Vermont Legislature SmartTranscripts:

[Sen. Virginia "Ginny" Lyons (Chair)]: And I can't resist. We need we something. I have no idea what's coming up. You

[Elena (Director of Policy, Green Mountain Care Board)]: are live.

[Sen. Virginia "Ginny" Lyons (Chair)]: Nope. Okay. Thank you. Yes. February 20. And this is, we are taking off s 1 90. And okay. Pass this one around. And, Jen, do you mind a quick comment about what is NS-one 190? Or you can come up. Okay. All right, Jen Harvey from the

[Jennifer Carbee (Office of Legislative Counsel)]: Office of Legislative Counsel. So just by way, a reminder, S-one 190 is an act relating to the Green Mountain Care Board, reference based pricing, and hospital outsourcing of clinical care. So it would set some requirements for hospitals and health insurers to meet, to facilitate the board's implementation of reference based pricing. It would establish regulatory oversight of hospitals use of outsourcing contracts for clinical services. It repeals language around healthcare provider bargaining groups. It asks some language clarifying or making some changes to the board's, to appeal processes for your Medicare board decisions and orders, and would allow the board to conduct examinations and investigations of hospitals, including audits, as part of the hospital budget review process. And finally, it would direct the board to develop an interactive health system performance tool, and it sort of has some completely oblique language, but that was a reference to the potential for federal money to come in from the Rural Health Transformation grant.

[Sen. Virginia "Ginny" Lyons (Chair)]: Would benefit the entire state, including Chittenden County.

[Jennifer Carbee (Office of Legislative Counsel)]: Said the entire state? So,

[Sen. Virginia "Ginny" Lyons (Chair)]: thank you for that. That's helpful. Good reminder of where we are. And so we're gonna hear from the Green Man Care Boards and other sponsors. And then I understand there's some recommendations, language recommendations that we'll be looking at to improve the bill. Senator Benson has asked a very good question that as you're speaking to this bill, I know it's a separate ask, but if you can't give us the full picture response today, we'll get it another time, and that is, as going forward on this bill with the sections that you are discussing, how does that improve access, quality, and cost issues? So that is a general question. Senator Benson has asked and I'm asking it for you Senator. So, you know, this is always on top of our mind and I also know when we hear from the hospitals and others it's the right care at the right place at the right time. All of those things may stand together. All right, so we'll start out with Owen Foster, chair of your board. How do you wanna do this?

[Owen Foster (Chair, Green Mountain Care Board)]: I think Elena and I, if it's okay with you, both testify at the same time, we're gonna go back and forth.

[Elena (Director of Policy, Green Mountain Care Board)]: I'm Alethanderbe. I'm the director of policies for Green Mountain Airport.

[Owen Foster (Chair, Green Mountain Care Board)]: My name is Owen Foster, and I'm the chair of the Green Mountain Airport. We're gonna go through section by sections. So that meets the committee's goals, provide our feedback. We'll start with the reference based pricing section, and Ms. Farabi will discuss that.

[Elena (Director of Policy, Green Mountain Care Board)]: Yeah. So in this section, if provide, well, we provided this language and then we discussed last time,

[Sen. Virginia "Ginny" Lyons (Chair)]: sets of parts of F

[Elena (Director of Policy, Green Mountain Care Board)]: and G. We had previously provided a number, but we've been kind of thinking about how can we make sure that we have the right number, and we went back and did some thinking and discussing and provided you with some language last night with

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

[Elena (Director of Policy, Green Mountain Care Board)]: two major components, and we wanna offer the third idea today. The first component is going to be to take our commercial revenue reduction or rate reduction that is established through the hospital budget process and have the ability to direct that to the highest priced services that a hospital offers. So to make sure that we're bringing down the prices and not creating further disparity between the lowest priced services that are those that continue to be more likely to be shed versus the high priced service. We wanna make sure that all of our services are reasonably priced, and this would allow the board an opportunity to bring some of the really high prices down.

[Owen Foster (Chair, Green Mountain Care Board)]: One example of that, so in Vermont, a lot of these imaging services, MRIs, are very, very, very high priced, sometimes 600, 700, 800% of Medicare, and other services like birthing and mental health and primary care might be considerably lower. When we see service line changes being made, it's to the ones with the lower prices, the ones that don't make any money. What this would do, the board has a rate reduction to apply to those ones that have really, really high prices and not to the ones that have low prices, because we wanna support those community based services that we need for preventative care. So that would be the goal of allowing us to do that.

[Sen. Virginia "Ginny" Lyons (Chair)]: Will that include evaluation of utilization?

[Elena (Director of Policy, Green Mountain Care Board)]: I think that's part of our process right now, is we look at volume change or It doesn't need to be, I don't think it needs to be. Do we need a volume control?

[Owen Foster (Chair, Green Mountain Care Board)]: You may see volume go down as prices go down.

[Elena (Director of Policy, Green Mountain Care Board)]: So we can monitor that, but I think maybe, yeah. Okay, so the second component is really to target some of the savings that will be driven to the QHP market. So, we're not because we're not fully implementing the hospital reference based pricing in one year, we still have some markets that are in really tough shape right now. GDP market being one of them. If we could go ahead and tap that market and concentrate these early year savings to that market, that would really provide relief for a lot of the folks. So that is the language that we offered in the guidelines. That's section x. I'm trying to follow what you said to us. Yes, so that's the reference based pricing section one. Targeting board ordered possible rate reductions. Hospital reference based prices for qualified health plans. That's the second quotation. Yeah, section X, title 33. That's that.

[Owen Foster (Chair, Green Mountain Care Board)]: The rationale for that is that our QAP plans have struggled vitally with really high rate increases the last five, six, seven years. Last year, the insurer came in with a 23% rate request on the individual market, just in one year. Enormous. We were able to make it smaller, but this year, we're losing what's called silver loading, which allows the board to reduce the actual amount people effectively pay, and we also have lost the enhanced substance. So this market has really, really, really been hurt just in this last year by those two very significant federal changes. It's also a lot of our small businesses. It's a lot of our nonprofits. It's some of our healthcare providers. It's our mental health providers. It's our restaurants. It's our plumbers. It's our carpenters. It's a lot of people that don't have greater market power, whereas some of the larger employers do have more market power to to argue for better rates. So our position on this is that given what's happened to that market, the relief would be an appropriate decision to go with them. We are seeing also dwindling numbers. The decline in that market is really significant, and that makes it more and more expensive. As the market contracts, gets more expensive and only the sickest people stay in there. So one of our responsibilities is equity and paying for healthcare, and we think this would be a positive step towards improving health equity. And access. It is your sickest, most vulnerable to evil other than your Batikaney constellation.

[Elena (Director of Policy, Green Mountain Care Board)]: And then the third idea, is not in language yet, but we wanted to kind of present, was to have differentiated rate reductions through the hospital budget process by plan. So this would allow us to essentially allow commercial growth to affect certain plans that may already be at different rates to equalize over time. We can come back with all

[Sen. Virginia "Ginny" Lyons (Chair)]: your size language. Okay? Sure.

[Owen Foster (Chair, Green Mountain Care Board)]: We can pause on section one if there's any questions.

[Sen. Virginia "Ginny" Lyons (Chair)]: Questions. Section one. Can you do now. Section one. Can you go through this one more time? Clarity, because we're all Yes. So,

[Elena (Director of Policy, Green Mountain Care Board)]: three things that we're talking about here are, one, to leverage our hospital budget process to be allowed to apply our commercial rate reductions to the highest priced hospital services.

[Sen. Virginia "Ginny" Lyons (Chair)]: So, I do have a question about that. Is there anything that currently precludes you from doing that right now? Yeah. So, our rate setting authority, please correct me

[Elena (Director of Policy, Green Mountain Care Board)]: if I'm wrong, but our rate setting authority describes our requirement to go through a rule making process before we can establish price gaps. So that is the work we're doing to implement the whole reference based pricing programs across the provider system. That's taking time. We are reviewing our bids right now for our analytic contractors to come up with a plan and a real free cadence for implementing the right number.

[Speaker 3]: The rule making process itself takes a long time.

[Elena (Director of Policy, Green Mountain Care Board)]: It's a huge stakeholder engagement process and a lot of oversight. So we are moving as quickly as we can, but that is why we need other tools in the meantime to make sure that we're moving as quickly as possible. Thank you. This is so important.

[Unidentified Committee Member]: I can say just one of clarifier.

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

[Unidentified Committee Member]: Since a large percentage of our population is either Medicare or Medicaid insured and we set prices, is that going to be acceptable in those programs?

[Elena (Director of Policy, Green Mountain Care Board)]: It will not affect those programs directly. Those programs will continue to set their own

[Unidentified Committee Member]: affect a small piece of

[Elena (Director of Policy, Green Mountain Care Board)]: the It'll it'll affect the commercial market, which is right now the really high price. Yep. That would

[Owen Foster (Chair, Green Mountain Care Board)]: be fine, James. And going to the request that we tie this back to affordability, access, and quality. So these changes, one, affordability, tapping the prices would increase affordability. It would reduce the amount of money that we're spending on hospital services, which are very high here in the state, so it goes towards affordability. Access is a question. Sometimes people say, well, hospitals have less money, have less access, period. Stop. Access is a much more nuanced question. People can't afford healthcare if they don't have access to healthcare. So if you look at it from the lens of helping people stay in the QHP market, in that insured market, it improves access quite a bit. If you also look at improving the ability of insurers to pay non hospitals money, it improves access there as well. And then in terms of whether or not it hurts access at hospitals, I think that's an open question. Whether or not hospitals can absorb this price reduction without losing services, I think it depends on the hospital, depends on their operations, and I do think we are gonna see hospital service line changes. There's no way around it at this point in the state. So it could have a negative impact on access to hospital services. That's also why we have $200,000,000 a year for hospital systems and state system transformation. That's why we're doing the whole transformation work as a state. And then the last question was quality. Quality, again, is a nuanced question. If you pull here and pull here, there's consequences on both sides. It's not clear whether or not this would impact quality negatively. It's really tough to forecast. We have seen quality of Vermont hospitals really tail off quite dramatically in the last three or four years, troublingly so, and it started actually, it didn't actually correlate to the board's provision of money. It actually started when the board was giving really, really large amounts of money to hospitals in 2023, 2022, 2023. So it's hard to say exactly it's a tightening type of a. And actually,

[Elena (Director of Policy, Green Mountain Care Board)]: in other states that have implemented reference based pricing or rate setting, they have not seen any reductions in quality as a result of some stuff. That's the worst. I was just

[Sen. John Benson (Member)]: I'm concerned that if you start pulling enough money away from the hospitals in certain areas, then they're going to no longer provide that service. Does the Green Mountain Care Board have the authority to say, No, you're going to provide that service?

[Sen. Virginia "Ginny" Lyons (Chair)]: That's 189. We're talking about that in the context of another bill, it's an excellent question. But maybe at this point, what's the Board's responsibility for that?

[Owen Foster (Chair, Green Mountain Care Board)]: Under current law, the board does have authority to say, No, you can't cut that service line. So what if they can't make it? Are you

[Sen. John Benson (Member)]: gonna give them more revenues?

[Owen Foster (Chair, Green Mountain Care Board)]: The rates. So, one, we have no control over Medicare. Two, it's AHS and the legislature, whether or they want to fund Medicaid more. Three, the only lever we have is over the commercial insurance market with some of the highest prices, if not the highest prices in the country. So if there's no money, I would love to give them more money.

