Vermont Legislature SmartTranscripts:

[Sen. Virginia "Ginny" Lyons (Chair)]: We start. All right, we're back. This is Senate Health's Home Fair. It's still February 18, and now we're moving on to S197, our primary care payment reform bill or alternative payment. I don't know what we'll call it but it's primary care. It's a critical bill I think for us to move forward on healthcare. And just FYI for the committee, we're gonna be spending quite a bit of time getting some good testimony beginning with Doctor. Elliot Fisher. We're gonna spend some time on the bill and markup with our Legion Council. Thank you for coming in and welcome. So why don't you introduce yourself for the record and Sure. Love to hear your testimony.

[Elliott S. Fisher, MD (Dartmouth professor; former VA primary care physician)]: Thank you so much. I'm Elliot Fisher. I'm a professor at Dartmouth. I'm a former primary care physician at the VA Hospital for twenty years. And I learned so much from them. So first, thank you for inviting me to be here. It is actually an amazing experience to get to drive here as we move on. I see it at the moment. It's a wonderful place to go. And the

[Sen. Virginia "Ginny" Lyons (Chair)]: you know, I think, you

[Elliott S. Fisher, MD (Dartmouth professor; former VA primary care physician)]: know, the luck that I have is that I have to drive here. I have a car accident. I knew my patients didn't. Yeah. I have great nursing care. Actually, in my Zulu, but I can get in some sort I've got

[Sen. Virginia "Ginny" Lyons (Chair)]: this fan favorite going on back here.

[Elliott S. Fisher, MD (Dartmouth professor; former VA primary care physician)]: That would be very helpful. Just shy

[Sen. Virginia "Ginny" Lyons (Chair)]: Anyway, they're not yelling anymore. I had

[Chuck Barnett (Joint Fiscal Office)]: a little bit battery in

[Elliott S. Fisher, MD (Dartmouth professor; former VA primary care physician)]: my hearing aids just a second ago. We're on the same page. So it's it really is a treat to be here. The drive was beautiful. I feel very lucky to have a car to get up here. I have children who have health care and have a house over their head, and we have so many remotters now who've suffered more. I think that doing something about primary care could be really powerful. That's a way of helping everyone to feel that they're part of this wonderful place that we live in. The piece of it is they probably they they have just as good access as everybody else, which I think is sad. Maybe this work. Meetings being live streaming. Okay. I'm glad it would be too. Why is this not? Maybe it's different cheating. Now it's not advanced. Okay. Alright. Here we go. Now we're good. So imagine, you know, you get advice about a health concern at any time of day, you know, for someone from someone that knows you, knows what that bladder?

[Sen. Virginia "Ginny" Lyons (Chair)]: It's okay. I'm just wrapping my head first. Hey. I used to be an attorney.

[Elliott S. Fisher, MD (Dartmouth professor; former VA primary care physician)]: From someone who knows you, and they could help you with most of their problem of your problems, and they can coordinate your care in what's an increasingly wild world of healthcare. Those were the four Cs of primary care invented by Barbara Sarkin many years before. Perhaps she published this book or probably didn't, but I don't know if we can see it with her. So but the current path is not great. We've heard from several people who testified that we are in real trouble. We all know from our colleagues and friends that access is getting worse. You know, as are the capabilities of primary care practice to coordinate care, help you find the right specialist, and then help you decide what how to manage the specialist's standards. Burnout of the moral injury are pervasive, but probably even more so in primary care than elsewhere, because it's so hard to do that work. And consequently, the primary care workforce is declining. You've seen the graphs that Doctor. Earlier in the testimony. He also pointed to a really important observation that, you know, better models are emerging in the private sector. They're pretty nifty. You know, the notion of direct primary care, having access to someone twenty four hours a day, or a function of these calls, are very promising ideas that we should be thinking about and learning about. They're wonderful for clinicians. We know the docs who work in them are less burned out. They're having fun. It's like reinvigorating again. And the patients with the means to sign up really one that can treat it within those programs. Unfortunately, I'm not paid for those. I'm usually out of pocket. I mean, their insurance continues. And as a consequence, they're undermining access and care for everyone else. And I think it's one of the sort of headlights that, you know, the tunnel that we're in, the train coming at us could be the complete, you know, the further collapse of primary care, direct primary care, the constituents, and really people pull people out of primary care practice, then they don't want to go back to. So we're we're facing we face some challenges. Know, is the most recent report from the Millman Fund. No one can see that. Please interrupt me to special when we do guys, you should all feel free to dwell if you have questions. So there is a better path. It was recommended a few years ago by the National Academy of Medicine. And if you have the following principles, make primary care available to everybody, pay more because it's underfunded right now, and pay differently in ways that can really provide flexibility to the practice, security about cash flow, and the flexibility to hire the kind of people who your practice really needs. You can't bill for those. Funding the gold codes and proof of service. So we move through different payment models. Support team based care, you know, advance the primary care. Expand the workforce, and take advantage of digital tools and technology, especially when you get that flexibility in the payment model that enables you not to to do things that set up a website or whatever that you wouldn't otherwise be able to build for. And then the narcotics I put in the National Academy of Medicine called support that I think we're not thinking enough about, put in place a plan for. That's what ninety seven had. Go ahead on the next slide, probably. Oh, let me just pause for a second. Where's Vermont now? I think we we are clearly motivated to act by what's really a broader crisis. It's not just the crisis of primary care. As we look at what happens when the extinguishes shrink or the Medicaid cuts coverage, people, the healthy people, pull out into the insurance markets, leaving sicker paid patients in those markets, costs go up, and starts, insurance deaths fail. But I think where, you know, I've talked to people in chambers and elsewhere, you know, they're seeing in their communities an economic death spiral. You know, people are, young people are speaking with their feet, talking with their feet, and moving out of state. Businesses are hesitant to live here, given the tax burden we face and the cost of health. Yeah. I got back into this last year. As I told you last year, what? We're the most expensive pulse in the country on my watch. How did that happen? I wasn't paying attention. I'm so embarrassed. I think the current bill has lots of those key elements, and government, really, the market I should say that one thing. I'm sorry. Didn't even solve it. Government has set the table for us to reverse this in the I think there are a number of ways that we should see. We have many of the tools we need. We have strong state agencies that are in position and service models. You know, what has been created here in terms of an operational infrastructure for care transformation, the blueprint with SASH and what's going on now in terms of possible regionalization positions us for really being able to do much, much better, you know, because there are there are good reasons to think that we could achieve savings. I'll come back to that in a second. But we also heard, thanks to your legislation last year, we had an even stronger Green Mountain Care Board, which made me qualified opinion in neck. I totally get it. It's hard. My friends who run the hospital, Mrs. Hartwell. Doctor. Fisher, Doctor Fisher, you're nuts. What did you do? I'm sorry. They blamed you, so they didn't blame you.

