Vermont Legislature SmartTranscripts:

[Sen. Virginia "Ginny" Lyons, Chair, Senate Committee on Health and Welfare]: Good, so this is Senate Health and Welfare. We're back live. We've taken some terrific testimony on S197 and have a lot to digest there. And now we're moving on to S190, the Accurately Green Mountain Care Board Reference Based Pricing and Hospital Outsourcing of Clinical Care. We'll start with Devin Green of the hospital and then we'll just move through our folks who are here to testify. We can learn what we need to learn. Okay. Give me one moment. I'm gonna get out. Okay. You're having trouble with that? There you go. I just would like to announce we have an honored guest who is your name? Former senator. That was. At least I didn't fall into this. No, exactly. How can she No! Yes, yeah. Yeah, right here. I'm just like Oh, that was your Yeah, we've seen people. You're good. All right. This is a she's a critic, so we have to be Very careful, dear. Good to see you. Okay. Alright. So we're on one ninety. I don't I think we have we have what you are putting up. Right? Yes. Yeah. We should.

[Owen Foster, Chair, Green Mountain Care Board]: Okay.

[Sen. Virginia "Ginny" Lyons, Chair, Senate Committee on Health and Welfare]: Great. Thank you for your patience. My name is Debbie Green. I'm with the Vermont Association of Hospital Home Health System. And thank you for having me in today to discuss S-one 190.

[Devon Green, Vermont Association of Hospitals and Health Systems (VAHHS)]: I will first start with section one, the reference based pricing reporting. The idea here is the bill proposes that hospitals report their prices as a percentage of Medicare or other benchmark that they set. Conceptually, we do not have a problem with that. Exactly. I think what we'd like to do is just get a very clear set of process or standards around this or see if it's possible for the Green Month Care Board to I think we just wanna talk this through a little bit more. Because one thing we're finding with Act 55 is the prescription drug cap bill, which is essentially reference based pricing. Yeah. Is that there's We really do want like one source of truth and very specific instructions. Like as we dug into that, we found that there's multiple postings of the prices in which to be follow, and we just want to get very clear. I think this is a chance, you know, over the years we've heard that hospitals report their budgets in different ways, and there's no standardization, and I think our ultimate goal is standardization for And so, that is like a process to get a very clear equation of how to do this, or the Green Mountain Care Board posting the prices, and that we put those in our transparency reports. We are happy to work on this. We get the concept, we wanna do it. We just wanna make sure that we don't fall into another space of each hospital is tweaking things a little bit differently, because as you can see up here, Medicare pricing- That's big problem. There are actually lots of factors in a Medicare price. That's our thought there. And then sections two to five with the hospital outsourcing. The first thing I just wanna address is, and this can be a little bit of, I just want to address that hospitals have been very upfront with a lot of their outsourcing. We've had newspaper articles about the company coming into the emergency department. We haven't been trying to hide anything, I would say, with this. I understand that there has been differences in reporting, and the Green Mountain Care Board wants to get its arms around that, and I hear that. So, I don't think we have any issues with the reporting piece and really standardizing and making our reporting clear. I think you'll hear from Blue Water and Brattleboro Memorial Hospital later about some of the issues this may cause for some of these organizations that are outsourced to and come in to the hospital. I think what we have here is the tension of some of these outsourced companies provide care at lower costs and better quality, and take out the difficulty of recruiting for providers and are able to help the hospital out? And do we want to Are we setting up a system where we're making it very difficult for these companies to come in? We want to make sure that there's a good balance between the ability for good companies to come in, help hospitals save money, help increase quality versus, you know, sort of making Vermont not attractive to those companies. So I think reporting, and very detailed reporting, is a good start there, and then the Green Mouth Care Board can decide where it will go with the hospital budgets. But sort of like capping those companies themselves, because they're underneath the hospital is could keep companies from coming into Vermont. And, again, you'll hear from Blue Water, which is one of those organizations later. But my proposal would be, you know, very transparent reporting in this space because I understand the Green Mountain Care Board's concerns. Section nine, the appeals piece, the Green Bond Care Board under statute was required to have internal appeals process. They are taking that out with S-one 190. I do have concerns around this from the very beginning, hospital budget process has been a bit cloudy, and we actually had a hospital lose a case at the Supreme Court level because there wasn't objection during the process, and later on they went back for a similar issue, and they actually won the case on the merits once they objected. But because there's no internal appeals process, I worry about the ability to create a record. I think it would actually save us from having to go to the Supreme Court. So I don't necessarily understand why they would take that away, I would ask for an internal appeals process and greater clarity there. Hospital investigation and audits in section 10. The proposal here is that the chair of the Green Mountain Care Board can investigate and audit hospitals when reasonably necessary for a health role, and we do oppose this section. This was apparently sort of taken from the insurance laws by the agency that licensed them, and there are limitations around that in the insurance space, for instance, every three to five years, or for purposes of investigating violations or complaints, and here with S-one 190, it's very broad. Whenever reasonably necessary or helpful is a very, very broad standard. In addition, we have our own state hospital licensure through DDH. They come in to inspect our hospitals. Hospitals have to have their accounting records of all operating and complete operating and financial statements available to VDH. We have DIVA investigating Medicaid fraud and abuse. We have federal hospital oversight from the federal government, that includes the Office of the Inspector General that investigates fraud, abuse and inefficiencies. There is a lot of oversight of hospitals, and I will tell you that these instances where these agencies come into the hospitals and investigate are very disruptive. There is a disruption in terms of the flow of the hospital and the daily tasks. There is a high stress level that's involved in it, and we understand that we're highly regulated. We do all these things, but they, I just want to emphasize that they are no small incidents. It is not a small thing to come in and be investigated. And the sort of like reasonably necessary or helpful standard is really broad. I have a question that is probably both for you and the board going forward, and that is if the if this were not a part of the bill, if it were not an investment grade mill, you know, part of the board, I guess this is a board question. But the board could send a notice to American Health or Diva or others. I mean, the board actually has the ability to go in. An investigation rather than to initiate its own investigation. The board has the ability to initiate its own investigation by sending in an observer. You passed that last year in Act 49, and it's when a hospital either materially misrepresents something, or it's materially not compliant with the budget. My understanding of that is if a hospital budget is off by 1%, they are materially not compliant with their budget, which is essentially I mean, can you tell me a budget that is on by less than 1% the entire year? Like, this encompasses essentially all of our hospitals. And if they are within 1%, then they should like, you know, that's that in and of itself is a very broad standard. The other piece I would just highlight is Ag 49 of 2025 is more in line with the actual governance of the Green Map Care Board, which is that the board itself is the one that appoints the independent observer. In this bill, it's the chair of the board appointing the independent observer. You know, I know in other agencies there are commissioners, but the Green Mountain Care Board, their leadership entity is the board. And so, and I think Act 49, having the Green Mountain Care Board itself appoints makes more sense than just a chair sub one thing investigation. Section 11. We support it. We're just using that. I'm using this as a blatant opportunity to promote something that BIOS is doing, which is we have put together a system performance tool. It should be available publicly fairly soon. I wanna say in a couple weeks, but probably more likely like a month or two. But we are really excited about it. Our board's really excited about it. They think it's going to be a really helpful tool for their own boards who govern them, and we're really looking forward to introducing it to you further when it's up and running. And that's all I have. Thank you. Questions?

