Vermont Legislature SmartTranscripts:

[Jennifer Carbee (Office of Legislative Counsel)]: You're following on.

[Sen. Virginia "Ginny" Lyons (Chair)]: All right, good morning. This is Senate Health and Welfare. It is January 15, and this morning we're going to look at various bills that are in committee and make decisions about how we're gonna move forward on those. But before that, we're going to hear from Joint Fiscal, the Provider Tax and FMAP. Nolan, it is all yours. Thank you. We look forward to this. We all need it. Well, thank you for

[Nolan Langfeldt (Joint Fiscal Office)]: the record, no language in the of Fiscal Office. The goal of these two very brief presentations is a refresher or just a very high level foundational FMAP and provider tax. As start getting pieces of the budget or start looking at bills that deal with Medicaid, this stuff you'll find is quite helpful and sort of foundational understanding of that stuff. So I'm going do the FMAP first. FMAP stands for federal and medical percentage. So just in terms of the state budget context, the total state appropriation is $9,200,000,000 Medicaid spending accounts for about twenty five two five of total state appropriation. That's state and federal. So you can see that Medicaid spending is just that piece, it's $2,400,000,000 Total fiscal year twenty five federal funds that we appropriated are $3,200,000,000 That's roughly 34% of the total state budget. 40% of that 34%, or 40% of the 3,200,000,000.0 is just Medicaid, our federal dollars for Medicaid. So 40% of all of our federal dollars have come in across 2015. So overall Medicaid expenditures are about $2,400,000,000 in fiscal year twenty five. Medicaid is funded through a combination of state and federal matching funds. So again, FMAP is the federal government match allowable state. So it's the state, the federal share, so we call it FMAP. You can see that FMAP accounts for 62% of our total Medicaid budget, and the rest are mostly state funds, or mostly general funds, with some other small amount of state funds that are in special funds. When you do 33 plus 34, 37% are state funds, the rest are federal funds. Most of that blue thing are from our asset map. There's a small sliver of them that are just federal grants. So most of that's Federal matching dollars range between 5090%, depending on the program. So for instance, Washington will get into the weeds if food falls into water. But on average, it's about 62%.

[Sen. Virginia "Ginny" Lyons (Chair)]: How does that relate with other states?

[Nolan Langfeldt (Joint Fiscal Office)]: Ah, perfect segue. I

[Sen. Virginia "Ginny" Lyons (Chair)]: can't see it.

[Nolan Langfeldt (Joint Fiscal Office)]: FMAP, there's a complicated formula. The federal government tells us every year where FMAPs will be for the following fiscal years. And they have a formula which I can't get into the weeds of because I don't know, but basically at the high level the way it's determined is it's three year average of state per capita personal income compared to the national average. So it's sort of relative to everyone else. So no state can receive less than 50% or more than 83%. So I have here a list of various other states just to give you a sense. So for instance, Mississippi has the highest death mat there at 76.9%. This is for federal fiscal year 2026. Now remember, federal fiscal year is for October, September, our state fiscal year is July to June. But this is their federal fiscal year. And then for the state, we have to do this whole conversion of how to look at our state. But this is the federal, and you can see there, 76.9. Then you can see the states that are at the low, there's the high per capita states, California, Colorado, New Jersey, New York, Massachusetts. And I just threw in the other new rule of just so you can get a sense. So Rhode Island is 57.5, Connecticut, New Hampshire, Massachusetts are all 50. We're at 59.01, again this is our federal fiscal year, I'll give you the state fiscal year for conversion. They made 61.29. Now, you'll see arrows next to them, up, down, up, down. That means that their FMAP went up from the previous year or down from the previous year. So it's a second point, I have another slide that shows you how it just sort of fluctuated over time. So this is the fiscal year, these are the FMAP for our first fiscal year, for fiscal year '26. The next slide is '27, which we do our budget. The current fiscal year, and this is our state, so we convert the federal fiscal year to state fiscal year, and that's what this number is. That's why it doesn't pass this number. But we are excited this is the FMAP that we are using. And so we have multiple FMAPs. Our regular FMAP is 58.1 to 41.2 per state. Converted that means for every dollar, every state dollar we put in, we get a $1.43 for a total of $2.43 So that's most of our FMAP. We also have an enhanced FMAP for our children health insurance, that's roughly $70.30. So again, for every $1 we spend on Chittenden, that's about 4,400 kids, something 4,500, four four thousand five five hundred kids. So every $1 we spend, we get $2.47 from federal government for a total of $3.47 And then we have our childless new adult. This is the expansion population of the Fourth of Care Act. We call them adults, it's just the category that's named. They're not actually new adults, this is just the category that they've named Anyway, let's just ignore the name. Just note this is the Affordable Care Act expansion population. We get ninetyten, every state gets ninetyten on this particular version. That's about 41,000 adults who do that. Our FMAF went down, so it was 58.81. For fiscal year twenty seven, it went down 58.07. Now that might not seem like a lot. Forget the conversion, but that little drop translates to somewhere between ten and fifteen million dollars of additional state dollars that we have to put in because the federal government's cut back. Now, what I always say is, from this budget period standpoint, when we see that the FMAP has gone down, we're like, damn, that's really bad for the budget. But if you recall, it's an average of state per capita income relative to the other states. So if our FBAT has gone down, it actually means that it's an indicator that our capita income has actually gone up relative to other states. So it's not a bad thing for the economy and for people, but it's a bad thing for the state budget. It's kind of a double edged sword. The other double edged sword I like to flag for people is again, so we're getting, for every $1 we spend, we're getting $2.38 cents in services. In times where times are bad, if we're looking to make cuts to programs, for every $1 we cut in Medicaid, lose $2.38 in services. It's a cut both way. Now the flip side, I've heard people say, oh, we're leaving money on the table. Why aren't we putting more money with all this math? That just comes down to still a dollar. Still a dollar, add something else. It moves about priorities. And then also, under our global equipment, we do have cap on how much we can spend total. That's a presentation for another day. This shows how the FMAP has gone up and down over the years. For instance, you can see where it's gray, it means that the decision state share. Where it's white, it means our state share went down, which means the FMAP went up. Where it's white, it means that the state is paying less. And then where it's gray, the state is paying more. For many, many years, you can see it was cyclical. It was up, it was down, was up, it was down. I put these little pieces. For instance, 02/2004, there was a downturn, and so the federal government did this temporary relief for states. Seems to be, even though it's cyclical, there seems to be a correlation, a lag, but still a correlation when the economy's bad. And then we had all these other things happen. Had a regular FMAP and then the American Reinvestment Act during the economic, the Great Recession, the states were given additional FMAP to help them get through the time. And then during the Affordable Care Act, had the late bump, which was at 1.5% over a short period of time. And then we also got a six point two percent FMAP bump during COVID. So we've also had these, but these trends are the regular base FMAP. And then I had these tiny little dots that show where the bumps were. But the bottom one is just straight at the map showing just the trench. You can see it goes up and goes down, goes up and goes down. We've never really gone above, we've never hit 50, we've never really gone below 40. So it seems to be consistent. So that's the FMAP. And the reason I kind of did that was because it blends, there's a relationship between the FMAP conversation and the provider tax conversation. So income, provider taxes, senators on my left, they're both on finance, and both we did receive this presentation last week. But

[Sen. Virginia "Ginny" Lyons (Chair)]: This will make them experts, but they will now have an armed committee. We'll test our name.