[Sen. Virginia "Ginny" Lyons (Chair)]: That's okay. We're ready to do it. So

[Elliott S. Fisher, MD (Dartmouth professor; former VA primary care physician)]: we have powerful regulatory authority, which I think will give us a tool here to make this possible. New investments from federal government, which surprised us all, the Rural Health Transformation Fund, but these are both time limited, and they don't apply everywhere in the state. You know, our most populous community doesn't get to have that investment take place there. But I think the most exciting thing to me, and that's why I have that copy at the that says an optimist and policy nerd, I sense an openness and meaningful change in places that could not have perceived a year ago. It's just that the prosecution leader, I talked to legal and hospital leadership in hospitals. I'm you know, if we act wisely, I think we could reverse a current period that's virulent through the virtuous cycle. So here's the slide I want you to ask questions on if I'm confusing. Because this has become, for me, anchor, I like to think about the opportunity we have in Vermont. That's not a short term opportunity, but we worked with colleagues at MRT who developed a very fancy computer model on Vermont, the same kinds of models that are used for climate change to test policy interventions or policy steps that could be taken and see what would happen, understand better what would happen over twenty five years. But the model also gives outputs, and we can think about them in more short term periods. It it allows we scaled down The United States to a place called Anytown, USA. It's just The United States. We've also at Ripple Foundation where I live where I work. We have models that we customize in different states. But there are a few elements of the model I'm gonna be walking through that are why it's it's worth holding this in mind as we think about designing and implementation. First thing the model suggests that you do for, you know, those who play with it is really make two investments, early investments, with a small innovation fund. One is improving chair delivery. Second is something that's free. You guys have to do it. It's payment reform. And then you try to do some of the public health things that help people become healthier, Encourage people to stop smoking, support smoking cessation, to be an example. Maybe tax them or sweetened beverages, those maybe other kinds of proven public health initiatives that do lead to that those arrows that go off to all of our rights, I assume, which is to improve health, and they reduce utilization from the best evidence. This is all based on ethics, literature needs of all greater. So what can you do if you do that? You can capture and share and reinvest some of these savings. That's a key step in the model that turbocharges everything that allows you to bring money into an innovation fund. And then because doing these things initially is kind of expensive, you can't afford to do all the care delivery improvement right away because you actually, even with the innovation fund that we gave these folks in the model, which is 1% per capita, you can't even see if you're only 27% of what happens, that you would want it to be to strengthen primary care. So the innovation fund can reinvest and make sure that you can implement all of these things that we know work to improve care and improve health and create that virtuous cycle. So you can imagine it going around improving health, reducing utilization, capturing insurance more, and improving care delivery, payment reform further, all the public health stuff that we paid for. And then, as, you know, and the model is very clear, that you have to delay some of this work, but the thing that really improves life expectancy over the long term, you know, it's almost trite in policy literature, pay attention to the social determinants of health. Those are expensive interventions, you know, adult education, childhood education, oh, provide, girls childcare, come back to You know, but then you can afford to invest in the things that are gonna make it for mom's life over twenty five years, of course. And what the model predicts, and this is my favorite, this is just, to me, surprising, but a twenty percent reduction over that time period in prevalence of chronic disease will have lower healthcare costs on a per capita basis. If there's less cost, it will be taking out some of the low waste stuff in the healthcare system. That third number is by far the largest number in terms of billions of dollars. That's a 10% increase in state GDP, or in community GDP. And the fraction of the population in support declines dramatically because people are healthy enough to work, and healthy enough later in life not to develop disabilities that cause dementia. It reduces nursing home costs. Sort of seeing ourself trying to build that kind of a system of self sustaining investments could be financially affordable if we speak thoughtfully about how we implement the economy. So I think the three major choices that you guys face, do nothing. That's the current path. I think that's neither wise or correct. I'm not I won't worry about it. Do you want any questions about this?

[Sen. Virginia "Ginny" Lyons (Chair)]: Let's ask questions about this while we're Makes sense. Code. We do that? So I'm reading the fine print down below where payers are investing 50% of their savings into the innovation fund and a five year grant established at 1% of local healthcare spending. So can you talk a little bit about the mechanics of how all of that happened and how you brought, how you, Yu, brought the payers together to do Well, this is,

[Elliott S. Fisher, MD (Dartmouth professor; former VA primary care physician)]: you know, what's Elliot smoking? Is what we have to figure out together. Yeah. So

[Sen. Virginia "Ginny" Lyons (Chair)]: This has not happened anywhere at this point.

[Elliott S. Fisher, MD (Dartmouth professor; former VA primary care physician)]: No, well, you look at the ACOs, where they've worked well, half of the savings go back to the organization for reimbursement, and half of them go to the payers. We could negotiate a different split for that, and some of it goes through an innovation fund that supports the stuff, or if you reduce total cost of care, as many of those programs do, then you can afford to invest more from the general fund because health care is not as attractive as you projected it to be. Does that help a little bit? Yes, or if RHT were eligible for the entire state, not just a portion of it, it could begin a process then. RHTP is so important as an investment, Talk to Craig Jones or talk to others about infrastructure we have and what that gives us. You still have to figure out how to make sure the whole state gets those benefits. That's our state.

[Sen. Virginia "Ginny" Lyons (Chair)]: We can't leave out 20% of the population. No,

[Elliott S. Fisher, MD (Dartmouth professor; former VA primary care physician)]: we need to this is about this is about how we decide to create an innovation fund, how big it is to start with, and blah, blah, blah. This is

[Katie McLinn (Office of Legislative Counsel)]: So simple as you look

[Sen. Virginia "Ginny" Lyons (Chair)]: at the innovation fund, are you including public and private payers, commercial payers, as well as Well,

[Elliott S. Fisher, MD (Dartmouth professor; former VA primary care physician)]: I would put quotation marks around the innovation fund. It's that if you would think of the savings we get and where they sit, and if they're in government, we try to think about, well, if we just take them and put them somewhere else and pull away all the things we're investing in that are starting to create this virtuous cycle and improve care and lower cost and improve the salary, well then we're not going to get savings in the future. So this is about the discipline of reinvestment in things that are really going to make a difference. Is that

[Sen. Virginia "Ginny" Lyons (Chair)]: Is that helpful? Yeah.

[Elliott S. Fisher, MD (Dartmouth professor; former VA primary care physician)]: No, I triggered a thought in my hip. Great. Other questions? And the 1% innovation fund is just, you know, we were trying to get people to play a simulation, and that you don't have all the money in the world forever. You have less than you can

[Sen. Virginia "Ginny" Lyons (Chair)]: Yeah, make it I mean, another huge question at rest here is, we're all very impatient. We've been waiting for years to see a reduction in healthcare costs and we did some of that last year with the bill and that's gonna continue with a decline in rate increase. Then I'm seeing what will happen by the end of twenty five years here. So the concern becomes how long does it take to actualize this model, evaluate how do we know it works, and how do we pull people together in a short

[Elliott S. Fisher, MD (Dartmouth professor; former VA primary care physician)]: time? I was teaching the model last night to a group of mid career health care leaders at Dartmouth with us. You know? And what you see when you play with the model, and I think one of your colleagues last year, when he was in the house, you know, that came to the model and they could play with it. But you start to see savings very quickly. You invest in health and changing people's health behavior.

[Sen. Virginia "Ginny" Lyons (Chair)]: Well, guess what I was talking about is how quickly can we put the model in place. That's one thing. Once it's in place, we're gonna see savings. Let's figure Keep out the first thing going, but

[Elliott S. Fisher, MD (Dartmouth professor; former VA primary care physician)]: Yeah, no, great job, our minds, they help me think about what we could do this year that gets us on this channel. Yeah. It's fine. You know, as we all But we all it wasn't good enough. So option one is do nothing. I don't think we should do that. I think it's just, you know, I mentioned the concerns about direct primary care, but people are really suffering now. I think whether it's the primary care practices themselves or the patients who are just go home from a hospital, see a service. Option two, we can increase investment in primary care in the current payment models. We designed a model for rural advanced primary care. Advanced primary care is a really spiffy way of thinking about delivering care through the teams, technology. It's very powerful. I think committing now, and I say we must do this, I think for two reasons. One is committing. We don't have to deal with it. Greg Jones says, no big deal. Actually, he probably wouldn't say that to you because he wants to leave you out there. But we know how to do advanced primary care, not just in rural areas, but all over. The committee now would make many think again about their other departments. I think primary care physicians might be less willing to jump to the deep and seek, because they may not direct primary care or concierge, because they may not know what the future holds for it, and knowing that they have hope that their current practice might really achieve some of the dynamics of decision making in the short term. And I think the third option is try to innovate. And you've got this idea in your ability to support people from Massachusetts, and then Right. Recover everything. It it gets almost all of the national government principles. It takes advanced care. If you couldn't make the advanced care of it, primary care of everyone, then it might be great. And I'm really nervous. And everyone I talk many people I talk to about the nuclear advocates are nervous and helpless. So they're financial, technical, and political. But I'm what I've tried to do in the next few slides is say, well, how might we overcome the risk? And so I'll walk you through some one at a time, and you can ask questions. So I think one of the big barriers, and it's it's one of the things that I've been the most strong about, is that we're disparaging people who actually know how to improve care or how to improve anything in ways that for health care support providers but hold them accountable and a piece of the total cost of care. Lack of knowledge about improvement is that there's sort of confusion in the world of improvement. If we think exhortation works, let's just tell the primary care doctors to do a better job, hospitals should be safer. And so what we do is we create dashboards that have red, green, blue on them. Red is you're not doing a good job. Orange is you're sort of okay, we need you to do well. And those are fundamentally for the purposes of the.