[Sen. Virginia "Ginny" Lyons, Chair, Senate Committee on Health and Welfare]: Yeah. Getting back to Thank you, Devin,

[Emily Brown, Green Mountain Care Board staff]: for the testimony section 10. Going back to the audits, I think some folks are happy to see that the agreement is working by the past some agents maybe Yeah.

[Sen. Virginia "Ginny" Lyons, Chair, Senate Committee on Health and Welfare]: That wanna be changed. And I'm wondering, is there do you

[Emily Brown, Green Mountain Care Board staff]: have any proposed language if you don't like reasonably necessary? Is there another phrase, or is there other language that

[Sen. Virginia "Ginny" Lyons, Chair, Senate Committee on Health and Welfare]: you can potentially propose that might be? I mean, I think the language that you had with the law that you passed last year is pretty clear. It actually has a very broad standard, and it allows the board to bring in a third party to do that work. And, yeah, fact that that is an available tool to the board plus this being available to the board and in both instances hospitals would also have to pay for them feels like a lot. And so I would say Act 45 from last year provides the sufficient tool that you need. 49. 49, sorry. 49. Thank you. Okay. Well, this is good. This is obviously, there'll be a difference of opinion probably or some nuance to this. We hear testimony from all of it.

[Owen Foster, Chair, Green Mountain Care Board]: Office is currently audited professionally annually.

[Sen. Virginia "Ginny" Lyons, Chair, Senate Committee on Health and Welfare]: Oh, yes. Yeah. They have their own audits

[Owen Foster, Chair, Green Mountain Care Board]: every year. Like professional CPA? Yes.

[Sen. Virginia "Ginny" Lyons, Chair, Senate Committee on Health and Welfare]: Thank you. Thank you. Good. And we have Elena and Emily, are you wanting? So if you test or all in, how's that gonna happen?

[Owen Foster, Chair, Green Mountain Care Board]: I can speak to the audit piece really quickly and

[Emily Brown, Green Mountain Care Board staff]: then I'll turn it, that's helpful. I'm sorry.

[Owen Foster, Chair, Green Mountain Care Board]: I can speak to the audit authority piece, and then I'll turn it to

[Sen. Virginia "Ginny" Lyons, Chair, Senate Committee on Health and Welfare]: Okay, that's fine. Yeah.

[Owen Foster, Chair, Green Mountain Care Board]: Just briefly. Thank you. My name's Omar Foster. I'm the chair of the Care Board. Just a couple quick points on the audit authority that I think are important for context. The Green Care Board already has subpoena authority. It has, to my knowledge, since the beginning of the Green Mountain Care Board, so we can subpoena and do investigations already. That's been there, as far as I know, for a decade. In the history of the CARE Board, my understanding is we've issued exactly one subpoena ever, and I issued it to the ACO about some information on their compensation. It was appealed and once we appealed. So in fifteen years, there's been one subpoena issued by the Green Mountains Bureau. Not a single subpoena to a hospital. We also have the Observer Authority that was implemented last year, we have never used, and there was a very, very clear case last year to do so, and we did not use it. My point here is we are very judicious in these authorities. We are not flying off sending sabinos around for a while. It's not appropriate to do so. So we are very, very cautious and thoughtful and mindful when we actually do exercise those authorities. The point that Ms. Green made about whether it should be the chair or the whole board, the reason why the chair board supported it being the chair is because it mirrors the subpoena authority. Subpoena authority has been there forever, solely vested in the chair. And it's solely vested the chair for good reason, which is the chair has run at the office, and it's very important for running the office to keep mindful of how we're using our limited resources. And you don't really want people who are not involved in running the office to start issuing and starting all these investigations. So that's why I believe the subpoena authority is vested solely with the chair, and why we supporting this authority being solely with the chair, just so that they're similar. Then the only other point I wanted to make on the audit was, yes, they do have CPAs that do it, but the information data we get is not the same data that's necessarily audited. We get a lot of other information that's outside of what's audited by the professionals, and that data's often not presented the same or analyzed same, or presented, know, we still see the same data. I, as the chair, do not anticipate doing a lot of audits. They take a lot of time, a lot of effort, and it'd be very similar to the subpoena authority under my leadership and the observer authority. Very, very, in my view, would only be used to truly necessary. I'm happy to answer any questions that you try

[Sen. Virginia "Ginny" Lyons, Chair, Senate Committee on Health and Welfare]: to explain with my colleagues. Questions? Okay, no, we'll listen, and then we'll still have to circle back and decide how to work with this.