[Nolan Langfeldt (Joint Fiscal Office)]: Testing memory, but I also feel like you can never hear this stuff too much. No, you're right. And there is stuff in HR1, the federal bill that the reconciliation bill was passed last year, that has a significant impact on provider taxes, which will have a significant, and I use the word significant because it is big numbers, it will have a big impact on state dollars that will be available in states to use for Medicaid or other. So what are provider taxes? They are healthcare related taxes, and there's a whole list of the specific healthcare providers that can be taxed. That's on the next slide, or it's one or two slides ahead. Again, as you know, Medicaid's financed through a state federal partnership, and traditionally these dollars have been used to draw a Medicaid drop match. Now, I am cautioned that because people say, Oh, we're taking the dollar from this and we're using it for Medicaid. Yes and no. We've walked a fine line because this all goes into the general fund. So I always think of the general fund as like a pond. There's water going into the pond from all various sources, and there's water going out of the pond from all various sources. Water goes into the pond from fees, from other different taxes, as well as provider taxes and others, and it's going into the same pond. Money's going out for Medicaid, money's going out for fish and wildlife, money's going out for ag. So I just sort of say, water is not like a pebble. It's just like water. It's very fluid. So on the one hand, we still consider it health related tax, but can't necessarily say that that dollar that's coming from that hospital is going to that service. Sort of blew it. You know what I mean. And then finally, provider taxes. We can't just go ahead and tax these providers with however we want and how much we want. There are limits, are federal rules around who we can tax and how much we can tax and the things that we can and cannot do with that money. Their deposits of the general fund, provider taxes are a significant amount of the general fund share. When you look at the amount of general fund, they are a big piece of the general fund relative to the total, just said the whole thing about money going in, money going out, but we're saying, you get the drift. Provider taxes account for, or equal to 28% of the general funds that we are using for the Medicaid program. Or they are 9% of all funds we take to state and federal. In short, it's a lot of money, and it's a big percentage relative to the general fund amount that they are using for our Medicaid. You've already been through this, but this is that point about if you raise this much money, that equivalent can raise even more money. I'll skip these and get right to this. So here are some of the rules that are on parameters. So provider taxes, they must be broad based, which means they must apply across the class of healthcare items provided. For instance, I can't, this is where Jen comes in, I always mix some of these up. Basically I can't say Copley, you're 3%. University of Vermont Medical Center, you're 3.5%. Berlin, you're 6%. It's like all hospitals are dating the same amount, broad based. You are applied equally regardless. Must be uniformly applied, which means it has to have the same per bed licensing fee across the same assessment rate for us. Okay, so actually that's the one. I always mixed up, this is where Jen usually comes in. She can tell you the difference between broad based and uniformly applied. Let's mix those two up. But anyway, the point is you can't discriminate. You have to administer these things across the class equally. And that you can't hold provider harms. So for instance, I can't say, okay, North Country, you've been taxed a million dollars. I want to make sure you get a million dollars back. The way that you get it back is through your Medicaid utilization. So some hospitals may pay a million dollars in prior taxes, but then bill $2,000,000 in Medicaid, some may bill less. You can't be like, Don't worry, we're not do that. I'm gonna make sure you get that money back. Remember that money is coming out and it's being managed and it's going back into the system. This is where things are going to change in 2028. Well actually, first of me slide to classes. So these are all the 19 federal classes that you can do. So inpatient and outpatient hospital, we just call that the hospital provider tax. That's just one tax. Nursing facility assessed nursing homes, if it's red, we have it on the books and we tax it. If it's black, we do not have the vaccines. So currently in the books, have hospitals, we have nursing homes, we have these intermediate care facilities, we have prescription drugs, and we have EMS services. We don't tax any of these other ones. We have looked into doing some of them in the past, and long story short, the juice wasn't worth the squeeze. Implementing provider taxes are very complicated, and sometimes, for instance, you're looking to doing dentists about the general administration of dentists. Yes, madam.

[Sen. Virginia "Ginny" Lyons (Chair)]: I'm looking at the list and the question comes up, we're very much interested in acute care services for recovery for substance use disorder as well as step down,

[Jennifer Carbee (Office of Legislative Counsel)]: you know, different levels.

[Sen. Virginia "Ginny" Lyons (Chair)]: Are they eligible for provider jobs? I don't believe they

[Nolan Langfeldt (Joint Fiscal Office)]: are unless they're owned by a hospital.

[Sen. Virginia "Ginny" Lyons (Chair)]: Well, think that. Also, if you're acute care.

[Nolan Langfeldt (Joint Fiscal Office)]: If you are owned by a hospital, so for instance, physician services is a separate class. We don't tax physician services, but physician services are provided in a hospital, they're captured in a hospital provider tax. So if it's within a hospital, it will be captured, but that specific one.

[Sen. Virginia "Ginny" Lyons (Chair)]: Does that include primary care practices that are clinically affiliated with hospitals?

[Nolan Langfeldt (Joint Fiscal Office)]: If they're part of the hospital's net patient revenue, so if they're part of the network, no, we don't tax the network, but we tax the hospital there. Or the hospitals, they're capturing the hospital's net patient revenue, it is captured. If it's an affiliate or a student, I couldn't get into the weeds of what

[Sen. Virginia "Ginny" Lyons (Chair)]: they Okay, so I'm looking at some of these. We've got outpatient services.

[Nolan Langfeldt (Joint Fiscal Office)]: Yeah, that's a great question. And that gets into the weeds of what is in and what now. But in terms of taxing a new service, in the past we haven't taxed more services because it was too complicated to do that. However, with HR1, we cannot tax any new service or increase any rate going forward. It sort of froze every day and time. We did reduce the service about three years ago. We were doing home health, and we eliminated the home health for biotechs many reasons. But under HR1 So just a clarification, some of that is effective as of now. Yeah. So, Chittenden, so bring to the next slide. So here is who we tax, here are the rates that we tax about. We can't, for instance, our ambulances are 3.3%. We can't up it to four, nor could we go, say, you know what, we want to tax dentists now. HR1 throws everything in place. We no longer can tax a new service, nor can we increase an existing rate. We probably could eliminate service. I don't see why they would be against that. Or we could probably reduce it, but I think we probably could increase it once we reduce it or eliminate it. That gets you the least.

[Sen. Virginia "Ginny" Lyons (Chair)]: Are you gonna talk about the effect of that happening? I will get to

[Nolan Langfeldt (Joint Fiscal Office)]: that slide, yeah. So these are all the ones that we currently tax. I'm here at the revenues we can bring in, and you can see hospitals account for 93% of people. Hospitals account for a big percentage of our spending in our system. They provide a vast amount of services. They get hit the hardest. They spend the most on providing vaccines. Nursing homes is a little funky because it's per bed. It doesn't go above the 6%. When this went into effect, nursing home providers were like, it's a lot easier for us to just pre tax us on a bed for the year than this for a particular net patient revenue. So that's how it's done, but long as it stays below the 6% threshold, which it does, their rate's been pretty consistent. Intermediate care facilities, we don't have any anymore. Those are like root calls. We don't actually have any of the but it's still on the books. And then pharmacy, we get to the 10¢ per script. And then home health or Sunset. Just to give you a sense of what other states are doing, in 2004, this is important to Kaiser, 35 states had at least one provider tax. By 2024, 49 states and the District Of Chicago had at least one provider tax. The most common was nursing homes and hospitals. And then approximately 13 states, including Vermont, had provider taxes greater than 5.5%, and 20 states had provider taxes at hospitals that were lower than 3.5. Now 6% is the max. You can't go above 6%. And then we have intermediate care facilities, 32 states have those. So this is the impact of HR1. So what HR1 does is it phases down the provider's case that expansion states can charge from 6% to 3.5%. So right now, under law, we can't go above 6%. What it's gonna do is over time, it's going to reduce the maximum rate by point five per year starting in 2027, and eventually until it gets to 3.5. So currently we're at 6%. It will go to 3.5. So if you look at all of our provider taxes, the only ones that's really impacted are hospitals because they're at 6%. Nursing homes are actually excluded in HR1, so they're okay, that particular one was excluded. Ambulances are at 3.3, which is below 3.5. Intermediate care facilities were also excluded, the two of those, we're not quite sure why, but we don't have any anyway. And our pharmacy again is lower than 3.5. So beginning at tenone was the beginning of fiscal year twenty eight, then started to go down. And as I mentioned, it also prohibits states from enacting any new provider taxes. Is the impact. Is the estimated impact. Now when you hear from AHS, their numbers are slightly different than mine, but we're consistent. And again, really at the end of it, we just don't know, but they're consistent with ours. So it'll hit us in state fiscal '28. We'll lose $15,000,000 and then it compounds over time. Then it'll turn to 35,000,000. And by the full rollout, by the time it's fully implemented by fiscal year thirty three, we will have $113,000,000 less in general fund.