[Sen. Virginia "Ginny" Lyons (Chair)]: You're not

[Elliott S. Fisher, MD (Dartmouth professor; former VA primary care physician)]: doing good enough job, You're red on these three. I'm on board of an organization that has read Greek. So but if you look at what's been done in the people who do leave, really, do we in the way it's supposed to be done, or Peter Provost's work at University Hospitals in Cleveland, what you see is a totally different way of doing this. You know? It's about building systems of improvement and accountability that work, that people know they're being held accountable, but they're being supported to do better. You know, this wonderful line, they're not a manager unless you have a run chart. And you're we support you in learning how to use it. And so he has an accountability system that has all these wonderful thinkers, and he was ready to testify today, but he couldn't do it that So time you guys

[Sen. Virginia "Ginny" Lyons (Chair)]: I hope Well, you'll bring he's on my list.

[Elliott S. Fisher, MD (Dartmouth professor; former VA primary care physician)]: I hope you'll bring him back.

[Sen. Virginia "Ginny" Lyons (Chair)]: He's on my list. He's,

[Elliott S. Fisher, MD (Dartmouth professor; former VA primary care physician)]: so, and we have, we are well positioned with VPQ. We have people trained at the Institute for Health Improvement who really know how to do this, but we have created improvement in Vermont as a hobby. I'm sorry. The blueprint set it up. We think we should be doing improvement. And what you get to improve is the choice of the practice. We think we want to do this to improve. And there's no accountability for you to do. There's we gave you the money to do improvement work, but what did you do? Building it into a system where you can compare yourself to others, can track improvement on the things that really matter, keeping people healthy and out of the hospital, that will change. It's a totally different way of doing quality work. It's more fun, and it's more effective. Any questions about that?

[Sen. Virginia "Ginny" Lyons (Chair)]: We do have section in the bill related to quality improvement, so critical. Thought that

[Elliott S. Fisher, MD (Dartmouth professor; former VA primary care physician)]: was wonderful to see, And the data that's necessary will make it happen. I hear sneakers behind you, and he said, It's a joke. No. I'm I'm I'm I'm so old that I have to have fun.

[Sen. Virginia "Ginny" Lyons (Chair)]: Excuse me. We're running a little bit late, so I may come back in ten minutes. Is that gonna let you ruin your schedule?

[Chuck Barnett (Joint Fiscal Office)]: Absolutely not. I'll be back in ten minutes.

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

[Elliott S. Fisher, MD (Dartmouth professor; former VA primary care physician)]: For five.

[Sen. Virginia "Ginny" Lyons (Chair)]: No. You're fine. You've got more time. No worries.

[Elliott S. Fisher, MD (Dartmouth professor; former VA primary care physician)]: So the other thing, talk to people in Vermont right now. I think the other symptom is panic. That bill that you guys put on. How can we do all this at once with so much else on our plates?

[Sen. Virginia "Ginny" Lyons (Chair)]: Well, didn't we think that last year about what Bill McGrath?

[Elliott S. Fisher, MD (Dartmouth professor; former VA primary care physician)]: We are still getting it, yes. So, and we want to reassure them. But I'd argue for committing now to the long term goal, make essential new investments, but establishing a realistic timeline and plan for the other elements that we need to do to put in place the system that feeds the long term. I think a big one in some of my conversations is uncertainty about the outcomes of alternative policy, are just possible harms for whoever it is, for the practitioners, the people who are buying practice, is there gonna be enough money in this thing for me? That's in California. That was a huge problem with their attempt to move to this when they figured out that, no, capitation rate's not gonna cover my costs. I'm not in. I'm gonna oppose this.

[Chuck Barnett (Joint Fiscal Office)]: And

[Elliott S. Fisher, MD (Dartmouth professor; former VA primary care physician)]: many, of course, worried that there weren't actually savings. There is a path out of that. The Congressional Budget Office scores bills, and one of my colleagues in charge of the CBO's scoring for health care bills in Congress for a couple of years. They and others, and good actuaries, can develop a model that will allow you to evaluate the impact of alternative policy provocations and when you put those in place. And, you know, my my birth and my childhood in health policy was with the accountable care organizations. Lived in the state. Lived in Vermont. Was having a case in them. But it was the model that allowed us to have that show up, the bill show up, the language show up in the Affordable Care Act if we would have made ACOs happen because we had a CDO score. That's saving money. Momentum's in every bill thereafter. Bridges to nowhere or whatever. And this is the last part of I'll spend a little bit of time on because I it's kinda complicated. It's brown, and it's got a few elements that I wanna walk through. But right now, we have a decision making process that gets the best and optimal solutions. We don't know what people care about. Don't know what the things are really gotten out of them, gotten to them. We have lack of evidence on the alternative approaches that might be taken to address those. And police officers have choices for the people whom you are asking to change their lives. So I think you need to establish a decision making process that can create an action with a role as a role as a reward and structure the choices effectively. So here's what I'm talking about. So this was developed first and first used the campaign. I might have mentioned it because last year. I think it's probably the same strategy as it's not. This is the idea. The first thing is you need to develop a proposal. You need to choose someone who's going to be the process manager and director at Camp David, if he's Cy Vance, with President Carter. Let everybody understand how you're going to do this because the decisions at the end that there will be a decision at the end changes how people think about working with you to develop a better. Then that process manager and draftees elicit interest of stakeholders, and that is so critically important. It's in private or public conversations depending upon who the stakeholder is. Some stakeholders won't wanna talk to you in public. But once once they understand the dynamics about my work, the hospitals, I think, would all join in. The key barrier that you probably run into when someone comes in to talk to you is that they don't necessarily want to tell you reveal what their absolute bottom line is, because that gives up any influence they have of by withholding that's apparent. But you would love them to share what they really care about. And so you don't ask them to commit at any point doing these things. Bill puts you after the bill, you take it back around, people go, well, this this is terrible here, but this I really like. Someone else may not like that, so you wanna understand what they're interested in. You go iterate through it, and there were 23 graphs. Now I made hive stakes in the house. Maybe we can get by with three or four. But you redraft until until the the person who's managing the process says, oh, no. I've talked to everybody. I don't think we can do better than this. And then you ask everybody a different question. So let's see what she does. I forgot. There's another bottom to the slide. There we go. Hey. The one sentence, parties push for their positions and withhold the engines, Leading to solutions that fail, and final choice is, can I get something better later? Let me see if I can kill this and get an extended alliance and get something better for me next year. This scares me how it is, because it's not very, wasn't drafted with their interest completely understood. But the final choice is very different. Final choice is, is this better than nothing? Is this better than what I could get on my own? And if anyone's done their job in that upper half of the slide, it should be a lot better than where we are. Some tweaks to this that Congress used for base closing commission and for free trade, and that's bringing it up for and our clients is getting really upset because it takes away some of the power that the chairs have, and that was one of the challenges for congress. That's bartering that gets you that deal for the other bill that you want. Anyway

[Sen. Virginia "Ginny" Lyons (Chair)]: Bad people. Lethal? Interesting. Bad people. Yeah.