[Owen Foster, Chair, Green Mountain Care Board]: And actually, case pointed out the limiters on the Audit Authority. Yeah. I think what I would recommend is the language should mirror the Spina Authority, not the Observer Authority, the same. It's purely investigation, so she can say language. I want it to be similar to what we do with scheme of 22. Thanks. All

[Sen. Virginia "Ginny" Lyons, Chair, Senate Committee on Health and Welfare]: right. Sure, together is fine, yeah. You got all the air? Okay. One of you gets the comfortable chair. Yeah. Didn't go back. I'm not very good at it. I'm all gonna happen yet. Good morning. Good morning. I think

[Emily Brown, Green Mountain Care Board staff]: it's still morning. For the record, I'm Emily Brown. Emily Beardeen. So we have submitted some written testimony this morning. Last time we were at the committee, we were asked to submit a written document outlining the suggested language as well as the reasoning right now. So you should all have that on your website. Just a few points that I wanted to raise in response to Boston's testimony. So the concern about the reference based pricing reporting, I think that's a valid concern. We wanna make sure there's consistency among how hospitals are reporting this out. You will see in the documents we submitted that there is a revised and proposed definition of, for section one of what the Medicare base is. So we're hoping that that adds clarity. We would also support language that requires the board to issue guidance to hospitals to make sure, again, that there's consistency between hospitals out there reporting out this data. For the appeals process concern, this is, so when the board, it's my understanding when the board was formed that this appeals process language was based on language that's similar to the PUC. That's what it was modeled after. So again, this is consistent with that language, and we feel that this is important. To clarify. There has never been an internal appeal. So this is clarifying existing practice of how things have worked since the inception of the board.

[Sen. Virginia "Ginny" Lyons, Chair, Senate Committee on Health and Welfare]: I guess the question that arises, because there is no internal appeal process, sounds like the hospitals would like something like that, but is there any kind of a negotiation process that goes on before an appeal to the Supreme Court? There's the board hearing process, which is extensive,

[Emily Brown, Green Mountain Care Board staff]: as I'm sure many of you know, and that is the opportunity for board members to ask questions, for hospitals to raise objections or other pieces of information which they feel are relevant to the board's decision making. So we view that process as the event where there could be the discussion, and if more facts are needed or more information, that is the time that it's entered into the record. We feel if there was an internal appeals process added, that would just add a lot of extra work to the board's already heavy workbook and then not add a lot to the process that's currently in place. Thank you. And so I know Chair Foster already addressed the audit issue, so I won't go into that. I will say that for the insurance statutes, which some of this language was full prompt, laws mentioned that it is a three to five year requirement for audits. That is because insurance companies are required to be examined every three to five years. There is no similar requirement for hospitals. So I just wanted to clarify that it's a very powerful tool. It's something that, as Chair Foster mentioned, the subpoena power has not been exercised acceptably. And I think it's understood how, you know, that that's a large responsibility, but it's also important, especially as we shift and think about compliance with our budget orders and wanting to make sure that when you put an order out there that the hospitals are actually complying.

[Sen. Virginia "Ginny" Lyons, Chair, Senate Committee on Health and Welfare]: And I think that was those were all my You've given us really extensive comments and backup information. So

[Emily Brown, Green Mountain Care Board staff]: I wanted to shift now to see if there are any other questions on my comments. I wanted to give only our time to speak towards reference based price. Can you put in some additional information into this document that wasn't brought up before? There were questions about the caps that we heard the Joint suggested, so I'll turn

[Owen Foster, Chair, Green Mountain Care Board]: it over to Brian.

[Sen. Virginia "Ginny" Lyons, Chair, Senate Committee on Health and Welfare]: Yeah, so I think, and I'll just go back to the definition for a moment as well, I think this definition is kind of a working definition, and we would expect as we continue to develop the rule that we would want to update that, and that would be the source of truth. So I think this definition that we have here is kind of our first take, and would give us at least some general consensus around what we're talking about for these first couple of sections. So I think on the consumer, the price caps are being section G, consumer price protection ceiling. We and Nathalie had proposed a cap of 500% of Medicare for any particular service. This was based on recommendations from Mike Smith.

[Brian (staff), Green Mountain Care Board]: We've been working with the network and looking into their operations. We know that some prices kind of are upwards of 700 or 800%, even 1500%, which is really, you know, you think about it's quite a bit higher than what Medicare pays. We had extensive discussions during yesterday's board meeting. We heard from Medicare payment experts and others in the field who done reference based pricing and exploring products. And they opened our eyes to some other ways of thinking about starting, so another option could be to start with service lines, it could be to start kind of in aggregate, bringing down these outliers, Some estimates that Rand put forward, or sorry, not Rand, Christopher Whaley, who used to work at Rand and Out Brown, put forward with Ross Murray, was to think about more of an aggregate approach as a year one, and they modeled some savings associated with different levels. So if you take 500 in aggregate, there's really no effect on hospital spending. If you go down to 400, there's an average effect around 92,000,000, but you have the detail, or 9,000,000, you have the details in here for those different thresholds. This is not analogous to the original proposal, which is bringing down the service level that we talked about. That would really require hospitals to kind of generate estimates for us to understand specifically how it would impact their budget. Another option that other states are exploring that was put forward was to think about establishing a cap or out of network crisis. So it's another way to kind of start, but it's different than the varieties that we are given.

[Emily Brown, Green Mountain Care Board staff]: So,

[Brian (staff), Green Mountain Care Board]: I'm happy to answer any other questions, but I think the challenge here is really having the detailed data to provide estimates of impact. That's why we're doing this contacting birth assistance to do that modeling, And we wanna make sure that we move the needle, but we don't move too quickly. And I think that is our our concern with, you know, giving you something really concrete and objective here. But I think if hospitals were able to kind of help us understand how it would impact their budget, that might be a way to see them. Well, is good to hear you say because I think in the original proposal when you asked to have a bill introduced, there was a definite number in there.

[Sen. Virginia "Ginny" Lyons, Chair, Senate Committee on Health and Welfare]: And I took it out as I said this is you can't do this right away. So now it sounds like we're on the same page. You do have the authority to put some reference based pricing reference based pricing in. You have the authority to do all of it. But there are some steps that could be taken sooner than later. My concern I think all of our concern is that we putting this off doesn't make a whole lot of sense. I I see it's good. Yeah. But on the same case, it's good. For me. Questions. This isn't the last time we'll be looking at this bill together. It sounds like there are some things we need to balance out between hospitals and board and try and get to a good place where nobody's happy and all the.