[Sen. John Morley III (Member)]: That's not quite half, right, from what you currently are?

[Nolan Langfeldt (Joint Fiscal Office)]: It's a little less, but we're over 6% to 3.5%. But what I've also done, to nerd out a little bit, as we say, okay, it's based on net patient revenue, and there's a formula for what defines net patient revenue. So I'm assuming our net patient revenue goes up 3% every year. So the base is increasing 3% per year, and you're just decreasing off that base. So that's why the numbers aren't fifteen, thirty, 45. There's a bit of a base increase built in there, which means you're higher revenue, which means you're losing revenue, higher net base of revenue base, which means it's more of a hit. Now again, it's $113,000,000 less that you have to spend on, again, goes into the general fund. The levers that the state will have to compensate for that will be to cut services, raise new revenues, find efficiencies, or find money elsewhere as they come in. And the answer is you'll be looking at all of those things as soon as you are still here at fiscal year 3033. But this is big money, And it doesn't affect us in this fiscal year, or even the next. However, legislators should be mindful they're doing the '27 budget, that any expansions that you do in '27 will potentially be on the chopping block down the road. So you have to be mindful, and I'm sure the governor is doing this as well. As you're building '27 budget, start being mindful of your future down the road of what's gonna be available. Rainbows and butterflies? Rainbows and butterflies?

[Sen. Virginia "Ginny" Lyons (Chair)]: I mean, a lot could change too. A

[Nolan Langfeldt (Joint Fiscal Office)]: lot could change, but this is the world that we are currently Right. So this becomes our new steady state. This is, you know, you

[Sen. Virginia "Ginny" Lyons (Chair)]: And we are in budget year '27, looking into '28.

[Nolan Langfeldt (Joint Fiscal Office)]: No, we're in '26 looking at

[Sen. Virginia "Ginny" Lyons (Chair)]: Well, we're in fiscal twenty six, but we're looking at '27 within budget. We're also looking '28. You know? Well, yeah. Yeah. It's not far away.

[Sen. John Morley III (Member)]: You know? I always thought that I always thought that fighter tax was just a state owned tax. So I didn't realize it was it was the federal government. So I didn't realize that. I guess that I didn't know if it was.

[Sen. Virginia "Ginny" Lyons (Chair)]: Yeah. There's a reason why that was such a bad thing that we were doing. Right?

[Nolan Langfeldt (Joint Fiscal Office)]: But, basically, what is the federal government said, look. We know you're taxing providers to raise money to pay providers. We're okay with that under these barriers, under these thresholds. Just don't go above six, and make sure you're not giving that hospital the exact amount. They were like, We know you're doing it, Wake's not, fine, But here are the rules for which you have to operate. Nolan, I

[Sen. John Morley III (Member)]: guess I'm concerned about because when god. Years ago, when I was on the folks we used to discuss, we cut a deal. It was meant for it was it was Medicaid waivers. Yep. And there was couple of them as I recall.

[Nolan Langfeldt (Joint Fiscal Office)]: There were when you were there.

[Sen. John Morley III (Member)]: Okay. States of j. Yeah. Used to

[Nolan Langfeldt (Joint Fiscal Office)]: be choices for care and the local commitment, and now choices for care is part of the

[Sen. John Morley III (Member)]: local community. Okay. So I'm concerned about how long that commit is commitment is for. Yep. And I would like to see worst case scenario, if you lost that commitment,

[Nolan Langfeldt (Joint Fiscal Office)]: what would happen? So you are asking the right question. I have another presentation on Not today, but but but but this is really important. Global commitment is basically the bigger it's the name of the agreement with the federal government for how we administer our Medicaid program. Almost every state has a waiver. We're the only state that operates our whole Medicaid program through that waiver. The idea behind a waiver basically is that basically Medicaid is like there's basic rules to Medicaid. Here's what you can cover, here's what you can't cover, here's how it's reimbursed. The idea behind a waiver is that they're called innovation waivers. It's the idea that when it was created, states could be innovative, you can operate same way, to operate your same program that meet our guidelines, and do not spend any money more than it would in the absence of the waiver, go for it, and here's the agreement. We have a lot of things that we use to achieving savings. We can reallocate those money for things that are within the terms and conditions of that waiver. And so we operate a lot of our Medicaid and substance use programs and public health and other stuff through that waiver, that in the absence of that waiver, we lose. And we have this thing called investments, and those again are things that we can spend dollars on that have been approved by the federal government and get matched on, that in the absence of it, we would not be able to get matched on. And that's somewhere in the ballpark of $150,000,000 That's what I want to say. Yes, somewhere in that, to it be up as high as 200, it's gone down a little bit because the government started ramping down on what could be investment. In short, the second part of your question is that traditionally waivers are five years and renewed five, for another three years. And we've been renewing global commitment for almost twenty years. With change, each time we renew it, there's new terms and conditions. But the basic premise, actually what the program looks like now versus what it looks like is actually quite different. But it could evolve to what the needs are of the policymakers and needs of the citizens. That said, this current waiver expires at the end of calendar year '27, and it will be under this particular administration. And there's a belief that this current federal administration will no longer want to allow us to do global commitment. That's my point.

[Sen. John Morley III (Member)]: So I think the finding is gonna be extremely visible.

[Nolan Langfeldt (Joint Fiscal Office)]: Yes. So to your point, wanna raise is that when we first when we first did

[Sen. Virginia "Ginny" Lyons (Chair)]: that So are we. I mean, there's a policy piece of that Yeah. In terms of choosing

[Sen. Martine Larocque Gulick (Vice Chair)]: Which ones?

[Sen. Virginia "Ginny" Lyons (Chair)]: Who is covered. Exactly.

[Nolan Langfeldt (Joint Fiscal Office)]: So the Global Commitment was first passed during George W. Bush. And at that time, if you recall, George W. Bush was pushing for federal block grants in Medicaid. This was the closest he came to a federal block grant, because it was like, we're going to operate within a specific amount. If we go over that, we'll pay it. But we never did. So they approved it because it fit within the president's philosophy at that time. It can be assumed that this no longer fits within the current administration's philosophy. There is a hope, last time around, last time during this last version of this administration, it also expired and we were able to negotiate, I think, a one or two year extension, or negotiations were happening during the Biden administration, so it changed once the administration but anyway, long story short, there's a lot of uncertainty about whether this waiver could be renewed or what it would look like. And and not to put words in administrative people's mouths, but they're not optimistic that what global commitment is now is what it would look like when we renew. And we have to start negotiating with them this year, because it's always like a year process. So we'll start this, and this budget will give authority to the administration to start negotiating, and they will be negotiating through this into next year. So we'll see what that looks like. But Senator Morley, you're asking the right question. So if there's any other more doom and gloom, I've got lots of different gloom in my pockets. I've heard of them. Invite me, I'm guaranteed to bring you right down. That's my idea. Who's doing the actual negotiating? HS.