[Elena (Director of Policy, Green Mountain Care Board)]: And the hope with transformation is that they'll be able to figure out how to create those centers of excellence, right, and make sure that we have them.

[Sen. John Benson (Member)]: Of course, I'm from the rural part, so hopefully some of the funds from the

[Sen. Virginia "Ginny" Lyons (Chair)]: That covers the entire state, that would be great. Okay. Anything else on section one? That's a tell if we're going through at the second.

[Owen Foster (Chair, Green Mountain Care Board)]: Yeah, it is.

[Elena (Director of Policy, Green Mountain Care Board)]: Yeah, just the second piece was the QHP, which I think we've talked about.

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

[Elena (Director of Policy, Green Mountain Care Board)]: quick question? So I think it's a good point that this is all being done in the context of a larger strategic plan, but will you be an integral part of creating that strategic plan so that all of the parts are fitting together? It's I sometimes worry that the buckets are kind of disparate and

[Courtney Harness (Blue Cross and Blue Shield of Vermont)]: can you

[Elena (Director of Policy, Green Mountain Care Board)]: speak to that at all?

[Owen Foster (Chair, Green Mountain Care Board)]: I'd say from current experience, our engagement with the transformation plans and vision is limited. That is my knowledge. Haven't seen the transformation plans have been submitted. The agency is working with the hospitals on that. I don't think we've seen them. So I would say our role's limited at this time, which may or may not be.

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

[Owen Foster (Chair, Green Mountain Care Board)]: section is sections two and three, which deals with hospital outsourcing, and just to level set what that means, it's hospital often have a group of physicians that it employs, or its medical group of employees, and they provide medical services at the hospital. It is often hard to retain and recruit physicians, and what's popped up more and more across the country are these what I'll call outsourced physician groups. Rather than the hospital employing this group of iwi doctors or this group of radiologists, they'll hire a group from out of state or maybe even in state, but generally I think they're out of state groups. When that's been happening currently, it no longer, that the money associated with that care is no longer under the Green Mountain Airports Authority. So if in year one, the hospital had a $100,000,000 budget and they outsourced their ED, and that was $10,000,000 now they have a budget of $100,000,000 but they're actually only bringing in 90,000,000, and somebody else is doing 10,000,000. That other 10,000,000 now is also not under the Green Mountain Care Board's authority on how much they can charge. So if we say, hey, you can't increase prices more than 5%, that group is not subject to that limitation. And if the hospital then wants to increase its utilization on those high priced services, whatever it may be, they now have $10,000,000 more of room to do it. So going to Senator Benson's question about affordability, this is an affordability concern because now those prices are not subject to caps, and the total revenue is not subject to caps. If have utilization increases from that outsourced group coming in, no one's no one's paying any attention to it.

[Sen. John Benson (Member)]: It can really increase. So hear what you're saying. I'm just concerned that if you do start doing that, what are the third parties gonna do? I mean, we're already hurting to a certain degree for physicians or people in hospitals who work, and are you sending a signal to them like, there's a lot of regulation all of a sudden on us. We're no longer supplying services in the state of Vermont.

[Owen Foster (Chair, Green Mountain Care Board)]: I doubt that will happen, but I gotta ask the question. Yeah, think it's a good question. Well, one, to remind a lot of the groups, and I don't have like an inventory, but a lot the groups are private equity owned groups. Private equity owned groups are often trying to make money for their investors to shareholders. So there is more of a I don't have the basis to say it's pernicious here, because we don't have that much granularity to it, but we don't know. Certainly any time you get private equity investors into healthcare, it can really harm patients. It can be beneficial as well. Your point, it helps you get doctors, that's true, but at what cost?

[Elena (Director of Policy, Green Mountain Care Board)]: And if they can operate within the cap and at the prices that we're setting, they're cheaper, then that should be no problem, right? So I think we want everyone to play by the same rules and make sure that Vermonters are having much more than

[Sen. Virginia "Ginny" Lyons (Chair)]: two years. I just want

[Owen Foster (Chair, Green Mountain Care Board)]: to talk to you. Vermont prices aren't low, they're high. So if they're under our cap, it's not like the prices are going be really, really, really pinched. Generally speaking, Vermont prices are quite high. So I would think somebody could make pretty good return on

[Courtney Harness (Blue Cross and Blue Shield of Vermont)]: it.

[Owen Foster (Chair, Green Mountain Care Board)]: But again, it would be service line dependent, depends on what service they're giving.

[Sen. Virginia "Ginny" Lyons (Chair)]: So I'm aware of the time, which I'm gonna ask us to hold some of our questions unless it's clarification, because we're trying to get into discussion. That's a good thing. But we will have an opportunity to do that again with these folks. Why don't you go right ahead and then Sure.

[Owen Foster (Chair, Green Mountain Care Board)]: The only other point on this would also be the provider tax. That set of monuments being outsourced now would not be subject to provider tax. Provider tax is how Vermont pays for a lot of under covered services that are really important to the community. They could potentially be subject to corporate taxes, what kind of tax rates or deductions they have, how much goes in the general fund as opposed to actually helping with the health system, I don't know the answers, but you would lose a provider's case if it's not a government. Moving on, section six, seven, and eight generally all refer to the same issue, which is the professional bargaining group provisions. Section eight was, sorry,

[Sen. Virginia "Ginny" Lyons (Chair)]: You have language for that, for the targeting group.

[Owen Foster (Chair, Green Mountain Care Board)]: Oh yeah, right, Section A, sorry, repeals A, yeah. So, the provider bargaining group, essentially what this had said, one, to my knowledge, has never been used in Green Mountain Airport's history and certainly not since I've been there. So this is a technical cleanup. And going to the question of affordability, this would, we don't remove FITS, it adds more administrative layers, and it actually wouldn't even work. So what you have is Green Mountain Care Board makes a decision, the hospital or provider group doesn't like this decision, they would then say, we wanna go to arbitration, which is nonbinding, which means we can just say no to it anyway. You go to arbitration. You have to have lawyers for the hospital, the provider group arguing. You have to pay for the arbiters. You then get a decision that then comes back to the Dream Mountain Care Board. Five member board can't do anything unless three people have a yes vote. You then have a hearing on whether or not you wanna be bound to the nonbinding arbiter's decision. Then after that, you would go to an appeal to the Supreme Court again. It makes no sense. It's a complete waste of time and money repealing it. No questions asked. This is total nonsense. It makes no sense for a regulator to be subject to arbitration. We are the arbitrator. If you don't like your decision, you go to the Supreme Court of Appeals. I don't think we should spend more money on administrative costs at all. The next section was about deals in the Green Board's decisions, and it's repealing a request for a procedure that the Green Bank Care Board has to come up with a procedure for internal appeals of our decisions. This is similar. You're adding an upper layer of bureaucracy to making these decisions that have been doing. There's already a right to the Supreme Court appeals. We've been appealed many, many times, and it's a really pretty fluid process. I don't know why the hospitals would want an internal appeal process, because it would actually hurt them. The reason for that is when we make a decision and it gets appealed to the Supreme Court, the Supreme Court doesn't decide the case until like June or July of the next year. By that time, you're already into Q2 or Q3 of the year, so during that entire time the Supreme Court appeal is pending, you're subject to our order. So when you actually get the opinion from the Supreme Court, it might be moot. So if you add another layer and another process in between that, by the time you get to the Supreme Court, the whole year will be over. So I don't know why a hospital would want an additional layer of bureaucracy and expense. Also, the way we do our budget process is very, very extensive to grow. It's basically a year long process at this point. The guidance is worked on for months and months and months. So even before we get the budgets, everyone knows months in advance where the board is directing hospitals to go to. Then you have a months long process on hearings, then you have, like, live hearings, you have all these submissions, and then they, during the course of the process, they raise all kinds of objections that are really helpful. Like a lot of times, we listen to them and we change course. So this happens as we do it, and adding another layer of steps and costs does not make much sense. I think you should to Senator Benson's question, repeal that, it will save money to the system, it will make it more efficient. We don't want more money around health care, we want more money in health care. Good enough, Doctor. Moose. Next section, section 10, is hospital audits. I understand that BFR testified as to their expense with audits. An audit of an insurance company, a full examination of an insurance company is very different than an audit of a hospital. It's apples and oranges. There's a difference between a full examination, which is what they're testifying to, and an actual audit, which is court limited. I think the hospital's position is that, if I understand it correctly, is that they already are subject to audits, but those audits don't cover their budget submissions. They cover their audited financials, not what comes before the Green Mountain Care Board. That's the point here. The data that we're getting needs to be subject to an audit to make sure it's accurate. We have examples where we've seen it being wildly inaccurate. Had it this last year with Brattleboro Memorial Hospital. The data was submitted, I think, three different times, and it was completely inaccurate the first time and the second time. You could not rely on it. When that happens, we are in a really tough position. We might make decisions that really hurt the hospital because we don't know what the numbers are. So do we cut it? Do we cut it too much? But we don't know because the data's no good. We've had other examples where the data wasn't accurate either, and I think it's really important that this authority exists. DFR has it for their regulated entities. The care board should, too. Something that like with the subpoena power, I would anticipate using it very, very sparingly, hoping they never. We did not use the observer bill. We just issued one subpoena in the history of the CARE Board. We're judicious about this. We know if it has expense, we don't wanna use it a lot. But there's a situation like Rattleboro with plainly false data, we need to be able to check it out.

[Sen. Virginia "Ginny" Lyons (Chair)]: Are we gonna get your comments on each of the segments?

[Owen Foster (Chair, Green Mountain Care Board)]: We can send something. Yeah. Would be great.

[Elena (Director of Policy, Green Mountain Care Board)]: Last Yeah. Section left. Thanks. The last is the price transparency and course transparency. It's a tool of our dashboard. So we provided some language a few weeks ago. Yeah. That just gives us more flexibility to make sure that we're, you know, reporting the right data and the

[Sen. Virginia "Ginny" Lyons (Chair)]: right metrics depending on the direct stimulus. And, okay, this is helpful. Great. Can I, I'd like to go back, ask one question, and then we probably should move on? This is a good start for our understanding of your perspective. I know that looking at qualified health plans could be problematic for some organizations or groups, And so, can you give us kind of what your understanding is of who is affected by that section?

[Owen Foster (Chair, Green Mountain Care Board)]: If the legislation were to include a cap, a specific cap for the QHP plans, it would affect all those small groups, small businesses, and individuals that are on qualified health plans. Would save them significant amounts of money. We would see a very large reduction in the rate increase of those patients. We would see improved access to health insurance, which would be very important at this time. We would see a reduction, but savings would come from the hospitals that would be getting lower prices. I think the recommendation was 250% of Medicare? Yes. So keep in mind, Vermont was over 300% on average. This would bring it down to two fifty. That would hurt the hospital's financials. It went from 300 to two fifty. There's no getting around it. If you're gonna save money on what people are paying, you're gonna have to take it from somewhere. Think the important point here is 250% for a small segment of the market, not the entire insurance market, limits the financial disruption. Right? If you did it across the entire board of every that's about 300,000 people in Vermont around commercial insurance. This would be about, I think it's around 65,000 people are stopped, give or take. So you're doing it for a smaller segment of people. It wouldn't cost as much money to the hospitals. And 250% is roughly, give or take, around the national average. So what you'd be doing is saying hospitals in Vermont, for this segment of patients, a smaller cohort, you have to receive the national average of commercial reimbursement. And then you do wanna see the transformation help with these types of transitions that are gonna happen when you have less money. So it's a cost shift. You're taking money from the hospital at 315% of Medicare, whatever it is, and you're taking it so that the insured, the patients don't pay so much.