[Elliott S. Fisher, MD (Dartmouth professor; former VA primary care physician)]: What I'm asking is your forgiveness just for not one fellow. If it doesn't pass, then you take it. So, you know, legislature might consider just doing an up or down vote first. That's what Congress did to tide its hand, says we'll do it. Alright. Oh, might the supply anywhere else? Someone's trying to build up a mass of new districts. But but the decision becomes, for stakeholders and legislators, is this better than nothing this year? Is this starting something better? Yeah. There may be a tax. There may not. I think that we can invent some way of doing this during the design process, the drafting process that may not require a substantial or anything else, but it can work. So that's that's the part of the model. I I know I know it's it's unusual, but we have examples of doing it, and in many ways, it is kind of what you do anyway. You're trying to do this yourself in the face of lots of competing interests and doing the best you can to get a grasp. But I, here, where I know primary care practices are scared about it. Will it be good enough? They're scared that it won't be fast enough. They want no co payments. You talk to a payer anywhere in the world, and they say no co payments, and they say no job. So and I, you know, I think there's a solution to that, but unless it's crafted in a way that we think that might go wrong, you know, what California did in their court open their change plans, you get three free visits a year. You know, get your that's get your you get three things, and then it's it's a $20 gift. A something just so that you don't come burn off the basic primary care physicians at this time.

[Sen. Virginia "Ginny" Lyons (Chair)]: It's also But you know after those three visits that you need the fourth one and you're willing to pay for it because it's

[Elliott S. Fisher, MD (Dartmouth professor; former VA primary care physician)]: critical to hear it out. Yeah. It's okay. Well and and the the barrier should not be the money to get. It's that if I did this a lot anyway, this is where we can figure out how to get the economists to agree with the private care advocates. And it's gotta be done in the community so that the public knows, this is why I really emphasize what I think is great about the all in alignment process was the public engagement at the same time.

[Sen. Virginia "Ginny" Lyons (Chair)]: Right. And so, so as you're talking about this new process, that there are elements of what we do here to establish, to build the actuarial analysis, to have the public engagement, to put people together in the room without, not here, not this room, but another room outside of the session that can bring solid recommendations. And then of course, there has to be some role for government in this, and legislature because there are state resources federal resources over The United When

[Elliott S. Fisher, MD (Dartmouth professor; former VA primary care physician)]: I spoke with Bob Wardown, who I mentioned to you, he's an international expert and is happy to invest in Bob, he was very clear that government is exactly one of those stakeholders, that you are one of those stakeholders, that HHS would be one of those stakeholders.

[Sen. Virginia "Ginny" Lyons (Chair)]: Sorry? Prevent Care Board. Of course. EFR.

[Elliott S. Fisher, MD (Dartmouth professor; former VA primary care physician)]: Exactly. They're all key stakeholders here, and that's why I labeled them the players. Yeah.

[Sen. Virginia "Ginny" Lyons (Chair)]: No, this is really very helpful. I know that some of the folks that we've been meeting with, you've been meeting with, have recommendations to come in to help us understand what is a possible next step. How do we go forward? And remembering also that we wanna be able to ask for a lot of these things. I keep an eye on it.

[Elliott S. Fisher, MD (Dartmouth professor; former VA primary care physician)]: I am poets that we can judge at it. I think we should try to set it absolutely critical, which you said in that regard already. Let's cover everyone else at Universal Primary Care. No. No. The proposal may you know, it's everybody well, I I think you I think you can get there. Because I hear enough curiosity about wanting to see what's possible from the people I talk to. So I think

[Sen. Virginia "Ginny" Lyons (Chair)]: Well, no, that's good. And I think one of the difficulties that we face, kind of the barriers we face, is ourselves, is if we can't impose on system stakeholders, we need to have that integrated. Yeah, well we want them to want them to want too. Yeah. So anyway, this is a good place. I appreciate you taking the time to come in and help us. And we will have other folks in, some of whom you've mentioned and had on your slides. That's gonna be They will probably have you back in.

[Elliott S. Fisher, MD (Dartmouth professor; former VA primary care physician)]: I'm happy to be as helpful as I can be. Yeah. You guys have such a hard job. I might even try to get things really easy. We have the fun job. Oh, have such a fun job. We do. I think we'll know how fun my job is.

[Sen. Virginia "Ginny" Lyons (Chair)]: Any last questions from the committee? We're good. This is great. You.

[Elliott S. Fisher, MD (Dartmouth professor; former VA primary care physician)]: No questions I need to ask? Okay.

[Sen. Virginia "Ginny" Lyons (Chair)]: Alright. Well, we'll get you back in then. So as we better understand Yeah. Yes. And

[Elliott S. Fisher, MD (Dartmouth professor; former VA primary care physician)]: hopefully find out if you want. Good. We've had some good conversations in the just in the last two days.

[Sen. Virginia "Ginny" Lyons (Chair)]: Thank you. That's great. Awesome. If you

[Elliott S. Fisher, MD (Dartmouth professor; former VA primary care physician)]: have another person to start in, I'll

[Sen. Virginia "Ginny" Lyons (Chair)]: Right. And we'll be I'll pull out.

[Elliott S. Fisher, MD (Dartmouth professor; former VA primary care physician)]: We'll be

[Sen. Virginia "Ginny" Lyons (Chair)]: connecting with lunch counsel on this as well. So so we go through one hundred and seven. So now we have Ted Barnett, who is not everybody now the room switches. Ted, thank you for being here for two hundred

[Elliott S. Fisher, MD (Dartmouth professor; former VA primary care physician)]: and Of course.

[Chuck Barnett (Joint Fiscal Office)]: Yes, it's always been a morning for me where I've been in a bunch of committees that I don't normally go to visit. It's been a big year.

[Sen. Virginia "Ginny" Lyons (Chair)]: We have your fiscal note on our webpage. I can check that.

[Chuck Barnett (Joint Fiscal Office)]: Great. Yes, Chuck Barnett, Joint Fiscal Office here to give quick a run through of the draft fiscal note for s two zero six. We'll yeah. So this is the title is in yellow here. Just you know, I know that there's a vote on the schedule, but, you know, if you were to change anything for the vote, this is the draft fiscal note, but it assumes that you all were to vote on the draft that's currently before you. High level. So we'll talk about two pieces, the appropriations, which you all have discussed and, I think, made changes to as the the bill spending committee, and then talk about fee license revenue once the program is stood up starting in fiscal year twenty nine. So to start with the appropriations, the bill would appropriate $262,000 for two positions from the general fund in fiscal year twenty seven. We wanna flag the there is an appropriation in the bill for fiscal year twenty seven, but in fiscal year twenty eight, there will be funding for these positions because fee revenue would not be available until fiscal year twenty nine. I think you all have addressed this issue or at least are aware of it because it was in previous drafts. Intent language and funding for these positions. I wanted to emphasize that piece. And then, also, additionally, reflecting that intent language and also in the OPR Sunrise Review assessment, they did note that an additional three positions above the two that are currently in the bill would be needed to stand up full regulation of the profession, and those positions would cost an additional $370,000 annually starting next fiscal year if you aligned position creation and appropriations with what is in that Sunrise assessment, and fee revenue would not be available until fiscal year twenty nineteen. There are some costs up front to getting this board and regulatory system set up. For the fee license revenue, presented it in a table before going into the table. I do wanna note that the information on this table is we received this information from OPR. The folks at OPR did good work in parsing through reports on the status of the industry and mapping data that is available through those reports to the proposed license structure of early childhood educator one, two, and three. So, yes, I'm indebted to the good work that they did at OPR, largely relaying numbers. But I did review the information they provided. Then please certainly check that today. So in fiscal year twenty nine, all of the folks who are currently in this profession would need to receive an additional license, and those additional or those initial license, they're shown here, scale by $50 from early childhood educator one to two to three, starting at $125 and then our family child care provider's at $175 so multiplied by the estimated number of licensees in that fiscal year, you can see that 5,000 estimated positions with that fee structure translates into nearly $800,000 of revenue in that first initial year of licensure, fiscal year '29. And then every two years, those licensees we need to renew, and these are biennial licenses, so they're paying every two years. And so, in fiscal year 'thirty one, in every odd year thereafter, you would see about $1,200,000 This is multiplying the estimated number of positions times the renewal fees, which are shown in this column here that I'm mousing over. Some notes. Right? This is an estimate, particularly when we're looking at fiscal year thirty one. That number to me seems like Jetsons time right very far in the future. And there are transitional licenses or not. They're licenses for family child care providers that they wouldn't be able to receive after 01/01/1929. So over time, you would see a decrease likely in this license type, but at the same time talking with OPR, they're anticipating an increase in the number of EC early childhood educators one, two, and three, because the profession would increase over time. So hard to know what that wash might be. For now, I'm holding it constant and saying what we're seeing in the beginning in terms of overall numbers in the profession will be somewhere in the ballpark. And, thankfully, there's a report in the bill that would report on the number of licensees in each category. You'd see around, once you've gotten that initial year, how many folks in the profession would be able to make adjustments if it's seriously out of WAF.