[Sen. Virginia "Ginny" Lyons (Chair)]: AHS. CCM. So

[Nolan Langfeldt (Joint Fiscal Office)]: Ashley Berliner, who I have a lot of confidence in, saying on the record, she's listening, she's bright, she knows her stuff, I'm confident that her and her team will be fighting for us.

[Sen. Virginia "Ginny" Lyons (Chair)]: And the decisions that we've made, asking for expansion, have been based on what we need in the state. They've been thoughtful requests. Well, see where it goes. Perfect. Thanks for all the cheery news.

[Nolan Langfeldt (Joint Fiscal Office)]: You're welcome.

[Sen. Virginia "Ginny" Lyons (Chair)]: Well, think it's interesting. We're gonna be losing within the next five years $115,000,000 No. We just got $195,000,000 Oh, but it's not replacing this. Completely different, but it looks like a gift. It is not. We've lost subsidies and we've lost this. So overall, the people who are in greatest need are still in, are now in greater need.

[Nolan Langfeldt (Joint Fiscal Office)]: Oh, thank you. If you need any more bad news, just call me. I'll come running down.

[Sen. Virginia "Ginny" Lyons (Chair)]: Which category was ended at 23 for providing fax? Beating at home health. Yeah. Thank you. You're welcome.

[Nolan Langfeldt (Joint Fiscal Office)]: Jen's gonna boost you back up to be the winner and be the savior. We

[Sen. Virginia "Ginny" Lyons (Chair)]: have a couple minutes. Jen, do you wanna get started right now or take a quick break? It's up to you. Why don't we get started,

[Jennifer Carbee (Office of Legislative Counsel)]: and then we'll take a little break up in the middle of all this. Okay. Yes. Let me just open today.

[Sen. Virginia "Ginny" Lyons (Chair)]: So we have, we put the bills on that we talked about during committee now we'll go through and look at

[Jennifer Carbee (Office of Legislative Counsel)]: what they are and then we

[Sen. Virginia "Ginny" Lyons (Chair)]: can make further decisions. This is the first crack at these bills. By no means have we looked at all of them and we'll have to have sponsors in to share the reason why they were introduced. That, Are we solving problems?

[Nolan Langfeldt (Joint Fiscal Office)]: We're

[Jennifer Carbee (Office of Legislative Counsel)]: trying. Yeah. So that and then So,

[Sen. Virginia "Ginny" Lyons (Chair)]: yeah, the back of center of light will be in a little bit, but so we'll start out. Alright. She's not coming until 10:00. Do you wanna start with one of with S one ninety?

[Jennifer Carbee (Office of Legislative Counsel)]: I'm gonna start I'm sure anywhere you'd like.

[Sen. Virginia "Ginny" Lyons (Chair)]: Okay. Well, let's do that. We'll we'll skip over Senator White. When she comes in Okay.

[Jennifer Carbee (Office of Legislative Counsel)]: I don't know what order you have on your Hang

[Sen. Virginia "Ginny" Lyons (Chair)]: on a second. I'll ask Melissa to see if she's available now.

[Jennifer Carbee (Office of Legislative Counsel)]: I can't even open up an. I don't have a. I have

[Sen. Virginia "Ginny" Lyons (Chair)]: to run down to transportation. Okay. Now let's just start. It shall pop in and we'll be all set. We're flexible. Right.

[Jennifer Carbee (Office of Legislative Counsel)]: I think. A lot of these

[Sen. Virginia "Ginny" Lyons (Chair)]: are my bills and so I'm not going to say anything unless I got it.

[Jennifer Carbee (Office of Legislative Counsel)]: Okay, so for the record, Jennifer Carvey, Office of Legislative Counsel. So there's an order on the website of the bills listed under my name, the last two are, I think, the ones you have external sponsors for. So if you wanna go in that order, we can start with 197, or we can start with 190. Your choice. Well, I think there's lot of interest with 190,

[Sen. Virginia "Ginny" Lyons (Chair)]: so let's start with 101

[Jennifer Carbee (Office of Legislative Counsel)]: night. Okay. Yeah. There's been committee interesting. This is the one that has broken face first. And, Madam Chair, you don't have to tell me how much detail, I know we're doing more detailed walk throughs next week. Okay, maybe we'll just start here with the statement of purpose that Bill has introduced, is always just the objective summary of what's in it. The bill would set out certain requirements that health insurers and hospitals have to meet to facilitate the Green Mountain Tribes implementation of reference based pricing. So, it required certain information to be provided as a percentage of Medicare or another benchmark in order to, for provider contracts, enter into on or after October 1, yeah. So FYI for us, a one foster approved care board will begin at 11:30. And we can ask him questions, and

[Sen. Virginia "Ginny" Lyons (Chair)]: Emily Brown as well, about reference based pricing and do a bit of a dive into what that means. But I'm gonna ask Jen maybe kind of the broader perspective of what would that mean if we had reference based pricing for hospitals.

[Jennifer Carbee (Office of Legislative Counsel)]: I'm not sure, what would it mean if we had reference based pricing?

[Sen. Virginia "Ginny" Lyons (Chair)]: Well, what is reference based pricing?

[Jennifer Carbee (Office of Legislative Counsel)]: Yes, and I think we talked about this a bit when we looked at 68, the reference based pricing is using a particular benchmark. We start by talking about Medicare. There are reasons Medicare might not be appropriate in all instances, but let's say it's Medicare. And the Green Mountain Care Board would set a percentage of Medicare, and in many cases more than 100%. Sometimes when you say a percentage of Medicare, it sounds like it's going be less than 100% of Medicare. Often we're talking about more than 100% of the Medicare reimbursement rate for a particular item or service. And they would set them for each item or service delivered in a Vermont, they're starting with hospitals, delivered in a Vermont hospital, and that amount represents the maximum amount that the provider can accept and take in payment for providing that item or service. So that allows us to, even if there would otherwise be variation among the payers, it allows us at the provider level to regulate the amount that they're actually getting paid, the amount they're actually receiving from as many of the payers as we can affect. The only one we can't really affect is Medicare. Medicare may end up just being 100% Medicare. And Medicaid is set through its own separate process. But for all other payer types, this is the maximum amount that a provider can get paid for a particular item or service. So we get some predictability and potential cost containment or at least cost regulation through the board's rate setting authority. Rather than allowing anyone to charge as much as they want for any Right.

[Sen. Virginia "Ginny" Lyons (Chair)]: Thank you. Does that help? Yeah,

[Sen. Martine Larocque Gulick (Vice Chair)]: no, I'm actually at a loss.