[Sen. John Benson (Member)]: How much is a cost shift?

[Elena (Director of Policy, Green Mountain Care Board)]: We have really rough numbers based on home data that's around $2.50 to

[Sen. Virginia "Ginny" Lyons (Chair)]: 100,000,000 across districts. Across the district. We're

[Owen Foster (Chair, Green Mountain Care Board)]: working on getting more up to date data, but the early data we have that's a little back of the napkin, our actuaries are working on it. It's over $50,000,000 Thank

[Sen. Virginia "Ginny" Lyons (Chair)]: you. Is really helpful for all the work that we've been doing and understanding where we are. Excuse me, if you can get us your comments on the sections of the bill, that'll be helpful, because we want to move into markup on this bill. We've got eight days left. Great. And I know that there are going to be some people who are unable to be here to help us through next week. So we want to be able to get as much as you can as short as possible. Thank you. Thanks for all those examples. And I know we'll be hearing from people about some of the recommendations. Courtney, you're here. Thank you. What are missing? We know stuff is happening when the room gets full. So we have your slides, and we've got mute and VMS and VOS, and we have time to where we've got, I think we have plenty of time to answer this. We might be a little bit late for the Department of Mental Health. Well, thank you.

[Courtney Harness (Blue Cross and Blue Shield of Vermont)]: And for the record, Courtney Harness, Blue Cross and Blue Shield of Vermont. I thought Elena and Chair Foster did a really nice job walking through what we actually believe to be really important parts of this bill as well, and so I'm not feeling compelled, given the time that we have, to walk through section by section. I might just highlight pieces and then go through the slides. On reference based pricing, you heard and through Processing and Shield, we certainly agree that there are certain service lines across our hospital system where prices, and you see this in some of the data that we sent in, are just frankly really high. We've seen some diagnostic imaging average as high as 1300% of Medicare. I should also say that the slides that you've seen, PAWS has already seen, and a lot of folks have also already seen in conversations that we've had already, and lab's the same. So when we're looking at those slides a little later, some important considerations that we see in other states, in New England particularly, lab services are typically reimbursed anywhere from 90% to 100% of Medicare. We see some numbers in this data as high as, I think, 900%, and imaging is around two fifty. And so we do have some numbers besides 1300%. In any case, our obligation statutorily and our mission is to all Vermonters, and so when we share data, we share it as just purely representative of the data that we have for Vermonters that are members of our plan, roughly anywhere from 180 to 200,000 at this time. So savings that you see are just in that group, just through Blue Cross and Blue Shield, and the data that you have is in six hospitals. In any case, I thought that the number of 250% from the Green Mountain Care Board was really good. Again, on our members, our plan, we see a reduction in just lab and diagnostic imaging services actually getting us pretty close to that 250% number for everyone in our plan, not just individuals. So I would say that to start, and that's important to us. Secondly, in this bill, and one, so when we get into the data, I'll say, from our perspective, the only thing that we'd like to see from an affordability perspective, and to share Foster's point, affordability helps us drive accessibility. We prefer to see some action this session on these two service lines similar to what was done last session with the ASP cap. We do think that that brings what we would call immediate relief to Vermonters, and we're very sensitive, which is why we've already had the discussion with the hospitals, very sensitive to the financial impact that this would have on hospitals. We just bring a range of data. The other component of this bill that's in here that we see, frankly, as critically important for transparency is NPI codes. The NPI code portion

[Sen. Virginia "Ginny" Lyons (Chair)]: Better, you should define NPI, and then that'll help.

[Courtney Harness (Blue Cross and Blue Shield of Vermont)]: Yeah, so there's a focus on

[Sen. Virginia "Ginny" Lyons (Chair)]: What is NPI?

[Courtney Harness (Blue Cross and Blue Shield of Vermont)]: So NPI is a way for

[Sen. Virginia "Ginny" Lyons (Chair)]: What does it mean? What's N mean? What's in

[Elena (Director of Policy, Green Mountain Care Board)]: It's an acronym. National Provider Identification. Thank you.

[Courtney Harness (Blue Cross and Blue Shield of Vermont)]: And so, currently, just how billing happens, unless there's an address on a bill and someone happens to look at an address, which rarely happens, it's nearly impossible for us to tell where a service is actually provided, and we have fee schedules based on where services are provided. And without, I shouldn't say without, with these codes, it would not only give Vermonters, frankly, the opportunity to have more transparency on the bills when they get it from hospitals as to where the service was provided, it also gives all insurers, not just us and as well as the care board and our regulator, the opportunity to better understand where services are being provided and to make sure that the billing is aligned with the fee schedules that are attributed to those locations. So I will say, and we've had this discussion with hospitals internally, and this might sound really weird to hear from us, I think the date for implementation of those in the bill is 10/01/1926. We would love that. I think it is maybe a little tidy. I think we would prefer to see that 10/01/1927. And again, not because we think that this isn't important, we actually think that this, other than the price reduction on service lines, this is perhaps the most helpful piece of, maybe, end bill that we have in here at the moment for transparency and access and affordability for Vermonters. So this NPI portion, we believe, is really significant and may take a little more time to implement than what's in the current bill.

[Elena (Director of Policy, Green Mountain Care Board)]: Just to be clear, it's the two service lines of imaging and lab services. Yeah, correct.

[Courtney Harness (Blue Cross and Blue Shield of Vermont)]: And there was a question on utilization. So the rest of the bill, in terms of appeals and relative, I think we don't have any issues with that. We love the concept of pricing gas for it. As probably all know, we've done some of that already with our Affordability Matters campaigns. And frankly, have had some hospitals that are not part of some of that campaign request to be included on those public pricing models. In any case, I wanna go Just along those lines, so you do have I know

[Sen. Virginia "Ginny" Lyons (Chair)]: I understand you have a dashboard analytic dashboard. Do you contribute your information totally to or will you contribute your information to the Agreement and Care Board dashboard? I don't see

[Courtney Harness (Blue Cross and Blue Shield of Vermont)]: any reason why we wouldn't share if it was requested, and I think to Chair Foster's point, the opportunity to come together with some of the Rural Health Transformation dollars represents a great opportunity.

[Sen. Virginia "Ginny" Lyons (Chair)]: Lot of it includes Chittenden County, up here. Well, is pretty important.

[Courtney Harness (Blue Cross and Blue Shield of Vermont)]: The ups of the folks around this table, this time, but yeah, I mean, we share mostly openly when asked and requested, especially when we know there's a benefit to the market.

[Sen. Virginia "Ginny" Lyons (Chair)]: But it can't exclude UBM, which makes us infectious.

[Courtney Harness (Blue Cross and Blue Shield of Vermont)]: And, but I can just kind of briefly go through that slide deck if you'd like, and there was a question around utilization. Part of slide deck and how this data is laid out is relatively new for us in the fall,

[Elena (Director of Policy, Green Mountain Care Board)]: yeah. I'm just wondering if we can go over the slides, can we bring it up on a

[Sen. Virginia "Ginny" Lyons (Chair)]: second? Well, I don't know, can you get someone to share? Calista can't do it, but, so we'll, let's go through it. We have it on our screen. And if you could go through the slide deck briefly with us and what we might do is to schedule you next week. And we're updating this during Blue to

[Courtney Harness (Blue Cross and Blue Shield of Vermont)]: All Hospitals, by the way.

[Sen. Virginia "Ginny" Lyons (Chair)]: Let's do that. Okay, let's go through it briefly here. Then we'll come back to it another time to get Paul under stage.

[Courtney Harness (Blue Cross and Blue Shield of Vermont)]: We can do that. I'll start by saying we take the accuracy of our data very seriously, and it's used for a lot of different purposes, not just our own internal work. And so from that perspective, we shared this with you. And, again, I believe this is full 2024 data. We haven't completed all of those draft on '25, or if we have, it's not enough to have that full set of data. In any case, on the first slide, on the top left, you'll see a per member per month comparison for our plan members compared to the region, which is the Northeast and National, and again, this is just loose plans, but I should say you can see that this broken out inpatient, outpatient, professional and pharmacy, and outpatient, which is where those lab and diagnostic imaging services lie, are clearly well beyond regional and national markers. I would also say we hear often about demographics of Vermont, and we're older, and that contributes to why our prices may be so high. I'm gonna just bring us to the next slide, which has an age and gender adjusted comparison. And so you'll see allowed cost, and then next to that is age and gender adjusted, where it does bring up the region and the national numbers just slightly, but we're still well beyond those numbers. And then below that, you see broken out the inpatient, outpatient, professional, and pharmacy. And again, other than outpatient, things are really not that far off. And so we do believe that we have some work to do in outpatient. The next slide where we see the bubbles, that's a factor of PMPM, and there's some utilization in there as well. And so you see imaging all the way The higher above the bottom line you are and the further right, the worse it is. And the bigger the bubble is, the more utilization there is in that particular area.

[Elena (Director of Policy, Green Mountain Care Board)]: Curious.

[Courtney Harness (Blue Cross and Blue Shield of Vermont)]: So code level detail, again, this is really granular, so I'll just kind of breeze past this. But so you know, we do have this at code level, and at code level, we do have not just our per member per month spend and how that compares to the region and nationally, but also utilization data, so services per 1,000 people. And the next slide, so I'm in slide six, and I should tell you that hospitals are blinded on purpose on this. So you have hospitals A through F. These are lab services. So I would remind you that I said what we see across some of our neighboring states is anywhere from 90% to 100% Medicare reimbursement on these services. And I think we have the highest at 941% And labs are one of our most highly utilized services. So chair foster having a great point.

[Sen. John Benson (Member)]: Is imaging then, is that imaging? Whoops, I

[Courtney Harness (Blue Cross and Blue Shield of Vermont)]: don't what I said.

[Sen. John Benson (Member)]: Diagnostic. Diagnostic. Is that what outpatient services basically is? Those are the two biggest drivers.

[Courtney Harness (Blue Cross and Blue Shield of Vermont)]: Well, so there's quite a few services encompass the totality of outpatient, but essentially, and what we see further on, on the very last slide, and this goes back to Chair Foster's point about the 250%, The very last slide shows what would happen if we reduce these two service lines to 305100% of Medicare at six hospitals only, all in Blue Cross plans. After ACT 55, after those reductions

[Sen. Virginia "Ginny" Lyons (Chair)]: ACT 55 being the cap on

[Elena (Director of Policy, Green Mountain Care Board)]: infusion We

[Courtney Harness (Blue Cross and Blue Shield of Vermont)]: actually get some numbers that are pretty close to that 250% number that Sheriff Foster referenced. So I just wanna go up to the slide prior, which is the actual savings here. So I will say, and this is direct cost. So when we talk about affordability and, like the care board mentioned, how that feeds accessibility, this is, again, across six hospitals, only Blue Cross and Blue Shield members, bringing these services down to 300, which is still over three times the average, and 500, which is still double, is a savings of $100,000,000 to Vermonters. So we love the opportunity.

[Sen. Virginia "Ginny" Lyons (Chair)]: All other things being equal.

