Senate Finance)]: that question here, so.

[Michael Landsberg (Athletic Trainer, The Rehab Gym)]: Yeah, so alongside physical therapists and occupational therapists. We have a bad name. I've been cursed with a bad professional name for the thirty three years I've been an athletic trainer. And, essentially, we're not personal trainers. We're not fitness trainers. Athletic trainers are allied healthcare professionals that are trained in treating musculoskeletal injuries, as well as things such as concussion in physically active individuals. So we're a key part of the healthcare profession and the healthcare continuum for the profession or the folks that have those types of injuries. I was actually privileged to spend a lot of time down at the State House working on the licensure law for athletic trainers as well as a law that reimburses athletic trainers, which was the first of its kind in the country. Vermont actually kind of stands, I think, alone. I apologize for that phone ringing in the background. Vermont stands alone as one of the only states that has such legislation, and that legislation is is essentially a a kind of payment equity or a nondiscriminatory law. The reason for the inclusion of athletic trainers here is in Vermont, we have a significant shortage of providers in the physical therapy profession as folks are aging out and we're seeming to get not the influx of professionals. And athletic trainers have been working in the clinical setting with physical therapists in concert and also receiving referrals from physical therapists providing the same care. And in many cases, you know, we have the same outcomes, if not better outcomes, depending on the patient population. And so that's why we were looking to be included or have this language where we're included, alongside these professions. And this I know and all your concerns are about is about the finance You know, what will this do in the big picture? Is it gonna save money? And I know that testimony was taken in the House that spoke to the fact that, yes, Blue Cross Blue Shield, I think, estimated somewhere between 2 and $6,000,000 if we go to site neutral reimbursement. And so what I'm, you know, wanting to make sure of is, one, that you have an understanding of who we are as professions. And secondly, with regards to the athletic training piece being a part of it, that with site neutral reimbursement, that we're included in that sense of getting that equal reimbursement to the other professions because of, if we don't, I think you're gonna see professions, or not professions, but organizations like the Rehab Gym, and Sharon's my boss, she would probably tell you that we wouldn't hire athletic trainers if we can't get that same reimbursement. So you would actually decrease the access that the patients have to providers in an already decreasing landscape that we're in.

[Sen. Ann Cummings (Chair, Senate Finance)]: Okay, thank you. Any questions from the committee? Okay, thank you. Thank you, Chittenden.

[Michael Landsberg (Athletic Trainer, The Rehab Gym)]: You. And you're in really great hands with Sharon. She can speak, I think, at great length to the benefits of all this.

[Sen. Ann Cummings (Chair, Senate Finance)]: Having been lobbied by the rehab, Jeff, I can come in. They are my I think you may have more than one, but one is definitely in City Of Barrie.

[Michael Landsberg (Athletic Trainer, The Rehab Gym)]: Yes.

[Sharon Gutman (Physical Therapist and Owner, The Rehab Gym)]: It's holding on. It's struggling, but I'm committed. Okay. Thanks, Mike. Thanks.

[Michael Landsberg (Athletic Trainer, The Rehab Gym)]: Thank you for your time.

[Sharon Gutman (Physical Therapist and Owner, The Rehab Gym)]: I just wanna add that Mike and I go back even before the rehab gym. I met Mike and I also was introduced for the first time with the profession of athletic training in a practice that was established in part by orthopedic surgeons who now since are at Tilly Drive. So, the prominent orthopedic surgeon group were unsatisfied with the traditional physical therapy and so the athletic trainers in concert with physical therapists produced greater outcomes. Outcomes pretty much that I think also save money in the long run. What I learned from working with Mike is this approach that is more involved in getting a person back into what it was they were working on before. If it was a sport, they were in tune with that sport and they not only had to get that patient well again, but strong again and as fast as can. While physical therapists don't have as much pressure and we are more trained to get people up a curb and into a building safely. So, the application of athletic training in concert with physical therapy, in my strong opinion, is the best way to handle physical rehabilitation. I have also worked with