[Emily Brown, Green Mountain Care Board staff]: I just had one other comment earlier. So there were concerns raised by Vermont Medical Society on the healthcare provider marketing group I wish that we had put in there. Yes. We have a meeting set up to have a discussion with them on language that's in there, I just wanted to update

[Sen. Virginia "Ginny" Lyons, Chair, Senate Committee on Health and Welfare]: you and let you all know that we're working on that. And

[Emily Brown, Green Mountain Care Board staff]: we also have other suggested language that's on the proposed language adjustment sheet that we submitted on revision to sections eleven and twelve. And essentially what it does is it just broadens the scope of the tool that we had originally outlined. We want to make sure that we have the ability if we want to add additional topics to cover. So the proposed language, again, just expands that into topic areas instead of being very descriptive on what information we're going to put out there. So I just also wanted to draw your attention to that suggested language and answer any questions if there

[Sen. Virginia "Ginny" Lyons, Chair, Senate Committee on Health and Welfare]: are any. We'll we'll take some time to look at it. No problem. We'll we'll get to Mark up on the bill and then John will help us interpret everything she's got. Good.

[Emily Brown, Green Mountain Care Board staff]: Thank you. Thank you so much. Thank you. You, Devin.

[Sen. Virginia "Ginny" Lyons, Chair, Senate Committee on Health and Welfare]: And also thank you for the very specific comments on the bill. It's just how we can make it happen. And also for the forward conversation. Yes. Okay. But we do have two more folks to testify. Doctor. Ada Abdich. Did I say that properly?

[Dr. Ida Abdic, Chief Medical Officer, Brattleboro Memorial Hospital]: Hi, good morning. Good enough. Ida Abdich.

[Sen. Virginia "Ginny" Lyons, Chair, Senate Committee on Health and Welfare]: Oh, there you are. Okay, great. So Doctor. Abdich,

[Emily Brown, Green Mountain Care Board staff]: he's from Brattleboro Memorial Hospital. We would like to hear your comments. Thank you.

[Dr. Ida Abdic, Chief Medical Officer, Brattleboro Memorial Hospital]: Thank you, Chair Lyons and the rest of the committee. Thank you for having me here and allowing me to testify. As you've heard, I am at Battle Memorial Hospital. I am a practicing physician, hospitalist here at Valvoline Memorial Hospital for the last fourteen years and chief medical officer at Valvoline Memorial Hospital for the last year. I am here to to provide testimony with regards to S-one 190, in particular to the section relating to the hospital outsourcing of clinical care. While I think this bill is well intentioned, it will unintentionally harm rural hospitals' ability to secure adequate and high quality staff for Doctor. Adeck, could you speak closer to the microphone? Absolutely. Is this better? Thank you.

[Sen. Virginia "Ginny" Lyons, Chair, Senate Committee on Health and Welfare]: Thank As

[Dr. Ida Abdic, Chief Medical Officer, Brattleboro Memorial Hospital]: I was saying, while this bill is well intentioned, it will unintentionally harm rural hospitals' ability to secure adequate and high quality staff for critical 20 fourseven services. Community hospitals hospitals face significant challenges in recruitment and retention of adequate clinical staffing to maintain 20 fourseven essential clinical services. The workforce has changed through the COVID-nineteen pandemic, particularly in the rural areas. Aging workforce, including aging workforce in Vermont of physicians and advanced practitioners, means that hospitals and healthcare facilities are competing for limited resources at this point, and small rural hospitals tend to be less competitive and attractive to new employees. Housing costs and limited housing availability has proven a challenge even for this skilled force to enter work in Vermont. And practice pattern changes of today's clinicians who are looking to structure their practice in such ways that lead to less call time, in particularly impact rural staffing models, where inherently there's a higher need for call coverage compared to more urban or high volume areas, where 20 fourseven coverage can be spread across a larger group of clinicians. So this leads to rural health systems to seek innovative ways of staffing 20 fourseven services and reliance on several types of partnerships to fulfill this need. When we think of outsourcing, we have a lot of negative connotations. It often is associated with, you know, job loss, with loss of community ties, with loss of control or handing over responsibility. That's not how community hospitals see our partnerships. And we consider this partnerships with vital partners who provide essential services for our patients in our community, rather than outsourcing. Community hospitals need to maintain this agility and flexibility to provide adequate and high quality staffing to maintain twenty four hours, seven clinical services. I want to highlight a couple of areas that BMH has worked over the last decade and longer to maintain these partnerships in order to preserve essential services for our communities. One of those is an area of pathology. We have partnered with UVM to provide high quality pathology services that allows for more flexible, high quality 20 fourseven care. For BMH and its patient, it provides access to high quality services. And it allows us to share pathology staffing across Vermont. And additionally, it is more cost effective for us than a direct employment of at least two to three pathologists, which we can't even recruit in order to maintain 20 fourseven access to this critical service. Another area that we have partnered with a different organization is in radiology services. Again, 20 fourseven need for a community hospital. We've partnered with the HMC. And again, sharing radiology staff, sharing their resources and benefiting from their expertise and 20 fourseven availability and their quality assurance programs and quality of radiology reads. Another area where we had to seek partnership was in providing anesthesia care. In the midst of COVID-nineteen pandemic, our local independent small anesthesia group, which partnered with BMH for decades to provide perioperative anesthesia services for our patients, including 20 fourseven emergency coverage for emergency surgical patients and emergency obstetrical cases. They rapidly resolved after a death of their leader. We were left to scramble to provide adequate 20 fourseven coverage for such essential service. We were able to partner with a CRNA group to maintain this essential service for our community. These are some of the examples I'm using. The most recent one is our partnership with Blue Water. Again, in the same vein, we had a partnership with local DHMC to provide 20 fourseven ED physician and advanced practitioner coverage. They notified us that they no longer could support us, and we had to pivot and find this coverage again. It is very difficult for small rural community hospital to recruit adequate staff, enough human beings who are willing to staff twenty fourseven, three sixty five days service in a very short notice. On average, it takes a hospital nine plus months to recruit any skilled clinician. So, we were given about six to nine months notice. There was no way we could recruit everybody. And we had to turn to organizations who have agility and ready made ability to provide that staffing at quality level that we want and at a cost effective level that Vermonters and our patients deserve. I am concerned that the current language of S-one 190 bill would significantly jeopardize small community hospital ability to maintain and restore essential clinical services in these situations. As I mentioned, it takes at least nine plus months to recruit a single, individual, at this skill level, and maintaining 20 fourseven services requires more than one individual. And some of these groups are a lot better positioned to recruit, to retain, to maintain high professional standards than individual hospitals could at any given moment. The benefit of this for our community is that these people actually work in our communities. They move into our communities. They become members of our communities. They are, as professionals, part of a group of like minded individuals with the same mission, same drive, and are able to maintain their quality standards, professionalism standards, and have connections rather than being a small isolated practice or hospital employed. I am concerned that requiring additional regulatory burden, requiring reporting under the hospital budgets will drive some of these smaller groups out of Vermont, as it's going to pause additional burden in terms of reporting, in terms of financial compliance, in terms of many other aspects that will not be palatable. And these groups will leave Vermont and ultimately leave small community hospitals scrambling to pay for either locum scare, which is three times more expensive than on average than regular hires, and often comes at the expense of quality and investment community. So I will end with this. I have, provided, written testimony with some more details and happy to take questions.

