Vermont Legislature SmartTranscripts:

[Sen. Virginia "Ginny" Lyons (Chair)]: Okay, so health and welfare back on January 22, and we're going to take a little deep dive, a deeper dive, and walk through S197 and then we'll hear from our medical society working on this issue as well.

[Jen Harvey (Office of Legislative Counsel)]: Great, good morning. Jen Harvey from the Office of Legislative Counsel. And yes, I think the way the rest of the morning is set up, we're gonna do a kind of deeper dive walkthrough on a bill and then hear some testimony and then Yes, exactly. You, and

[Sen. Virginia "Ginny" Lyons (Chair)]: I'm glad you're here for the morning. It's really All

[Jen Harvey (Office of Legislative Counsel)]: right, so, putting the language up on the screen, so S197. And this is an act relating to establishing a primary care payment reform program. Starts off with legislative intent, stating that it is the intent of the general assembly to invest 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 Vermonters and reduce healthcare system costs. And then, so that's the sort of intent of the act, or at least as part of the act.

[Sen. Virginia "Ginny" Lyons (Chair)]: I just say one thing? Sometimes we have findings at bills, and this bill in particular would sort of welcome findings. However, we know that findings come and go and we just saw some data that would help us want to invest in primary care. So in talking with Legg Council, I thought intent would be a better way of going with the bill rather than having a long list of findings. We'll hear testimony that will validate or invalidate the answer will be.

[Jen Harvey (Office of Legislative Counsel)]: Alright, section two adds a new section into the same chapter where the blueprint is, and it directs the Department of Vermont Health Access in in coordination with the Green Mountain Care Board and the Blueprint for Health, and in consultation with the Vermont Steering Committee for Comprehensive Primary Health Care, that was established in last year's Act 68, and other interested stakeholders, directs them to develop and implement a primary care payment reform program, and kind of using some of that language from the intent statement, that will promote the public good by investing in primary care and reducing administrative burdens in order to increase access to care and reduce health system costs. It says the program will initially be voluntary for primary care practices, and then it becomes mandatory, and it will be funded by allocating a portion of commercial health insurance premiums, a portion of premium equivalents from other participating payers, though some of this should seem sort of familiar after you've heard from folks about the funding model there, and to the extent permitted by federal law, waivers of federal law, and federal initiatives, public funds for Medicare and Medicaid. So to start with, it would be voluntary, beginning in 2028, all primary care practices should be in the program. It would require the program to collect and aggregate the payments from participating providers in order to provide a capitated per member, I'm sorry, participating payers, in order to provide a capitated 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 are covered by the participating plans without any cost sharing for the patient. And I also wanna flag on that piece, and this will probably come up more in testimony, but I was asked on a similar bill in the House if there's an issue with this provision about not having any patient cost sharing for high deductible plans, where the federal government is very prescriptive around what can be covered first dollar, and there actually is this, think, language is capitalizing on a new federal opportunity that allows primary care to be covered first dollar under certain program parameters, so we'll want to make sure we're complying with that, but it is a new option. To the extent that the program includes any practice participation requirements, administrative or documentation requirements, or quality measurements, This would direct the department to establish them in a way that streamlines and reduces administrative burdens that the program imposes on practices and that payers impose on practices, including trying to align with, incorporate, or reduce the burden for health requirements. It's looking to establish this program, but also not add to administrative burdens, but perhaps reduce street life. And then it goes into some more detail about requirements. It says the program shall establish not more than 12 quality measures, and it can only require a practice to adopt up to six of them. And it specifies that each quality measure must be claims derived, so come from claims, patient centered, appropriate for a primary care setting, and supported by peer reviewed evidence based research indicating it is actionable and using it will lead to improve patient quality. Clarifies that the goals of the subsection are to reduce the amount of time that primary care practitioners are spending on administrative tasks, going from an average of 50% of practitioner time to 10% of practitioner time, and reducing the need for administrative staff as measured by the ratio of administrative to clinical staff. It requires the department to adopt by rule a risk adjusted allocation model for primary care practices participating in the program that may be informed by previous work methodologies from accountable care organization, and may blend a base per member per month capitated payment with fees for service payments as needed for specific primary care services. So there may be some things that are outside the scope of routine primary care that would be covered by, continue to be covered by fee for service. Requires the allocation to include a reimbursement model and level that accomplish the primary care spending target, which comes up the end of the section, that supports sufficient access to and sustainability of primary care services in the state, incorporates different methodologies as needed to address the unique needs of all practice types, including independent practices, federally qualified health centers, and rural health centers, and hospital based primary care practices. Must incorporate a methodology that's flexible enough to support and adjust for the different scope of services delivered by different practices, that accounts for the closure of accountable care organizations, that accurately attributes patients to primary care practices, so the practices are getting paid for all of their patients, is sufficient to support practices in offering comprehensive team based primary care, including supports for mental health and social drivers of health, and to the extent permitted under federal law, does not require individuals covered by participating health plans to pay cost sharing amounts when receiving routine primary care services from participating providers of practices. That was the piece I was mentioning about federal law. Directs the department to operate a payment pool where it would collect the primary care allocation of the premiums, premium equivalents, and public program funds that are due from each payer, and to determine the per capita payments or other payment mechanisms to distribute the funds to the participating practices. Directs DIVA to adopt rules to implement the primary care payment reform program, including determining the scope of the primary care services that will be included in the advocated rate and which practices are eligible to participate. If using what the practice participation requirements, administrative and documentation requirements, and quality measurements are in accordance with those limitations on their imposition, the risk adjusted allocation model, the operation of the payment pools, so some of these are just pulling the pieces that have come before and after into rulemaking. Program parameters, yes.

[Sen. Virginia "Ginny" Lyons (Chair)]: I just wanted to, I know you mentioned risk adjusted allocation model a couple of times, maybe a brief explanation of what that Sure,

[Jen Harvey (Office of Legislative Counsel)]: I think in this case it's really looking at sure that practices that are taking care of sicker patients are being appropriately reimbursed or compensated for the fact that it's more expensive to care for a sicker population. Alright, the rules would also address program parameters to address and mitigate against practices avoiding high risk patients or otherwise engaging in adverse selection, so that's kind of that same idea of trying to not have the sicker patients to reduce costs and trying to mitigate that. But also striving to maximize practice eligibility and participation. Coming up with definitions of direct and indirect primary care spending, and I think that's a piece of the federal language around the high deductible plans and the health savings accounts and the eligibility to have first dollar coverage is applicable to direct primary care. Appropriate limits on indirect primary care spending as a percentage of health care spending, which you'll see coming up. Then benchmarks for determining the program's performance. How will we know if the program is performing as expected or meeting its goals? It directs the Agency of Human Services or the Green Medicare Board or both to enter into negotiations with the Federal Centers for Medicare and Medicaid Services to try to get Medicare participation in the program. I also direct the agency or board or both to conduct outreach to the self funded non governmental employer sponsored plans. This is what the Blueprint folks were calling the URISA plans, sometimes how we say

[Sen. Martine Larocque Gulick (Vice Chair)]: it.

[Jen Harvey (Office of Legislative Counsel)]: In shorthand, but the important piece for us to know is that all plans are regulated by IRSA, but the state is granted under federal law for regulating these self funded non governmental employer sponsored plans. That's why we are conducting outreach about opportunities for their voluntary participation in the program, but we cannot compel their participation. And also to have the AHS or the board discuss with interested plans the appropriate allocation of premium equivalents, how much they should be contributing to the payment pool, and those amounts should not unfairly disadvantage individuals covered by fully insured plans, self funded governmental plans, or public benefit programs. So not looking to subsidize with the folks we can regulate, but

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

[Jen Harvey (Office of Legislative Counsel)]: them pay, if they're going to participate, and having people share. Then we talk about the primary care spend target. So this is stating that implementation of this primary care payment reform program must increase the proportion of total annual healthcare spending in Vermont that is spent on primary care with an initial allocation target of 15% of overall Vermont healthcare spending by 01/01/2029, and it directs DIVA to establish a transitional schedule, increasing the proportion of primary care spending over time in order to achieve the target, specifying that the increased spending on primary care shall not increase total healthcare spending. It's just shifting the proportion that is primary care and non primary care. Directs Diva to limit indirect primary care spending as defined by rule, as a percentage of the total direct and indirect primary care spending that goes into making up the target, And it allows DIVA to establish a new higher primary care spending target once the initial target has been reached if DIVA's analysis determines that the program has met specific benchmarks established by rule in areas including access to care, primary care, quality of primary care, impact on health outcomes and containment of overall costs. And it specifies the definitions to use for purposes of the primary care spending allocation target. Talked last time briefly about the difficulty in defining primary care and what constitutes primary care services. Who qualifies as primary care provider? So, it says, for purposes of this target, use the definition, or use the definition of primary care services that aligns the definition in the 2020 report that determined the proportion of healthcare spending in Vermont allocated to primary care at that time. That was submitted to the legislature by the Green Mountain Care Board and VIVA pursuant to a 2019 act, and aligned with the definition of primary care services used by the New England States Consortium Systems Organization for MS. I know that you sent

[Sen. Virginia "Ginny" Lyons (Chair)]: me that report when we were working drafting this up. It would probably be helpful, Melissa, if we could get that report on our webpage so we could Did I send

[Jen Harvey (Office of Legislative Counsel)]: you that one last time or not? When I sit down Melissa wasn't around. No. I mean, like, I walked through this.