[Courtney Harness (Blue Cross and Blue Shield of Vermont)]: Yeah, yeah. I love it. So I know that was a lot, and like I said, we do have all hospitals hopefully being done today so we can come back and share data.

[Sen. Virginia "Ginny" Lyons (Chair)]: No, that would be great. And we did invite MDT and just to come in and chat about their work. We'll have that happen. And we'll also get the healthcare advocate in to chat about this a little bit. An It's it's it's going back

[Elena (Director of Policy, Green Mountain Care Board)]: to '98 of. Yeah. And you're suggesting what he choose is aspirational.

[Courtney Harness (Blue Cross and Blue Shield of Vermont)]: Yeah, I mean, I think we would love it. There's just a lot, without speaking for the hospital, but knowing that we've had the conversation, it's a lot of work, and it frankly takes a lot of time and a lot of investment to do it right, to make sure that and you have to you have to get the codes first. So I think our perspective is, as important as this is, to rush it might not be the thing that gets us the best result.

[Elena (Director of Policy, Green Mountain Care Board)]: There's an urgency to it as Correct, 100%. Portability is a real issue.

[Courtney Harness (Blue Cross and Blue Shield of Vermont)]: Like I said, if it were 10/01/1926, we would certainly not argue. We would just share that, I think our feeling is that it might be a plan for, a prep for, and implemented with more success within a different date.

[Sen. Virginia "Ginny" Lyons (Chair)]: I have one question. Yes. Thank you for bringing all of this to It will be helpful to go through it again. It is thought provoking, to say the least. But now obviously people are continuing to point the fingers at hospitals where the hospital costs are 38% of our total healthcare world and look at administration, administration could be pulled out in different ways. But also, you know, I think there are my constituents and others who say, what about the insurance companies? What about their administrative efficiencies? Sure. Can you talk about that a little?

[Courtney Harness (Blue Cross and Blue Shield of Vermont)]: Yeah, of course. And first, if I go back to, hey, how do these cost savings, or how do these price reductions at hospitals affect premiums? I think when we had our solvency discussion in here, and I mentioned this estimate of $87,000,000 on Act 55, we estimated that to be about 4% on premiums. So that's just the premium discussion, right? So how does that impact us? Now, administratively, we're pretty proud of how lean we are. We got a question in another committee about whether or not we should be that lean, and maybe if we weren't that lean, maybe we could have some different financial results. But we have just over 5% of our total operating expenses are administrative costs, and so how that plays out for us, and this is kind of like a dire scenario, but to give some insight into the reduction of services and costs versus if none of our 400 employees exist, right, so we figured out how to deliver all of these benefits to a third of Vermonters with no people and no cost, frankly, that would reduce people's premiums by about 5%. So we feel really good about, administratively, where we're at and where we invest our dollars. We also feel really good that Vermonters have consistently rated us over 95% in terms of their satisfaction with how they get the phone answered, and how they talk to someone, and how they get help and support that they need, and that mission is really close to us, and we take it really seriously. And so, yeah, I know I didn't get asked directly, but I think when we come back to present the full deck of data at that time, we might be done with some of our financial filings. I think interestingly enough, we're anticipating a reduction in the total amount of our executive team compensation from last year by probably double digit percentage. So we're doing the work, and it's hard work, and it's work that Vermonters need us to do for the community.

[Sen. Virginia "Ginny" Lyons (Chair)]: And it makes you empathetic with what the hospitals are doing to children.

[Courtney Harness (Blue Cross and Blue Shield of Vermont)]: And like I said, we have talked, and I think we heard Doctor. Leffler and others in joint testimony talk about just how frequent the conversation is and how different that collaboration looks than maybe a year ago, and we're also really proud of that. Really, really happy with the direction that that's going and the end results for Vermonters.

[Sen. Virginia "Ginny" Lyons (Chair)]: Thank you. Yeah, you're welcome. Thank you for bringing all this in.

[Courtney Harness (Blue Cross and Blue Shield of Vermont)]: Of course. Thank you.

[Sen. Virginia "Ginny" Lyons (Chair)]: So we're gonna move on to Jessica Byron from BMS, and then we'll go to the Boston facility. This is all helping us understand what is in the bill and then some of the things that we might consider as we have a discussion around the table and go to the

[Jessa Barnard (Vermont Medical Society)]: We are gonna do that. Good morning, thank you for having me back. Jessa Barnard with the Vermont Medical Society, and appreciate your time on the bill. I'll be talking about two different concepts in the bill, I did submit this in writing with some language suggestions. So the first chunk of sections I'm talking about are sections two through five, which talk about the outsourcing of services. And I will back up a little. I feel like both of my sections include a little store, historic context. And that while the Green Mountain Care Board is sort of defining these or discussing them as a new concept, this has been since the beginning of hospitals that hospitals have worked with private medical groups that aren't employed by the hospital. In fact, historically, that was almost all of the the specialty in medical services. They were private, independent medical groups that were and came into the hospital or on the medical staff and provided services, but were not employed by the hospital. So you actually spent a lot of time talking about how maybe that hasn't been a good thing and actually we want to encourage independent medical groups and alternatives to hospital services. So these are local, I mean not all, but many of these local Vermont based independent provider organizations that provide services within a hospital. These are not by and large, in fact I don't know that we have any private equity backed medical groups. Some may be out of state, but these are not big corporate megaliths providing these services. Some of these are, you know, your local independent practice. You know, I'll give an example of, there's been a lot of conversation, the pediatric services in Rutland. Those are not Rutland employee pediatricians, those are actually employed by the local FQHCs and then provide the inpatient pediatric services

[Sen. Virginia "Ginny" Lyons (Chair)]: at the hospital. So I just want

[Jessa Barnard (Vermont Medical Society)]: a little context for what some of these entities may be. And I think we could all agree, maybe we would like a little more understanding of who these groups are, how they operate in Vermont, how are they billing, how are they being paid. I think everybody agrees transparency is a good goal. Let's work towards the transparency, take a reporting of the information of what is being spent on these contracts or on these services. But until, VMS' position is until we really understand who these provider types are that we're talking about, does it, some of what's in the bill is really, feels premature and actually unworkable, for example, having the hospital bill for their services. These are independent third party organizations. The hospital I don't even know legally can bill for their services. These are not hospital providers, you know, are not hospital employees providing these services. So we support the approach that Bob will be talking more about and recommends, which is reporting on the outsourced services, and after getting more information from both the hospitals and these contracted independent providers, and assessing the impact on access, quality, and affordability, then there could be recommendations about just do more regulatory, is more regulatory oversight needed, what form should that take, what should it look like? I personally don't think we have our arms yet quite around what groups are we taught, are they all the same? Are we treating them all the same? How are they impacting, are they actually in fact lowering costs for responders? We do know a couple of things, I just wanna be really clear. Patients should not, are not paying out of pocket anymore for these services. They are covered by the federal No Surprises Act that's already addressed in federal law. So this should not in any way be harming Vermonters, and it actually is helping, we think, provide access when the hospital either can't or doesn't think it's the most effective, affordable, high quality way of providing those services. So our language suggestions are in our testimony. And then I'll, I can pause there if that's helpful, or I can, you shall have We'll an have, we'll question? Sure.

[Sen. Virginia "Ginny" Lyons (Chair)]: I have a patient, well, patient budget.

[Jessa Barnard (Vermont Medical Society)]: So, from where I'm sitting, you know, we ask the Green Medical Care Board to do what they can to bring down costs, and then, you know, then we criticize them for not doing enough, and, you know, damned if you do, damned if you don't. I guess I'd like to hear how this got in the bill if you're saying no one knows what it is and no one understands it. And now we need to do a study.

[Sen. Virginia "Ginny" Lyons (Chair)]: Didn't put it in, the Green Man Board requested this bill. Okay. So that is a bill that the Green Mountain Care Board has requested. I understand.

[Jessa Barnard (Vermont Medical Society)]: I think, I don't wanna say we don't know anything about that. That is an overstatement. I think I, we, there is, and actually, Bob can probably give, or Green Mountain Care Board can give more specific. I believe there are, is some reporting in the hospital budget process about what they are spending on these contracts. I think the, but who, I don't know, mean, I just heard the chair say there may not be full information about who the contracted provider types are. Like I think you know about the costs, but in, and the cost of the contracts, but exactly who it is providing those services, I think it would be useful. And how, so I think there's two different, there's two different pieces of the costs in my mind. There is what the hospital is paying for the labor. And that, I believe the hospital wouldn't do unless it was less expensive than employing their own clinicians. But then there is what that provider is charging the payers to provide that service. And that, I think, is the piece we could have more information about. I don't because, again, this is not billing that the hospital is doing.

[Sen. Virginia "Ginny" Lyons (Chair)]: It is billing from an independent entity. So we may not have Labs are independent entities.

[Jessa Barnard (Vermont Medical Society)]: Labs are all, well, some

[Sen. Virginia "Ginny" Lyons (Chair)]: are, and some labs are contracted out. Some lab services are contracted out.

[Jessa Barnard (Vermont Medical Society)]: Right. I think that may be a little diff I think labs may excluded. And radiology may be excluded. I think they're really trying to look more at the people labor piece rather than services.

[Sen. Virginia "Ginny" Lyons (Chair)]: This will get us into discussion where we are so we understand one of the reasons I'm not I don't want to put words in the mouths of the board, but my interest here is what effect, if any, does it have on the provider to act? She's one of our community Yeah,

[Jessa Barnard (Vermont Medical Society)]: I, yeah, I'll, I'll maybe defer to boss to talk more about that. Yes. I mean, I know they are paying corporate income tax and stuff, or, or, again, depends, it depends, again, I think it depends on who we're talking about.

[Sen. Virginia "Ginny" Lyons (Chair)]: Depends on where it goes and how

[Jessa Barnard (Vermont Medical Society)]: it's utilized. And how the entity is structured. I mean, these could be different types of provider groups providing these services if they're not all properly they're not all taking the same form. I mean, again, these are inter So that's a problem.

[Sen. Virginia "Ginny" Lyons (Chair)]: Mean, you know, so. Good. Okay. People opened up Pandora's box.

[Jessa Barnard (Vermont Medical Society)]: Sections six through eight are, as introduced, proposed repealing healthcare professional bargaining groups. Again, a little history. These were created by the legislature in the 90s, specifically to negotiate items like global budgets and expenditure targets. They wanted to enable healthcare professionals to discuss healthcare budgets with state governments and to allow those discussions to be protected from violating federal antitrust law, so that there can be honest, open discussions talking about specific prices and rates. BMS formed one in, first back in 1994, the Physician Policy Council, PQC. There were others at the time, such as dentists. And it expressly authorizes those entities to negotiate with government agencies like STEVA, AHS, Green Mountain Care Board, and Department of Labor. We also activated ours in, again in the 90s and 2000s to discuss Medicaid reimbursements. Statute and rule outline the requirements to apply and be approved as a PPC. The Green Mountain Care Board actually has that authority, and they, our group, the PPC, most recently applied and was approved by the Green Mountain Care Board just last year, 2025. Now, I understand this, and it does, it's an arbitration process. It is, in my mind, a bit similar to a union. Do employers always love having to come to the table and talk with a union? I'm not sure they do, but that is the process that we, it provides a structure and a framework for the transparency, the conversation, the process of how to have conversations. And again, this is not just for the Green Mountain Care Board, it's for other entities as well. We, in the past couple of weeks, have met twice with the Green Mountain Care Board to discuss this proposal or this section of the bill. We exchanged a number of emails with them and all of those conversations. Prior to yesterday, the Green Mountain Care Board staff expressed that their primary concern was reference based pricing and that there are specific rules and there's gonna be a lot of transparency and stakeholder engagement in that process. They didn't wanna disrupt, derail, slow that process down. We are comfortable that we understand that is a specific defined next step that they and the legislature want to take and that there is gonna be, you know, stakeholder input and a process around how that is structured. So we are proposing in language and comfortable with a specific carve out saying that the provider bargaining groups are, know, basically that would be an exemption from a topic that the provider bargaining groups could target over. That is, we are amenable to that. What about adding global budgeting? Think that's wrong. Let me think about that. I don't think

[Sen. Virginia "Ginny" Lyons (Chair)]: that's the question on the table because it's also going to be an important going forward.