[Sen. Ann Cummings (Chair, Senate Finance)]: the

[Sharon Gutman (Physical Therapist and Owner, The Rehab Gym)]: okay, we have physical therapy, occupational therapy. So, occupational therapists in the outpatient setting, we have a lot of them involved with pediatrics and in schools, there's a great majority of them there. They're less used in a clinic like the rehab gym, even though we hired that, but they work with hands pretty much. Occupational therapists are more with the upper extremity and outpatient rehab clinics. But they also work with that person, getting them back into, let's say, you know, and driving again or whatever their goals are in an occupation. An occupation doesn't mean it's not necessarily a paid vacation. It's your occupation. Could be housework and gardening and such. So, I will then say it is rare that I think the finance committee gets testimony on something that is not asking for money from anyone, government or payers, and also patients, in this case, the public. I am here with a passion for healthcare reform I have from the get go. I have since college days in the 70s. This is my opinion, is that we need to be progressing past an old model into the future. And the whole reason behind my starting the rehab gym was to push the boundaries. And we understand what's insurance reimbursable. We have guidelines we have to follow to get reimbursement. We have contracts. But there's so much more that a physical therapist can do. So when I launched the rehab gym, I offered much of that. I offered more than I can now because back then the profit margin afforded that. But one of the reasons why I'm here today and really pushing site neutral billing is it will allow me to get back into the role of being a disruptive innovator that is sorely So, that said, I speak about the whole of healthcare. Yes, I'm a physical therapist. Yes, I have a business that incorporates physical therapy as a major part of it. But this is so much broader than that. This is about basically allowing there to be the ability to rebalance what has become an unbalanced healthcare system. Two decades ago, 8% of providers of all forms, not just doctors, PTs and so forth, but nurses, they were independent and that has actually reversed. Now, most are really associated with hospital, call that more hospital owned care. And in this migration from community based care into hospital, and not just hospital, but hospital systems, we've actually evolved the hospital into creating a mega system far beyond critical care. And what we have seen from this is a marked increase in the cost of healthcare and decreased accessibility, okay? So, these are factors that spike my interest. I am a solution oriented person. I love a challenge. I don't focus on symptoms. I think we all can see the symptoms of the crisis we're in. I'm not bringing that up. I want to talk about what I see as a real solution, and it's exciting. And I think it's also exciting that if this bill is passed, five eighty five, and this is section seven of that bill, this will be the first in the nation. And it's meant to be a stepping stone. It's meant to be a way for us to evaluate whether site neutral billing really actually produces the promises that it offers. I will not, I mean, I know that we have Blue Cross and Shield in the room and they can speak about the projected savings. I'm after the discussion that I can present is how that kind of happens. How this is the good solution. Right now, we do know independence, and again, I don't speak just for the professions of physical therapy, occupational therapy, and athletic training. We all know primary care and other independents are suffering right now, and they're going out of business. This is serious. We have businesses at risk. If we lose the independent market, we won't be able to shift. There won't be that ability for independence to absorb and take on what would be the migration. And the solution is also a way for us to sort of take less attention and finances towards the administration of what services do, but right into the services themselves. We all know small businesses, they can turn on a dime. They don't have the bureaucracy in large businesses. We don't have a lot of people running our business. The business is run by the providers. And there's also a direct connect between the highest, which is in my role, to the front lines. I'm at the front lines. And I really depend on the front lines to help me guide this business. I think that that's what makes independent strong. The facts are we can get patients in and out of their rehab even before the hospital can maybe have their first visit. So, accessibility is already there. We do need more providers, though, to take on more of the load. So, if we could have the financial stability that we once had, we could then attract people from other states, and hopefully athletic trainers, because I think that ATs would love to jump into this profession, but right now they're more led into, you know, the other ways that athletic trainers can express their profession. So, and then it will allow us, I mean, now we're in damage control. We've got things that need repairs. We are losing providers to the hospital because they can pay more. We are losing people to getting out of PT completely. We call that moral injury where they just don't get paid enough to cover the frustrations that are involved with dealing with a lot of payers, not all payers, but we have payers out there that would love to deny payment, especially after we've already delivered it. There's nothing better than get free care. And so, what I am proposing is more of a plan that isn't mine. I mean, it's been in the process for over a decade and