[Sen. Virginia "Ginny" Lyons (Chair)]: Oh. Oh, yeah. I can't remember. When we talked about it. Okay. Good. So department of redundancy.

[Jen Harvey (Office of Legislative Counsel)]: Well, no. That's okay. I'm not sure if I actually did it. So when I go sit down, I will do it. Section three is an implementation date, so it directs Diva to begin operating the program, primary care payment reform program by 07/01/2027. Again, participation is voluntary to begin with, but within six months all primary care practices must be participating. And on or before December 15, DEVA, in coordination with Green Mountain Care Board, would report to this committee and others regarding its progress in establishing the program and a timeline for implementation and options for revenue sources and mechanisms, along with an operational and financial plan, for expanding the program by 01/01/2028, to any patient ever participating in practice, regardless of their type of health insurance or whether they have health insurance coverage. So that is that program, then we move into some primary

[Sen. Virginia "Ginny" Lyons (Chair)]: care related or healthcare and primary care related reports. Questions for Jen. I know we're going through this path, we're going through it line by line. So if you have questions, this is the time to capture meaning and the lines in front of you.

[Sen. John Morley III (Member)]: One question I had is talk about primary care provider, but the primary care provider also uses other services in their implementation of their practice, such as labs for blood work and so forth, so are those covered in this, are those separate, if they're independent laboratories, how would that work, so, there's more to primary care than simply the physician seeing the patient.

[Jen Harvey (Office of Legislative Counsel)]: Right, and other witnesses can probably speak to this in more detail. One thing is that the rule making would determine the scope of primary care services that would be included in the rate. But assuming there are services delivered by providers who are not part of the primary care practice, if there's somebody sent out for labs, think that would continue to be billed as fee for service or however they're being billed currently.

[Sen. Virginia "Ginny" Lyons (Chair)]: Unless they are somehow Sales into, since we got people up here and they're listening around the world.

[Jen Harvey (Office of Legislative Counsel)]: So then we get to different report. This is requiring section four, that by 01/01/2027, the Green Mountain Care Board report to this committee and the House counterpart with an updated version of the Board's 2017 Vermont Clinician Landscape Study report that reflects the current climate on practicing clinicians in Vermont, how are they feeling about the practice of medicine in Vermont, and an updated version of the board's previous reporting on-site neutral reimbursements pursuant to a number of acts from 2015, 'sixteen, and 'seventeen, including the current state of reimbursement differentials, how reimbursements are different based on practice setting and ownership type, and a description of any significant efforts that have been implemented since 2017 for achieving site legal reimbursements. I think I mentioned that there's a house bill from the administration that is in the House Health Care Committee does have a section on and looks to start implementing site neutral reimbursement provisions in connection with regular placement. Right.

[Sen. Virginia "Ginny" Lyons (Chair)]: Sorry, did you have a question or that was No, I was just thinking that we have all those sections of law referenced and you have the dates and the action resolved so you can look them up. I'm not gonna have anyone else put them up for us.

[Jen Harvey (Office of Legislative Counsel)]: Section five is on transitioning care to community settings. This would direct the agency of human services by next January 15 and in consultation with the Vermont Steering Committee of Comprehensive Primary Health Care, which as I mentioned was established based on last year's Act 68. Also the Blueprint for Health, the Vermont Association of Hospitals and Health Systems, Vermont Medical Society, and other interested stakeholders. The agency would report to this committee and your house counterpart with recommendations for ways to accelerate the appropriate transition of patients from hospital care to care delivered in a community setting, including ways to reduce the extent to which primary care services are delivered to patients in an inpatient hospital setting following surgery or other acute care, when care delivered by a primary care provider in the community would be as or more effective and less costly. It specifies that the recommendations must include opportunities to use community health teams through the blueprint to coordinate care transitions. Section six, looking at access to certain data and build back. This directs the Green Mountain Care Board in collaboration with the Vermont Program for Quality and Healthcare, the Vermont Information Exchange Steering Committee, that's an existing committee, and the Office of Healthcare Advocate to consider the existing regulatory structures in place for access to information from V Cures and VUDs. This is the Vermont Healthcare Uniform Reporting and Evaluation System, the All Paired Claims Database that you heard about some from Blueprint folks, and the Vermont Uniform Hospital Discharge Data System, and recommend ways to improve access to the information for quality improvement purposes while preserving appropriate patient privacy protections. It also directs the board in consultation with VPQHC to recommend any statutory modifications or current practice modifications needed to enable BPQHC's expenses in maintaining the statewide quality assurance system to be billed back to hospitals and health insurers. There is existing statutory provisions on bill back for BPQHC's efforts, perhaps implementation issues. So, look at what's causing problems there. And has the report due by 01/15/2027 to risk and payment? That's not fair.

[Sen. Virginia "Ginny" Lyons (Chair)]: Next year. What? That's next year. It is '27.

[Jen Harvey (Office of Legislative Counsel)]: We have Regional Universal Primary Care and report, as it strikes the office of the state treasurer in consultation with the Agency of Human Services to collaborate with other Northeastern states to explore the potential for a regional universal primary care program that will be open to all residents of the member states, and the treasurer is to report by January 15 to this committee and House of Care on the outreach efforts, whether there's interest from other Northeastern states, any legal or regulatory obstacles that they identify in the recommended next steps. Finally, Section eight removes the sunset on a primary care medical student incentive program through the University of Vermont College of Medicine under existing law, but is to be repealed on 07/01/2027. This will remove the sunset and keep that scholarship program going indefinitely, although it's subject to funding. And the act would take effect on passage.

[Sen. Virginia "Ginny" Lyons (Chair)]: Questions for Jen? I have a question. I'm not sure if it's for Jen or maybe more for you. So your clients are not sure. I'm trying to think more critically about reports. So my question is, it's on page nine, at least of fiscal year. The report that the Green Medical Care Board would be doing on the current climate among practicing physicians in Vermont, I'm just wondering how would that inform this work? Good question. Okay, we can answer it later, but I'm just curious. Well, it's a very long answer. So, we'll have to go back and ask, is this a helpful program for you in the place where you live and work? And will we have more people serving Vermonters in this way if we do this? So it's like, what's out there? Who's doing what? And then would it make a difference for you to have this in place? Okay. We're attracting these people. Sure, so

[Sen. Martine Larocque Gulick (Vice Chair)]: there's a lot going on. I'm trying to wrap my brain around. So the cost savings is on the administration side, plus trying to get more access to primary care. JFO looked at what the savings may be if this bill moves forward?

[Sen. Virginia "Ginny" Lyons (Chair)]: No. They don't do that until after we've looked through the bill, made the changes, made recommendations,

[Jessa Barnard (Executive Director, Vermont Medical Society)]: and then the AFO will come in

[Sen. Virginia "Ginny" Lyons (Chair)]: and say, this is where you are. You know, that's that whole thing. Otherwise, they'll be making doing it every time we work on the bill. There are a lot of questions here that you have and Senator Gulick just asked that we're gonna hear testimony and it will help us get to where we want to be. It will obviously be making changes in the bill. The goal is, I just saw some data up there indicating the savings and access for patients who have access to a blueprint or expanded primary care. For the state itself, having access to primary care in our regions across the state is important and we know this would have been in the findings. We know that there's been a decrease in the number of primary care doctors in some parts of our state. How can we fix that? How can we bring folks in and then at the same time decrease access at a cost to that people can afford. So it's all in here in different ways and ultimately primary care will be a good prevention for chronic illnesses that put such demand in our EDs or in our hospitals, so we'll be able to level off costs over time. I see this a little bit, there's more to it, but Senator Cummings. Is the space of the Rhode Island model? Rhode Island. There is a little bit of Rhode Island in here. Just, yeah, a little. I started working on this bill in June, and I didn't realize that there was a bill in the House and then there is a bill in the House so then I worked with Jen and we tried to work together with what Vermont Medical Society is going to come in and testify with us a little bit on this. There's been a process to pull pieces that Okay and Medicaid is there a big It's like a diva will have to come in and share with us what they think. John Saroyan is part of the whole AHS team working on this. Yeah, I mean, I'm just thinking of the new Medicaid rules. Yes. With no special state funding. Problematic. And they are a major player. Yes. Absolutely problematic. And if we're losing federal dollars, that's even worse. If we can maintain our federal dollars maybe there's a way to have them, maybe there's a way we can have them shifted around into this payment pool that will help. So there are lot of questions that you have that we hope we can get answers to as we go forward. Okay, we're good. Questions for Jen. I mean you're asking the right questions as we have testimony. Bring those back up. This is a big lift. A question about it, but we've seen big lifts before. We had the biggest lift of the world last year, 01/1926. This is like two steps below, but it's still a big lift. We're gonna get there. We can do it. The federal landscaping. We'll be focusing on the federal landscapes. No question about it. What we wanna know is what's the infrastructure that we can put in place and then how much of it can we pay for? So we may not be able to do it all chunk at once and we'll keep our fingers crossed that going forward we'll have this infrastructure in place that will improve access across the state and we can do it. So there's my half full cup and the federal government's gonna fill the rest up.

[Sen. Martine Larocque Gulick (Vice Chair)]: This is good.