[Elliott S. Fisher, MD (Dartmouth professor; former VA primary care physician)]: I've been reading well. I've been talking as well. This OPR, you have to have a renew the fee every two years, she said. How? Fees aren't gonna stay stable all the time. Are they linked to an escalator or anything like this? So household?

[Chuck Barnett (Joint Fiscal Office)]: So yeah, they're not linked to any sort of inflator in the bill as it's currently in front view. However, So would need

[Elliott S. Fisher, MD (Dartmouth professor; former VA primary care physician)]: to come back to legislature or increase the fees through, Yes.

[Sen. Virginia "Ginny" Lyons (Chair)]: Go through the fee bill, or it can go through a separate bill like this and it goes to finance, finance with the fee place.

[Elliott S. Fisher, MD (Dartmouth professor; former VA primary care physician)]: That's what what my concern is, if no cost numbers go up, and so I just wasn't sure if was if OPR had some authority, I didn't.

[Sen. Virginia "Ginny" Lyons (Chair)]: We talked the other day. There used to be a regular 03:30 cycle that's been interrupted by the President's administration, but when things get behind, know, OPR is losing money because we've got all these compact licensing, and we know we're going to have to do something about that.

[Elliott S. Fisher, MD (Dartmouth professor; former VA primary care physician)]: Yeah, because just so

[Sen. Virginia "Ginny" Lyons (Chair)]: we don't

[Elliott S. Fisher, MD (Dartmouth professor; former VA primary care physician)]: know what capacity, right, OPR pretty much collects and sends out. Okay. Sorry about that.

[Chuck Barnett (Joint Fiscal Office)]: No, absolutely. Happy to answer questions that I do in talking with OPR yesterday. Right? They're doing a lot of work on evaluating their funding model and are gonna come they have an interim report, and we'll be submitting a full funding an analysis of their their funding model.

[Sen. Virginia "Ginny" Lyons (Chair)]: And finance and

[Chuck Barnett (Joint Fiscal Office)]: Nice. Yeah. Yeah. Yeah. Absolutely.

[Sen. Virginia "Ginny" Lyons (Chair)]: And so can you join fiscal office?

[Chuck Barnett (Joint Fiscal Office)]: Oh, absolutely. Absolutely. It was one of the first things I did in 2023 was work on the OPRT bill. It went through that year.

[Sen. Virginia "Ginny" Lyons (Chair)]: So I'm

[Chuck Barnett (Joint Fiscal Office)]: gonna be yeah. Don't feel good. Maybe a little familiar.

[Sen. Virginia "Ginny" Lyons (Chair)]: Yeah. You'll you'll be back down to college. Absolutely. So, questions for Ted on this one. This is helpful to us. I'm wondering how expensive all this is, and obviously having the initial investment is something that appropriations will have to look at and analyze. We'll see you down there as well. But OPR has asked us for this amount of money to stand up the program or we have shared concerns with them about how quickly that can happen in the economic world that we're in right now. So they are looking at it. My natural approach was that was a good time to see you there.

[Elliott S. Fisher, MD (Dartmouth professor; former VA primary care physician)]: Thank you for putting that together. That's Yeah.

[Chuck Barnett (Joint Fiscal Office)]: Really helpful.

[Elliott S. Fisher, MD (Dartmouth professor; former VA primary care physician)]: Yeah. It's great. It's good. Are

[Sen. Virginia "Ginny" Lyons (Chair)]: we all set? Thank you. Of course. Thanks for your patience and for coming back.

[Chuck Barnett (Joint Fiscal Office)]: Absolutely. Give me ten minutes. I talked to the people in the hall.

[Elliott S. Fisher, MD (Dartmouth professor; former VA primary care physician)]: Okay. All

[Sen. Virginia "Ginny" Lyons (Chair)]: right. So now we're gonna work with Katie at both we'll go to 206 first, Katie. We'll to 206.

[Elliott S. Fisher, MD (Dartmouth professor; former VA primary care physician)]: 206?

[Sen. Virginia "Ginny" Lyons (Chair)]: 206 is the bill. We don't need to go through the program. Been doing it. And we put in all the changes, and now we've had the physical note, which is always at the end. So are there any questions of case? I would entertain a motion.

[Elliott S. Fisher, MD (Dartmouth professor; former VA primary care physician)]: Entertain the emotion. I know, I know. Is there? Yep, she's got it. I saw you. So

[Sen. Virginia "Ginny" Lyons (Chair)]: I'm entertaining the motion with the motion on S306.

[Elliott S. Fisher, MD (Dartmouth professor; former VA primary care physician)]: What draft? This is 3.1.

[Sen. Virginia "Ginny" Lyons (Chair)]: 3.1. I think we make a motion to vote favorably on draft 2.1 of Three Three point one of s two zero six. Send it out to full senate. K. Thanks for motion. Is there other is there discussions? We've had a discussion. We've of discussion. There's had a a of concerns that we have moving forward, some of us, but it seems like what we're hearing predominantly from a profession to support of Alright.

[Elliott S. Fisher, MD (Dartmouth professor; former VA primary care physician)]: Senator Benson? Yes. Senator Cummings? Yes. Senator Gulick?

[Sen. Martine Larocque Gulick (Vice Chair)]: Yes. Senator Morley? Yes. Senator Lyons? Yes.

[Elliott S. Fisher, MD (Dartmouth professor; former VA primary care physician)]: Five zero zero.

[Sen. Virginia "Ginny" Lyons (Chair)]: Thank you, committee. Your work has been good on this, and your questions have helped improve the odds significantly. You'll appreciate it. And so the only thing we need is a reporter. I do. So because I'm looking. It would probably end up being. And I'm fine. That would be great. I appreciate that. I just like to. The attorneys go into finance and they compare in the try to get a trust. So the reporter and so you'll get a clean copy and the original bill to go upstairs and we'll have a clean copy. That's great. Great. And and maybe Melissa, if it would be helpful, I'd like to have a big coffee as well. So now we can move on to this other little bill. Congratulations everyone in the room. You've done really good work, and I appreciate your It's gonna steal one and create outside finance. Yeah, know. They do get loud down there. Well, they're enough for tropes, it gets really Yeah, I know. It gets loud out. So here we are, we're on 243. Think we do need to look at 243 again. Okay.

[Katie McLinn (Office of Legislative Counsel)]: I didn't say good morning yet. Good morning. Morning. Office of the council. Nice to see everyone. Here is oh, that's as introduced. Did you have the amendment to two forty three? I sent it. Probably We do a week ago now. You know what I'll do? Costa, I'll just pull it up from Oh, where it's at.

[Sen. Virginia "Ginny" Lyons (Chair)]: Okay. Thank you. Here we go.