[Sen. Virginia "Ginny" Lyons, Chair, Senate Committee on Health and Welfare]: Thank you. Thank you for your comments. And we are our time has gotten to be precious right now, but I do have a question for you. We will, we're gonna hear from Blue Water next, which will be helpful. But at some point it would be helpful to understand how you are working with the Act sixty eight Agency for Human Services and board and transformation, regional transformation. Don't have to do that right now, but it is a question that I have which I think will be helpful to us. Okay. Yeah, thank you. Thank you for being available and being patient. So we'll move to Jay Mullen, is President and CEO of Blue Water Health. Jay, thank you for being here.

[Dr. Jay Mullen, President and CEO, Blue Water Health; Emergency Physician at Brattleboro Memorial Hospital]: Great, thank you. Chair Lyons, Vice Chair Gulick, the members of committee, yeah, thanks for this opportunity to meet with you, at least virtually. As you noted, my name is Jay Mullen. I'm an emergency physician at Brattleboro Memorial Hospital. I'm also the president and CEO of Blue Water Health. Blue Water Health is an independent physician owned and led emergency medicine group serving hospitals across Northern New England. I also chair a national coalition called the Emergency Medicine Business Coalition, which represents 46 groups just like Blue Water across the country, where every physician has a pathway to become an owner in the group. So we're what's called a democratic group, meaning that our owners are physicians and our physicians are our owners. I'm here today in opposition to S-one 190 as currently written because recognizing that it's got good intentions, the unintended consequences would harm the very physician groups Vermont's community hospitals depend on for reliable, cost effective twenty fourseven emergency care. I'm going to summarize my written testimony and really focus on six points. The first one is independent groups are essential partners. We're not cost drivers. Independent physician groups fill critical staffing needs in emergency medicine, anesthesia, radiology, pathology, etcetera. Community hospitals choose groups like mine because we offer lower overall cost, higher flexibility, strong quality performance, and local physicians who are embedded in the communities they serve and believe in the hospitals that they work in. This is this really is not outsourcing in the corporate sense. It's local doctors caring for local patients supported by the shared expertise across our 11 different emergency departments. For many Vermont hospitals, independent groups are the most affordable and highest performing group options available. My second point is the S-one 190 undermines this model and makes recruitment significantly harder. When physicians join a group like mine, are choosing independent practice because it provides local governance, professional autonomy, predictable compensation, and probably most importantly, to take part in a mission driven community focused environment. By folding independent group revenue into hospital budgets and subjecting it to rate setting, S-one 190 removes the stability and independence that makes these groups viable. This would make Vermont far less competitive at a time when emergency physician shortages are really quite severe across the state. It also means hospitals would lose access to partners with lean administrative overhead, efficient staffing models, and better throughput and performance metrics. The long term result would be predictable. If independent groups exit, hospitals have to turn to either employing the physicians directly or depending on large national corporate staffing companies, private equity backed and the systemic costs increase. My third point is that S-one hundred ninety appears to be attempting at least in part to solve a problem that's already been solved by federal and state law. In January 2022, the federal government passed the No Surprises Act which completely completely protects emergency patients from balance billing whether they're in network or out of network. So under this federal law emergency patients cannot be balance billed. Insurers must treat all emergency care as if it was in network, even if it's out of network, and payment disputes, if there are any, occur only between the insurer and the providers. Patient is left out of that dispute. So there is no remaining gap in emergency billing protections that S-one hundred ninety needs to fill. Adding state level regulation duplicates a federal and state level framework that already works quite well. Fourth point, the bill reduces both patient choice and physician choice. If Vermont becomes inhospitable to independent practice, physicians will choose to work in neighboring states with more supportive regulatory environments. That would threaten Vermont's ability to recruit and retain the very clinicians that the community hospitals need to keep functioning. That would lead to less diversity of clinical expertise, less local involvement, less innovation, fewer staffing options. And all those are, that is all the opposite of what Vermont's rural healthcare system needs. This leads me to 5.5, which although I've been pointing out the frailties of the bill, I do agree that oversight is appropriate, but the approach as outlined in this bill is overly broad and counterproductive. Transparency and accountability are important goals, but s one ninety applies a regulatory structure designed for hospital departments and applies it to independent physician led groups that consistently already reduce costs and improve performance. We already have show this through shorter lengths of stay, fewer patients leaving without being seen, strong community integration, strong integration into the hospital leadership framework, and lower overhead than hospital employed or corporate models. These are the partners that Vermont should really be supporting, not sweeping into a regulatory framework that makes their work impossible. So point six I'd like to make is that in my opinion, there's a better approach in this area. Vermont can achieve its goals without dismantling of already functioning cost effective staffing model. More targeted solutions could include requiring disclosure of outsourced contracts, as Devin mentioned, without merging those independent group revenue into hospital budgets. Applying consistent financial assistance policies without redefining independent groups as hospital entities, recognizing that federal law already protects patients from surprise bills, and lastly, preserving hospital flexibility to choose the staffing model that best meets their local needs. Independent groups are part of the solution, not a driver of the problem. So I would urge you to consider rewriting or voting against S-one 190 as it's currently written because it would unintentionally drive physicians out of the state, reduce hospital staffing options, raise long term system costs, and shrink patient and physician choice. Independent physician led groups deliver high quality, cost effective community based care, and we should be aiming to protect those staffing models, not undermine them.