[Jennifer Carbee (Office of Legislative Counsel)]: And so, understanding, and you can ask the board more about it, but it's that there may not be the same price

[Nolan Langfeldt (Joint Fiscal Office)]: for the

[Jennifer Carbee (Office of Legislative Counsel)]: same service at all hospitals, There may be reason based on the mix of the patients, the volume of the patients, various other factors may affect the financial needs of the hospital, resources that it has access to through other state and federal programs. There may be reasons that the board sets the rate differently for a particular hospital, and that kind of gets into their hospital budget processes as well. So they establish the budgets for hospitals so they have an eye on what the hospital's financial needs and expenses are, and then what services they provide. All of that is under development. There are certain requirements in the bill for what hospitals and health insurers have to do so that it can help the board to implement the reference based pricing and gives them particular parameters and ways to code and report information so that it can be more easily identified and tracked and compared with apples to apples across the different hospitals. And then it allows the board to set kind of a default percentage of Medicare as the ceiling for new codes until the board gets to setting codes for new items and services. Then there is couple a of sections on hospital outsourcing. This is an issue that came particularly to light during the most recent hospital budget processes and the extent to which hospitals are outsourcing clinical services, like emergency medicine, anesthesiology, radiology, laboratory services, and other specialized care to outside entities. So sometimes this is for things like radiology, it might be, and I think this, my understanding has been going on for quite a while, they might send images to be read by somebody not employed by that hospital. They might contract out that service. But there are others, like emergency medicine and anesthesiology, that really direct patient care, that are increasingly in some hospitals being provided by providers who are not clinicians who are not employed by the hospital, but are employed by contracting, sort of employer contracting or employee contracting services and sent to Vermont hospitals for some limited period of time, sort of like traveling nurses, but in this case traveling physicians or others. And so that brought up some issues for the board, revenue from those outsourced clinical services. I'm going go through the findings I think is helpful, Madam Chair, on this piece just to explain it. So revenue from these outsourced clinical services is not consistently reported in the hospital budget process. The Green Mountain Care Board does not have regulatory oversight. It may be a way that hospitals are getting around some revenue caps that the board has imposed and spending limitations, which can have an impact on budget transparency and accountability. There's also the potential that these outsourced services can operate outside of price controls that the state is trying to put in place, including reference based pricing. There's potential for patient spacing network adequacy issues, surprise medical bills, and inconsistent access to the financial assistance policies that otherwise apply at these hospitals when they get care from outsourcing providers. So this enacts a new section on hospital outsourcing and it gives the purpose, the future purposes, bringing all hospital affiliated revenue within the purview of the Green Mountain Care Board's regulatory authority, ensuring that records based pricing applies to outsourced services, and applying network adequacy requirements and billing protections to protect patients and ensure access to the required financial assistance policies. So having that capacity then will do two things.

[Sen. Virginia "Ginny" Lyons (Chair)]: One, it'll keep it in the provider tax umbrella. Right, so I

[Jennifer Carbee (Office of Legislative Counsel)]: think that comes up in

[Sen. Virginia "Ginny" Lyons (Chair)]: a little bit. Oversee rates in a way that it's equitable rather than having one part hospital here.

[Jennifer Carbee (Office of Legislative Counsel)]: Do have examples of

[Sen. Virginia "Ginny" Lyons (Chair)]: the outpatient services or will you do that and do percent? What is that? Some examples of the outsourcing thing.

[Jennifer Carbee (Office of Legislative Counsel)]: Yeah, I think the board can give you. Yeah, the boards came out during

[Sen. Virginia "Ginny" Lyons (Chair)]: the Springfield bankruptcy that their emergency room services would be provided by a company in Chester, Vermont. Yeah. I assume that's an office,

[Jennifer Carbee (Office of Legislative Counsel)]: but the so I assume they want one that was outsourcing. Yes. Often these are national, you know, that's terminal to Vermont based entities that employ the clinicians and send them rotations to different states. Alright, so this creates a new section and kind of defines what we mean by outsourcing and outsourced services and what we don't mean. It would require revenue from outsourced services to be included in hospital net patient revenue limits, commercial rate limits, operating expense limits, and other hospital budget guidance set limitations from the board specifies that the board's rate setting authority, including reference based pricing and global hospital budgets, will apply to outsourced services. Deans revenue generated by outsourced services delivered in a hospital owned facility as part of the net patient revenue of the hospital for purposes of the hospital provider tax, so that would be in particular interest to Senator Cummings, and other applicable state assessments. That was another piece as well, is that revenue has not been, our understanding has not been included in the hospital net patient revenue for purposes of the provider tax. And then there is some consumer protection language about ensuring continuity of coverage. There's another piece that came up just that a clinician who is not employed by the hospital may not be there the next time a patient goes in for services, so there may be some issues with continuity of coverage. And preventing surprise medical bills. This makes the hospital responsible for billing the patient or health insurance for all outsourced services delivered to a patient by a contracted provider who would otherwise be out of network. So that was an issue that came up, is that somebody could be receiving services in the hospital from a provider who turns out to be out of network under their insurance plan because they're not employed by the hospital where the services are getting delivered. Minimizing billing complexity and applying hospital financial assistance policies. Section four, just adds some conforming language to a couple, sections four and five to a couple of other sections. So the financial assistance policies for large healthcare facilities, with some parameters in statute, and this specifies that financial assistance policy would apply to outsourced services. Similarly, in section five, adding to the definition of net patient revenues for provider tax purposes to specify that it includes outsourced services delivered as possible. Section six repeals some language about healthcare professional bargaining groups, recognizing them and authorizing them. That happens in four different sections. So this is just a reference to them as part of definition of painkiller reform in the Green Medicare Board statutes. And similarly, in the rate setting, pre Medicare board statutes, a reference to healthcare provider bargaining groups. And then it repeals, section eight repeals the bargaining groups statute. Talk to the board about the rationale. I think some

[Sen. Virginia "Ginny" Lyons (Chair)]: of the bargaining groups will be interested in testifying too.

[Jennifer Carbee (Office of Legislative Counsel)]: I don't know how many there are any left. I don't know if there are any, I mean, think it was contemplated and maybe used on a limited basis at one point, but I'm There may

[Sen. Virginia "Ginny" Lyons (Chair)]: be some. There was a big deal about getting it in statute. I'm not,

[Jennifer Carbee (Office of Legislative Counsel)]: not specifically talking the status. Okay. This clarifies or cleans up some language about the remit covered appeals process, including, I think the board does not particularly have an administrative appeals process. Really, results of any final order from the board, final action order or determination, is appealable to the Vermont Supreme Court. Providing some clarity on that, the lack of administrative appeals process. Hospital audits. There's some additional language added to the Green Mountain Care Board Hospital budget review authority, allowing the Green Mountain Care Board to conduct investigations and examinations, including audits as needed, and retain others, and require a hospital that's subject to an investigation or examination to pay the reasonable costs and expenses of that investigation or examination. Section 11 directs the Green Mountain Care Board to, in addition to an existing price transparency dashboard, to develop and maintain a public interactive tool with information on health system performance, including hospital prices relative to Medicare rates, able to be sorted and have it be updated at least quarterly. Section 12 says they only have to go ahead with that because this was a piece that was requested as part of I think, the in the Rural Health Transformation Grant application. It'd be helpful to understand if that has been deemed to be a permissible use, it will need the board to receive sufficient funding from the federal government or other source to create that health system you can perform it's true. So that's actually, that's act Or act We don't want an unfunded mandate. Right, exactly. Exactly right. What the best is saying. Only if there's funding. Right. So that's S-one 190.

[Sen. Virginia "Ginny" Lyons (Chair)]: Questions? It's a lot here, but this is a really important bill. There's some sections that probably should be considered fairly quickly. And I know you, I think we all identified this as important when we went through the so that's good. And so with the, we'll have testimonies specifically on the bill. When Colin Foster and Emily Brown in today, it's really more about an introduction to who they are and what they're doing. And we'll ask them to come in at some point and talk about the bill and give us some details. Any questions for Jen? No, she's.