[Sen. Virginia "Ginny" Lyons (Chair)]: Thanks again. So I asked Jessica Barra to come in. Why don't you come on up as soon as Jen gets out of there?

[Jessa Barnard (Executive Director, Vermont Medical Society)]: Good morning. Thank you very much for having me. Jessa Barnard. I'm the executive director of the Vermont Medical Society. So, welcome to the the new members. I don't know the new members. I do not. So, let me have them introduce. John

[Sen. John Morley III (Member)]: Morley from Orleans District. Hi. John Benson from Orange.

[Sen. Virginia "Ginny" Lyons (Chair)]: Oh, sorry. Senator Lyons. Hi. Hi.

[Jessa Barnard (Executive Director, Vermont Medical Society)]: Hi, good morning. So just briefly for community members I have not met, so we represent individual physician and physician assistant members or membership association, so primary care, specialty care, all practice settings. We're not linked to a specific facility type, so they could be independent practice, FQHC, are qualified health centers, that hospitals. So our members are interested in a broad range of healthcare issues. We're here in the building pretty frequently on a whole number of types of bills, but on this one particularly, we're also joined I'll clarify. Sure.

[Sen. John Morley III (Member)]: What percentage of the physicians do things do you actually represent?

[Jessa Barnard (Executive Director, Vermont Medical Society)]: Great question, thank you. We estimate around two thirds of practicing physicians. It's a little bit not apples to apples because we also represent, say, medical students and retired physicians and other categories, but if we're matching sort of actively practicing physicians, it's about two thirds. And we also are, we work very closely with a number of the medical specialty associations. So those are organizations, they're their own independent membership associations that are specialty specific. So family practice, pediatrics, the whole ophthalmology, psychiatry. But on this bill in particular, we're joined by our colleagues from the American Academy of Family Physicians and American Academy of Pediatrics here in Vermont who are very supportive of S197. As you've already had a long walkthrough, so I'm gonna try to just back a little bit to give the big picture of why the primary care clinicians of Vermont are supporting this type of approach and really interested in moving this bill forward. I won't restate everything that the chair has already said and this is why she's introduced the bill, but we do think that primary care is an essential component of helping solve some of the problems Vermont's healthcare system is in right now in terms of fragmentation, high costs of care. There's a lot of really excellent data out there in terms of how comprehensive primary care is better for patients and better for the healthcare system and helps get patients care at a lower cost. I'm not gonna go into all that data today, but I will encourage you to hear from other witnesses who are really experts in analyzing the impacts of primary care. It's great I got to follow John because they got to talk right here in Vermont about how the Blueprint has already been doing that work, and sort of what we know in general in terms of when you have a comprehensive health team and effective primary care that can give things like after hours access, how that really does improve care across our healthcare system. I will mention, in Massachusetts, there was a question of sort of where does this bill come from? It really was a, our own Vermont ideas, talking to our clinicians about what's working well in Vermont right now and what they want to see more of and what can support them and their patients. But I will say we got to almost the end of drafting the bill and then heard from a physician in Massachusetts about an initiative they're working on there called Primary Care4U, Wayne Alpin, and we went through, wait, does your bill do this? Does your bill do this? And amazingly, are quite aligned. They've done some fairly in-depth analysis, the cost savings of the bill, and showing that their model would of break even or be achieving savings within four years. So I would encourage you to hear from him as, I think he would be an excellent witness, and really talk about how they also developed a similar approach. I believe you're, I think they've already shared that name, but I'm happy to do it again. He's a great speaker too. He really enjoyed meeting with him and hearing the

[Sen. Virginia "Ginny" Lyons (Chair)]: work they've been doing in Massachusetts. So,

[Jessa Barnard (Executive Director, Vermont Medical Society)]: again, so the way I envision this bill, there's three big chunks working together. One is how can we reallocate within all of the money our healthcare system is spending, over time incremental larger piece of that spending towards primary care. How do we help really shore up the foundations of our healthcare system? The bill sets the target of 15% by 01/01/2029. I'd also encourage you to hear from folks either at Diva or Green Mountain Care Board about the reports that were done that Senator Lyons just referenced, sort of how has Vermont already measured that, already doing. We were about at 10% right now. It really varies between payer. Medicaid is actually the highest percent of their spending goes to primary care, at least well. When this was last measured, almost twenty four percent. Medicare was actually the lowest, around four to 5%. And I believe the commercials were right around, maybe a little over 9%, so already actually pretty close to that target. And so, when you're directing more of that, if we can accomplish this direction of spending more to primary care, then the goal is to invest that in this primary care payment model and paying differently for primary care services. And so one other piece I wanted to address, why pay differently for primary care? We have a couple, our practices have really learned, so the Blueprint's already done a little bit of that through what, know, NAEP call that more of a value based payment. So, you know, are you doing well, are you hitting the measures, you get a little add on payment, Or are you receiving this national accreditation called Patient Centered Medical Home Recognition? You get sort of an add on payment. So it's a small component of how practices are getting paid. It's not replacing, they are still billing also for everything else they are also doing. They're billing every visit, every test. A model we've seen work really successfully in Vermont, and another witness I might encourage you to hear from is actually from One Care Vermont, the ACO that has now ended. One of the really successful programs they ran is with independent primary care practices called their Comprehensive Payment Reform Model, CPR, and really I will say largely the motivation and how we're envisioning this bill is can we continue and scale up a CPR type program? Because instead of, they blended the payments from different payers, Medicaid, Medicare, commercial, and paid that practice a chunk of funding to replace all of that fee for service billing. And what's called a capitated payment based on the number of patients and who that practice was serving. And why do that? It gives the practice more stability. It helps some of these practices get through COVID when patients weren't coming in and they needed to immediately transition to telehealth and other models of care. So it keeps the doors of the practice open. It also, and really the goal, is more flexibility. How do you need to best serve that patient? It may not be having them come in that day. Maybe a five minute phone call, it may be a text message, it may be seeing the, you know, phone call with the nurse, it may be the care coordinator, And the blueprint is getting us there to support some of that, especially through their community health team payments, getting more staff in, but there's still just inherent limitations in a billing per service model, where you have to have that patient either in front of you or now with telehealth, you know, on the front of the screen to get paid. But there's a lot more we can do and work more flexibly if you weren't having to work under that system. So the goal here is really to get more of the payments different. The goal is, and somebody asked about, well, about all the other services? The way the CPR program works is kind of a mix, so it's a caveat that you sort of come up with that, what's that bundle that pretty much, you know, that we really expect sort of core primary care services to include? Your wellness visits, some of your acute care visits, things like that. But maybe there are things we actually do still want to pay people or service for, so maybe vaccine administration, maybe some procedures, and then there's a reason for that. Partially the reason is not all the practices do those things, so we can't really come up with one bundle that works for every practice. The other thing is maybe we actually want that sort of incentive, the fee for service incentive, to have practices do more of that because it's more affordable in primary care than going to the specialist.

[Sen. Virginia "Ginny" Lyons (Chair)]: So I can give you

[Jessa Barnard (Executive Director, Vermont Medical Society)]: an example we hear about a lot from one of our members as a family practice physician, skin biopsies. She can do them, or removal of the bowls, sort of basic dermatology services. She can do that a lot less expensive per visit in her primary care practice than sending that patient to dermatology. So maybe we want to give primary care practices more of an incentive to continue to do that, or even do more of it than referring to specialty care when appropriate. So we asked, one of the principles we sort of thought of in suggesting some language for this bill is enough guardrails so the legislature, the public, the agencies know what we're asking, know what we want implemented, but flexibility and actually asking whichever agency is implementing this program to work with the, I have to always look this up, steering committee for comprehensive primary health care. I followed the new primary care committee to help develop CF. To make sure this payment model really works for the primary care practices we're asking to implement it. Because this is very complicated work. We know, again, from One Care doing their program, they were every year, again, in fact probably more often than ever, making tweaks to the program, what codes should be in, what should, what are the right quality measures, what makes sense, what's gonna work, sustain the practices, support the practices, have the outcomes we want. So leaving a lot of the really nitty gritty details to rule making and working with primary care practices to make sure we get this right and get it to work well. Then the last piece, I do wanna mention, we're very excited about the possibility, if we can, to have the payments sufficient and the contributions from payers sufficient, that we don't need to charge out of pocket costs for patients. That anybody, and then eventually step two or three or four, whatever step we want to consider it, the report on could we even expand this to uninsured patients. So that anybody who goes to the primary care practice in Vermont, those primary care services are kind of, everybody's paying in, and and then the

[Sen. Virginia "Ginny" Lyons (Chair)]: payments are going to the

[Jessa Barnard (Executive Director, Vermont Medical Society)]: practice so they can care for their population of patients regardless of their insurance. And then the final piece, really important to the bill, workforce, and making sure we have enough primary care clinicians to do this work, and removing a sunset in this bill on a primary care scholarship program that we could talk more about and explain how that program works, but it's tuition reimbursement. So if a primary care, a medical student at the Lawrence College of Medicine commits to staying and practicing primary care in Vermont, for each year they serve after they're done training, they have the in state tuition waived.

[Sen. Virginia "Ginny" Lyons (Chair)]: That's not in here, is that?