[Emily Brown, Green Mountain Care Board staff]: Thank you

[Dr. Jay Mullen, President and CEO, Blue Water Health; Emergency Physician at Brattleboro Memorial Hospital]: very much, and I welcome any questions that you might have.

[Sen. Virginia "Ginny" Lyons, Chair, Senate Committee on Health and Welfare]: Well, you for this, and you've given us six critical areas to think about. We appreciate that. And again, I think it would be helpful for us to understand the work that Brattleboro is doing with the transformation process overall, because our goal there was to ensure financial sustainability and make certain that some of the problems that hospitals are seeing don't persist. So at some point it would be good to have you folks come back in and talk about that. But thank you for today. We appreciate it very much. Thank you.

[Owen Foster, Chair, Green Mountain Care Board]: Thank you.

[Sen. Virginia "Ginny" Lyons, Chair, Senate Committee on Health and Welfare]: So we're fifteen minutes off schedule, but we're gonna do everything we have to do. We're going to hear first from Shannon McGuire of Howard Center, and then we'll move on to the s one sixty three. Wanted to talk with OPR briefly about that. Yes. Have. Welcome. Thank you for having me. It's good to see you.

[Emily Brown, Green Mountain Care Board staff]: It's good to see you all.

[Sen. Virginia "Ginny" Lyons, Chair, Senate Committee on Health and Welfare]: Thank you for all you do. I sit here and listen to these conversations in advance, and I'm just mindful of all the information you come to do all day long together. So, appreciate the opportunity to be here. Chair Lyons and members of the committee, thank you for the opportunity to be here and especially for the attention on Mental Health Advocacy Day. All sorts of good conversations happening in the building and next door, and a lot of appreciation for the folks that do the work in this house every day.

[Sandy McGuire, CEO, Howard Center]: So I extend that on behalf of lots of my friends and colleagues next door and in this building. For the record, I'm Sandy McGuire. I'm CEO of the Howard Center, and I want to begin with a story that was shared with me just a couple of days ago. A parent reached out to reflect on several years when their child was experiencing a prolonged mental health crisis. During that time, the family interacted with hospitals, emergency departments, shelters, law enforcement, state agencies, and with the Howard Center. Those years were exhausting and frightening for the family, but today, the young person has been stable for more than three years. They're doing really well and they've got strong supports in place. As the parent reached out, they also wanted to update or describe their role during that time, and they used an old Roman word, benefactor, not just in the sense of financial help, but as someone who could advocate, persist, push systems to communicate, and stay engaged when things became overwhelming. They also acknowledged something important. Most people who come through our doors do not have that kind of advocate. They don't have family with time, resources, or influence to navigate multiple multiple systems at once, and that difference between having an advocate and being alone is often the difference between stability and crisis. Howard Center is a designated community mental health and developmental disability agency for Chittenden County and a preferred provider for substance services. Along with our peer designated agencies and specialized service agencies across Vermont, we operate as part of a coordinated statewide network for Vermont Care Partners, ensuring that in every region of the state there is a provider responsible for delivering essential community based services. Designated agencies deliver Medicaid entitlement services required under Vermont's state plan, and we also provide additional mandated safety net services that our communities rely on every day. We are not simply one provider among many. We are part of Vermont's public mental health, substance use, and developmental services infrastructure. We're required to serve individuals regardless of complexity, acuity, risk, or ability to pay. When systems are strained, when needs are severe, and when options are limited, designated agencies do not get to opt out. We work in close partnership with hospitals, schools, law enforcement, shelters, housing providers, and community organizations, and that coordination is not incidental. It is absolutely core to the model and core to our success. At the Howard Center, that responsibility translates into real scale. Each year, we serve more than 19,000 Vermonters across the lifespan, children, adults, families, and older adults. We provide services twenty four hours a day, seven days a week, three sixty five days a year because crisis is an essential services don't follow traditional business hours as we all know. With more than 1,300 employees, the Howard Center is the fourth largest healthcare employer in Vermont. Our staff work across outpatient care, crisis response, residential services, and community supports, often behind the scenes but essential to the functioning of our healthcare and public safety systems. Our services include outpatient mental health, substance use treatment, emergency and crisis response, school based and family supports, developmental disability services, and community based housing and support programs. What ties all of this together is continuity. People rarely experience challenges in neat categories. Needs change, crises emerge, recovery and stability takes time. Our role is to stay with these people as their needs evolve in whatever capacity and to do so in the community whenever possible. Over the past several years, the work has become more urgent and more complex. We're seeing higher acuity across the board and particularly among children and youth. We're seeing increased co occurring mental health and substance use needs and more people whose challenges are intertwined with housing instability, medical issues, and involvement with emergency systems. As Vermont's population ages, we are increasingly supporting older adults experiencing depression, anxiety, cognitive decline, and mental health impacts of isolation, loss, and medical complexity. These needs often intersect with housing, caregiving, and healthcare systems requiring coordination in that community based response. At the same time, workforce shortages and financial constraints make it increasingly difficult to meet demand at the level people deserve, And despite this, our staff continue to show up. Clinicians, crisis workers, case managers, residential staff, direct support professionals doing work that is emotionally demanding, often under recognized, and absolutely essential. Much of what designated agencies do is the hardest work in the system. We provide services that are high risk, labor intensive, and available around the clock. We serve people in crisis, people with the most complex needs, and people who have often been turned away elsewhere and have nowhere else to go. This work is among the most difficult and the least financially supported in our health care system, but communities cannot function without it. It is precisely this work that keeps people out of emergency departments, reduces involvement with law enforcement, stabilizes family, and supports community safety. Howard Center has served this community for over one hundred and sixty years, and that history is not about preserving the past or standing still, it's a constant evolution. Across generations, we've adapted to new clinical knowledge, new community needs, changing expectations, and increasingly tight fiscal environments. Today, like many providers in the state itself, we're facing difficult choices. Resources are finite, needs are growing, and trade offs are real. We've had to make difficult decisions. In some areas, that means reducing or ending programs that are no longer sustainable, while at the same time, we continue to evolve to meet emerging needs, partnering and leading new initiatives such as the mental health urgent care, a recovery shelter, and a new specialized program for military members and veterans. These efforts reflect our commitment to adapt even in constrained environments in service of community needs. Our responsibility is to steward the resources entrusted to us in service of our mission, making careful, often difficult decisions so that within the resources that are available, we achieve the absolute greatest impact for the communities that we serve. Mental Health Advocacy Day matters because the decisions made in this room and in this house are not abstressed. They shake whether Vermonters receive help early or only once they reach crisis. They determine whether families must act as full time system navigators or whether care is accessible and coordinated. They determine whether designated agencies can continue to meet our mandated responsibilities safely, sustainably, and effectively. Mental health, substance use disorder treatment, and developmental services are not separate from healthcare. They are foundational to it. As your work continues in this session, we respectfully ask that you support stable and adequate funding for community mental health, substance use disorder, and developmental disability services, so access does not depend on crisis status or geography. Invest in the workforce through recruitment, retention, and competitive compensation. Strengthen prevention and early intervention, especially for our children and families, and older adults, and continue building alternatives to emergency departments for mental health crises. These investments do more than improve individual outcomes. They strengthen families, reduce strain on other systems, and support healthier communities across Vermont. I want to close by returning to that parent who reached out to me. They expressed deep gratitude for the people who showed up during their families' hardest years, often quietly, often behind the scenes, and often under extraordinary pressure. That is the work of designated and specialized services agencies. It's complex, it's challenging, and it's essential. We are proud to do this work on behalf of Vermont, and we're grateful for your partnership in ensuring that when people reach out for help, there is a system that is ready to move them. I appreciate your time. I know it's tight having to answer. It is tight, but this is really important. We haven't had an opportunity to talk about our community based services. And today is Mental Health Advocacy Day, and I know that Teri Kelly will be talking to us a little bit later. But I thank you for that summary, and thank you for the work in particular on the mental health clinic that now has reduced the pressure on the emergency room in Burlington, which is just outstanding. We thank you for your work, Symbi. Thanks, Senator, and I think Mental Health Urgent Care is a great example of what we do with our partners and how we take the limited resources and stretch them that much further. When we bring together the hospital, the designated agency, our FQHC, and our peer agencies, we all bring what we do best, incredible things can happen and make a real impact.