[Jessa Barnard (Vermont Medical Society)]: Yeah, I mean, I will say that that was at least originally one of the intensive But talk though that could be discussed in this we would not at this point support eliminating all Green Mountain Care Board work from the potential of engaging with provider bargaining groups understanding. Just like they have tools they rarely implement, we have not activated this in years and don't have any present intent to, but it is a tool we would like

[Sen. Virginia "Ginny" Lyons (Chair)]: to keep on the table.

[Jessa Barnard (Vermont Medical Society)]: Those are the sections of the bill that we have language on and suggestions.

[Sen. Virginia "Ginny" Lyons (Chair)]: Thank you. Thank you. This is our time. So we have a whole lot of things that we're gonna have to put together. This this provides us with great discussion points and understanding. So, Devin, welcome.

[Speaker 3]: Thank you. And happy to come back if we run out of time or attend.

[Sen. Virginia "Ginny" Lyons (Chair)]: We will. I know, but this is the beginning. Yeah. So, yeah, we need we'll have May and June next week. We'll see how that goes.

[Speaker 3]: Great, thank you. Jen Green, Vermont Association of Hospitals and Health Systems, thanks for having me in today. Just to start off on section one with the reference based pricing piece, the language that the Green Mountain Care Board presented today is new to us. If that's replacing the, and I think it's replacing the requirement that hospitals report their prices as a percentage of Medicare. I haven't had a chance to sit down and look at that language, but I'm actually happy to sit down and look at it.

[Jen Green (Vermont Association of Hospitals and Health Systems)]: It may be workable. Our hospitals understand that our radiology and lab prices are too high. We aren't interested in lowering those prices. I will point out that the Blue Cross Blue Shield numbers are from 2024, and so the numbers may be different now. But we're happy to look at the Green Mountain Care Board proposal. The Blue Cross Blue Shield proposal, I also want to point out that it saves $100,000,000 for Blue Cross Blue Shield. The impact of hospitals will be much greater because Blue Cross Blue Shield is just one insurer that hospitals get paid from. And the way the proposal would work is hospitals would have to apply that price to everyone, and so we are potentially looking more at something like $300,000,000 impact to hospitals, which would be pretty devastating given our financial situations at the moment. But what I will say is that hospitals have been talking to Blue Cross Blue Shield. We've been really optimistic about the direction that Blue Cross Blue Shield has been going in. I think hospitals are changing their direction as well, and we are coming together on a lot of things, and I think we have a good opportunity going forward to come up with something that will create greater affordability for our doctors.

[Elena (Director of Policy, Green Mountain Care Board)]: So just maybe semantics, use your language that you just used, $100,000,000 when we say Blue Cross Blue Shield. The language they use was $100,000,000 saved for the people of Vermont.

[Jen Green (Vermont Association of Hospitals and Health Systems)]: For the people of Blue Cross Blue Shield.

[Elena (Director of Policy, Green Mountain Care Board)]: Right, God. That's what I mean. Thank you. Yes. That's what I'm making sure. Yes. You.

[Jen Green (Vermont Association of Hospitals and Health Systems)]: So that's where we are on that piece. And for the National Provider Identifier, NPI, we agree with Blue Cross Blue Shield that that would be a heavy lift for 10/01/2026. In addition to that, the Feds just passed a law requiring hospitals to do this, and they're gonna be putting out rule making with definitions, and that law is implemented for hospitals on 01/01/2028, and we don't want to get into a position, if we have to do it for 2026, where the definition that the feds are giving is different, and that would be a waste of administrative resources and affect supportability. So we would ask for some alignment. I will go back to my members, but I think 10/01/2027 should be pretty reasonable. That would make sure that we apply to the, will fit in with the federal law, we will have all the definitions at that point, and so I think we can make that work. And put here 01/01/2028, but I'll go back in. And then sections two through five, outsourcing of services. I understand the Green Mountain Care Board's concern about budgets. You know, they do not want a hospital to say that their budget is 100,000,000, but then 10,000,000 is outsourced, and in terms of their revenue. I think that, you know, detailed reporting will help them get there. They have all the tools. If they see the reporting and they say, actually your budget is, your revenue is 90,000,000, then they can cap our revenue at 90,000,000. They don't have to cap it at that 100,000,000. So I think it's more important that they get the correct information, and then they can take it from there. In terms of the impact of this, I am really worried about its impact on access in hospitals. I was surprised to hear the chair say that a lot of this is going to private equity. The experience that we've seen, and you can see it back on Doctor. Ada Adeck's testimony from previously, was- Rattlesboro Memorial Hospital. They used a pathologist from UVM when they could not hire a pathologist, and one concern I have there is if UVM is counting the pathologist's revenue, but then Brattleboro also has to count the pathologists' revenue. It's like double counting artificially inflating the revenue numbers. And then the other piece that Brattleboro used outsourcing for was when their anesthesiologist leader died quite suddenly. He was young and died very suddenly, and they were not able to provide those anesthesiology services, and the only thing that they could find in that time period was a local CRNA anesthesiology group. And so they outsourced that service then to ensure that they could continue to provide those critical services. I'm not sure if that local anesthesiology group would want to get into a situation where they're essentially regulated by the Green Medical Care Board. They may be less likely to join the hospital in that case. And so I would want Green Mountain Care Board to get input from those folks about how this regulation impacts them so that we can ensure that we don't decrease access. And then finally, the out of state portion was Blue Water Group, which you heard from, and they are not private equity, and they are four chalked it. They do pay corporate taxes, and they're regional, New Hampshire, Maine, Vermont organization, and they did come in and help when their key contract was dropped quite suddenly from Cheshire Hospital. And so again, we were looking for how do we maintain access to care quickly, and that's where the outsourcing happened. So our proposal is not to shy away from this. We want to shine a light on outsourcing. We understand the need to do that, but we also don't want to impact access to care. And so let's take a beat and get good reporting on it and talk to the stakeholders and organizations. And then finally, for the hospital audits piece, I appreciate what Chair Foster spoke to in terms of wanting to ensure that budget reporting was accurate. The language here in this bill is much broader than that. It would allow for the kind of auditing that Dan Bar testified to that would cost significant dollars to hospitals and take up to a year's time. The standard that they provided, is helpful, reasonably necessary, which is a legal standard, but helpful, that's not a legal standard. It's really vague. And we don't understand the need for this when we also have the observer at home. And we worry about having both the observer and an auditor in the hospital at the same time. The current observer has charged, I think, about 250,000 for UVM Health. We heard from Mary Block that auditing, like a full audit could cost 300,000. That's a significant amount of money and time to hospitals. And it doesn't mean that we don't want to be regulated or anything like that, we just think that there needs to be more guide rails. We think the observer fits this bill, and the current powers that's remapped here for it already has since this bill.

[Elena (Director of Policy, Green Mountain Care Board)]: So, I think I should suppose the problem, it's very possible, but isn't the observer going away? It's these two later this year?

[Jen Green (Vermont Association of Hospitals and Health Systems)]: No, it's not. Not this year, I think

[Elena (Director of Policy, Green Mountain Care Board)]: it's like in three years, Yeah, pictured it two

[Sen. Virginia "Ginny" Lyons (Chair)]: Thank like or you. Some questions. Go ahead and

[Sen. John Benson (Member)]: get by Ashley. It's a question earlier to Chair Foster. And I just want

[Owen Foster (Chair, Green Mountain Care Board)]: to get an understanding.

[Sen. John Benson (Member)]: You're charging, it seems like, pretty high rates for imaging and the Flat. Right. But that and you're undercharging probably in other services. Mhmm. I don't know. But if we start pulling the revenues away from the higher charging ones and sending it somewhere else, and I'm calling it Akash, have to put it this online, Is that going to impact the other services at the hospital because you're not

[Owen Foster (Chair, Green Mountain Care Board)]: making as much money on those?

[Jen Green (Vermont Association of Hospitals and Health Systems)]: Yeah, and I haven't had a chance to really go through the new proposal, so someone could correct me here. So, yes, ideally you would take some of that money from, you know, you would take some of that money, provide it back to Vermonters as affordability, and take a little bit of that money and put it to things like birthing and pediatrics and things that are typically underfunded so that those are sustainable. It sounds like that that sort of scenario is not necessarily happening under this proposal. So those areas may still be at risk. Would need to Well, that's concern.

[Sen. John Benson (Member)]: The other services that Yeah. That are big finding. Just just my consent.

[Jen Green (Vermont Association of Hospitals and Health Systems)]: Yes. Thank

[Sen. Virginia "Ginny" Lyons (Chair)]: you. Other questions? We good? Thank you. One more thing. Oh, On the dashboard, I'll

[Jen Green (Vermont Association of Hospitals and Health Systems)]: say that Miles is going to come out with a dashboard within the next couple of months that addresses hospital quality access and affordability, and we will not need the RHTF funding to do it, so hopefully there will be more available to go to all of Vermont.

[Sen. Virginia "Ginny" Lyons (Chair)]: Thank you. No thank you and we will have folks back in as we just debate the bill and look at the bill. We do have another topic coming up and is there anyone else who we have skipped to think so? Emily Hawes I think is here. She might be in the in the hallway. She's in the hallway. We should partner for the pregnancy and and but we'll see. So,

[Speaker 3]: okay.

[Elena (Director of Policy, Green Mountain Care Board)]: It'll take me a couple minutes to get cleaned up. Alright. So we've

[Sen. Virginia "Ginny" Lyons (Chair)]: just had our heads filled up with Pre Mental Care Board and Hospitals, so that we're now, we're going to another place, the mental health world. The reason that I ran into Emily yesterday and I want to appreciate your availability on short notice. I want to say that because I know it's not a simple thing. But I thought it would be helpful for us to look at where the department is, what the department is currently doing, and just kind of an overview. We haven't spent a lot of time on mental health issues in here at all this year, but have, tangentially. We have specific questions. And I'm gonna have to leave in about five minutes, and Senator Gulick will be taking over.

[Speaker 3]: Power grab right there. So

[Sen. Virginia "Ginny" Lyons (Chair)]: this would be helpful, and I know there's a lot coming up on the Rural Health Transformation grant process that you and I talked about that maybe you can go back in a little bit, because this isn't the day, but it will be helpful when you come back in that we know how the entire state is being covered, including Chittenden County. And so, right now, we'll just look at what we have here.

[Owen Foster (Chair, Green Mountain Care Board)]: Okay. Great. I

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

[Elena (Director of Policy, Green Mountain Care Board)]: Oh, are.