[Jennifer Carbee (Office of Legislative Counsel)]: Okay. All right, perfect. Next we have, well, let's see, we can add whatever you want. Next we have, we do S197. Yeah. S197 It's produced by some members of this committee. This is an act relating to establishing a primary care payment reform program. It starts off with some legislative intent about investing in primary care by establishing a streamlined primary care payment system that will promote the public good by increasing access to primary care in order to improve the health of the providers and reduce healthcare system costs. To create a new Can I say one thing? So within this, I

[Sen. Virginia "Ginny" Lyons (Chair)]: was thinking about how to provide equal pay for equal work, equitable reimbursement overall. And then as part of that, alignment of reimbursement or amount of funds that primary care folks can accept through public and private insurance. So once we have some alignment of codes and payment, then we begin to provide a system of care that will build the workforce in our more rural areas because we're losing primary care big time. So a lot of the motivation here is to look at how we can improve the rate of that primary care doctor provider can accept anywhere in the state and then looking at those primary care offices, whether they're affiliated with a hospital, whether they're independent, and so on. So just for me that's really important and it's also important because once you have a robust primary care program across the state, including our blueprint program, then you have a prevention program that lowers costs later on by reducing chronic care problems. We've seen that already with Blueprint, but we need to ensure that these primary care folks can stay in place and we can add more. Not a difficult construct, but just the weeds get problematic. I'm still working on it. We're gonna work hard on this. Maybe, if we want to.

[Jennifer Carbee (Office of Legislative Counsel)]: So this bill directs the Department of Vermont Health Access in coordination and consultation with others to develop and implement a primary care reform program. I'm really sure to restate some of that intent. It will be initially voluntary, but pretty quickly become mandatory for primary care practices. And you'll see some more provisions developing some of this, but basically the funding would be a portion of premiums from commercial health insurance, premium equivalents from other payers. There's voluntary outreach to the self funded employers who we don't have control over, we don't have authority, so we can't tell them they're gonna participate, but we can invite them to participate, and can explain the benefits. And then trying to the extent permitted by law, waivers, etcetera, trying to get money from Medicare and Medicaid. And then beginning 2028, all practices would be in. So the idea is that the program would collect and aggregate the money from all the participating payers, and would provide per member per month. So capitated a per person per member per month payment to each participating primary care practice that would cover all of the routine primary care needs of attributed patients who were covered by participating plans with nothing out of pocket from the patient. So a lump sum will be provided to the practice for each participating, each attributed patient whose insurance or other payer is participating and that would cover all of their healthcare needs, nothing else out of their pocket for their primary care needs for the month.

[Sen. John Morley III (Member)]: These are independent primary care practices? This

[Jennifer Carbee (Office of Legislative Counsel)]: would be both. This would be, I mean part of the language at the end you'll see is rule making and part of the rule making is determining which primary care practices are eligible for this. I think it must be. If you can be more specific, you can take up the bill. Then there's some provisions around minimizing the program's administrative burdens, so trying not put too many new administrative burdens from this program on providers. Derives the program to establish some, or allows it to establish some quality measures, but put some limits on how those can be applied. There are some other goals around reducing administrative tasks and the amount of time that providers have to perform administrative tasks and the additional staff they need for that. The rest of departments would dump a risk adjusted model for practices, so that can reflect the mix of patients that they have. So there be areas that are needier than others or have sicker patients that might need higher paying amounts. I'm going go through these details yet. Directs the department to operate a payment pool that would collect all the money coming in for the program for the various payers, and then determine the per capita per member per month amounts and distribute the funds to the practices. Here's where it directs Diva to adopt rules, including determining the scope of services that would be included in the capitated rates, or what constitutes the routine care that would be included, and which practices are eligible, and then some more information about practice participation requirements and other administrative aspects, risk adjusted allocation model, operation of payment rule, program parameters that try to avoid having practices turn away patients or otherwise avoid high risk patients or otherwise engage in adverse selection. You can't try to cherry pick patients to have a healthier patient base so that less money is needed to provide the services. Defining direct and indirect spending, benchmarks for determining program performance. Subsection F directs the Agency of Human Services or Vermont Care Board, or both, to negotiate with the federal government to try to get Medicare participation. Also, here's where it directs them to conduct outreach to self funded, non governmental employer sponsored plans to try to get their voluntary participation, try to get the BPA in and announce that make sense. Do you want me to pause here? Oh yeah, let's do that, and we'll turn to It's

[Nolan Langfeldt (Joint Fiscal Office)]: gonna

[Jennifer Carbee (Office of Legislative Counsel)]: go white. We're turning right over here. Did you hurry We are ready whenever you are.

[Sen. Virginia "Ginny" Lyons (Chair)]: All we have to do are remember the number of the bill, S163. And so I love this early, Greg. Well, no, you're just fine. We have not addressed the bill as yet, but it is about advanced practice nurse, registered nurses and hospital care. And

[Sen. John Morley III (Member)]: so Senator White, we're glad to hear. Well, you. Again. Thank you, Madam.

[Sen. Rebecca White (Windsor County)]: For the record, I'm Rebecca White and I'm the Windsor County State Senator. And this bill came to me largely because I live in Hartford. And if you live in Hartford, you're either a nurse or you're not adjunct faculty at Dartmouth. So I get a lot of nurses in my community. All the doctors live in Norwich and Hanover. So this bill is very important to me because a lot of my neighbors are the ones who would be impacted by it. So I am not on the healthcare committee. I'm not familiar necessarily with the ordering of bedside physicians, but generally what this bill does is under current law only physicians are recognized as eligible to serve as the attendee of record for hospitalized patients. This restriction is inconsistent generally with the scope of practice that Vermont is granted to advanced practice RNs, or I'm gonna say APRN from now on, just to make it even more confusing. Those folks who are authorized to independently diagnose, prescribe, and manage patient care across all those settings. This doesn't expand the scope of the practice of the APRNs who already manage that inpatient care. Rather, APRNs in Vermont hospitals do already admit patients, write orders, coordinate treatment plans and communicate with families and often they do serve as the primary provider of record at the bedside. So this is really trying, in my opinion, to right size what we have on the books when it comes to APRNs, and that's all the information I really can provide you on it. I think so. If you wanna grill me, I will defer to friends in the room. You have friends in the room? I'm hoping the legislative counselor will be my friend in the room to explain what the bill functionally does in the health

[Sen. Virginia "Ginny" Lyons (Chair)]: care setting. We're appreciative that you brought it in, and it's we really like to have bills that come from people who are boots on the ground, you know, working in the the the health care world. So this is one of them. And you, I hope, will have some recommendations for folks who might testify on this, and I'm sure there'll be others who want to join in on this.

[Sen. Rebecca White (Windsor County)]: Would it be appropriate for me to email your committee assistant with a That list would of like terrific.

[Sen. Virginia "Ginny" Lyons (Chair)]: That would be terrific. I know you're always very responsive to our needs. Questions for senator Wayne. You have some really good neighbors. Thank you. Yes. Okay. Thanks for

[Sen. Rebecca White (Windsor County)]: reviewing the bill, and good luck in here. Thank you.

[Sen. Virginia "Ginny" Lyons (Chair)]: Thank you. We need our own active transportation. Yeah. So I'm so

[Jennifer Carbee (Office of Legislative Counsel)]: It is. Yeah. Darn. He's good. Good addition.

[Sen. Virginia "Ginny" Lyons (Chair)]: Both of them. Yeah. Okay.