[Jessa Barnard (Executive Director, Vermont Medical Society)]: Yeah, so it's hard to see in here. The language is striking, that program is scheduled to sunset at the 2027. So it is striking sunset language towards the end

[Sen. Virginia "Ginny" Lyons (Chair)]: of the day. It's a subject that's one day. I see.

[Jessa Barnard (Executive Director, Vermont Medical Society)]: My understanding, just talking, I would encourage you to hear from the new there's a new dean of primary care at Larner who's the head of the AHIP for their health education center program that helps implement this scholarship. There is some remaining funding for the program, so they could continue funding some more years of students if the program's not sunset. Wow. So we have removing the sunset I mean, ideally some longer term funding would also help stabilize the program, but even absent that, it's also independently really important to remove the sunset so they

[Sen. Virginia "Ginny" Lyons (Chair)]: can spend the money they can do. Right, okay, great. Thank you. Yes. It's great, and you've given us a significant number of folks we

[Jessa Barnard (Executive Director, Vermont Medical Society)]: have in. We'd love to hear more to make sure that phone's

[Sen. Virginia "Ginny" Lyons (Chair)]: the docs who are able to come in and the others who can I've got the Massachusetts people. Perfect. I've got Abe Berman, APAC, Yeah, so, and

[Jessa Barnard (Executive Director, Vermont Medical Society)]: I know you're short on time, yeah. Can I make one more comment? Go

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

[Jessa Barnard (Executive Director, Vermont Medical Society)]: And I do have some detailed, like, pretty nitty gritty comments. The big pick, I do wanna just add one suggestion as we've talked to other sort of stakeholders and people interested in this bill since it was introduced. We would recommend, again, subject to hearing more from the Agency of Human Services, that rather than charging diva specifically with implementing the program, that the agency as a whole makes more sense because we really wanna make sure we're coordinating with the blueprint. We just heard from John and Adi and how much work they're really already doing in this direction. And and the blueprint really has a lot of the the guts and and sort of mechanisms to help advance this work in place already. And we definitely don't want to it was never the intent, I don't think, to either cut them out or start something separate from the Blueprint. We wanna make sure this really aligns with their work. And so if it's naming AHS as a whole and allowing Diva Diva has a lot of expertise in building payment models, but for Medicaid, where Blueprint really has some expertise with multi payer programs.

[Sen. Virginia "Ginny" Lyons (Chair)]: So we wanna make sure

[Jessa Barnard (Executive Director, Vermont Medical Society)]: we have all that expertise designing this, not just one program or

[Sen. Virginia "Ginny" Lyons (Chair)]: the other. And I saw that you have a number of comments.

[Jessa Barnard (Executive Director, Vermont Medical Society)]: Yeah, I'll save the rest of details. We're not ready for that. That's fine. No, you're slowly out. No, one I wanted to say, especially before AHS testified, I don't know for sure. I'm guessing they may make a similar recommendation, I would just wanna say we're supportive No, we've got a ways to go. We've got

[Sen. Virginia "Ginny" Lyons (Chair)]: a little path ahead of us, but you're beginning to set the table and it's good to hear the support that your organization is getting from folks on the ground. That's important to us.

[Jessa Barnard (Executive Director, Vermont Medical Society)]: Great, and we'll have more, and we're happy to have lots of primary care practitioners share their specific feedback. We love that, that's good. Yep, thank you so much.

[Sen. Virginia "Ginny" Lyons (Chair)]: And for taking the other thing that we'd like to hear from are the family doc residents or students Oh, who are Are they gonna think about living here in Vermont? That would be really helpful. That was one of the goals we have in here is workforce. Unfortunately, the governor's budget cuts AHEC a little bit, so you're gonna have to see what that means. That's not helpful as far as I'm concerned, but that's a discussion. Thank you. Thank you. All right. So, Jen, do you want us We have 190. We also have the Medicare board in So, can go through the bill. Yep. We do that and then, we manage our board. Thank you for being patient. Yes. With our legislative time. It's typical. We're usually on time. We we've got a whole lake start today, so it was good. Thanks. So maybe the 2,000

[Jen Harvey (Office of Legislative Counsel)]: foot? Not sure I'm clear enough on the elevation altitude there.

[Sen. Virginia "Ginny" Lyons (Chair)]: No, we don't wanna get too Stupid. Involved in the

[Jen Harvey (Office of Legislative Counsel)]: again, Jen Harvey from the Office of Lectricity Council. We are looking at X X 190, which

[Sen. Virginia "Ginny" Lyons (Chair)]: is an act relating to

[Jen Harvey (Office of Legislative Counsel)]: the Green Mountain Care Board, reference based pricing, some hospital outsourcing as from folks there. First pieces deal with reference based pricing. Section one specifically is an implementation provisions. So, under the law of the past last year, the board is supposed to begin implementing reference based pricing as soon as practicable, but not later than hospital fiscal year 2027, which starts in October. The board doesn't specify when in year. And this would add some language to the board's reference based pricing authority, saying that for provider contracts entered into on or after 10/01/2026, which is beginning of the year of 2027, each hospital and health insurer shall express the rate for all items and services as a percentage of Medicare or another benchmark if the board picks a different benchmark, so that that information is being reported in a consistent way that allows them to implement reference based pricing. It also directs each hospital to apply for, get, and use a unique national provider identifier, NPI, on all claims filed after 10/01/2026, for reimbursement or payment of items provided and services delivered in an off campus department of the hospital that is distinct from the NPI used for services delivered at the main hospital campus or any other off campus hospital department. So starting to get a unique a national provider identifier number for where services were delivered. And it gives some definitions. Campus uses the same definition or similar definition as in federal law, which is the main buildings of the hospital. Physical area immediately adjacent to a provider's main buildings, we're located within that two fifty yards of the main building. So, sort of the main campus of the hospital, and then off campus is located more than two fifty yards from the main hospital. Also requires that we're making public the charges for items and services under the federal requirements for hospital price transparency. Each hospital must include in its machine readable files pricing information shown as percentage of Medicare rates, as well as in dollars and cents, and disaggregated by payer and by plan. It directs the board to establish a default percentage of Medicare, that's a cap, above which a hospital shall not accept payment for an item or service under any newly established codes, unless and until the board can establish a reference based price for that item or service. So, to give the board time to look into and decide what the right default presenter should be, they

[Sen. Virginia "Ginny" Lyons (Chair)]: would have a default can. So, I will admit that the board asked to have a specific number in there and suggested that it would be something we need to hear about and a defense of any number, I wouldn't know what the data would be.

[Jen Harvey (Office of Legislative Counsel)]: And similarly, the board would establish a default maximum percentage of Medicare above which a hospital cannot accept payment for any individual inpatient or outpatient item for service. Section two gets into outsourcing, and we looked at some of this when we looked at the bill last week, but it starts with some findings about the increasing use of outsourcing for clinical services, including emergency medicine, amphesiology, radiology, lab service, and other specialized care to outside entities, and the fact that the board does not know about the revenue, isn't able to include that revenue in its hospital budget process or otherwise within its regulatory oversight, It may allow hospitals to circumvent their revenue caps and spending limitations. It also undermines budget transparency and accountability. Makes it difficult to use price controls like reference based pricing if there's not oversight over these outsourced services, and they can contribute cost inflation and market inefficiencies. There may be issues for patients with network adequacy, surprise medical bills, and inconsistent access to financial assistance policies that are otherwise received when care is provided by outsourced providers. And so the purposes of the next section, which enacts a new statutory section, would be to bring all hospital affiliated revenue within the board's regulatory purview, ensure that reference based pricing applies to outsourced services, and applying network adequacy requirements and billing protections to shield patients from surprise medical bills, and ensure consistent access to legally required financial assistance policies. It adds a new section in section three, a new section in title 18, with the definition of outsourcing. So it's an arrangement where a hospital contracts with an external entity that assumes sole control of direct clinical care offered within the hospital facility. It may include emergency medicine, anesthesiology, hospitalist services, and other direct patient care services provided on-site at the hospital by a contracted entity. Does not include services provided by a nurse on a short term contract at a hospital where the hospital retains oversight and control of location care, does not apply to off-site diagnostic services, including radiology and lab testing, which does not apply to non clinical services like laundry, nutrition, information technology, or cybersecurity. It requires revenue from outsourced services to be included in a hospital's net patient revenue limits, commercial rate limits, operating expense limits, and other limits specified by the board. It specifies that the board's rate setting authority, including reference based pricing and global hospital budgets applies to outsourced services, and it requires revenue generated by outsourced services delivered in a hospital owned facility to be part of the net patient revenue of hospital for purposes of the provider times and other applicable state assessments. Can I ask a question? Do we know

[Sen. Virginia "Ginny" Lyons (Chair)]: much is being outsourced now? Because there's a study done on that.

[Jen Harvey (Office of Legislative Counsel)]: I think you'll hear more from the board, but we're still getting their arms around what that looks like.