actually the federal government are the experts in site neutral site neutral billing analysis, projections. They've already successfully implemented site neutral with physical therapy. Now we do get paid the same as the hospital, and, they're the experts. What I see is exciting. I do see that there is headwinds for hospitals. I don't deny that there is going to be resistance, but what I have heard is less about the healthcare system and more about me, whether it be the owners of those institutions or the people that work for them. They're afraid, what will this mean for them? But this is the feeling is that we as independents are already there. We've already learned how to make adaptations, already learned how to become more efficient. There is no better incentive to become efficient than when you don't have the money. You find a way. So, think that my testimony too, I didn't want to spend time talking about what I wrote. You can read it. Feel that this is an opportunity. I think this is a safe opportunity because most PTs are in the community and also we're spread out, not like a hospital where people have to travel far and if anybody's had PT, you know that this requires multiple visits. So, we live in a climate that makes travel challenging in the wintertime, so you really don't want to travel far to get your care. And to stay with the plan of care, you've got to stay with your number of visits. It's just the way our profession works. So, I wanted to actually take some time to go into also what will create, I feel the success, which is, I'm also very honest. You know, I don't try to sugarcoat anything. And what I think is possible as far as what we need to give attention to in making this site neutral billing a success is we need to account for the practices that take out Medicare and Medicaid. Not all do, right? Not all hospitals do. So, in fairness to hospitals, to give them the feeling like we are not thinking just of ourselves, I don't believe success is in dollars in the bank of a business or a provider, but, so possibly site neutral billing should come with a condition that you will be seeing Medicare and Medicaid. There are other ways you could do an add on to those that do and still allow site neutral billing for all. And then the other condition is we do have differences in costs of facilities. We hear the hospital talk about facility costs. Well, in the physical therapy realm, there's nothing within the square foot print of a hospital and PT clinic and the rehab gym, actually we have greater square feet. It's the pools. I mean, these are 20 fourseven, $3.65 expenses, but the value of aquatic therapy cannot be replaced by other forms. And sometimes it's the only form of rehabilitation in a patient's need for rehabilitation to begin with. So, I would say that's just the only thing that I could see that we need to give a little extra attention to. Now, don't think we need to solve that now. I'm just saying, possibly we will look at a bump up for those facilities. Now, last thing I wanted to mention is I do believe in reference based pricing and you'll hear a lot of that. I also wanted to make note that the other initiatives that have been applied in the past to help independence and what's in the legislature outside of site neutral billing does not affect independence. And we thought there would be a trickle down, but that has not happened. Site neutral billing could do what none of the other initiatives can do and it would be done organically. The legislature, the Green Mountain Care Board don't need to get involved. After it's set, then it'll be flushed out within the professional environment. So, reference based meaning the reference is Medicare, CMS. Right now CMS doesn't pay the fee schedule straightforwardly. Physical therapy, there's always multiple CPT codes which are measured in like fifteen minute increments and in Vermont most rehab is over an hour. What CMS has done is taken the first CPT code or the highest and given us 100% of that, but then it has been reduced for all CPT codes after that to basically take what would be otherwise say $120 a visit and has reduced it to 100. And so, we have to be careful when we are designing the site neutral billing to make sure that the fee schedule of CMS is translated as is. And I don't think other, there's really, I can't think of another biller. There might be one that also does this multiple reductions. I don't want them to hear that that happens. It's frustrating. Not even my biller can understand the bills when they finally get paid. But we basically get around $100 so that's not enough to pay the bills. My cost of care is about 138 an hour and so Medicaid is even below that. We got a reduction when the primary care went up 15%, we went down 15%. So it's between $80 and $100 We're talking about every visit, the rehab gym will pay about $50 to treat a Medicaid patient And this is why clinics have dropped them. That's a way to save business. And then the last thing is, we might have a payer that takes advantage of this site neutral billing. I have no fear that Blue Cross and Blue Shield will handle this well in setting that rate, but I think it's important to have the Green Mountain Care Board just oversee it to make sure there's fairness amongst the commercial payers that are involved in this. They don't have to set the rate necessarily, we need to just have some oversight. And I would think that providers and the insurers to make should provide that information to the Green Mile Care Board of where the sweet spot is. We don't want to make it so that the hospitals suffer too much, but we don't want to also make the independents pay more than they need so that the benefit to the healthcare