[Jennifer Carbee (Office of Legislative Counsel)]: Thanks. So, Jen, here we are. Yes. Would you like to go back to primary care, or would you like to talk about the bill you've just heard about? I'm going to zip through the one that

[Sen. Virginia "Ginny" Lyons (Chair)]: we I mean, zip. I mean, it's not a long bill. So The one you just heard about? Yeah. So why don't we Yep. Finish out the

[Jennifer Carbee (Office of Legislative Counsel)]: Now, that one, Patrick. That's 01/2023, etcetera. Great. Again, John Benson, the Office of Legislative Council. This is S163. And it's entitled, An Activating to the Role of Advanced Practice Registered Nurses in Hospital Care. And as Senator White said, there are, in particular, a few places in statute where the language only speaks to physicians and does not recognize that an APRN is qualified under the law to provide services. First we are in the hospital patient bill of rights. This is just numerically, I meant through in numerical order of statutes. So we're in a chapter on Bill of Rights for Hospital Patients, and adding a definition of advanced practice registered nurse, or APRN.

[Sen. Virginia "Ginny" Lyons (Chair)]: There's advanced practice nurse and there's physicians who

[Jennifer Carbee (Office of Legislative Counsel)]: essentially do this. They do similar things. Their scope of practice is not the same, and their independence is not the same under our statutes.

[Sen. Virginia "Ginny" Lyons (Chair)]: Okay. So I'm just, I don't wanna do this and then next year find the I think it's different. Okay.

[Jennifer Carbee (Office of Legislative Counsel)]: I mean, may be, you may hear from the advocates for physician systems if they believe this is appropriate for them as well. Think you'll want to hear from the OPR. I did check-in with OPR in this bill just to make sure that this was within the existing scope of practice for APRN so there wouldn't be surprises for the sponsor if the bill was introduced to have OPR come in and say, No. And they said, I'll let them speak for themselves, but they indicated to me that this was consistent and appropriate. So we have, oh yes.

[Sen. Martine Larocque Gulick (Vice Chair)]: I'm not an attorney. And when a patient is in the care, who has the legal responsibility? Is it the doctor in terms of setting that patient's care? What I'm wondering here is if, in fact, we give more authority to the nurses, which I'm not a supposed student, my mother was a nurse, But how does that work? Because if, in fact, legally, the doctor in charge of that patient has the legal responsibility, how can that authority kind of be transferred, how does that work?

[Jennifer Carbee (Office of Legislative Counsel)]: So I'll say a couple things. One, we'll look at the language because it's narrower than that, but generally under existing patient care, I think whoever is the clinician of record who is treating the patient has the responsibility or the legal liability if they do not practice in accordance with the prevailing standards. So you could have a patient being treated by a number of providers with different license types and if something were to go poorly in a way that was legally actionable, they could have a claim against several different providers and the hospital itself. So, I don't think this doesn't change anything about liability, but because we're talking specifically about advanced practice registered nurses, which is a subset of registered nurses who have additional education and training, They do have a larger scope of practice and are able to be the one treating the patient without involvement of a physician. I don't think it applies to all specialties necessarily, so there may be some that are not with any scope of practice for an aviara and are for a physician. But the scope of this bill is really looking at a couple of very narrow circumstances. And if you want more than that, then we will bring in other people because We will. We'll be bringing in other people. Bring the ones I

[Sen. Virginia "Ginny" Lyons (Chair)]: don't have. Guess. It's not about a scope. Alright, so let me share. So

[Jennifer Carbee (Office of Legislative Counsel)]: first we are in, as I said, the Bill of Rights for Hospital Patients, and there is a long list in statute of rights that hospital patients have regarding their care and access information and who can receive information about their care or be present in the room. We can look at that separately when we look at this bill if that's helpful. But the first thing we do here is add definitions of advanced practice registered nurse, which is someone who is licensed under this APRN sub chapter in the nursing statutes. And I've changed person to individual, just because person entitled one for all of the statutes is both individuals and corporations and partnerships and entities. So, this case, patient is always going to be an individual. And then a physician, we have two different types of licenses for physicians. They can be an MD, or some allopathic physician, if you're what you may be more useful, who goes to a medical school like what we have at University of Vermont, our College of Medicine. And then there's also doctors of osteopathy, osteopathic physicians, who have the same scope of practice, but slightly different. So we have a DO school in New England at

[Sen. Virginia "Ginny" Lyons (Chair)]: the New England College in Bedford, anyway. Yes, my daughter went there.

[Jennifer Carbee (Office of Legislative Counsel)]: Oh, perfect.

[Sen. Virginia "Ginny" Lyons (Chair)]: That is it, yeah. Oh.

[Jennifer Carbee (Office of Legislative Counsel)]: Sorry about marine biography. So here we are in section two, is opening up the patient's bill of rights itself. I went through and made some just non gendered language, or change it to take out the gender and trying to get rid of gender at all and just go with non gendered language like the patient. And so in existing law, it says the patient shall have an attending physician who is responsible for coordinating the patient's care. Here is a place where it may be an APRN who is responsible for coordinating their care. And then this does add in, because of APRN, so this may go to some of your questions, the physician consultation and support shall be available to an attending APRN at all times in accordance with applicable standards, practice and regulatory requirements. So the scope of practice is not the same, but maybe the APRN is the attending. And then adding in everywhere we talk about physicians, adding in APRNs, and again, it's non gender language as they other change throughout. And then subsection B, existing law says that failure to comply with any provision of a section can be the basis for disciplinary action against a physician, and this one is a little out of date anyway. It only refers to a physician under the medical doctor, board of medical practice chapter and not the chapter 33 entitled 26, which is the osteopathic physicians who are regulated by the Office of Professional Regulation, and then also adding in the APRN, and then a complaint may be filed with the Board of Medical Practice or Office of Professional Regulation based on the license held by the practitioner, and then adding in OPR, Office of Professional Regulation, Couple of other places as well. And then section three deals with hospital licensure. So shifting out of the hospital patient bill of rights into hospital licensure. The Department of Health is the licensing agency that issues hospital licenses. Hospitals have to meet certain minimum standards. So under existing law, says all patients admitted to the hospital shall be under the care of a state registered and licensed practicing physician as defined by the laws of the state, here this would change to a physician that licensed under either of those two physician licensing statutes, or an APRN. And then adding APRNs in another place in here that refers specifically to an attending physician and the aftertake effect on passage. Okay.

[Sen. Virginia "Ginny" Lyons (Chair)]: So, I mean, we can pick this one up. We can hear from the Department of Health, Board of Medical Practice, OPR for the regulatory pieces and then from the Nurses Association and the APRN folks. I'm not thinking that it will be a long, protracted process, but keep your fingers crossed. It doesn't sound like, I mean it's not an expansion of scope of practice, that's where it gets difficult.

[Jennifer Carbee (Office of Legislative Counsel)]: Right, it's authorizing a role that is not currently available to APRNs because it specifies physicians, it is not expanding the scope of what they are permitted to do under their license. Yes, that's an important point. That's a question you were asking. Yeah.

[Sen. Virginia "Ginny" Lyons (Chair)]: Do we know what other states do with us? We'll find out. We'll find out. Okay. We'll find out. What what bill are we going back to? Well, you're

[Jennifer Carbee (Office of Legislative Counsel)]: going back to $1.09 97. Okay. Find that one, and we will just, we'll refill your account. It'll be a spin.

[Sen. Virginia "Ginny" Lyons (Chair)]: Right.