[Sen. Virginia "Ginny" Lyons (Chair)]: It's hard to tell, because each hospital is independent. And I think

[Jen Harvey (Office of Legislative Counsel)]: the board just learned about some of this yesterday. Got it. Consumer protections, this requires the hospital to be responsible for billing health insurance claims for all outsourced services delivered to a patient at the hospital by a contracted provider who would otherwise be out of network under the patient's insurance plan. Requires a hospital that contracts for out of work services to minimize billing complexity for patients and coordinate billing processes with the outsourced providers to the greatest extent possible, and it requires the hospital financial assistance policies required by law, and any other policies around bad debt or charity care to apply to outsourced services as well to ensure that patients are receiving consistent financial protections, regardless of service delivery model. Sections four and five are some new forming changes to implement some of these provisions. The first is specifying that outsourced services are included in what the financial assistance policy must cover, such as financial assistance policies for hospitals, ambulatory surgical centers, and other large home care facilities. Section five specifies that net patient revenues for purposes of the hospital provider types includes outsourced services delivered at the hospital. Next couple of sections repeal language relating to healthcare provider bargaining groups, so some actions, some references to them, and then the authority to create them in the first place, and I will defer to the board to explain the rationale on that. There's some appeals. Section nine has to do with appeals of Green Mountain Care Board orders, and it's reflecting that there is no, I believe no, administrative appeal process, so under existing law, the board is supposed to adopt procedures for administrative appeals, and then those would serve as the basis for judicial review. This is clarifying that the board's process is to provide for a final order, and judicial review is at the court's final actions, orders, and other determinations. And similarly, removing a reference to exhausting administrative appeals before an appeal can go to Vermont Supreme Court. That's where appeals from or actions go, or court orders go. Hospital audits, section 10 allows,

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

[Jen Harvey (Office of Legislative Counsel)]: is in the hospital budget review subchapter, it allows the chair of the Green Mountain Care Board to conduct investigations and examinations, including audits of the hospitals as reasonably necessary or helpful to the board's administration of the hospital budget review process or rules or orders. Pursuant to the sub chapter, retain experts or others to assist in any investigation or examination, and to require the hospital that is subject to the investigation or examination to pay the reasonable costs and expenses of the examination or investigation. Data infrastructure sections, I think eleven and twelve here, are dealing with adding a health system performance tool to the board's existing authority or requirement to maintain an internet based price transparency dashboard that allows consumers to compare prices. This new provision would be on a public interactive tool that displays information on health system performance, including hospital prices relative to Medicare rates as a percentage of Medicare and in dollars and cents, and allowing the user to sort information by service line and payer, requiring more to update the information in the tool at least quarterly. Section 12 says that that requirement to develop the health system performance tool is only in effect if the court receives sufficient federal funding or funding from another source for that purpose. I believe that was one of the specific asks in the World Health Transformation Grant, so maybe only hear from others about whether that appropriate funding has been received or is allocated. And finally, the act will take effect on pest insurance.

[Sen. Virginia "Ginny" Lyons (Chair)]: So, there's a lot in here. And just so folks know, this was a request by the board for introduction for us to consider. There it is. Okay, so questions again. Well, there were a lot of questions and we'll get to them, but I think as we hear from the board and their requests, some of the things that are in here that will help us and then we'll move ahead. And I know BMS also wants to ask the question. And I think the hospitals may at some point want to testify. So, Elena and I had planned on testifying together. Then we get a pair. Was it? Her chair for Elena, her eight and halfway together. We're going to get an antique cushion chair over there. We've got to do something. Melissa, help me. You've got to make it as a Tokyo top. Top. You're in this chair. Have you moved to that, the two, though. Good morning. Good morning. So welcome, and we'll turn it over to you. For the record, I'm Emily Brown. I'm the executive director of the Green Healthcare Board. And I'm Alina Barrett, the director of policy. And Owen is not coming in. Owen is not coming in. I believe he is available if there are specific questions that come up, but We're good. For today, it's Alina and I. So as you heard from Jen, there's a mixture here of what we view as technical corrections and then some more substantive sections that are really trying to set up the board and our regulated entities for success in certain aspects of our oversight. So the first one being the reference based pricing.

[Emily Brown (Executive Director, Green Mountain Care Board)]: I think Jen mentioned the board must begin implementing reference based pricing in FY twenty seven. Only I can provide you an update of where we are with that, but really the changes contained here are meant to really try to put our regulated entities on the right foot for beginning to implement reference based pricing, and I think are signaling to certain changes and steps that can be made so that when we actually do get our rule in place and start requiring hospitals and insurers to contract in this way and setting the prices that they will be ready for that step. The second section I wanted to draw your attention to is outsourcing. So I think there were some questions around the scope of this practice right now. I believe we have some requests for information out to hospitals on this issue. This is something that came up during our budget hearing process, I believe last year. This, The changes contained here are really just to make sure that those outsourced services are being reported accurately, that the provider tax is being applied effectively. That also just gives the Green Mountain Care Board some tools so that we can make sure that we're able to effectively regulate those services. I know time is precious, so I want to defer to you all to see where if you wanna ask questions, if you want to focus on a certain section, we're happy to do any of that. Or I could we could also walk through the bill, but up up to you can walk through the sections of the bill and then there are specific, you have specific reasons. Correct. That would be helpful. So the motivation for this and then not to get too far into weeds, but at some point your thoughts on reference based pricing and a little more depth. So to start, I'll let my colleague Elena walk through the first two sections on reference based pricing and outsourcing to speak to the reasons behind these changes. Great.

[Elena Barrett (Director of Policy, Green Mountain Care Board)]: As a reminder, I think you all asked us to begin implementing a cap implementation date of fiscal year twenty seven. So, that would mean that in this year's hospital budget guidance, we will be establishing caps on prices hospitals could receive for services. Because we have the state's rulemaking process, as Ann mentioned, and that takes time and we want to build stakeholder engagement, be thoughtful about the nuances of establishing a methodology and approach. That work, we're still actually waiting for our bid responses for our contractor to help support us, and that's going happen soon and hopefully have something changed by March. So you can see this is taking some time. So I think we're not going to have anything for this fiscal year, but what we want to make sure is that everyone is committed and moving and not going to be caught flat footed since whoever hits the road. So therein lies a real problem with me and I know that the board, I see Owen is here with us, I know the board has been, we've been talking about reference based pricing now for several years and it would seem to me that the board would have some leg up in providing guidance to hospitals on at least some services for reference based pricing. Well, I'm not happy with the idea of letting it go for another year. I'm really unhappy.

[Sen. Martine Larocque Gulick (Vice Chair)]: And

[Elena Barrett (Director of Policy, Green Mountain Care Board)]: I will just say that we share that, and in this year's guidance, we are looking at that relative crisis across hospitals. So, the law says twenty seventh. Yes. I am not bent on changing that date. It will make an interesting interesting conference committee. Uh-huh. So anyway, just that's my I need you need to know this. Yeah. Okay. Yes. Thank you. Okay. The cab.

[Sen. Martine Larocque Gulick (Vice Chair)]: Is the cab across all hospitals? Or is it different per hospital?

[Elena Barrett (Director of Policy, Green Mountain Care Board)]: I mean, are design choices, right? And that's what we're

[Sen. Martine Larocque Gulick (Vice Chair)]: trying So that's really they're working on.

[Elena Barrett (Director of Policy, Green Mountain Care Board)]: We'd like to have something that's nuanced and not a one size fits all because we recognize there. Oh, we did that. Yeah. I totally got that. And each hospital will be different, each service will be different. There's a lot to do there, but just one something somewhere across the world of hospitals is where we need to start so we can begin to get data back. I know that probably seems difficult for, I know it's difficult. And that's why you have this language that we propose because I think we don't have a mechanism to go faster because of the rule making process that we're required to go through, which takes a minimum of six months once you have a design. So I think if there's something, you know, we can work with you on language if you wanna make sure this happens for 27, and think about which services, what number seems like the right first. That comes from you. We're not gonna produce that, so something has to come forward. So it's not just let's put it off another year. We don't know what's going to happen federally in another year. And right now we can focus on what we can do to contain costs and to improve access. And this is all so important for that. Right, and I think the numbers we included here, Mike Smith, who's been working with the medical center recommended to us a no service shall exceed 500%, so that was the number we passed forward. There was also a 250% for new services, and that was based on conversations with other states that had done this work and comparing the methods. They've used 200% actually, but have a different method than I think we're anticipating moving forward with, which is why I'm recommending two fifty for new services.

[Sen. Martine Larocque Gulick (Vice Chair)]: That's above Medicare.

[Elena Barrett (Director of Policy, Green Mountain Care Board)]: Above Medicare. Right. So it'd be two and a half times, right? Which is still quite a bit of price. And your recommendations include that. And then we can adjust, right? So I think that's what the flexibilities that we'd like to be able to have a method that is clear and transparent and predictable, that we all know what we're working towards. There are no surprise prices and surprise billing, right? You know that we have a set of expectations. And then we can adjust to this things change. Ironically, the surprise billing comes when we don't have that. Right, right. So, we can't use that as an excuse. What we can say is we're going forward with this particular number for these services and so, I've said my piece and so, you're gonna have something. Yep, this could be an insurance step that's put in place to your point to try to control costs at least at the high end. Then we'll again start getting hospitals and insurers thinking about pricing and how far to Right, that's helpful. Okay, all right, we'll consider that. Okay, Joyce. Great. So, I'll just say one more thing. Some of the other elements you've included here are really about making sure we have the right data, that everyone is prepared to provide that data. This NPI requirement is really about tracking where services are being provided. This is something that's, I think, being discussed at the federal level and and would be really helpful for making sure that we're not overpaying in some settings just because of bad data. And so I think if you have specific questions, we're happy to come back. But that's really the spirit about that. Have about space rights inception. Do we have we

[Jen Harvey (Office of Legislative Counsel)]: have something for you on our web page

[Elena Barrett (Director of Policy, Green Mountain Care Board)]: about that? I only have the report. I don't know that we provided any materials, we're happy to write something on the rationale. No, that's correct. Something's going to happen. Yes, yes, can do that. Okay. The next section's on outsourcing. If you're ready to, I'm happy to talk about that as well. This year in our hospital budget process, I think we learned more about different ways that hospitals are constructing their business models and able to provide services.