[Speaker 2]: system is lacking.

[Sen. Ann Cummings (Chair, Senate Finance)]: We are behind schedule. Well, that's it. Thank you. Thank you. I think this will be very helpful. Representative Black, I have one more. No, I'm glad you're super early. I just thought I would come down and watch out.

[Sharon Gutman (Physical Therapist and Owner, The Rehab Gym)]: I think we may get to you a few minutes

[Sen. Ann Cummings (Chair, Senate Finance)]: because representative North is not gonna testify. Okay. So I'm gonna go on to Doctor. Brinson. How much did I have?

[Susan Ridzon (Executive Director, Health First)]: Brinson, but I am not a physician, although I appreciate the undesirable health. I

[Sharon Gutman (Physical Therapist and Owner, The Rehab Gym)]: have MD out there. Yeah.

[Susan Ridzon (Executive Director, Health First)]: Good afternoon, Thank you, Denise. All right. I'm also a first timer in this committee, so I appreciate the to testify today. For the record, my name is Susan Ribson, not an MD, and I'm the Executive Director of Health First. We're an independent practice association, so we exist to promote and foster the success of independent practices. We represent roughly two fifty, over two fifty physicians and advanced practice professionals, working in 76 primary care and specialty care, clinician owned practices across Vermont. In my testimony that I submitted, I did include some information about our network, just high level. I encourage you to look at that at your leisure. I also encourage you to consider me a resource if you have any questions about independent practice or suggestions on this bill. I'm here in support of the House Pass version of five eighty five, particularly two sections. One, the expanded access to association health plans and the site of neutral billing. The association health plans, I realign somewhat here with Ms. Paradis' stance on this. Our practices are small businesses, so they're buying out insurance for their employees. They're forced to do this on the exchange largely. The costs have gone up astronomically over the last several years. We need options. That is why we are in support of having the association health plan as an option. We do acknowledge that it's a potential threat to the exchange risk pool, shrinking that. However, the high cost of health insurance for our practice is an exponential threat to some of them. So, you may be losing them from the risk pool anyway if the rates keep going up, and on top of that, you'd be losing those options for care for the sponsors. So, we would like to see those options out there. Then moving on to site neutral billing, we're in very strong support of this concept. Equal pay for equal work has been an issue that we've been repeatedly, we've repeatedly sought to remedy over the years, and Chair Cummings may recall some of those discussions that we had this issue. We've now dealt with that in this committee before, with an essentially different committee, but we did. Yeah, so folks may not realize, but right now, a clinician could be paid 30 to 80% higher only for the sole reason that they are located in a hospital owned environment. It could be the same level of training of the clinician, the same care, same equipment. The only difference is the location. And that is crazy. It's costing Vermonters more money because it affects their co pay, it affects the employers, the insurers, the entire health system. It's crazy that it exists this way. It's illogical. And it's also quite unfair to those hardworking independent clinicians. And it results in even more struggle for these practices to compete with better resourced entities. Site neutral billing, and as Ms. Gulick testified, this has been recommended at the federal level by a group called MedPack, which is a non partisan legislative body that advises Medicare or CMS. They've done a lot of work around this and it's a pretty clear money saver and common sense approach. It would correct this unfair and illogical reimbursement practice, it would lower the cost for all of us, And if done in a balanced way, meaning you're not just bringing the hospitals down to the independent level, but you're bringing the independence of some to help support them as we try to shift care out of the hospitals into the community, and just do it in a blended way. We can save money, not decimate the hospitals, but also support those community providers. Site control billing also discourages further healthcare consolidation, which has been associated with higher costs, which we are facing here in Vermont, obviously. And it better aligns payment with value and outcome. So, you're paying for that and not the location of where the service is provided when there's no clear reason or need for a difference. So, H85, five eighty five as written, definitely is moving in the right direction and we support it, the push toward site neutral billing. We do think there's some opportunity. We do recognize the desire to keep the suite of codes focused at first. We do think though that, and we suggest that you consider strengthening the bill in two ways. One, adding language, and I did suggest language, I'm not an attorney, so legislative counsel could probably come up with better ways to say it, but the goal is to basically amend the bill so that your, that this site neutral work isn't kind of a one and done thing. That you're building in a ramp to evolve the policy over time so you're not having to come back to the legislature to look at every service type to do it. Build it into the ability to expand over time. And then two, well, you know, the physical therapy codes are a great place to start. We think that the benefit could be expanded if we also include a discrete set of, they're called E and M codes, or evaluation and management codes. These are the codes when you go see your doctor. You have a new concern, like a urinary tract infection, and I did include in the testimony I submitted some, and I can hand this out if this is helpful, but basically, these are the codes that we're suggesting get added. There's no clear reason, there's no clinical justification for one clinician who works at a hospital or hospital owned outpatient practice to get paid more than an independent clinician at an independent practice. So, we think it makes complete sense to add these POVs, the opportunity for savings is more, and it just makes sense to do so. Okay. So, I appreciate the opportunity. Well, thank you. Committee, any questions? Thank you, Madam Chair.

