Meetings
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[Virginia "Ginny" Lyons (Chair)]: And we are live. Senate Health and Welfare, it's still January 15 and we are walking through a fairly high level introduction to various bills with Ledge Counsel. So will play it back over to
[Jennifer "Jen" Carbee (Legislative Counsel)]: you again. Great. All right, think I mentioned we will do S189, begin January '19 or 01/1988? I'm sending you 01/1989. I'm doing 01/1989. Just because it wasn't so I turned
[Virginia "Ginny" Lyons (Chair)]: it over to you. So
[Jennifer "Jen" Carbee (Legislative Counsel)]: this is an act relating to an approval process for reducing or eliminating hospital services. Those of you who were here last year may remember there was language in what is now Act 68 of S-one 126 on notice of service reductions requiring a hospital that proposed to reduce or eliminate a service in order to comply with the budget order had to provide notice to the Green Mountain Care Board, Agency of Human Services, the legislators in hospital service area, and others. And the board could make changes to their budget orders or otherwise make changes as needed to preserve access to necessary services. This is addressing that same issue in a little bit of a different way by putting in an approval requirement from the agency of Human Services. So this would prohibit a hospital from reducing or eliminating any service without approval from Secretary of Human Services. So this creates an affirmative approval requirement. And it requires the hospital to provide a notice of intent to, again, the same folks, including the legislators. This is not less than sixty days, not forty five in the current law prior to the proposed reduction or elimination, explaining why they're doing it. Post a notice of intent on the hospital's website. Publish the notice in a newspaper of general circulation in hospital service area, conduct a public engagement process, including holding public hearings, and provide a summary of the community's response to the proposal, including any public comments to the agency of human services weekly. But also then require the agency of human services to review the proposed service reduction or elimination for consistency with the statewide healthcare delivery strategic plan, which has not been established yet, but will be. And the agency is the one who's establishing it. And the community health needs assessment require the community input and the impact on access to care allows the agency to approve the proposal that the agency finds. It's not inconsistent with the statewide healthcare delivery strategic plan or the community health needs assessment. It does not unduly burden access to necessary care and services and the pros outweigh the cons. If the agency approves a service reduction or elimination under this section, the agency has to notify the Green Mountain Care Board so the board can review the impact on the hospital's budget. Then it takes out, in section two, takes out the language that was added last year around notice to the Dream Act of Care Board and others, because it's replacing this process. And instead it says, once the board receives notice from the agency that it has approved the hospital's reduction or elimination, the board will review it for the impact on the hospital's approved budget, and the board may change the hospital's budget as needed to reflect the elimination or reduction, which might include directing that any savings related to that reduction or elimination are returned to payers and Vermonters to address affordability concerns, or to reinvest them in primary care, prevention, and other community based services. And directing the board to monitor implementation of any reduction or elimination. And I wish I could check the final message. So there's a lot in here
[Virginia "Ginny" Lyons (Chair)]: in terms of who's in charge of what?
[Jennifer "Jen" Carbee (Legislative Counsel)]: Yes, it shifts the Shifts responsibility. And we'll have
[Virginia "Ginny" Lyons (Chair)]: to hear from EHS it will be dependent on all the regionalization work that's going on and it will also be dependent on how budgets are reviewed. There's a lot here and I don't know who's gonna like it and who's not going to like it. But at least it's a start in the right direction. Right, and
[Jennifer "Jen" Carbee (Legislative Counsel)]: you know there have been some coordination issues between the various authority that's at the board and the agency under the current, the way it's currently structured because of the kind of different directives they've been given as part of Act 68 and other wording. Yeah, so that's been kind
[Virginia "Ginny" Lyons (Chair)]: of an ongoing tension there between who does what, whose authority it is where. I mentioned that earlier in the session, the authority that the board has versus the authority has and then land in a good place.
[Jennifer "Jen" Carbee (Legislative Counsel)]: And I do think on this particular piece around those service reductions, there's been, they've identified a mismatch between responsibility and authority. Yeah. And that this is one way of address.
[Virginia "Ginny" Lyons (Chair)]: Can I ask a quick question? Yeah. This sounds great. I'm excited about this. I love that there's a public engagement process. That brought me to the statewide health care delivery strategic planning process. And I probably should have asked this yesterday, and I please, I may have just completely missed this, but what is the public outreach process for that? Is there one?