[Sen. Virginia "Ginny" Lyons (Chair)]: Calista, can you let Commissioner Voss share? Can you have her share the screen, please?

[Elena (Director of Policy, Green Mountain Care Board)]: Or Claire. Or Claire. Who is it?

[Sen. Virginia "Ginny" Lyons (Chair)]: Claire Neil. Claire Neil, please. Didn't hear you.

[Elena (Director of Policy, Green Mountain Care Board)]: Nobody's in the Zoom. Yes, can you send me the link? Please. Claire

[Sen. Virginia "Ginny" Lyons (Chair)]: Neil needs the Zoom link and then the share, please.

[Owen Foster (Chair, Green Mountain Care Board)]: I don't know how you guys did it in those years during COVID.

[Sen. Virginia "Ginny" Lyons (Chair)]: I can tell you the story someday about the telephone meetings we had. Those were exciting.

[Owen Foster (Chair, Green Mountain Care Board)]: I see.

[Sen. Virginia "Ginny" Lyons (Chair)]: By telephone. It was fun. It was only for two weeks till we went along March 13, whatever year it was. Was. And we went, it was March 13, and we dived into the telephone, and it was,

[Elena (Director of Policy, Green Mountain Care Board)]: let's see. An opportunity for resilience.

[Sen. Virginia "Ginny" Lyons (Chair)]: Only spoken welcome reservation right now. I had it marked on my calendar, and it was the police dogs here, whatever calendar got given to the last thing my family did was that weekend is we had, like, five birthdays where you count in laws and grandkids, and we always do Claire, dinner. You That is it. Half. Just just a year and a half.

[Elena (Director of Policy, Green Mountain Care Board)]: We're working on it. The Internet is a little Oh,

[Sen. Virginia "Ginny" Lyons (Chair)]: it gets slow. And especially where she's sitting, it gets a little slow.

[Elena (Director of Policy, Green Mountain Care Board)]: Yes. We do have a dark hole. Oh. Hello. That We used

[Sen. Virginia "Ginny" Lyons (Chair)]: to blame senator McCormick because he has a blood eye and was always having trouble sitting in that seat. And then I came in and sat in that seat, and I couldn't get

[Owen Foster (Chair, Green Mountain Care Board)]: on a lot of it.

[Sen. Virginia "Ginny" Lyons (Chair)]: And they did have the text down. There's a dark hole. Alright.

[Elena (Director of Policy, Green Mountain Care Board)]: Let's see what's happening here.

[Sen. Virginia "Ginny" Lyons (Chair)]: Did you get the link? Yeah. Okay.

[Elena (Director of Policy, Green Mountain Care Board)]: But I think I can meet up with you. That's fine. All right, well thank you. For the record, my name is Emily Hawes and I'm the Commissioner for the Department of Mental Health. So thanks for having me here today.

[Emily Hawes (Commissioner, Vermont Department of Mental Health)]: Just gonna provide a general overview of the Department of Mental Health, answer questions that folks might have, and we'll go from there. So just real brief, the mission for the Department of Mental Health is to promote mental health as a vital part of overall health and well-being, and that Vermonters live in caring, inclusive communities that respond with compassion and respects to mental health needs. We want to make sure that we're partnering with individuals, families, communities to provide equitable, effective, and compassionate support. As a department, we operate under the departmental core values, which is compassion, equity, integrity, collaboration, accountability. And this is the framework for how we make budgetary decisions, engage in new initiatives and think about our system from a statewide perspective. So what we do, so we're responsible through statute for the mental health system of care for Vermont. Your name is out there now,

[Sen. Virginia "Ginny" Lyons (Chair)]: not your slides yet.

[Emily Hawes (Commissioner, Vermont Department of Mental Health)]: Okay, well, your slides were there, but it seems like they weren't moving forward. Is that right?

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

[Emily Hawes (Commissioner, Vermont Department of Mental Health)]: we are. Okay. So you just went through this one. I did. I breezed right through it. We're composed of three twenty six staff positions, which primarily includes the staff within the two facilities that the department oversees and runs. We oversee 10 designated agencies and two specialized service agencies. Like I said, we have two facilities, the Vermont Psychiatric Care Hospital, which is currently a 25 bed hospital level of care for adults. And then River Valley Therapeutic Residence, which is a secure facility residential program for individuals who are under the care and custody of the commissioner, so a step down from hospital setting. We also manage several contracts and grants to peer organizations, forensic psychiatrist, psychiatry consultation with primary care, and then of course we partner with just about anybody and everybody who wants to partner with us, but that certainly includes hospitals, community providers, housing specialists, police departments, sports, and so on.

[Sen. Virginia "Ginny" Lyons (Chair)]: Can I ask a question? Absolutely. Can you give us

[Emily Hawes (Commissioner, Vermont Department of Mental Health)]: a sense of how full or you're asking me at River Valley and the care hospital? Yes. So River Valley has a, have up to 16 folks. They're currently on a census of 12, and for two reasons. One is some construction is going on there that takes three rooms offline. They're building a seclusion and restraint suite there, which was not included in the original development. And so, the other factor that leads to how many folks that River Valley can serve is the amount of staff that they have. And we have to balance paying for travel staff with hiring permanent staff. And so, how River Valley is operating right now is they're able to open more beds as more permanent staff come on, and we're slowly weaning off the travel nurse contracts there.

[Sen. Virginia "Ginny" Lyons (Chair)]: You had Tenth City for Middlesex.

[Emily Hawes (Commissioner, Vermont Department of Mental Health)]: Oh, the Middlesex Therapeutic Community. Yes. Yes. The FEMA trailer.

[Sen. Virginia "Ginny" Lyons (Chair)]: Yes. They're quite interesting. Is that still functioning? Or That's a great question. Heard that youth were going there.

[Emily Hawes (Commissioner, Vermont Department of Mental Health)]: Yes. So that is currently being utilized by the Department of Children and Families, as

[Sen. Virginia "Ginny" Lyons (Chair)]: a Woodside sort of?

[Emily Hawes (Commissioner, Vermont Department of Mental Health)]: It depends on what the clinical needs are and jurisdictional needs for a particular use, but DCF would certainly be the ones who can provide more information about that particular program. It's a smaller scale program than when DMH was I think we had maybe eight or nine beds there now and it's probably half of that.

[Sen. Virginia "Ginny" Lyons (Chair)]: Okay. I just drive by frequently, I haven't heard very much about it, which is good. If there were problems, I would have heard.

[Emily Hawes (Commissioner, Vermont Department of Mental Health)]: Yeah. There were some, you know, from the adult perspective, there was some, back after Tropical Storm Irene, there was an adjustment going into that placement, but I think overall it served the system well. Certainly the adults who are being served at River Valley Therapeutic Residence are doing quite well there. So, what this slide represents is a overall description of our broad system. You'll see at the bottom is our foundation to the rest. And our foundation really sits with community mental health services. Those are your outpatient services that are delivered across the designated agencies, specialized service agencies. There are private providers within the system, but this is reflecting the programs and services that are delivered and overseen by the Department of Mental Health. So we also have included in here various group homes for youth. And then those that are called out in orange are services that reach across the age span. So, we're providing those services young all the way up to our motherboard modules.

[Unidentified Committee Member]: So, you really did a question of if you could blame me for the London that you and I attended. We were talking about different things on mental health, and and we also just heard a lot of testimony about the substance abuse and the homes that are being set up and, you know, people come out of intensive, and they have support from, they can live in a safe environment, a home, but have somebody make sure they take their medication and goes to their appointments and so forth. And they seem that would be great to have that awesome kind of support network for mental health. And I mentioned that chair and as you know, there's the big federal grant for rural health here and she suggested I send the note off to Jill just mentioning So if you get a call from her saying, what is all this about? Now you will know. Yep. I just sent that note and said, maybe this might fit and can't maybe support the process going forward, but maybe the establishment of few homes in some communities might fit into that program.

[Emily Hawes (Commissioner, Vermont Department of Mental Health)]: Yeah, I believe that Jill Olson and perhaps myself and other AHS folks might be happy to come in next week to talk a little bit more about that. I'll come back to question and just make sure that Jill knows it came up during today's testimony as well. Thank you. Next up from our foundational perspective are crisis supports and response. So the department partners with the designated agency system and other partners to incorporate crisis support in response to our communities. What that looks like, you'll see 988 here on my tablet. 988 is a national crisis in lifeline text call chat for folks who are experiencing any kind of crisis or seeing someone that they may be supportive of experiencing some challenging times. That 988 line is for both mental health and substance use. In those calls, we contract with Northeast Kingdom Human Services and Northwestern Counseling Services and Vermonters are answering those calls. Claire, I'm sorry, I'm gonna skip down to our crisis system real quick and talk a little bit more about those slides under crisis since we're talking about our continuum of care a little bit. So, slide 20, we never even get

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

[Emily Hawes (Commissioner, Vermont Department of Mental Health)]: Department of Mental Health follows the SAMHSA guidelines for developing and implementing. Sorry, Paula.

[Sen. Virginia "Ginny" Lyons (Chair)]: I'll get there.

[Emily Hawes (Commissioner, Vermont Department of Mental Health)]: There it is. Is 20 gone? Oh, Is it 20? Yeah. Oh, it's 14 for you. Well, We love shared It's 20 for me, but that's all right. So, we operate under a crisis continuum of care founded on someone to call, someone to respond and somewhere to go. And so that is how we look at our 988. We also look at our mobile crisis response. We have two person teams that can respond out into the community 20 fourseven. And then we have implemented mental health urgent cares across the state and then a crisis meds, which is where somebody can stay overnight or a few overnights if they need to before transitioning back into their independent living. This system has really evolved over the last couple of years in that it is moving towards better integration with individuals experiencing substance use crises. So it's not just for folks who are experiencing a mental health crisis, but we're really able to respond to folks who are also experiencing substance use crises. Pause there and see if there's any questions about our crisis continuum before I make clear go back to the pyramid. I'm so sorry. You'll see that our next level of care is sitting in the middle, and those are our intensive residential treatment programs. A majority of those were developed out of the response to Tropical Storm Irene. And then we also incorporate residential programs for persons with lived experience. And then for youth PNMI is a private non medical institution. There's a funding model around PNMIs. And then our newest program, is hopefully coming online this summer in July, is the youth psychiatric residential treatment facility, and that will be online at the Rattleboro Overtreatment. Currently, who require that level of care are sent out of state, and so this is our opportunity to provide that level of care here in Vermont and decrease the amount of youth who are receiving services out of state. It won't solve all of it, but it will be an additional resource for folks to have access to. The next level up, as I stated, our secure residential, which is the River Valley Therapeutic Residence. And then you'll see at the top line, we have inpatient hospitalization and inpatient hospitalization for psychiatric care has the same requirements as inpatient hospitalization for medical care. And that is that somebody requires 20 fourseven nursing and physician supports. We have currently aligned at the Brattleboro Retreat, all youth inpatient beds currently sit with the Brattleboro Retreat. We are in the process of building and coordinating with Southwestern Vermont Medical Center for another youth unit within that facility. We're in contract negotiations right now, so that's why you won't see that on this pyramid yet, but next year, hopefully so. Then we have general inpatient beds for adults who are both voluntary and involuntary. And then what is historically known as a level one unit and level one was the language that the state of Vermont chose to replace or to define individuals who historically would have gone to the Vermont State Hospital. So those individuals need a higher level of staffing and service array to meet their clinical needs.