[Sen. Ann Cummings (Chair, Senate Finance)]: Sorry I missed the beginning of your testimony. I was in another committee, but I'm looking at your testimony in terms of the specific language that you're suggesting in Section seven. Is it mostly just that you want the ability to once these first categories are successful, then there's a way to move forward with other categories of billing without having to come back and change the law. Keep the ball rolling. So, you're not tied to this language, that's just what you're trying to Correct.

[Michael Landsberg (Athletic Trainer, The Rehab Gym)]: She said she's not asleep.

[Sen. Ann Cummings (Chair, Senate Finance)]: I think. Hospital would it'd be the insurance companies and the cost and the impact on rates, because we're not, I don't think, suggesting lowering. We are working at lowering rates in another committee hospital rates, but it'll be the impact on insurance premiums. Yeah. But I think the point of this is that It's supposed to save money because there are some sites that are being built higher than others for the same services. So it's not it's worth the goal is not to bring everybody up to a higher It is. You find Boardwalk. Boardwalk. Yeah. But as we know, most of our hospitals are in pinkish to reddish financial condition, and so how we transitioned, and we could find the transition, suppose, hooked on the shade of pink at the hospital where we could move to that because we, in the past, have heard some really compelling stories from private practitioners. Yeah, I mean, you know, if you think about the they're suffering too. They're going they just go out of business. And we have a loss in the practices because they're not properly supported.

[Sharon Gutman (Physical Therapist and Owner, The Rehab Gym)]: Yeah. Yep.

[Sen. Ann Cummings (Chair, Senate Finance)]: So Okay. Thank you. Appreciate it. Thank you. Okay. We're gonna get to representative early. Representative North for blood test today. Right. And it's the new valve. So welcome. We're standing by the but please. Or disturb your thought about sepsis. Well, for the record, representative Elizabeth Black, the chair of House Healthcare, I wanna make it clear that I am not the reporter of this bill. Okay. The reporter of this bill was Copper McFawn.

[Rep. Elizabeth Black (Chair, House Health Care Committee)]: Aw. And I'm pretty sure he resigned just so he would have to give me all the bills. So I still didn't. So I'm done laying it for him. I did I did work both Topper and I. I get to call him Topper now instead of representative on top of the Why don't you? Topper and I worked really collaboratively on this bill, particularly the Department of Financial Regulation. So, I feel like I'm pretty well versed in it. I did even do a couple sections on the floor when we were reporting out the bill. I think you asked me in here to talk about, I believe, sections one and two regarding the governance And I

[Sharon Gutman (Physical Therapist and Owner, The Rehab Gym)]: think that across probably