[Jennifer Carbee (Office of Legislative Counsel)]: So just reorienting ourselves a little bit. This is the primary care payment reform directing Department of Vermont Health Access to develop and implement first voluntary, then mandatory participation by primary care practices. We would get a per member per month payment to provide care. So we were on page seven, and this is looking at something that has been talked about in this committee a number of times over the last several years, which is trying to increase the proportion of healthcare spending that is spent on primary care. So not increasing the overall amount of spending, but just shifting the allocation so that more of that 100% of spending is on primary care. And so this language says that implementation of this primary care payment reform program needs to increase the proportion of total annual health care spending in Vermont that is on the primary care, starting with a target of 15% by 01/01/2029, maybe increasing that more in the future, but also specifying that this increased spending for primary care shall not increase total healthcare spending, just looking to reallocate the Inosysyn or potentially even less urgent funds. That's a really important distinction, so thank you for that. What's the percentage now? Depends on the payer referenced in here in 2020. 2019 and submitted in 2020, I believe. That looked at it and Medicaid was something in the 20s, some of the private ones were more in the upper, I don't even know if it was 13. That might have been overall, might have been 12%, but I think some of the commercial was at or around 10%. I think Medicare was lower as well. So Medicaid was definitely the highest, definitely at that time not the highest. It would be interesting to know, I think some of this may direct.

[Sen. Virginia "Ginny" Lyons (Chair)]: Just to interject, the pandemic gotten way over. Yes.

[Sen. John Morley III (Member)]: Go ahead. Sorry. Know I why, but it's always interesting to compare us to other states. Do we

[Jennifer Carbee (Office of Legislative Counsel)]: have that information out there? At the time, right, at the time that Vermont's report was done, it was looking at some work being done in Rhode Island and at least one or two other states that were also targeting a percentage looking at where they were in meeting that. So I don't know if those if other states have been continuing with that work, if those states have been continuing with that work. But this may be something that some of the state agencies and or advocates have been tracking. Massachusetts perhaps. No, I know Massachusetts. Oh, represent, yeah. Represent. New records. Her Olsen. Her Oh, Olsen. I'm He's setting Olsen down.

[Sen. Virginia "Ginny" Lyons (Chair)]: He has got his head in it.

[Jennifer Carbee (Office of Legislative Counsel)]: I know. He he went he from here. Was it WSHCA? Ledge He was led council before I got here. Yeah. I worked with the. Right. Yeah. And then he was at WSHCA,

[Sen. John Morley III (Member)]: and then he went with he

[Jennifer Carbee (Office of Legislative Counsel)]: became, like, I think, the commissioner of insurance reports. I have been the commissioner's office in Rhode Island. And he has a somewhat similar bill to this that was just introduced in the house.

[Sen. Virginia "Ginny" Lyons (Chair)]: I think it's age six eighty. When I talked with him, he came in and we were talking about how to coordinate a little bit. So we're starting with a bill here and then the house will pick it up over there. His work will be part of it. So we'll all be working together on this one.

[Jennifer Carbee (Office of Legislative Counsel)]: And there is a reference in here on page eight to that 2020 report determining a proportion of healthcare spending in Vermont allocated to primary care that was in accordance with the 2019 Act. So we can you, again, help you find that information.

[Sen. Virginia "Ginny" Lyons (Chair)]: Sorry. I'm sorry to interrupt. That was not appropriate. Have this bill. We have this report. Can we make sure we get it

[Jennifer Carbee (Office of Legislative Counsel)]: up on- Yes, that's what was just saying. I can look

[Sen. Virginia "Ginny" Lyons (Chair)]: it up and send it to I have that. Great.

[Jennifer Carbee (Office of Legislative Counsel)]: Will you personally email me or not? We work really

[Sen. Virginia "Ginny" Lyons (Chair)]: hard on this desk and and then we got put on the telephone and Zoom.

[Jennifer Carbee (Office of Legislative Counsel)]: Alright, section three moves into some information pieces and reports that requires DIVA to start operating the primary care payment reform program by 07/01/2027. As I mentioned, participation is voluntary to begin with, but by 01/01/1928, all primary care practices in the state shall be participating. By December 15 this year, so just before the next session, DIVA and their mentor board would report to this committee and others about progress in establishing the program and its timeline for implementation and options for revenue sources and mechanisms and for expanding the program not later than 01/01/2028 to any patient who have a participating practice regardless of their health coverage or coverage status. So it wouldn't matter if you said your payer would participate or not. All patients would be infirmetic. Section four calls for an update of a report, a couple of past reports on the clinician landscape. So how Vermont clinicians are feeling about practicing medicine in this state. By January 1, the board will report an updated version of its 2017 Vermont Clinician Landscape Study to show the current climate among practicing clinicians, and an updated version of the board's previous reporting on-site neutral reimbursements, and it mentions a couple of items that have been looking back, including the current state of reimbursement differentials based on practice setting and ownership types, and anything that's happened since 2017 toward achieving site neutral reimbursements. There is some language in the bill introduced in the House, H585, that is looking at implementing site neutral reimbursements as well. Section five requires the agency of human services to report by next January for consulting with others on ways to accelerate the appropriate transition of patients away from hospital care and for care in a community setting when that's appropriate. And include opportunities to use community health teams through the Blueprint to coordinate patient care transitions. Section six would be a report from the Living Mountain Care Board in collaboration with others considering the existing regulatory structures for access to information to B Cures, which is our all payer claims or most payer claims now database. That's the Vermont Healthcare Uniform Reporting and Evaluation System, the Vermont Uniform Hospital Discharge Data System, BUDS. So we have BUDS features and BUDS. Just looking at ways to increase access for the Vermont Program for Quality and Healthcare

[Sen. Virginia "Ginny" Lyons (Chair)]: to that

[Jennifer Carbee (Office of Legislative Counsel)]: information. And the board, in consultation with DPQHC, the Vermont Programs for Quality and Healthcare, also recommend any modifications to statute or current practice help make sure that DPQHC's expenses are billed back. There is an existing bill backs provision from each QHC, it sounds like there may be some inconsistency in how that's being implemented. So that report, again, January 15. Section seven directs the Office of the State Treasurer and AHS to collaborate with other Northeastern states to look at establishing a regional universal primary care program that would be available to all residents of the member states, and has the treasurer reporting by January 15 year about their outreach efforts, interests from other Northeastern states, and any legal or regulatory obstacles they have identified. Finally, section eight removes the sunset on a loan repayment program or scholarship program for medical students who commit to the language to primary care in Vermont. That program was set up in 2021 and is due to expire or to be repealed at the end of this fiscal year. So this would remove that sunset and keep that program ongoing. Yeah, could take effect on that.

[Sen. Virginia "Ginny" Lyons (Chair)]: Go ahead. I may be putting the curtain for the horse, but we may not be able to answer this, but I'm thinking a lot of these bills will have an effect on hospital transformation and hospital strategic planning and the rural health grant and all of

[Sen. John Morley III (Member)]: Is there a system to make sure all this work gets Right,

[Sen. Virginia "Ginny" Lyons (Chair)]: so beginning with this one, with primary care, remember we have the primary care advisory board, and I consulted with them in helping put this together, and they are working directly with the group that's working with the HS on transformation. A big chunk of transformation is getting primary care in the rural parts of the state and keeping folks where they should be so we don't shut down the primary care in motor building. Right. Yeah, so yes, it's coordinated. It will be coordinated. It has to be. This will help with that transformation process. Yeah, it should come. Yeah, good question, really.

[Jennifer Carbee (Office of Legislative Counsel)]: Ready for another one? We're halfway through our bills, but

[Sen. Virginia "Ginny" Lyons (Chair)]: the rest of them can we take a shorter

[Jennifer Carbee (Office of Legislative Counsel)]: Yes. I don't get stop talking. We'll go offline.

[Sen. Virginia "Ginny" Lyons (Chair)]: Give you a little break. Break. Six, seven minutes, go back, you know, tomorrow around 10:30. That would be good. Thank