[Sen. Virginia "Ginny" Lyons (Chair)]: Sometimes those services are owned and operated by hospitals, and other times they contract out with other providers to go over those services. There may be good reasons to do that. I think one thing, one implication of that kind of activity, one implication, sorry, of that activity is that those revenues, if billed by another provider, fall out of what the board regulates and sees as part of budgets. We also cannot establish prices. I don't think the reference based pricing would clearly extend to those services. We also don't really know how efficient it is actually better for Vermonters. I think there's a lot of reasons why we want to be able to at least identify when this is happening so we can understand kind of what is going on and if it's an endemic choice. The center bench just be Question.

[Sen. John Morley III (Member)]: Is there another state out there that has initiated this type of a system? Right.

[Sen. Virginia "Ginny" Lyons (Chair)]: What do mean this? Which part of the system? Referenced. Referenced.

[Jessa Barnard (Executive Director, Vermont Medical Society)]: Oh, we're probably at hygiene. Yes.

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

[Sen. John Morley III (Member)]: So Would you build off of some of those Yes. Already existing models?

[Sen. Virginia "Ginny" Lyons (Chair)]: We are we have met with states that already have this in place for their public payers who can do it for their teachers and state employees. Maryland has also had a rate setting system in place since the 1980s, and the flyer I handed to you discusses some speakers that we will have next week that will be talking more about the history of rate setting in healthcare, and kind of how we got to where we are. This is not a new innovation, this is something that has happened and we've learned from, and there are different elements that still shift across the country. So we are, yes, we are learning it. And we've been through the issue around hospitals versus independent or individual risk pools last year. Okay. Any other questions on outsourcing? No. That's helpful. It's good. It's doable. Yeah. So the next substantive change starts in section six and goes to section eight. This is the clean up technical change for removing provider of our

[Jen Harvey (Office of Legislative Counsel)]: main

[Sen. Virginia "Ginny" Lyons (Chair)]: groups from some of the language in our statute. It's my understanding this is a relic from a law that was passed in 1990. It's no longer applicable. I believe there is one provider bargaining group currently in the state, but there hasn't been any activity under the statute for over ten years. So it's our suggestion here to repeal the healthcare provider bargaining group language from our statutes. Okay. I don't think anyone has peeped up about this one. I think we're gonna hear from BMS. Yeah. I think that's what I was trying to say. Spoke to the physician. They have a physician bargaining. I know they do and I don't know whether that was captured in this. It is. That's the only one in that. That's the intent here. Okay. Alright. Moving on to hospital audit section 10. This language is to allow the Green Bank Care Board to give it clear authority to conduct audits. So while we review budgets, we currently don't have explicit audit authority over the hospitals. So this language, it's my understanding, largely mirrors the Department of Financial Regulations audit authority that they have over insurance. So this would just give the board that same or similar authority to audit hospitals. All right. Section eleven and twelve, as was mentioned, relates to a project that the Green Mountain Care Board put forward along with AHS for the Rural Health Transformation Funds. This is a data infrastructure project that would allow us to track system information and hospital performance data in more of a real time way than we do now. Would also allow us to We outsource a lot of our data projects right now, and this would allow us to kind of take that in house and do a lot of good work ourselves. So it should have generate efficiencies. It should generate efficiencies. Correct. That's the goal. And provide more transparency. Right. Yes. Yeah. Okay. This is good. And appreciate this. I think what we'll do is we'll jump over to the next bill and then we'll have you back in and we'll set some more time after BMS goes, obviously. But we'll set more time for this bill. So we're gonna find a day where we have just this bill or just January or January. So but, yes, we'll do that. And I appreciate thank you. And we'll our glasses. I didn't see Owen smiling. Yes,

[Jessa Barnard (Executive Director, Vermont Medical Society)]: good morning, Jessa Barnard again with the Vermont Medical Society. I think I can be brief. We, happy to talk to the Green Mountain Care Board more about infection, but I did want to make sure that we just spoke up to let you know we do have a healthcare, an actively approved healthcare provider bargaining group. Current statute that is proposed to be repealed allows bargaining groups to negotiate with public entities, public payers, including Secretary of Human Services, Green Mountain Care Board, and Commissioner of Labor. We have had one since the 90s, and that, which is when this statute initially was created. It would our group was dormant for a while, but reconstituted itself in around 2013 in response to single payer. I will say we have not our group has not been particularly active, however, the most recent instance when we considered kind of activating it was actually around workers' compensation. I believe I've, in the past, updated the committee that the schedule is about almost twenty years out of date now. It took years of sort of persistent pestering of Department of Labor to encourage them to and they acknowledged they wanted to update it. Finally, actually just had a meeting a week ago. They now have a proposed new fee schedule. However, I just wanna be clear, I think there are instances this is still very relevant and needed. We certainly would not be opposed. The rules, for example, around how these are dated are quite outdated at this point. I do wanna emphasize that all this leads to is a non binding arbitration process, and there's nothing that actually requires the payers or agencies to ultimately accept the outcome of the arbitration. It simply gives framework and a process if arbitration became needed over not just these schedules, but things like administrative simplification, quality of healthcare, workforce issues. We've typically resolved these directly with the agencies or working with you for legislation, but it gives us as providers one more tool. So we would simply ideally request this not be stricken and that we do certainly work with the board if needed to update sort of the rules or framework around them.

[Sen. Virginia "Ginny" Lyons (Chair)]: That suggestion, last suggestion is a good one to make before we categorize Thank you. Thank you. I remember the 2013 discussion and it happened in judiciary. All right so Jen let's go back up we'll look at 01/1989 and then we're now on a really fast track but I'm hoping that we can just do this with alacrity and get to where we need to go. I'm gonna select something last year.

[Jen Harvey (Office of Legislative Counsel)]: Great. Again, Carter from the Office of Legislative Council is built. This is S-one 189. It's shorter than the other ones we've looked at. This is an act relating to an approval process for reducing or eliminating the hospital services. There was language that you'll see struck later from last year's Act 68 that corrects what hospitals have to do if they want to reduce or eliminate service as far as providing notice and giving an agreement with care board an opportunity to make adjustments. This would replace that with a new requirement or provision on a hospital reducing or eliminating any service without approval from the Secretary of Human Services. So, not just notice, but active approval. It requires a hospital that wants to reduce or eliminate a service to provide a notice of intent to the agency, to the Agreement Care Board, Office of Healthcare Advocate, and members of the General Assembly who represent the hospital service area, similar notice of intent to what's in place now. This is not less than 60 prior to the proposed reduction or elimination. It's forty five days in the existing notice, but this adds, again, to get approval from the new. The notice must explain the rationale and describe how the proposed reduction or elimination is consistent with the statewide healthcare delivery strategic plan once established, and the hospital's most recent community health needs assessment conducted pursuant to state and federal law, federal wide or non profit hospitals. They must post the notice of intent on the hospital's website on or before the day on which they provide notice. Also publish notice in a newspaper of general circulation in the hospital service area within ten days after providing this notice. And conduct a public engagement process, including one or more public hearings in the county where the hospital is located, and soliciting and responding to public comments about the proposed reduction or elimination that gives some flexibility in when the public engagement process can begin, can be prior to giving notice, must continue for not less than thirty days after the notice, and requires the hospital to provide a summary of the community's response, including any public comments received to the agency of human services weekly during the public engagement process. Directs AHS to review the proposed reduction or elimination for consistency with the statewide healthcare delivery strategic plan once established and the community health needs assessment and consider the community's response and the impact of the proposal on access to necessary care and services in the area. It allows the agency to approve the proposal if the agency determines that the proposed reduction or elimination is not inconsistent with the statewide healthcare delivery strategic plan or community needs assessment, does not unduly burden access to necessary care and services, and the advantages outweigh the disadvantages. If the agency approves the service reduction or elimination, the agency must notify the Green Mountain Care Board within five business days so the board can review the impact on the hospital's budget. Section two amends the hospital's budget review statute to take out the existing process for notice of proposed reduction or elimination, and instead, require that the board review the impact of an approved reduction or elimination on receipt from AHS that it has approved one, and allows the board to adjust the hospital's budgets as necessary to reflect the elimination or reduction, which may include directing that any savings related to the reduction or elimination are returned to payers and Vermonters to address affordability concerns or are reinvested in primary care, prevention, and other community based services. And then there's a little bit of language tweak here, directing the board in collaboration with DFR to monitor implementation of any authorized reduction or elimination in hospital services to determine benefits to the monitors or the healthcare system for both, and the active take of that requirement as a teacher.

[Sen. Virginia "Ginny" Lyons (Chair)]: Right, so we have a process that we just put in place in Act 68, and now this is gonna change it.