[Rep. Elizabeth Black (Chair, House Health Care Committee)]: Well, I'm more than happy to talk about the other sections. Okay. That would be helpful just to know what it why because there's there's several very distinct sections Yeah. Of Susan's great testimony. I will just add one thing that she, and I have been around long enough, I know that you have, and I know that this is something that has been discussed. It's not just that independent providers are going out of business, it's that they then are hired by the very same hospitals and the rates I believe Chittenden County just lost its last independent oncologist last year, and that oncologist now works for UBM Medical side. And there are advantages, I believe, for malpractice insurance, which is a big expense. Regular scheduling, you know, calls in the middle of the night. I believe he made a very public case of the disparity between the payments that he was getting from insurance as opposed to hospital payments. Yes. So, infections one and two. Know that, as we were doing this deal, frankly, there wasn't actually a lot of controversy around these two sections until the very last day. I actually stronghold my committee on every single section in the bill to get before we actually voted on the bill, to sort of get everybody to read on where they were falling. I was surprised that I lost that straw fall in Conceptions one and two. Department of Financial Regulation came back in to retestify on it. I and the committee completely was swayed and was in support of including it after that testimony. I have heard this argument that somehow it's some kind of slippery slope for nonprofits. I will just say I've had to sit in many meetings, and I know, Madam Chair, you have been in some of those meetings with me. This is a insurance company that, like a year ago, we were seriously discussing insolvency and going into receivership. This is an insurance company that by most measures touches at least half of Vermonters. I'll bet if you went around and I asked you to pull out your insurance cards, half of you might have a Blue Cross Blue Shield or Vermont card. Insolvency would absolutely collapse our entire system of healthcare. This is not some folksy nonprofit. Understanding the financial situation that they were in, understanding their relationship with Blue Cross Blue Shield of Michigan. I mean, effectively, are an affiliate of Blue Cross Blue Shield of Michigan, and we think that there's, okay, there's seven members of the board who are the honors, but there is veto power by the Blue Cross Blue Shield Michigan over who sits on that board. I just feel it's very imperative that with an organization and this bill, it is very specific. It will never affect some other nonprofit. It is written in the statute under nonprofit hospital service corporations, which we only have one in the entire state. I don't think anybody would think that we will ever have another one, particularly with the state of our healthcare market. We may all love our present governor, but he won't be there forever. And we could get a governor that had very different political opinions around health care, and once we've set the precedent of having a governor, court representatives on a private board, it's very you know, essential to the state of Vermont that that precedent could be done to other boards, that other governors That would take legislative action. It would take legislative action, and we would all love us too. But the agents out there knows that a third of us will probably not be here next year. That's our average turnover. And so that I think it's the setting of precedent that's making people notice. I I hear that. I'm not sure I agree. Yeah. Would, what it effectively would do is there would be at least two members on that board who are tasked with the Vermont healthcare system as a whole and Vermonters rather than the aims and goals of Blue Cross Blue Shield of Michigan. And maybe we should also talk about the Community Mountain Care Board and their role in this. I will say Do we have a problem with Michigan? I I don't know, but I would imagine that Blue Cross Blue Shield of Michigan's mission is not to the system of healthcare in the state of Vermont. Don't know what their mission statement is. I did wanna say, to your point, and I'm looking over at DFR, I was a little concerned about having the governor appoint to. We went back and forth. I thought, well, maybe the legislature should have one appointment, and the speaker can appoint one member and the governor get another. Then it turned into, frankly, essentially a whole new Green Mountain Care Board nominating committee. Frankly that exhausted me, so I'm like, Fine, the governor can have to. So, if you'd like to change how these two people are fit, that is, I'm totally in agreement with you. We really do feel like, with an organization, it's so imperative to the healthcare system in the state of Vermont that perhaps there needs to be a couple members sitting on that board that are looking out for the welfare of all Vermonters, not just the financial bottom line Blue Cross Blue Shield of Michigan or Vermonters. Thank you, madam chair. I'm just curious, and, you know, maybe this is more of a fair question for DFR than you. So I I if it is, please, I can ask that. They're all here. Which is Blue Cross Blue Shield got into a really bad situation even though they were being regulated by DFR. So how did did DFR not do what their jobs well enough? And what makes us think that two members sitting on a board are gonna have any more ability to prevent the financial collapse of the corporation than the regulator. The DFR is the regulator. And maybe they didn't do a good enough job regulating. Oh, I think that that is a great question for DFR. Okay. I know that you did we did discuss that as but I will say that what happened with Blue Cross Blue Shield happened so quickly. It was a matter of a couple months of claims Mhmm. At the end the last, like, two or three months of 2023. Yep. And I will say that that they did prop themselves up by taking out $30,000,000 loan from Blue Cross Blue Shield of Michigan at 8% interest. Yeah. That's from all rate payers that were paying that interest.