[Sen. Virginia "Ginny" Lyons (Chair)]: I'm going back many years. Channeling Senator Lucy. Therefore, people in the corrections system. Because of their behavior or in solitary confinement, they would come out and they would go right back in because the behaviors repeated themselves. Some of them had been in solitary for years. And the thought was that these were really mental health patients at some level that it was fairly cruel to keep people in solitary for many years. Can we fix that at all? Have we found because I know the hospital up here in Berlin is a secure facility. And I'm also asked I know we were having trouble staffing that when it first opened. What's So happening at that intense level?

[Emily Hawes (Commissioner, Vermont Department of Mental Health)]: Sure, and that's a really good question. I will defer to the Department of Corrections around how they're supporting folks, But in general, the correction system has really acknowledged that being alone in a cell for long periods of time, regardless of who you are as a human, impacts someone. But I'll defer to DOC to talk about how they approach folks who are in their care who are dysregulated for a variety of reasons, whether it be someone experiencing a mental health challenge or others. There's a lot of different complexities that can play into someone's behavior. From a Vermont Psychiatric Care Hospital perspective, which is a 25 bed hospital currently operated by DMH on the hill here in Berlin, they experience the same staffing challenges that any hospital experiences. And then on top of that, there is a workforce challenge for people, nursing staff and psychiatrists who are serving individuals with mental health needs. And so, they certainly have a high number of travelers, but that number has come down significantly over the past several years. Good. And both of all? There are 21 individuals admitted there, and that is as high of a capacity that VPCH can That serve right

[Sen. Virginia "Ginny" Lyons (Chair)]: was subject to a lot of discussion. Yes.

[Emily Hawes (Commissioner, Vermont Department of Mental Health)]: So they are what I would consider full. Okay. Any more questions about the broad system from the diagram? I'm gonna move into a little more direct information around our children's mental health system of care, because I think that has been a topic of interest in this committee. What you'll see from this slide is we are looking at the system of serving both the youth and the families that surround them. And so, from our lowest barrier intervention like promotion and prevention, such as wellness and psychoeducation, young adult leadership training, school mental health role, and then the mental health consultation. Then we also have specialized rehab services for youth, clinic based therapy, respite. And then one of the opportunities I'd like to highlight is the Vermont CPAP program, which is an opportunity for a primary care physician who's serving some youth to get consultation from a psychiatrist in real time. That was historically, is currently funded through a HRSA grant, and that's been something that has been quite successful with our primary care providers.

[Sen. Virginia "Ginny" Lyons (Chair)]: We're hearing a lot about adult health costs in schools. And this seems to be a relatively new phenomenon, at least the intensity of it started before COVID. But does anyone look looking into why why are we suddenly seeing all this mental health issues with adolescents? And is there something you can do? Is have you charged anyone with them than that? Is anyone doing it on their own?

[Emily Hawes (Commissioner, Vermont Department of Mental Health)]: Yeah. That's a that's a great question. So I the short answer is yes. Absolutely. We want our youth to be resilient, and youth are the most resilient group of folks around.

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

[Emily Hawes (Commissioner, Vermont Department of Mental Health)]: I still think we are I still think look at me. I'm 50. I just called myself a youth, but, you know, you're a youth. I'm a healthy. I what I don't want us to do is lose sight of that youth are still resilient, but what we have identified, and DMH works very closely with our partners at the agency of education and with DCF, and talk about how we can make and support youth and families in accessing services when and where they want to and need them, having them readily available, and then also supporting our educators, not only with their own challenges, because adulting is hard too, but also supporting youth that are

[Sen. Virginia "Ginny" Lyons (Chair)]: in their lunch rooms.

[Emily Hawes (Commissioner, Vermont Department of Mental Health)]: So I would say yes, we have several work groups who meet regularly and talk more broadly, and then there's more pointed conversations about particular youth and how to support their families. The next couple of I'm just being a little bit aware of the time. But one thing I'd also like to highlight is the work that the department has done in line with a national funding model referred to as CCVHC. So certified community based integrated health clinics. And a CCVHC payment model is very similar to what most folks know as an SQHC, the Federally Qualified Health Center Paid Comodel. But this is specific to clinics who provide an array of required services. And so, services include crisis interventions, it includes outpatient mental health and substance use services, it includes primary care screening and monitoring, specific targeted case management, screening assessment, diagnosis and risk assessment. Also has a specific integration of persons with lived experience, peers and caregiver supports. There is a requirement to integrate services for uniformed service members and veterans. It's person centered and family centered treatment planning,

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

[Emily Hawes (Commissioner, Vermont Department of Mental Health)]: then also psychiatric rehab services. And so, what this shift will do is provide a cohesive delivery of services across the system of mental health and substance use from the outpatient level. So, not your residential programs for substance use or so on, but this is a payment model really looking at your outpatient array of services. It is currently happening, we have two agencies that have met the certification criteria and are drawing down an enhanced match for those services. Those two agencies are the Clara Martin Center, which is Orange and the upper five Windsor towns. And then also Rutland, the Rutland Mental Health Service. So they're currently operating under this model because Vermont is under a federal demonstration waiver, we are able to provide an enhanced match. We have five more agencies in the process of certification with a goal for those agencies to come online in July. So I'll pause there and we probably are about through with a general overview, but you've asked really great questions, and so I want to make sure that we have some time if there's any additional, yes. I have one that I've been asked to ask. Oh, great. I have just the conduit here, but I was asked to mention or have you weigh in on the forensic facility for mental health and the judicial process. Sure. What your thoughts are? Yes, DMH did provide testimony yesterday in the Senate judiciary along with the Department of Corrections, and this is an AHS in collaboration with the Governor's office. And one thing I'd like to differentiate is that the concept of the forensic facility is to address some of the gaps in the system. And those gaps are for individuals experiencing a mental health condition or perhaps substance use, traumatic brain injury, dementia, who do not need a hospital level of care, but still have either pending charges where competency is under question, or they perhaps have been found not guilty by reason of insanity, still have treatment needs and still have public safety needs. And so that's 01/1993 is something that DMH is in support of as we continue to collaborate with the state's attorneys, Department of Corrections, and the agency of human services, and of course

[Sen. Virginia "Ginny" Lyons (Chair)]: that's been awesome. How are we doing? Yeah. Picture box. Yes. You're welcome. I'll have to eat ice cream. Oh, that happens later too. No ice cream.

[Emily Hawes (Commissioner, Vermont Department of Mental Health)]: No ice cream. Wait, you can schedule me around ice cream? No, I schedule ice cream during

[Sen. Virginia "Ginny" Lyons (Chair)]: my fitting meeting. Oh man. I just wanna say it would be great to hear your testimony. I will look at it and listen, We've just finished the conference on the budget adjustment act, so that's why. Great. Very important.

[Emily Hawes (Commissioner, Vermont Department of Mental Health)]: Unless there's any further questions, I was right at the end, so. Perfect timing.

[Sen. Virginia "Ginny" Lyons (Chair)]: We'll get to Rural Health Transformation another time. We really want to, we'll continue to meet and talk with AHS overall, but mental health is an important component of what's going happen. Yes, absolutely. Thank you.

[Emily Hawes (Commissioner, Vermont Department of Mental Health)]: Thank you, appreciate it. Thank you Claire for dealing with the interwebs.

[Sen. Virginia "Ginny" Lyons (Chair)]: We have Katie here and we have January and then we ask Michelle Child to come in just to walk through another bill that we might be able to read something with. Maybe not. Thank you, team. And I know you're on a tight schedule. Everybody's on it. Claire, thank you for being here. Thank you, Shane. Take care. Thank you. Good morning.

[Elena (Director of Policy, Green Mountain Care Board)]: Katie, we've got an office with the council. Do you want me to pull up the latest iteration of your draft? We can

[Sen. Virginia "Ginny" Lyons (Chair)]: put it up. Think that we went through it yesterday. We've had the conversation about not adding additional language. We made one change yesterday. We did. You added volunteers. We added volunteers, and I hear that that's acceptable to the folks interested. All in favor of volunteers say Do you think John's feeling bad? He's telling more people

[Courtney Harness (Blue Cross and Blue Shield of Vermont)]: that I I don't know.

[Unidentified Committee Member]: Didn't say why he popped up.

[Katie McLinn (Office of Legislative Counsel)]: I think he'll be back. Why?

[Sen. Virginia "Ginny" Lyons (Chair)]: He's the clerk. You want us

[Katie McLinn (Office of Legislative Counsel)]: to just just kill a little time?

[Sen. Virginia "Ginny" Lyons (Chair)]: We can chitchat. We can chitchat. Well,

[Katie McLinn (Office of Legislative Counsel)]: didn't Melissa leave us the form to fill out and stuff like that? Yes. They are on my desk by the

[Sen. Virginia "Ginny" Lyons (Chair)]: the Maybe Calista Yeah. On

[Katie McLinn (Office of Legislative Counsel)]: the desk in a folder. Perfect. Making a motion to vote favorably on version two point one? Three point one. 3.1 of S one that could be seven. And accolating the recovery risk and certification. Adding the force file. That makes the new draft so

[Sen. Virginia "Ginny" Lyons (Chair)]: all those volunteers make it exactly okay the discussion committee on the bill I want to say that this committee has been working on putting a system in place for recovery residences now for two or three sessions and working with Katie on this. It doesn't feel like a big bill, but it is a big bill. It is significant to our substance use disorder support system in the state and I'm really glad that we've done this. Having said that, I'm gonna turn the to get this part of the

[Owen Foster (Chair, Green Mountain Care Board)]: Okay, Senator Benson? Yes.

[Sen. John Benson (Member)]: Senator Cummings? Yes. Senator Gulick? Yes. She's an. Senator Lyons? Yes.

[Sen. Virginia "Ginny" Lyons (Chair)]: Regressed. Yep. Yep. That down. That we can celebrate, and the house has work to do. Thank you. You're welcome. Who, who will be reporting? Oh, that's a good question. I'm looking over on this side of the table. If, one of the new senators would like to report the bill, it would be fine or not.

[Sen. John Benson (Member)]: I don't care. I'm doing one of them. Tuesday.

[Sen. Virginia "Ginny" Lyons (Chair)]: And Senator Benson, are you interested? Yes, could be. And you could give it justice, I'm sure. Thank you for that. I know, for me, this is a very important bill. I'm very committed to continuing our work on recovery.

[Katie McLinn (Office of Legislative Counsel)]: I'll email you a clean version probably And in the next hour or

[Sen. Virginia "Ginny" Lyons (Chair)]: a section by section.

[Owen Foster (Chair, Green Mountain Care Board)]: I was gonna ask a question.

[Katie McLinn (Office of Legislative Counsel)]: Section by section, I'll send that to you, not in an hour. That's right, I didn't

[Sen. Virginia "Ginny" Lyons (Chair)]: get into sections by section. Yeah, you just asked. There's only three sections. Martine, are

[Katie McLinn (Office of Legislative Counsel)]: you on 206? It's just about it.

[Sen. Virginia "Ginny" Lyons (Chair)]: Okay, thank you. You're good? Thank you for that. It's Friday. Yeah. It's good.

[Sen. John Benson (Member)]: Oh, I just wanna see you.