[Jen Harvey (Office of Legislative Counsel)]: Right, so Act 68 has a notice of hospital service reduction. This would require an approval process and would put it more squarely in the agency of human services with reporting the Green Mountain Care Board, which would then take actions regarding the impact.

[Sen. Virginia "Ginny" Lyons (Chair)]: Is there a consequence if it possibly doesn't follow this? Just have to find out. Doesn't I mean,

[Jen Harvey (Office of Legislative Counsel)]: there's no no specific no. There's no specific enforcement mechanism. In this case, it's an interesting question. You might wanna hear some testimony on what that might look like. When it's in the hospital budget context, there's enforcement authority for the rematch of work, but

[Sen. Virginia "Ginny" Lyons (Chair)]: outside of that context. AHS doesn't currently regulate hospitals.

[Jen Harvey (Office of Legislative Counsel)]: Well, they're involved in hospital transformation efforts. Right, that's good. Right, so I don't know, I

[Sen. Virginia "Ginny" Lyons (Chair)]: would defer to the board on that. Have a lot.

[Jen Harvey (Office of Legislative Counsel)]: AHS and whether they have or need, first they may want

[Jessa Barnard (Executive Director, Vermont Medical Society)]: to tell you whether they like what you have proposed.

[Sen. Virginia "Ginny" Lyons (Chair)]: All right. Okay, so let's hear briefly from the board, and then I know that AHS is here in the room. Do you want to comment? Rachel. She left? I'd be happy to after.

[Jessa Barnard (Executive Director, Vermont Medical Society)]: Right, your career always looks good.

[Sen. Virginia "Ginny" Lyons (Chair)]: I got you. Okay. You're right. I'm not attending. So just take five minutes each. That's what we're will feed you. Appropriate side tenants. Thank you. Again, to the record, Emily Brown, Green Mountain Care Board. This bill, I don't I'll rephrase the video here.

[Emily Brown (Executive Director, Green Mountain Care Board)]: You've heard from Jen about what it does. I just wanted to point to a few reasons why we feel like this is important. So as many of you are aware, we just went through a notice of service reduction with regional, the Rutland Regional Medical Center. They had a proposal in front of the board. And as we went through that process, there were a lot of issues that came to light that we felt like needed to be fixed to make sure that this process is efficient and effective and also serving the purpose it's intended to serve. The biggest thing here was that when the Green Mountain Care Board received the Rutland proposal, we had one proposal in front of us in isolation. We had no concept and no picture of the broader picture of transformation that's happening within the state. As you are aware, the board, has budgetary oversight of hospitals, but is not directly charged with the transformation efforts that currently is living with AHS. So when staff were working on the interim policy, which we have in place now, and figuring out how do we judge this reduction, we really just had the information from Rowan in front of us and weren't able to put it in the context of, well, does this change make sense in the broader picture of whether it's a regional transformation or a statewide transformation? So we just felt like any decision the board was going to make wouldn't necessarily be informed by, like I said, the broader picture. That's really the main emphasis and reason behind this bill. We support AHS doing this work. We want to be partners. I think that's really important to us. We don't want to completely remove ourselves, but we just believe that decision making should happen in a different place aside from within the board. A few other things I just wanted to point out again, the timing. Right now it's forty five days. That was a very short timeline to try to get information back from Rutland, follow-up with questions. And the notice of intent had already gone out. So there was, as you are aware, a lot of public input here and a feeling that things were moving along and there was no way to stop it. There was a date set for the service to be reduced. We believe extending that to sixty days is actually a good way to mitigate some of those problems. Other pieces of this, though, which I want to point to are the public input. So that was another feedback loop that we received from the Rutland experience. A lot of the public didn't feel like they had had an opportunity to meaningfully engage in this process with Rutland. So, this bill would require the hospitals to run a public engagement process and actually take feedback from those in their community. Again, I think a very important part I wanted to highlight- Ann sorry, sorry, is that a process you laid out? Does it already have a structure to it or is it house? What you see right now is in the bill. There's not a separate process. Currently, don't in our interim notice of service reduction policy that we have at the board. I don't believe we lay out a public input process, but this would add that requirement. And, two other things I really wanted to quickly highlight is that we also believe that prior to providing the Notice seven ten to AHS, it would be very helpful to require the hospitals to do their own analysis, making sure that they're taking all steps necessary to preserve necessary and essential services there may be. This work could be in conjunction with AHS, it could be done with the board to make sure you don't understand budgetary impacts. But having that process before anything is filed, I think it's very important because you could eliminate a lot of constant consternation anxiety that, again, we saw with Brooklyn. And then the other suggested change that I would like to propose here is for similar reasons as I spoke with AHS during the review, we would like to suggest that the budget adjustment for any elimination or reductions in service is not done in isolation, that that is actually part of our annual budget hearing process. And that way, if there are services being reduced, but other services being increased, we're able to have that holistic picture of a hospital's budget, instead of looking at one reduction in isolation and saying, Oh, you need to reduce money from here, whereas they actually need that money to do something else. So that is our other suggested change and we would be happy to provide some language that reflects my comments today. Yeah, this will be, as I said earlier, we'll put this bill up for broader discussion. Mean, best response needs to testify as well.

[Sen. Virginia "Ginny" Lyons (Chair)]: Anyways. Thank you first to hear from Amy Jess on this, because really what this does is it places some work into the agency that wasn't there before. It's different, and I Chittenden for some running around and thinking. Is that me? Am I the Chittenden? Yeah. We're talking Chittenden. Okay. Good morning, I'm Jill Mazel Olson. I am the state Medicaid and Health Systems Director.

[Jill Mazza Olson (State Medicaid and Health Systems Director, Agency of Human Services)]: So, I've been to this committee before, but just to remind you, I have broad responsibility for Medicaid and for healthcare reform at the Agency of Human Services. So, just so you know where I'm going, we're not comfortable with the bills as introduced and some of the major changes. I'm gonna start with where I think we agree. Think that the example, the sort of first example out of the gate of a hospital proposing a reduction of service under the new language that was passed last year did reveal some problems. So, I actually think we have a broad amount of agreement about some of the problems that it serviced. The questions about whether there was a public process, that there could be stakeholder engagement in advance of the work, the notice requirement, the fast timeline that is triggered if we don't know something is gonna happen before it does. So, I think there's a lot that this bill is trying to solve that I think we agree on the problem statement. But I would say we're not entirely comfortable with a solution. So you may remember just last week, we heard testimony from Katie Carroll, our Director of Transformation. And so it's really task that's been given to AHS that is really finally coming to fruition, I think, after some time, is this transformation work, where we're working with every hospital, much of it in response to the Oliver Wyman report, which came out two years ago, to try to figure out how each hospital is best, how to best structure for the future. What changes do they need to make? Where might we have centers of excellence? Where services might be more regionalized? Where might some hospitals actually increase certain kinds of services? Taking a load off of our tertiary care center, but are sometimes not able to serve everyone. This is work that requires a lot of trust. It's a consultative process between AHS and hospitals. It includes technical assistance in the form of analytic support and also just some clinical expertise to have some of these conversations. I don't think we can serve an innovation role and a regulation role at the same time. I don't think they work together. And this actually increases the regulation, because under the current law, there's a May, I think the board has felt like it's, felt like they needed to look at that Rutland case. This makes every single one subject to approval, and it means that we are now the yes, no, and somehow trying to provide innovation, technical assistance, and that sort of help. It's really hard, because hospitals are gonna have some hard decisions to make. They are gonna need to bring those decisions to their communities, There's just a lot of tough thinking ahead. We're starting to see these plans come to fruition because we're in the process of draft plans. I think Katie shared she'll be able to provide you a summary in March when we start to finalize those plans. It's really good work, really good work that needs to be done that I think is going to be disrupted by this change. I really am hopeful there's a third way, something that we can do to solve some of the concerns that we saw. I think there are ways to make more clear what's in connection with transformation, which is what the bill says, which I think there was a lot of confusion about that. I think that I really appreciate the longer run out. I appreciate the noticing and the public process requirements. To move it into a new, and then of course, is the least of it, but AHS would need an apparatus for this. We don't have a team or a process that would just sort of step in to be break litters. So, there's a piece there too. So, that's I think where we are.

[Sen. Virginia "Ginny" Lyons (Chair)]: Good, thank you. So, I think what will help us actually, and I will include Boz in this, is for some communication between the board, AHS, whomever, whether it's A. Carroll or you or as to how to find that sweet spot with this because it's not gonna work to have you come in one position and another position and who's doing what where. Transformation's going on. We're gonna have a state plan, and then when we get there, we'll know what we can do. Right now, we're in a transition. I'm asking and sending you all out to the hallway, literally and figuratively, to come up with some proposal. There's an agreed upon problem. Let's find some solutions together, I guess, would be the best thing. I agree with you. This is difficult. There's no question about it. It's difficult for the board. I get that. Difficult for the hospitals and it's really difficult for AHS. You're seeing a whole new thing and VMS is sort of they're out there bargaining for everything. Whatever. So, please do that. I think we get it. The bill is complicated. It's always more complicated. So thank you. Thank you. And appreciate the openness and transparency of the conversation. This is really helpful. We try to be that way. Thanks for the opportunity share our viewpoint. All right. So, Jen, we have time to do 163. Folks, And it'll get better, believe me. Do that. We're just trying to get through the first round here and then we can dive in going forward. This is to bill on advanced practice dentistry. Of

[Jen Harvey (Office of Legislative Counsel)]: Maybe say the shortest class.