[Sen. Virginia "Ginny" Lyons, Chair, Senate Committee on Health and Welfare]: And we didn't have to do it. This is the best part for me. It just happened organically. Thank you. Are going to move on to S163 and we ask OPR to come in and talk a little bit about the APR and bills revised. Oh well, you both want to come up or have you worked on?

[Emily Brown, Green Mountain Care Board staff]: Well, actually, Lauren Lauren's

[Sen. Virginia "Ginny" Lyons, Chair, Senate Committee on Health and Welfare]: with us. They're with you. Oh, good. Okay. Scrub on my shoulder. Alright. She's still mourning. Good morning. Going ahead.

[Lauren Hibbert, Deputy Secretary of State (Vermont)]: Good morning. For the record, my name is Lauren Hibbert. I'm the deputy secretary of state for Vermont. And I have with me

[Chan Cullen, Director, Office of Professional Regulation (OPR)]: Chan Cullen. I'm the director of

[Sen. Virginia "Ginny" Lyons, Chair, Senate Committee on Health and Welfare]: the Office of Professional Regulations. Collaborate. Gay to be regulars. Yes, every day.

[Lauren Hibbert, Deputy Secretary of State (Vermont)]: We feel honored to be here every day. And on every issue that you have. But we don't have additional testimony. What we understood is that there were additional questions that you folks would like answered about APRN scope of practice, how it intersects with hospital certification, and why we are asking you to remove the consulting with the physician language from this bill. So I'm happy to answer that question. Is that the core question that this committee Yep,

[Sen. Virginia "Ginny" Lyons, Chair, Senate Committee on Health and Welfare]: let's do that.

[Lauren Hibbert, Deputy Secretary of State (Vermont)]: Okay. So, you know, APRNs have independent practice, as you've heard, we're one of 27 states that do after you're fully credentialed as an APRN. This is really important for the fabric of Vermont's healthcare that APRNs have this independence. They work in many situations, many places, and frequently in locations where physicians both allopathic and osteopathic work. It's important that in all healthcare professions, it doesn't matter whether you're a physician and you're board certified, whether you're an APRN and you have a specialty in, since it's Mental Health Awareness Day, your psych APRN and you're a prescriber, or you are an LPN. All healthcare providers do need to collaborate. It's very rare that one provider is the sole provider for a human. Humans are complex and care, especially in facilities like hospitals, lasts multitudes of days. If there's a complex condition, healthcare providers need to consult with their peers to get additional perspectives. I'm saying something you all know. So all healthcare providers should collaborate with others. That being said, some hospitals have certifications that put additional restrictions around providers. Not all hospitals have the same certification structure, and the way that they're providing oversight to all of their providers within their facility. Again, I'm not an expert in hospital certification. We're here because we are somewhat experts in APRN scope of practice. And APRN scope of practice is really determined, just like every other healthcare provider in the world, by what you've been trained to do. Sometimes it's because you have additional certifications, like a national certification as an APRN in psychiatry, you're a psych APRN, or you are a physician like my sister, and she's a critical care pulmonologist. She would be the first to tell you, she, that's her job. That she would never do other areas of medicine. So, you are, you receive your core training, you receive additional training, and then you are really constrained, for the lack of a better word, by what you know, with your current training. And that's true for every healthcare professional. And that is what we're looking to preserve is that APRNs know what their scope of practice is, just like other healthcare providers do. APRNs know what the boundaries of their knowledge is, and APRNs know when to seek help. And we are just not asking that this bill doesn't have this restrictive language in it, because it will be seen not only by the APRNs in the state, but by APRNs in the nation as a step backwards. And we know that APRNs come to Vermont in part because they're able to practice at the highest scope of their license.