[Sharon Gutman (Physical Therapist and Owner, The Rehab Gym)]: No. I understand. I I mean,

[Rep. Elizabeth Black (Chair, House Health Care Committee)]: I was involved I was on health care, so I was following all that, and I remember how fast it happened. But I also sort of think it begs the question of why what were our regulators doing? Why were they not watching the shop? And the governor appoints the commissioner of Department of Financial Regulation and all those people, how is this gonna be any better than what our current system is? Our regulators, that's their job, and they didn't do it. I will say, if I recall that time, it was the regulators that came to the legislature. Right, but the Blue Cross had been asking for rate increases for their reserves. We told Green Mountain Care Board, your job is to keep down the cost, and they regulated the rates. Green Mountain Care Board doesn't regulate the company. They just regulate the insurance rates. D The DFR rep regulates the insurance companies. So I that's where I'm wondering what happened in that. Yeah. That that you know? And and now we have DFR, the regulator coming in and saying we want two members on this board, and I wanna know why they didn't why why did they not know this was happening beforehand? And maybe we should be looking at better regulation of insurance companies not putting members on private boards. Maybe this is part of it. I don't know. Maybe this is part of it, but I I feel like that's the question that needs to be answered. They think the answer is to put members on a private board, and I wanna know maybe there's a better way to regulate insurance companies. Because this health insurance DFR regulates other insurance companies, other kinds of insurance. Mhmm. They're the only ones. Yep. Health insurance gets split between the Green Mountain Care and DFR. And But but Green Mountain Care Board only regulates the rates. But the rates So the revenue. Their ability their their reserves, their all of that stuff, which is what DFR is looking at. And so maybe it needs we need to tighten up the regulation regulatory body does. I see you. Going to I'm going to let DFR answer through that labor debate. I do wanna say just I can't put it. I won't sorry. I'm apologizing for the board. I think the the rate was actually, actuarially accurate for what was thought of at the time that they would need more reserves. No one anticipated a massive claim surge. There was the last part of 2023 was unprecedented in hospital claims. Okay. But how would two members on this board make a difference? How would that have changed that? Feel like this may not be the solution to the problem we're trying to solve. Yeah. And so maybe it's we need better regulation. I just wanna make sure that we're fitting the right solution to the problem. I'm gonna let DFR make that piece Alright. For We're gonna, we are going to spend, I think, more time on this section than any of the others. I will say that there was an amendment on the floor to remove these first two sections. The member who did that ended up withdrawing their amendment. And then the bill passed. The committee did do a straw poll on that amendment, and the straw poll, I think, in our committee was eight two one. I think it was eight two one. We were doing a lot of straw pulls that week. So, we will definitely be I know you asked me on sections one and two. I just wanted to, first of all, the site initial, I think Susan did that. Yeah. I feel like we've got the association health plan section to a really good place for a lot of compromise. We were obviously all incredibly concerned about our QHP market and destabilizing it, but I really feel as though it's sort of got to the right place. I've been saying, I want the QHP market to be the place that we want to be. I don't want individual employers to have to become self insured, or forming associations to try to lower their healthcare costs. I want to make the QHP market the lowest cost option. And we're working very hard on things, and I know you all are obviously on Senate health and welfare, understand that. I want to make a plug for section 10. This is around healthcare sharing plans. There were two amendments to remove this. One was withdrawn and the other was voted down on the floor 103 to 26 to keep it in there. Have brought and I'm gonna leave this with chair if she would like this. This is just simply reporting. And frankly, I see it as a consumer protection. This is a viable option for many, many people who are struggling to afford any sort of type of insurance. I want people to be confident that if they're planning on choosing a sharing plan, that they have all the information, that they understand that it's not insurance, that it's not regulated like insurance, and the legitimacy, and anyone can form one of these things. Anyone. They're completely unregulated. We're not asking for them to be regulated. We just would like to know what sort of business they're doing in the state of Vermont. It is based word for word on legislation that came out of Colorado. Were told that Colorado is in court. I'm gonna let I'm gonna let Jen Harvey Yeah.

[Sharon Gutman (Physical Therapist and Owner, The Rehab Gym)]: I mean, we will look into that.

[Rep. Elizabeth Black (Chair, House Health Care Committee)]: But that was the main concern that until the court case is settled, we might not want to jump in. Yeah, first. And I believe we heard from the Office of the Attorney General who had no concerns and was not Okay. I just wanna leave you, I have a copy of the report. I'm gonna get with you, take it for your own pleasure reading. Okay. And you can see just the kind of information that we see in Vermont's report. Alright? Anything else on 584? Any questions? Okay. Committee, we're gonna have a ten minute break. I don't