[Katie McLinn (Office of Legislative Counsel)]: So, to refresh your memory, this was the bill about the Vermont Language Justice Project. It had an appropriation of $150,000 That appropriation is still in here. What has been added is a finding section, and a little bit of language has been tweaked as part of the appropriation. The new findings section. The General Assembly finds that Vermont ranks sixth per capita in refugee resettlement, finds that Governor Scott has recognized the important role immigrants play in Vermont's economy. General Assembly finds that when health information is available in only one language and only in a written format, it faints barriers that lead to confusion. The General Assembly finds that the Vermont Language Justice Project's videos fill a critical gap in patient education, particularly for families with limited English proficiency. General Assembly finds that the language Vermont Language Justice Project has created and distributed videos pertaining COVID nineteen and COVID nineteen testing, the importance of immunizations and how immunizations work, MPOTS, preventing mosquito and tick bites, and safety during flood events, high cold weather, cyanobacteria outbreaks, wildfires, and more. The General Assembly finds that the Vermont Language Justice Project's videos are made in 10 to 21 of the languages commonly spoken in Vermont, in collaboration with the Vermont Department of Health. Finds that the Vermont Language Justice Project is usually able to respond to a crisis within twenty four hours with information in multiple languages and in multiple formats, such as written translations, audio files, and videos. And lastly, the General Assembly finds that in January 2025, the Vermont Language Justice Project's grant from the US Centers of Disease Control and Prevention abruptly ended, leaving it to be funded solely through donations from individuals and foundations through fee for service work. So that is the new findings section. Then the appropriation itself is for fiscal year '27, 150,000 is appropriated from GF to the Department of Health for distribution to the Vermont Language Justice Project to prepare information, sorry, informational materials for Vermonters who speak languages other than English in the event of a disease outbreak or other public health emergency, including ongoing personal and public health information. It's effective July.

[Sen. Virginia "Ginny" Lyons (Chair)]: Do so we should get this on a 120 page. Do you do you not have it? No. I'm sorry if I didn't send

[Katie McLinn (Office of Legislative Counsel)]: it to you. I mean,

[Sen. Virginia "Ginny" Lyons (Chair)]: I thought I did. I saw everything.

[Katie McLinn (Office of Legislative Counsel)]: I'll stop sharing, and I'll send it to Vista, and then I'll pull it back up.

[Sen. Virginia "Ginny" Lyons (Chair)]: And then once we have it up, can we go through a different slope of briefly Slower. Sure. And I know that we're also have we have two ten, s u 10, the autopsy bill. We if we have time, we'll look at it. And judiciary hasn't looked at it yet. I and I did send a note to senator Rashid. So I'll make sure that he looks at that because it has superior reporting. Well, that's how the courts want to do. Yes. Okay.

[Katie McLinn (Office of Legislative Counsel)]: So go through the language again.

[Sen. Virginia "Ginny" Lyons (Chair)]: Do you want me to repeat that again, or

[Katie McLinn (Office of Legislative Counsel)]: would you like to As

[Sen. Virginia "Ginny" Lyons (Chair)]: soon as we can. Okay. I I don't what's here. Thank you for making the. Yeah. No problem.

[Elliott S. Fisher, MD (Dartmouth professor; former VA primary care physician)]: So the one I'm looking at is not right then?

[Sen. Virginia "Ginny" Lyons (Chair)]: If it says the one is introduced, then no. But no. So I still don't see it.

[Elliott S. Fisher, MD (Dartmouth professor; former VA primary care physician)]: Yeah. Don't know. It's it's

[Sen. Virginia "Ginny" Lyons (Chair)]: Okay. So let's go through it.

[Katie McLinn (Office of Legislative Counsel)]: You have it? Oh, it's listed.

[Sen. Virginia "Ginny" Lyons (Chair)]: Doesn't say it'll be refreshed. I'll give it refresh. Haven't refreshed many times. Refreshed. I'm sorry. It's a very refreshed. I don't know. Yep. A lot

[Elliott S. Fisher, MD (Dartmouth professor; former VA primary care physician)]: of refresh.

[Sen. Virginia "Ginny" Lyons (Chair)]: They extended my IT expertise.

[Chuck Barnett (Joint Fiscal Office)]: Oh, That's fresh.

[Sen. Virginia "Ginny" Lyons (Chair)]: Let's go through it, Paul.

[Katie McLinn (Office of Legislative Counsel)]: I'll read more slowly.

[Sen. Virginia "Ginny" Lyons (Chair)]: Yeah. That that would be good.

[Elliott S. Fisher, MD (Dartmouth professor; former VA primary care physician)]: Okay. Yep. It's on now. Okay.

[Sen. Virginia "Ginny" Lyons (Chair)]: 2.1?

[Katie McLinn (Office of Legislative Counsel)]: Yes. Okay. The General Assembly finds that Vermont grants six per capita in refugee resettlement. Governor Scott has recognized the important role immigrants play in Vermont's economy. When health information is available in only one language and only in written format. I have a question.

[Sen. Virginia "Ginny" Lyons (Chair)]: Do we ordinarily put the name of a governor or a lieutenant governor in for the findings, or we simply say the governor or the administration? I don't know. I don't know that I've ever included the governor, I must have. Finally, or the administration. Including us. Or it might be in violation of

[Katie McLinn (Office of Legislative Counsel)]: the rules. You could say the governor if you would like to. Would you prefer

[Sen. Virginia "Ginny" Lyons (Chair)]: to say that now? Better. Okay. It is governor Scott. Yeah. Has a contract with them. With Actually, yeah, Department of Health. Administration. And?

[Katie McLinn (Office of Legislative Counsel)]: Three, when health information is available in only one language and only in written format, it creates barriers that lead to confusion. The Vermont Language Justice Project's videos fill a critical gap in patient education, particularly for families with limited English proficiency. The Vermont Language Justice Project has created and distributed videos pertaining to COVID-nineteen and COVID-nineteen testing, the the importance of immunizations and how immunizations work, MPOTs, preventing mosquito and tick bites, and safety during flood events, hot and cold weather, cyanobacteria outbreaks, wildfires, and more. Top of page two, the Vermont Language Justice Project's videos are made in 10 to 21 of the languages commonly spoken in Vermont in collaboration with the Vermont Department of Health. The Vermont Language Justice Project is usually able to respond to a crisis within twenty four hours, with information in multiple languages and in multiple formats, such as written translations, audio files, and videos. And lastly, in January 2025, the Vermont Language Justice Project's grant from the CDC abruptly ended, leaving it to be funded solely through donations from individuals and foundations and through fee for service work. Brings us to section two, which is the appropriation. For fiscal year '27, 150,000 is appropriated from GF to the Health Department for distribution to the Vermont Language Justice Project to prepare informational videos for Vermonters who speak languages other than English in the event of A2D's outbreak or other public health emergency, including ongoing personal and public health information. And we have an effective date of July. So the biggest part

[Sen. Virginia "Ginny" Lyons (Chair)]: of the change is by that findings, which I think is important. I don't think that should be

[Elliott S. Fisher, MD (Dartmouth professor; former VA primary care physician)]: I understand because that 150 were basically, in the reserve of the quality. It means if there's an emergency.

[Sen. Virginia "Ginny" Lyons (Chair)]: No. No. It would go to the justice prod project, and then they would produce communications, whether it's video or audio.

[Elliott S. Fisher, MD (Dartmouth professor; former VA primary care physician)]: Right, but for a health emergency. Yeah. So if there's no health emergency, if the body's transferred, and sits there until such time, but there is a need.

[Sen. Virginia "Ginny" Lyons (Chair)]: Yeah. It will probably go through the department of health. So there'll be some accountability for college students. So that will be a question answered in the interim. They straight up general fund must have.

[Elliott S. Fisher, MD (Dartmouth professor; former VA primary care physician)]: Yeah.

[Sen. Virginia "Ginny" Lyons (Chair)]: Yeah. Yeah. Yeah. Yeah, we're saying it's an important consideration. The bill will go down there. What usually happens with a bill like this is the money gets stripped out, then the language goes forward. And then as the budget's considered, it'd probably be I don't know if that will make it into the budget in the house, but as the budget's considered over here, it'll be considered with everything else. The amount could change. It could be eliminated. It'll go forward because there's nothing in the field when you quote the issue. We'll see. Depends, usually if there's any study with a per diem, and in the end they lighten up. Well that could happen with us. I mean, if it's sitting on the wall and appropriations until we have the budget. They get all the needs and all the money. All of it. All of the It's a waterfalls. Senator Gulick may never get an opportunity to present it on the floor of the Senate. Aw, that would be a shame. It's a it's a small bill, but it has very huge impact at the state. I'm hoping that you can make Thank it. You, Bill. So, I don't know, questions for Katie, discussion, is this something we want to send out the hall to approach for consideration? Yes. But then, it says, if you do, then I accept the motion. That's a motion. I can't find the draft. Point one. 2.1.