[Sen. Virginia "Ginny" Lyons (Chair)]: And we've already done a high level. We did. Yeah, we did. It won't take long to remind us what's here.

[Jen Harvey (Office of Legislative Counsel)]: You. Ann, John Benson from the Office of Legislative Counsel. This is S163, an act relating to the role of advanced practice registered nurses in hospital care. We looked at your phone line as well. First, we just have the definition of advanced practice registered nurse or a urine for purposes of the hospital's patient bill of rights.

[John Benson (Office of Legislative Counsel) ]: Also, a definition of physician, just going by their licensure statutes. Section two adds in an APRN throughout the hospital patient's bill of rights, wherever a physician is mentioned, and for an APRN specifically in the language requiring that a patient have an attending physician, now or APRN, who's responsible for coordinating their care, this would add that physician confirmation and support would be available to an attending APRN at all times in accordance with applicable standards of care and regulatory requirements. So, again, adding an APRN throughout wherever a physician is mentioned, and getting rid of some gendered language to use, non gendered language. That is a hospital patient's bill of rights, and in the, and adding in references as well for failure to comply with with the section may constitute a basis for disciplinary actions, could be against a physician licensed by the Office of Professional Regulation, so an osteopathic physician. Right now, it just references those licensed by the board of clinical practice, which is 26 VSA Chapter 23. So adding in board 33, recognizing that the physician may be licensed under either practice type, and then also against an APRN under their nursing licensure, and corresponding language, and the Office of Professional Regulation as applicable based on the license held by the practitioner. And references to OPR being added in, in addition to Board of Medical Records. Section three amends the hospital licensure statutes saying that all patients admitted to the hospital, one of the requirements is that all patients must be under the care of a, and under existing law, it's state registered and licensed practicing physician. This would say a licensed physician, but referencing the two licensing chapters, and adding an or an advanced practice registered nurse license pursuant to the subject chapter specific to the APRNs. And, again, professional case records must be signed by the attending physician and adding in for advanced practice registered nurse. So again, the high level version is just adding in that an APRN may be the healthcare professional responsible for attempting to and coordinating a patient's care in the hospital setting, both for hospital licensure statutes and for the patient bill of rights. Which is within their scope of practice. To the extent within their scope of practice, and you'll hear bronchodilators on

[Sen. Virginia "Ginny" Lyons (Chair)]: I'm gonna thank you about it, because we've been through it, and I think we're okay. And we have is it Sheila Boni or Bonai? Sheila, welcome.

[Sheila Gulick (Nurse Executive Officer, Vermont Office of Professional Regulation)]: Good morning, madam chair. It's Sheila Boni with a b.

[Sen. Virginia "Ginny" Lyons (Chair)]: I can't hear you. We'll have to turn the sound up. And Madam Chair, she looks from the Office of Professional Regulation and I was planning to testify with her Why if that's don't you come right now? Good. You helped coordinate us then. I see what we're doing here. Morning. Can you hear me?

[Sen. Martine Larocque Gulick (Vice Chair)]: Yep.

[Sen. Virginia "Ginny" Lyons (Chair)]: Yes. Thank you. So we're we're we're going to begin with Jenna Collins, right, of OPR, and why don't you go ahead? We've got eight minutes. Hopefully it won't take that long.

[Jenna Collins (Director, Vermont Office of Professional Regulation)]: So I'm the director of OKR. Thanks for having us on this bill. And I have with me today Go ahead, Sheila.

[Sheila Gulick (Nurse Executive Officer, Vermont Office of Professional Regulation)]: Good morning, madam chair, members of the committee. My name is Sheila Gulick. I'm the nurse executive officer the Office of Depression Regulation.

[Jenna Collins (Director, Vermont Office of Professional Regulation)]: Ann, so thank you so much for having us then to testify about S163 related to hospital licensure and a hospital patient's rights to specify that an advanced practice registered nurse may be the healthcare professional responsible for a hospital patient's care. As you know, the mission of OPR is to protect the public from incompetent or unethical practitioners through a system of licensure. Also have a system of enforcement within our agency. We achieve our mission by supporting boards and advisor groups that oversee licensure of 50 professions and approximately 80,000 licensees. OKR and the Board of Nursing are committed to partnering with our legislative colleagues to reduce barriers to licensure and to support Vermont nurses to practice to the top of their licensure without imposing conflicting regulatory requirements or restrictions to their authorization to practice. So before action is taken on this on proposed changes to 18 VSA eighteen fifty one, we're appreciative of the opportunity to support the bill and also share one concern that we've identified with a proposed revision to the current language of S163. I'm going to turn it over to Sheila to share our specific concerns, which is through remedy.

[Sheila Gulick (Nurse Executive Officer, Vermont Office of Professional Regulation)]: Thanks, Jennifer. The background is that Vermont is one of 27 jurisdictions in The US that provide all practice authority qualifications for licensure. Hang on a second.

[Sen. Virginia "Ginny" Lyons (Chair)]: If anything you can do to turn your sound up or get closer to the mic would be helpful. Okay.

[Sheila Gulick (Nurse Executive Officer, Vermont Office of Professional Regulation)]: Alright. Good. Sorry about that. So as I was saying, that's one of 27 jurisdictions in The US that provide the full practice authority to APRNs once they've met qualifications for licensure. The Vermont laws do not require supervision of APRN practice by a physician or other provider. They have full practice authority as established in Part 17B and C of the Vermont Nursing Administrative Rules, which authorizes APRNs in Vermont to be primary care providers of record, conduct acts of medical diagnosis, including ordering and interpreting diagnostic tests and procedures, prescribing medications and medical therapeutic or corrective measures, and initiating written or verbal orders to other healthcare providers, and managing and evaluating care. The concern that we've identified with the proposed language is specifically the language that reads physician consultation and support at all times. Because this conflicts with and is more restrictive than the established nursing statutes and rules. So, OPR does not support having standards for APRNs based on the location of their work. Without understanding the intent for the inclusion of that language, OPR is concerned that this change does not reflect current law, and it takes Vermont APRN's scope of practice a step back. APRN practice requirements are established in nursing statute 26 BSA fifteen seventy two number four and part 17 or part nine seventeen B and C of the Vermont Nursing admin rules. So, OPR respectfully requests the committee's consideration of striking the proposed sentence that begins on page two, lines 13 through 15, which reads, physician consultation and support shall be available to an attending APRN at all times in accordance with applicable standards of practice and regulatory requirements. Removing this language will keep S163 consistent with APR and scope of practice as established already in Vermont law. So that's the conclusion of our formal testimony. I don't know if anyone has any specific questions for either Jennifer or I.

[Sen. Virginia "Ginny" Lyons (Chair)]: Questions? Pretty clear. Oh, go ahead.

[Sen. Martine Larocque Gulick (Vice Chair)]: Just, well, my question is, I was a patient in the hospital, do I have a choice on whether or not I want a physician to oversee or pay PRN?

[Sen. Virginia "Ginny" Lyons (Chair)]: That's a great question.

[Sheila Gulick (Nurse Executive Officer, Vermont Office of Professional Regulation)]: We've got I believe that's in the bill.

[Sen. Virginia "Ginny" Lyons (Chair)]: Patient's bill of rights? No. It's not? We'll have to get the answer to that question. Does a patient have the right to ask for an APRN versus a PA versus an MD versus a DO? No. Treatment is your treatment. As long as it's in their scope of practice. That's what I'm seeing. I'm seeing heads around the bones shake that. I thought so. There are some cases where types of services are the practitioner, say

[Sen. Martine Larocque Gulick (Vice Chair)]: But there's a difference between these two individuals, isn't it? Which two individuals? A physician and the APRN.

[Sen. Virginia "Ginny" Lyons (Chair)]: Within the scope of within the scope of practice. Thank you. Go ahead, Brian or John. My primary care is an APR. I go into the hospital. I never see my APR. They're out of a year, at least a local hospital. Everybody's at hospitalist death, and nobody I mean, if you read the name tag, might know what their credentials are, but you get cared for within the scope of practice of whoever walks through that door. I suppose I could say, No, I don't want to see you, but I might wait six hours before somebody else comes on duty. So I guess what we will ask of you the next time we pick this bill up and we'll do a walk through and mark up on it is a little description of scope of practice and how that sorts out. But I think that's your question. It is. Yeah. I just

[Sen. John Morley III (Member)]: want make this one question for the

[Sen. Virginia "Ginny" Lyons (Chair)]: rest Yes, sure. You the

[Sen. John Morley III (Member)]: made a recommendation for a change. Have you submitted that to us in writing?

[Sen. Virginia "Ginny" Lyons (Chair)]: We have submitted, I hope you have it, written testimony. And I think it's on your

[Sen. John Morley III (Member)]: way. Next

[Sen. Virginia "Ginny" Lyons (Chair)]: time we're in, we have that background section that talks about the APRN scope of practice, but we can elaborate on that a little bit further next time. That would be helpful. Okay. Great. Thank Alright. Thank you so much. Thank you, Sheila. Going down the freeway. We're gonna get off on a we're gonna take an exit soon and take it slow. This has been great. Thank you all.