[Unidentified Committee Member]: Your name in there. That's okay.

[Owen Foster (Chair, Green Mountain Care Board)]: Now, What are you looking for? Oh, the date for the draft.

[Sen. Virginia "Ginny" Lyons (Chair)]: Okay. So you put one in today?

[Owen Foster (Chair, Green Mountain Care Board)]: Yeah. Normally, do you have to use the date that's on The draft. On

[Sen. John Benson (Member)]: the draft.

[Sen. Virginia "Ginny" Lyons (Chair)]: So he'll get a clean copy, and Alright. We can pull it And we're good on that bill, Michelle. We're finishing up also.

[Owen Foster (Chair, Green Mountain Care Board)]: You want me to just leave Don Colson to death?

[Sen. Virginia "Ginny" Lyons (Chair)]: Yes. And then we need to get the we'll get the original bill now, a complete copy of the bill, and then you take The recorder. Upstairs or something.

[Sen. John Benson (Member)]: John? Yeah. You Or Melissa.

[Sen. Virginia "Ginny" Lyons (Chair)]: You take it out. Your recorder, and you put it in vote five zero zero, and you give it in to Melissa or someone in the Senate Secretary's office. You have to sign something different. Yeah, that's the, you'll have that on the complete copy of the bill.

[Elena (Director of Policy, Green Mountain Care Board)]: So good morning. Morning. And you haven't been here this year. Glad you're here. Me too.

[Sen. Virginia "Ginny" Lyons (Chair)]: And we're, at least one member of the committee, who is my left, was coming back, asked if we could just look at this bill and see how realistic it might be to take it up in the remaining time that we have before the crossover. We need you to go through the bill with us. Sure thing. For the record, Michelle Childs, Office of Legislative Counsel, and haven't met your two newest. Thank Not to actually. Let's do that, so go ahead.

[Sen. John Morley III (Member)]: John Morley from Orleans. Nice to meet you.

[Sen. John Benson (Member)]: John Benson from Orange. So,

[Michelle Childs (Office of Legislative Counsel)]: I'm Michelle Childs, and I typically staff the judiciary committees. I work on family law, criminal law, focus a lot on domestic and sexual violence issues, drunk laws, and had done all the cannabis stuff for a number of years. So, oftentimes I would be in this committee while this committee worked on the medical program, things like that. So, I definitely have a little crossover and love to come and visit. So, thanks for having me in. So, would you like me to put it up on the screen? It's super short. It's teeny weeny bill. It's a teeny weeny bill. It can get bigger. But generally, what it is is creating a working group. So, you're looking at 39 as introduced. It did kind of come in right, skated in right at the end Yeah, I understand, I know. So, typically when you see creation of a study committee or working group, you know, it might say, oh, is, we're gonna say, this person will be the chair, you'll say, this is how they'll elect the chair, you'll talk about how many meetings they can have, if there's any kind of appropriation. There's none of this, this was just, I think, something that the sponsors wanted to get in, kind of make sure something could be discussed this year, if you were willing to take it up. And it's creating a child abuse and a black working group. So, you can have, this committee has concurrent jurisdiction with judiciary over child abuse issues. So, is working in Title 33 in the Human Services title, in Chapter 49, which is with regards to child abuse and lacks. There are, I don't know how much foundation I should lay around the child abuse We have the

[Sen. Virginia "Ginny" Lyons (Chair)]: child abuse advocate right now, Matthew Bernstein, who is working on some of this area, but this is different. This is looking at what we have in statute and practice of

[Michelle Childs (Office of Legislative Counsel)]: Right, so this is, I think, intended to Pretty look big. So, in Chapter 49, in Title 33, there is a whole process for, that's like where you have your laws on mandatory reporters, right? So, teachers, law enforcement officers, people like that who are required under law to court if there is suspected abuse or neglect of a child. And then there's a whole process that is conducted within the Department for Children and Families around assessments, investigations, and substantiations of child abuse or neglect. That is a system that is separate or apart from any type of criminal action that might be going on in a criminal division. And so, sometimes people might be investigated and substantiated for some type of abuse, sort of lack of a child, and there is a child abuse and neglect registry that is kept by the Department for Children and Families. It is not a public registry, so it's not like anybody can just go in and Google and see if someone is open on that registry, but it's used for very specific purposes that are identified in law. So, things around provisions in law where if you're gonna be in certain types of employment working with children, that they check that registry to make sure that you haven't been substantiated for anything before they hire you as an educator, as someone who works in a childcare center, or as a coach, or something like that. And so there's a relatively comprehensive process for how DCF goes about, you know, they get the call, what do they do next, right? And there's a system that the legislature has created and has tweaked over the last couple decades.

[Owen Foster (Chair, Green Mountain Care Board)]: It's a

[Michelle Childs (Office of Legislative Counsel)]: nice guy. Yeah, so it's a

[Sen. Virginia "Ginny" Lyons (Chair)]: great I've worked with the family, so I've been a skeptic of the past on this one and it has shaped up.

[Michelle Childs (Office of Legislative Counsel)]: There's a whole process around like, what do they do when they get that intake call? How do they proceed? And there's a lower level of assessment, there's a higher level of investigation, and there's a process, there's things in there for due process for the person under investigation to make sure that they have an opportunity to be heard, to respond to any allegations. And so that's kind of what's contained in Chapter 49. And what this bill does, is it creates a work in the group to essentially look at Chapter 49 and say, you know, are there things that we should tweak there? Ways to kind of modernize the statute. Is statute reflecting best practices in this field? That sort of thing. But again, it's really kind of an outline. Not that it couldn't go just as introduced, but you might wanna explore expanding it a little bit just in terms of if there's anything specific that you want the working group to take a look at or anything like that. But I can walk you through, just tell you what's here for right Yeah.

[Sen. Virginia "Ginny" Lyons (Chair)]: Let's do that. And then the suggestion might come out as you're going along, we might think about folks we need to have come in to testify, that might expand. And then Albies Vermont. Right, Albies Vermont and I think of Matthew Bernstein coming in. And

[Michelle Childs (Office of Legislative Counsel)]: they're on the list. So just in section one, subsection A, it's creation of the working group for the purpose of examining existing statutes, rules, and policies regarding the reporting of abuse and neglect of a child and recommending changes to modernize and then reflect current best practices. The working group is comprised of the Director of the Office of Professional Regulation, or the Deputy The Executive Director of the Center for Crime Victim Services. That is a state agency that provides, just like it says, services to victims. A co executive director of the Vermont Network Against Domestic and Sexual Violence, and a member of twenty five day attorney general, someone appointed by the chief administrative judge, and a member appointed by the Commissioner for Children's and Evangelist. And I thought the advocate was on there, but

[Sen. Virginia "Ginny" Lyons (Chair)]: I guess it was too. Is she on there?

[Michelle Childs (Office of Legislative Counsel)]: No. Cool. That would be the first time. And then it's just, Subsection C is that the working group has to report its findings and any recommendations for legislative changes by November 1. And it doesn't, so sometimes when we require reports back, it'll say which committees it goes to, sometimes you just say general assembly. This doesn't specify, but I don't know whether or not the charities it makes that much difference if you say certain committees versus the general assembly, because they all get uploaded to the same database for these things. So the idea of it coming in November 1 would be that if they have recommendations for statutory changes, that you've got time to connect with Legis Council and pass legislation for introduction of a bill when the session starts the following January.

[Sen. Virginia "Ginny" Lyons (Chair)]: So, I guess the first question for the committee is, do we take this bill up and take some time with it? I'm not thinking it'll be a significant amount of time, and so think about that. We have and we'll have Michelle come back in, we would have to have testimony on this. Question number one, is it necessary? What problems is it solving? We might bring the sponsor in. This was short notice, so we'll bring Senator Vajhosky in to talk about it. I think one of her interests was in my mandatory reporting, but I'm not sure here, but we'll see what she says. So think about it, and then what we'll do is we'll try to make a decision on Tuesday just to bring this up and talk about how we might follow through with it. And from your perspective, when's the last time that maybe this section of law was evaluated?

[Michelle Childs (Office of Legislative Counsel)]: You know, I would have

[Sen. Virginia "Ginny" Lyons (Chair)]: to check. So I I can take the numbers on your tissue.

[Michelle Childs (Office of Legislative Counsel)]: No, Martine, I know that they have made some updates to chapter 49 in recent years, but there was a lot of work for several years there, and it was a while back and it was, but, and I used to do, all the child abuse and neglect in the chins cases and things like that, there was just two lawyers on the judiciary team. But then when we added a third, it shifted to that portfolio. I'm just covering this right now because we had somebody leave and we just hired a new attorney, and so I'm kind of covering some things in that portfolio for But I can certainly look and see, but I don't think

[Sen. Virginia "Ginny" Lyons (Chair)]: that there's been, I mean,

[Michelle Childs (Office of Legislative Counsel)]: well, I don't know, can't say that.

[Sen. Virginia "Ginny" Lyons (Chair)]: I would have to Well, we'll look at it. We'll have Senator Bobhosky in and see what the motivation is for this, and then we'll have Matthew Bernstein in and there is an oversight, child abuse, family oversight committee. Maybe we'll have to chair that committee then. But it's in someone in the house. Just joined with I don't know. It's Daniel Noyes. I think Dan Noyes. I'm not sure. Yeah. Anyway yeah. So we'll have we'll we'll look at it. I just I'm always asking when I was working in the field, we didn't do the problem for the community. A significant number for Walters parents grew up with spare the rods, spoil the child, and they were doing what they thought was good parenting, and they found themselves being reported for abuse. And if you were when I graduated from college, one of my classmates was hired by the courts to be a marriage counselor, social worker. You could be very young at 21 years, two years old and be a state worker and you were passing judgment on someone else. 15 did not. But, you know, if you're if your profession now has anything to do with working with kids and somebody's reported you, there's some severe consequences. So I always wanna know who's telling the parents what best practices is if we're holding them accountable, who's telling, you know, more I listen to teachers of what they're dealing with. I'm starting to wonder about what are we doing to help support parents so they know what they're supposed to do. Yeah, no, this will be a good this might be an opportunity for some of that. But you know, we can add into the bill what we think is important. So what I'm gonna suggest is that we thank you for the help here and we'll probably, we may get you back. We'll talk about the bill. I'll try to get Senator Butchowski and Callista. Callista, if you could do that for Tuesday. I don't know what our room is on our agenda, but maybe on Tuesday we could get Senator Butchowski in just to talk about the generation of the bill. And then we'll make a decision about whether or not and how to go forward.

[Michelle Childs (Office of Legislative Counsel)]: Thank you. You also just mentioned, know, House is working on a DCF omnibus.

[Sen. Virginia "Ginny" Lyons (Chair)]: Oh, they are. I forgot. That's good. So, this fits maybe. Yeah, was

[Michelle Childs (Office of Legislative Counsel)]: just saying, like, you and you got two weeks left.

[Sen. Virginia "Ginny" Lyons (Chair)]: Exactly, I'll be to do all

[Michelle Childs (Office of Legislative Counsel)]: that work If right you're interested and you need more time, you might have another Thank you

[Sen. Virginia "Ginny" Lyons (Chair)]: for that. That fits. That fits. That totally relaxes us, but we'll still hear from the senator, but in that Yeah, public perfect. So this is great, this is a wrap. Can go

[Owen Foster (Chair, Green Mountain Care Board)]: live.