[Katie McLinn (Office of Legislative Counsel)]: Yep. Because we just made this change from governor Stout's.

[Sen. Virginia "Ginny" Lyons (Chair)]: That's right. Right. Right. Sorry. Yeah. 3.1.

[Elliott S. Fisher, MD (Dartmouth professor; former VA primary care physician)]: Oh, it's three.

[Sen. Virginia "Ginny" Lyons (Chair)]: One. Move. We vote favorably on draft 3.1 of S two forty three and send it to all senate.

[Elliott S. Fisher, MD (Dartmouth professor; former VA primary care physician)]: Okay,

[Sen. Virginia "Ginny" Lyons (Chair)]: that's the motion. Alright. Any further discussion? That

[Elliott S. Fisher, MD (Dartmouth professor; former VA primary care physician)]: was with amendment. Favorable with amendment.

[Sen. Virginia "Ginny" Lyons (Chair)]: Yep, yep, as amended. All set?

[Elliott S. Fisher, MD (Dartmouth professor; former VA primary care physician)]: Yes, all right. Mr. Clerk? Yes. Senator Hoover. Senator Benson? Yes. Senator Cummings, yes. Senator Gulick, yes. Senator Morley, yes. Senator Lyons, yes. And I take it you're gonna report this as well.

[Sen. Virginia "Ginny" Lyons (Chair)]: You know what, I don't think we could take it away from her. I'd be honored. She's getting all the good bills.

[Elliott S. Fisher, MD (Dartmouth professor; former VA primary care physician)]: Yeah. Yeah. So

[Sen. Virginia "Ginny" Lyons (Chair)]: somebody Think about whether she wants the autopsy,

[Elliott S. Fisher, MD (Dartmouth professor; former VA primary care physician)]: girl. Other

[Sen. Virginia "Ginny" Lyons (Chair)]: things coming up. To that end, I am going to be scheduling our bills very consistently so that we can get the closure because we've had a lot of testimony. And do think about which bill you might like to present. Vote favorably on a bill. I'd like to know if you want to present the bill. It would be nice. Everyone should be in town. Because we've been involved in discussion. And as I heads up, we're gonna do our agenda planning today, and I'm thinking that we probably meet earlier in the morning, like, thirty for the next next week and then the week after before Crossover. Crossover. And you'll see how that goes. That's what I'm saying right now. We can have. So the week after next is our is town meeting week, but the week after that. Okay. So that's it. 02:10. 02:10, do we want to talk about that? Yes. Briefly, we've got a few minutes, and then we have a visitor. Okay. About eight minutes. Okay.

[Katie McLinn (Office of Legislative Counsel)]: So here is the amendment to S210, draft 1.2. This is the autopsy reports. And if you remember, there was conversation with Judge Sone, with the health department about getting access to autopsy reports if they weren't otherwise allowed to be distributed yeah, distributed under HIPAA. So, this amendment has been the work of conversations with Judge Zonay with the health department. The health department ask that the state's attorneys receive notice. So the state's attorneys have weighed in on this. So I think at this point, what you're seeing is consensus language from those three parties. What this language does, it is not a strike all amendment, it replaces subdivision, I think B2A of or B2 of the bill as introduced, which was the language that created a judicial path to obtaining the autopsy report. And you'll see we have a lot of language in yellow. So those are the changes since we've last seen it. This adds notice requirements, it adds language, like a timeline for being able to respond. It adds notice to the state's attorneys. Most noteworthy, it defines what good causes to help judges have parameters for making a decision about when to release the document. So I will go through it with you, but those are sort of

[Sen. Virginia "Ginny" Lyons (Chair)]: the big changes you're seeing. They've reached consensus on this? That would make life a lot easier in judiciary.

[Katie McLinn (Office of Legislative Counsel)]: I have been told that those three parties are in agreement with this language. Each one has. Thank thank you.

[Sen. Virginia "Ginny" Lyons (Chair)]: Because they're okay with this. Okay.

[Katie McLinn (Office of Legislative Counsel)]: So an individual who is not authorized to receive an autopsy report pursuant to subdivision one of this subsection B, meaning under HIPAA, may petition the probate division of the Superior Court for a copy of the autopsy report. The petition shall contain an affidavit attesting to the petitioner's relationship to the decedent and the reason the petitioner is seeking the autopsy report. The petitioner shall notify the office of the chief medical examiner and the state's attorney of the county in which the death occurred within five days after filing the petition. The office and the state's attorney shall have an opportunity to respond within fourteen days after that notice. If the superior court finds that the petitioner has demonstrated good cause for the petitioner to obtain the autopsy report and the state's attorney does not object, it shall order the office of the chief medical examiner to provide a copy to the petitioner in whole or part, that means it can have the redactions if the court finds that appropriate, and may place restrictions on the petitioner's dissemination of the copy provided, meaning I am giving this to you but you can't distribute it outside. It's it's for the petitioner themselves and not for other parties. So the court can place that limitation on this language.

[Sen. Virginia "Ginny" Lyons (Chair)]: So so does that imply that the court couldn't say you can read it here but you can't take it out of the Possibly. Okay. Yep. Makes

[Elliott S. Fisher, MD (Dartmouth professor; former VA primary care physician)]: me feel better. I think something

[Sen. Virginia "Ginny" Lyons (Chair)]: me feel better. Better.

[Katie McLinn (Office of Legislative Counsel)]: Page two, this is our definition. In determining the cause, the superior court shall consider the relationship of the petitioner to the decedent and the decedent's family, whether the disclosure is necessary for the public evaluation of governmental performance, the seriousness of intrusion into the decedent and decedent's family's privacy, whether the disclosure is by the least intrusive means available, including whether and to what degree redaction of some portions of the autopsy report is appropriate, and the availability of similar information and other public records regardless of form. That is how the court would balance its decision making on whether to disclose and the extent to which the disclosure can happen. I

[Elliott S. Fisher, MD (Dartmouth professor; former VA primary care physician)]: don't remember number two v two, whether the disclosure is necessary for the public evaluation of governmental authorities.

[Katie McLinn (Office of Legislative Counsel)]: So when judge Zoning was here, he referred us to Wyoming statute. Yeah. And this was language from Wyoming about government. About government.

[Elliott S. Fisher, MD (Dartmouth professor; former VA primary care physician)]: I'm just trying to come up.

[Sen. Virginia "Ginny" Lyons (Chair)]: Maybe the police didn't do a really good job. There was a bullet wound. That was I could be able to say the

[Elliott S. Fisher, MD (Dartmouth professor; former VA primary care physician)]: Okay. Okay.

[Chuck Barnett (Joint Fiscal Office)]: I could I could come up

[Elliott S. Fisher, MD (Dartmouth professor; former VA primary care physician)]: with a with one of those.

[Sen. Virginia "Ginny" Lyons (Chair)]: That's what I would take it. Yeah. Me too. It's probably more. Hope not. That's funny. You're planning on voting this? It's up to you and the committee. I've gotta go to money chair. So we've got three minutes. Okay. Oh, you gotta go. I can Again. Can make a motion. I'll move to. Okay. And I will make sure that Senator Vaishim has a close look at this. It's a good rule of opinion. All the parties that are in agreement. Who's making the motion? I think she did. Senator Cummings. Thank you.

[Chuck Barnett (Joint Fiscal Office)]: Oh, can I

[Elliott S. Fisher, MD (Dartmouth professor; former VA primary care physician)]: Discussion? Right, James. We're good. Senator Benson. Yes. What's love starting at B? I

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

[Elliott S. Fisher, MD (Dartmouth professor; former VA primary care physician)]: Senator Gulick.