[Jennifer "Jen" Carbee (Legislative Counsel)]: I have to look at
[Virginia "Ginny" Lyons (Chair)]: the language. Yeah, they talk about what they're doing regionally. Okay. Yeah, and they're having various community meetings. We can remind ourselves of that. I think it's on the, I think there's a reference to the exact process on Okay. That's so those are the ones that are Elizabeth Clogwood or Charmacy Mason. Alright, thank you. Yeah. I can go back and look
[Jennifer "Jen" Carbee (Legislative Counsel)]: at Yeah, and I'm looking at So
[Virginia "Ginny" Lyons (Chair)]: this one is this
[Jennifer "Jen" Carbee (Legislative Counsel)]: is important
[Virginia "Ginny" Lyons (Chair)]: for a lot of different reasons. I don't know if it's the first thing that we have to do, but I think we do need to pay attention to it before the process. Now, my ears are open. Brain is open. Okay.
[Jennifer "Jen" Carbee (Legislative Counsel)]: Alright, we ready for 01/1988? S-one hundred eighty eight is an act of that into hospital governance. It does a couple of things around hospital governance. First, it requires hospital, it specifies some of the composition of the hospital's board of directors, and it would requires, require a hospital to have two voting members of their board be representatives of the public appointed by the governor. And it specifies what their term would look like and how they can be removed. They can be terminated only by the appointing authority, and if their term or voluntary resignation, and talks a little bit about their work on the board. They're an equal member to all other members. It also allows the board of directors to create one or more committees and appoint members of the board, including the representatives of the public, to serve on them, and it directs the boards to have a compensation committee to review and recommend to the full board all compensation packages offered to the hospital's officers and executives. At least two representatives of the public would be voting members of the Compensation Committee. Got some guiding principles for representatives of the public on the board, and they're supposed to act in what they think is the best interest of the hospital, and also consider effects on patients, employees, community and societal concerns at the state, including the principles for healthcare reform, also known as the Act 48 principles. They can consider any other relevant factors that they think are appropriate. And they shall not give priority to the interests of any particular person or group, or the interests of anyone else. There's some just language saying this doesn't conflict with the non profit corporation statutes, gives limitations on liability, representative of the public is not responsible, not liable for the failure of the hospital to have specific impacts, general or specific impacts on the community or healthcare system, and they're not liable to the hospital for actions taken in their official capacity. Section two deals with compensation of hospital executives. This would go in the hospital budget sub chapter. So we have definitions of compensation and executives, and it would have one time on or before 07/01/2026, and then any time prior to approving any future changes to the compensation of any hospital executive, the hospital would have to file with the Green Mountain Care Board a statement including certain information about compensation paid to hospital executives, So what benchmarks they used to compare with, including any information used by anyone that hospital hired to assist with compensation. A detailed compensation survey or peer group data used by them to establish compensation benchmarks. If bonus or variable compensation was provided during the previous year, what criteria was used to determine whether it should be paid and how much. It allows the board to require the hospital to modify its peer group, so include other hospitals or other entities as peers if the board thinks that the group contains entities that are not sufficiently similar to the hospital based on various factors. Allows the board to retain at the hospital's expense consultants and other experts needed to help the board evaluate the compensation information they receive, who are purely advisory, and it allows the board, the hospital to designate material it provides to the board as proprietary or confidential and board recuited confidential. Take effect on passage. Very similar language to this for non profit hospital service corporations, which is statute speak for, at least partly for Blue Cross Blue Shield, is included in a bill in the house that does some of these other provisions that I mentioned, so H-nine 85.
[Virginia "Ginny" Lyons (Chair)]: So needless to say, this was a request on the part of the board and others, and so it's been introduced. The Hospital Association is not happy with this. To let you know, there's controversy associated with this. And so we'll look at it at some point. We'll hear from folks at some point. I think it doesn't rise to the top, but it does rise to a level of concern about both compensation and governance. Heard some concerns about governance over the with respect to what was happening with the UVM network, and that's somewhat that's been somewhat addressed. Well, the question is, is this needed at this point? And it's something I think we should look at. The other piece of it is I know that the hospitals had a grant that allows for them to work with boards and to improve their governance structure. We've also seen some attention to compensation, but is it a reaction to something they think might happen or is it something that would be ongoing? So we need to sort that out. So this bill will help us then. I'll get some testimonies for later. Thank you.
[Jennifer "Jen" Carbee (Legislative Counsel)]: You ready for our last one? Are you hearing Senator Harrison today?
[Virginia "Ginny" Lyons (Chair)]: Senator Harrison is not able to do it today. She indicated that she would be happy to come in the next time we pick up the bill. Why don't we go right ahead and then she can come in and talk about the work that's been going on to get the bill where it is. Great. Yeah. Okay.