[Sen. Virginia "Ginny" Lyons, Chair, Senate Committee on Health and Welfare]: Okay, thank you for that. I do have two questions. Can APRNs practice independently, open their own practice, given their scope?

[Lauren Hibbert, Deputy Secretary of State (Vermont)]: Yes, And

[Sen. Virginia "Ginny" Lyons, Chair, Senate Committee on Health and Welfare]: we have those in our state.

[Lauren Hibbert, Deputy Secretary of State (Vermont)]: We do.

[Sen. Virginia "Ginny" Lyons, Chair, Senate Committee on Health and Welfare]: Would a hospital become staffed only by APRNs?

[Lauren Hibbert, Deputy Secretary of State (Vermont)]: I don't believe that there's anything that would prohibit that, Madam Chair. I don't think that a hospital would do that because they're, I mean, honestly, APRN scope of practice, as broad and large as it is, don't, APRNs can't perform heart surgery. There's so many things that are outside of the scope and training of APRNs, core functions that need to occur in a hospital.

[Sen. Virginia "Ginny" Lyons, Chair, Senate Committee on Health and Welfare]: So then the other thing that we heard from our APRNs the other day, and we just heard from you, was that they should collaborate, they need to collaborate. Is it required that they collaborate?

[Lauren Hibbert, Deputy Secretary of State (Vermont)]: No. That's what we're asking that you remove, the requirement. They should. And we have we have prosecuted a dentist for failing to to collaborate when he should have. We've we've prosecuted an APRN for failing to collaborate when she should have. It goes across all of our healthcare professionals, people get themselves, we call that the failure to phone a friend case. You know, if you are outside of your scope of practice, your knowledge base, it is your job to seek collaboration and help from others. That doesn't need to be mandated. That's really commonly understood. And the way that this bill is written, it's not just that you would have to collaborate if you were at the outside edge of your knowledge and scope, it would be every time. And that's the piece that is objectionable. It's objectionable because it's mandating for every interaction as opposed to when you need it. And the when you need it doesn't need to be written in the law. It's happening all across the state all the time in every direction. And I would imagine just like APRNs consult with physicians, physicians consult with APRNs. And I have seen as a patient before, a physician consult with an RN about my care. So that happens in all directions. Think the interplay and the roles in healthcare are so important. And this is a community that really knows how to figure that out. And that's why I don't think it needs to be restricted in

[Sen. Virginia "Ginny" Lyons, Chair, Senate Committee on Health and Welfare]: the statute. I have one last question and that is you indicated that some hospitals have restrictions on practice. So as part of the hospital's mission and their perspective, will the next step be that you'll challenge those hospital restrictions?

[Lauren Hibbert, Deputy Secretary of State (Vermont)]: I don't think so, Madam Chair. I think that's, you know, what employers choose to do in their facility and who decides to work in a facility is those are marketplace decisions that I don't think OPR would get involved in. I really don't think so. It may be that hospitals themselves want to shift those things, and employers might want to shift those things. But I don't think OPR would be involved in that. It's just that if we see that without The reason why we're here is just this is a universal restriction, not one by one hospital, as opposed to, you know, and APRNs shouldn't be constrained, their scope should be constrained based on where they choose the setting. They can it can be based on which employer they have. That's a different thing than having it restricted by the state.

[Sen. Virginia "Ginny" Lyons, Chair, Senate Committee on Health and Welfare]: Okay. Thank you for that. And then, is the Board of Nursing looking at, the Board of Nursing obviously is interested in this particular bill. Will the Board also be considering hospital restrictions within the bylaws, hospital bylaws.

[Lauren Hibbert, Deputy Secretary of State (Vermont)]: That's so far outside of the scope of the Board of Nursing. The scope of the Board of Nursing is really just this. Shouldn't have used the scope. The jurisdiction of the Board of Nursing is really related to the scope and practice of nurses in the state, regardless of setting in primary care, walk in clinics all the way up to hospitals.

[Sen. Virginia "Ginny" Lyons, Chair, Senate Committee on Health and Welfare]: Not that

[Lauren Hibbert, Deputy Secretary of State (Vermont)]: primary care is less than a hospital care. Didn't mean to imply that.

[Sen. Virginia "Ginny" Lyons, Chair, Senate Committee on Health and Welfare]: We get it. Yes. So all the questions that I'm asking are things that have popped up, you know, like hallway conversation. So I think it's important to clarify what is in the bill and what's not in the bill, what's happening and what's not happening. Oh, this is very helpful. Appreciate your taking the time. Anytime. Other questions can be. And you know what? Every bill is more complicated than the people. Every 100. So

[Lauren Hibbert, Deputy Secretary of State (Vermont)]: That's what makes it so interesting, madam chair.

[Sen. Virginia "Ginny" Lyons, Chair, Senate Committee on Health and Welfare]: Yeah. It makes it fun. It's it's nice.

[Lauren Hibbert, Deputy Secretary of State (Vermont)]: I think it's really fun.

[Sen. Virginia "Ginny" Lyons, Chair, Senate Committee on Health and Welfare]: Oh, we're good. We're gonna we'll we'll pick up one sixty three another day. We do wanna get into a markup markup on the bill and look at it more closely. But we appreciate your being available to us in the way that you are. Anytime. We'll see you I know you will. Yeah. Right? Yep. Okay. No. We're early. I think Terry Kelly. Terry Kelly here?