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

[Elliott S. Fisher, MD (Dartmouth professor; former VA primary care physician)]: Senator Senator Gulick. Morley. Yes. Senator Lyons. Yes. Wow. You guys are keeping me busy.

[Sen. Virginia "Ginny" Lyons (Chair)]: We are in conductive today. So Is there anyone who wants to report this? No. Wait. I'm not.

[Elliott S. Fisher, MD (Dartmouth professor; former VA primary care physician)]: You're reporting it. And

[Sen. Virginia "Ginny" Lyons (Chair)]: It's either you, Senator Morley, or Senator Benson. I can't take it up right now. Leave it. No.

[Katie McLinn (Office of Legislative Counsel)]: You'll be with Charlotte. I'll bring it up.

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

[Elliott S. Fisher, MD (Dartmouth professor; former VA primary care physician)]: We're good. Alright.

[Sen. Virginia "Ginny" Lyons (Chair)]: She's unless you wanna do it or unless send her Benson on. Is there an interest in presenting it? Oh, give them the option. I'd rather see a few more. Okay. Got it. Understood. This one does not have money in it.

[Elliott S. Fisher, MD (Dartmouth professor; former VA primary care physician)]: Right. Yeah. He read it. This was fixed. So

[Sen. Virginia "Ginny" Lyons (Chair)]: Senator Cummings Very good. Okay.

[Elliott S. Fisher, MD (Dartmouth professor; former VA primary care physician)]: 1.6.

[Sen. Virginia "Ginny" Lyons (Chair)]: Judicial background of Experience in the judiciary. Voila. We are finished. We're not finished. We're finished with the bills. We're we're gonna invite Tess up to talk with us about Compass Pathways very briefly. Absolutely. Thank you for being here. Thank you so much for having me, Doctor. Chair, members of committee.

[Tess Butler (Compass Pathways, Government Affairs)]: My name is Tess Butler. I'm the associate director of Women Affairs for Compass Pathways. I do have hard copies of my testimony if you would like me to distribute those. Thank you. Thanks. So, thank you so much for your time today. Compass Pathways is a biotechnology company dedicated to accelerating patient access to evidence based innovation in mental health. Our focus is on improving the lives of those who are living with mental health disorders and who do not benefit from existing standards of care. Compass Pathways is conducting the largest vaccine regulated clinical trials ever, studying the safety and tolerability of psilocybin with our lead compound, POM360. POM360 is a synthetic pharmaceutical grade proprietary formulation of psilocybin. POM360 is manufactured according to FDA enforced good manufacturing practice standards for quality, consistency, and purity. Phase III clinical trials are currently being conducted with COMM-three sixty in treatment resistant depression. Results of our Phase IIb clinical trial for TRD were published in the New England Journal of Medicine in 2022. For your reference, I have included the results of that study. I think I'll leave it posted online. And the FDA granted Breakthrough Therapy Designation to COMT-three sixty for treatment resistant depression in 2018. Assuming positive results of these phase three studies, Compass Pathways plans to seek FDA approval for COMM-three sixty as a medication prescribed and administered under the supervision of a licensed healthcare professional in a professional healthcare setting for treatment with cystic depression. And along with our clinical development in TRD, in May 2024, Compass announced positive top line results from an open label phase two study evaluating the safety and tolerability of COMM-three sixty in post traumatic stress disorder. Compass plans to pursue further development and investigation on COMM-three sixty and PTSD. We are asking for your help to ensure that patients have access to this innovative treatment in the event that it is FDA approved and rescheduled by the Drug Enforcement Administration. The United States is in a mental health crisis, and depression is one of the most common mental health disorders. Depression significantly impacts relationships, work performance, overall quality of life, and is associated with an increased risk of suicide. Major Depression Disorder is ranked the third highest cause of the burden of disease worldwide in 2008 by the World Health Organization, which has projected that this disease will rank first by 2030. An estimated twenty one million adults in The United States suffer from major depression, and approximately nine million are drug treated. Due to the limitations of existing MDD medications, approximately one third of patients with MDD will develop TRD. TRD is broadly defined as an inadequate response to two or more appropriate courses of approved medications. TRD has a significantly greater impact on individuals compared to MDD, leading to residual symptoms, poor quality of life, increased comorbidities, higher mortality, and an increased risk of suicide compared to non treatment resistant MDD, and there are currently only two medications approved by the FDA for TRD. PTSD is a serious mental health condition that can develop after exposure to traumatic events, including assault, combat, natural disasters, and serious accidents. Is marked by intrusive memories, avoidance behaviors, negative changes in mood and cognition, and heightened arousal. About five percent of US adults experience PTSD each year. Symptoms may emerge soon after the trauma or be delayed, they must last longer than a month and disrupt daily functioning to meet diagnostic criteria. PTSD can impact anyone, though certain populations, including veterans, first responders, and survivors of abuse, are at elevated risk. Individuals living with PTSD frequently experience comorbid mental health conditions, most commonly depression, anxiety disorders, substance use disorders, as well as a significantly increased risk of suicide. These overlapping conditions can intensify distress and complicate treatment. Despite affecting roughly thirteen million people in The US annually, PTSD remains underserved despite its prevalence. Only two FDA approved medications exist for PTSD. This limited pharmacological landscape underscores the urgent need to advance and expand care for patients experiencing this debilitating condition. PTSD disproportionately affects certain demographics, including women, people from different racial and ethnic backgrounds, and military veterans. Of patients treated for PTSD, only twenty to thirty percent reach full remission with currently approved pharmacological treatments. All psychedelics, including psilocybin, are currently DEA Schedule I substances, which are defined as drugs with no currently accepted medical use and a high potential for abuse. Schedule I drugs may not be prescribed, dispensed, or administered. However, upon FDA approval of a current Schedule I medication, the DEA is expected to review clinical trial information provided by the company during a new drug application submission and make a federal rescheduling decision. States will need to reschedule the medicine through their defined process to allow the medicine to be prescribed to patients in their state. In Vermont, legislation must be passed to add a drug to the state's regulated drug list, ensuring it can be prescribed. Vermont has done this before. In 2018, the legislature passed a law adding FDA approved cannabidiol drugs to the state's regulated drug list, which allowed for these drugs to be prescribed and administered in the state upon FDA approval. I have submitted draft language to make a similar change with respect to synthetic psilocybin to my testimony for review and discussion, and in conclusion, this committee has the opportunity to ensure timely access to this innovative treatment, provided the language we have submitted with my testimony is incorporated into legislation currently moving forward. I also include some sources for various systemic phenomphapienism. Terrific, very helpful. Mean, did have a study committee looking at psilocybin and I know there's been discussion with the Department of Health for use of psilocybin on uncertain conditions, end of life, that you're going through the process.

[Sen. Virginia "Ginny" Lyons (Chair)]: Yes. Go ahead, Senator. Thank you. Thank you, John. I appreciate it. I was just, if it's okay, Senator, just very quickly wanted to tell the new Well, Senator, please go ahead. That in my first session, had a civil side of bill in this committee because I really felt this test underscored that we're in the midst of this mental health crisis and it feels like we're doing a lot of the same things. I felt like it's time to take some bold action to try something new. We took a lot of testimony a couple years ago from folks who work in the therapeutic realm and use, and have used psilocybin in a therapeutic setting. And they shared with us how incredibly impactful it has been on the lives of people, especially those suffering from PTSD, a lot of veterans. So that was where the bill came for the study committee. And they really need more time, is there's actually another bill to continue the study committee. But I'm just very much in favor of us exploring alternative therapies under the watchful eye of a practitioner and a therapist and a doctor. Just wanted to share that it's been in this committee now for few years. At least. And we do have a bill, S-one 154, a biomarker bill for Alzheimer's that conceivably something about psilocybin could germane and go on. Think about it. We haven't taken s 154 off the wall yet, but I was thinking we might do that. We asked for it from finance and that's very important to the Alzheimer's Advisory Committee, which has legislators on some people. Just a little process that we might think about. Thank you for coming.