[Jennifer "Jen" Carbee (Legislative Counsel)]: So our last one that I am gonna be reviewing this morning is s one forty two, which was introduced late in the last session in in 2025 session. This is an act relating to a pathway licensure for internationally trained physicians and medical graduates. And this was introduced by Senators Harrison, Gulick, and others. So first, this starts by adding a provision to the existing physician statutes under qualifications for medical licensure. This is specifically in the chapter governed by the Board of Medical Practice, and allows the board to issue a license to an internationally trained physician or medical graduate student who has successfully completed the pathway to licensure that you'll see in the next section. So section two establishes the pathway to licensure for internationally trained physicians and medical graduates. It has some definitions that I think may be useful. Internationally trained physician and medical graduate is someone who received a doctor of medicine degree and who has been licensed or otherwise authorized to practice medicine in a country other than The United States. And a participating healthcare facility is a hospital, federally qualified health center or community health center that the Board of Medical Practice approves and has the capacity to provide an assessment and evaluation program designed to evaluate an internationally treated physician. So that term comes up a lot as well. This sets up, as far as the pathway, it sets up first a provisional licensure which can lead to a, a provisional license which can lead to a limited license, which can lead to a full license. So that's sort of the path. It allows the board to issue a provisional license to practice with supervision to an applicant who meets certain criteria around receiving a Bachelor of Medicine degree or a similar degree from an approved institute of medical school outside The United States, recognized by the World Health Organization or others, or appearing on an official list, recognized by the Medical Board of California, which I believe has sort of the authoritative list that other states look to. The applicant has been licensed to practice in a country other than The United States, and practice for at least three years in most cases. The applicant provides sufficient evidence that the applicant has the capacity to practice medicine, completed a three year post graduate program in their country of training, and practiced as a medical professional for at least three of the last five years. They can't have been out of practice for more than five years unless the board approves. Otherwise, they have to have a valid certificate from the educational commission for foreign medical graduates or another equivalent evaluation credential, although the board can waive that if the applicant is unable to obtain the required documentation because their country is non cooperative. They also have to have achieved a passing score on both step one and two of The US medical licensing exam. They have to, before applying, they have to have entered into an agreement for employment with the participating healthcare facilities. That was the definition at the beginning, That it's offered to serve in the role as evaluator and mentor. And the applicant can't meet any disqualifying criteria. Provisional license is good for two years, and then the person can apply for a limited license. Provisional license means they can only practice at the participating healthcare facility that they're working at and only with supervision. Some provisions around what happens if they wanna change employers during that period. The things that would make them ineligible to receive a provisional license is if they have previously had a license or other authorization to practice medicine suspended, revoked, eliminated condition, or otherwise restricted based on unprofessional conduct, or they've been convicted of a crime, or they've otherwise demonstrated a lack of competence or lack of moral character. So the participating healthcare facilities, in order to be eligible to be a participating healthcare facility, facility must agree to provide medical mentoring, evaluation, assessment, support to a provisionally licensed physician, ensure that their role is being fulfilled by one or more fully licensed physicians located physically in Vermont, and the provisionally licensed physicians only seeing patients located in Vermont. And they have to have medical malpractice that covers the provisionally licensed physician, and they have to agree not to retaliate against or discipline the provisionally licensed physician for making a complaint or otherwise objecting to employment based behavior. If somebody has done the provisional licensure process, then they are eligible to apply for a two year limited license, cannot be renewed more than once, and after two years of practice under a limited license, they are eligible to apply for a regular full unrestricted license to practice medicine in Vermont. But there's criteria for the board to issue a limited license and look like they're on track to complete the program at the participating healthcare facility. They have to have a full time offer of employment from a healthcare facility, or they will keep working at the one they've been doing their provisional licensure training at. And the facility must be located in Vermont and accept patients covered by Medicare or Medicaid or both. And they have to have achieved a passive score on step three. So the first provisional license was steps one and two of The US medical licensing exam. This is step three. And then, would be they're looking at no gap in coverage, so a limited license would start as soon as the provisional license ends. And reasons the board can rescind or refuse a limited license if the person does not complete their provisional license process. If the board refuses to issue a provisional or limited license, they have to provide specific reasons. And a refusal is a final order that can be appealed. And it directs the Board of Medical Practice to collect information to evaluate the program, the pathway to licensure. So information about number and types of inquiries, how many applicants, where are they coming from, how many provisional licenses were granted and how many were refused, how many limited licenses were issued, why applications were refused, how many full and unrestricted licenses were granted, so who actually made it all the way through this pathway process, how many complaints have they received about holders of provisional and limited licenses, what did the board do about it, practice setting and specialty of applicants in their country of origin or licensing country and here, and the practice setting and specialty that they're going into. So, information about how all of this is turning out. Annually by April 1, the board would provide that information to this committee, the Ginny Lyons Committee and the House counterparts. There's rule making for the Board of Medical Practice, including determining which country's licensure or other authorization is acceptable to the board or the pathway, and establishing the criteria for participating in healthcare facilities to use in assessing and evaluating the provisional and licensed physician. This was introduced, as I mentioned, in 2025, so it has most of the provisions taking effect on 07/01/2026, but would really need to go out and year the rulemaking provision and missection. Effective dates would take effect on these sections.
[Virginia "Ginny" Lyons (Chair)]: And I know there's quite a group in the Browardville area working on this, Senator Harrison will come in and then that we'll have that group come in and talk about it. Board of Medical Practice has also been discussing this since it's introduced and I believe they have a meeting on February 4 vote to on the bill and it is right now. So, we'll see where that takes us. So, we'll go and we'll have others come in to testify on this one and we get there. How does language play into this? And I'm just asking because I there's no language or TOEFL test or anything as part of this bill. So just assume that that will get evaluated sort of indirectly in the other exams that they have to take?
[Jennifer "Jen" Carbee (Legislative Counsel)]: It's a good question. I don't know if this bill, as introduced, doesn't address that, but maybe something that you want to, you have a similar question. Yeah, it's a good question, and I don't know that was not addressed in the information I was providing.
[Martine Larocque Gulick (Vice Chair)]: It's not only speaking, but writing, because doctors convey the message to staff on how to carry out treatment. And so having an English kind of requirement in there I think would be beneficial to all. Yeah. Well, having lived in other countries there,
[Virginia "Ginny" Lyons (Chair)]: I mean, language testing is usually just part of of, you know, a bunch of, you know, whatever test you could be learning. Right.
[Jennifer "Jen" Carbee (Legislative Counsel)]: Or whatever. Yeah. Know if it's part of The US medical examination, If it's part of any part of that. That's a great question. Think something to be looked at. Well, something to be addressed. Either you get an answer that the agency language works because of some existing aspect of it, we need to put something in.
[Martine Larocque Gulick (Vice Chair)]: Certain places, French would be okay.
[Virginia "Ginny" Lyons (Chair)]: Yeah, I know. It's true. It could work. It could work. And who do we currently have in the country? How has that currently happened? I know we have folks from other countries practicing medicine. Who are they? Which ones? I have another question and that is, other states are doing this. I can't remember the exact number, we'll find out. Quite a number of other states are doing this, but does Vermont recognize those out of state provisional licenses? I think we have to
[Jennifer "Jen" Carbee (Legislative Counsel)]: ask the board about medical practice. I mean, there's certain ways that are expedited licensure reciprocity from other states, licensed by endorsement, but I don't know if that applies with a non full license. Yeah, the provisional type Right.
[Virginia "Ginny" Lyons (Chair)]: Any other questions for Jen on any of these bills? We've been through quite a bit here. A good chunk of We're getting more every day. We are getting more every day. And so we're gonna take a break in just a minute, but we have a new list of bills that are in our committee, and I'm gonna go through those again myself. It'd be helpful for you to go through. Is this one up on our webpage? Yes. Okay, so we have this list on our webpage. Go through and consider, we also, you know, there's still the twenty twenty five bills that are up there. We sort of went through most of those. We have one more that we'll be looking at, looking at some with Katie tomorrow. And we didn't look at the optometry bill yet, we're looking at that one. And then we have twenty twenty six bills and police has done a good job of identifying the newer ones. So go through that again.
[Jennifer "Jen" Carbee (Legislative Counsel)]: And I will just flag that S-two 45 that's tele alarmed televisions being recorded was, the house in hand was voted out of house health during yesterday, and it's likely before, if you want to ask them to be coming to you.
[Virginia "Ginny" Lyons (Chair)]: And it is kind of an emergency type bill, it's the immunization bill? No, not that much.
[Jennifer "Jen" Carbee (Legislative Counsel)]: Well, it's not the telephone. This is telehealth, the telehealth,
[Virginia "Ginny" Lyons (Chair)]: recording telehealth appointments for patient providers. Okay. All right. Yes. I don't know if that's an emergency. We hear that it's
[Jennifer "Jen" Carbee (Legislative Counsel)]: an emergency. I'm not if
[Virginia "Ginny" Lyons (Chair)]: anybody comes running up to you and says, Please pass 245, let me know.
[Jennifer "Jen" Carbee (Legislative Counsel)]: Think it's something that maybe other providers would like, but I don't know that it's quite as insensitive. And
[Virginia "Ginny" Lyons (Chair)]: so we have a bunch of other things. Look at the ones that we haven't yet identified and sort out your thinking on those. Are these bottles of that we got including yesterday's? Yes. Okay, cool. That's good. Alright, so do that and you want to go through it together right now, we could do that. Or we could take a break until 11:30. I'm open to suggestion from the committee. Do you want to go through these bills? Do want to take a break? I'm always happy to take a break and get up and move around. That's always a good thing. Me too. Let's do that.
[Jennifer "Jen" Carbee (Legislative Counsel)]: Let's take breaks. Back
[Virginia "Ginny" Lyons (Chair)]: here