Vermont Legislature SmartTranscripts:

[Sen. Virginia "Ginny" Lyons, Chair]: Welcome back everyone. 97, an act relating to establishing a primary care payment reform program. We have some folks who will be sharing some have in the room. Tess Ginny is BioState's president CEO. She works with a lot of federal policy, and supporting our FQHCs in both New Hampshire and Vermont. We have Stephanie Padluka, who is the director of our recruitment center. They work really hard to organization, and she is also a wealth of all recruitment, retention, anything, workforce development related policy. So if we have questions, I just wanna That's it from Orange. Ann Cummings from Washington District. Wonderful. Okay. Okay. Would you like to That's up to you. Thank you.

[Chris [last name unknown], CEO, Northern Counties Health Care]: Good morning, and thank you for having us. I first wanted to start by thanking the committee and the legislature for the support last year. Last year, we came to you with asking for support in several areas, and that support is really appreciated, and really welcoming the communities that we serve. So today, we're talking about S197, which further recognizes the importance of investing in primary care. As Mary Kate said, I am the CEO of Northern County's Healthcare. We serve Vermont's most rural corner of the state, the Northeast Kingdom, with Senator Morley in his region, and in fact, we are the only provider of primary care dental and pharmaceutical services in Essex County. We are it. So, really, financial support is greatly appreciated, but today, in regards to S197, we support, obviously, continued investment in primary care, and the goal of getting that spending to 15% as outlined in the villas. I think one of the things that's important as we move forward is to simplify it, that dabbles in the details. How we implement it, timeframe, all of that really matters. And in particular, I think things that we would like to see in alignment with the state's healthcare initiatives, so the head model, rural health transformation, That part, I think, will be critically important to ensure we're all growing in the same direction. And then one particular ask in section seven of the bill, there is a transitional care community settings report, and I'd like to advocate that Bi State Primary Care Association has the seats at that, and developing that is critically important. FQHCs in the state of Vermont provide care to a third of Vermonters across the state. So that is a very significant number of Vermonters that we are impacting, and a majority of those patients are low income. The, and it's over a third of Medicaid enrollees as well. The, and Michael's gonna join us as well, we know that investing in primary care stays fun. We provide a host of services, especially in an FQHC environment, wraparound or supportive care services, including care coordination, we do financial counseling, we do connect folks to other services in the region. The FQHC model really is focused on a holistic approach to providing care. For example, when we worked with Senator Morley years ago on starting Orleans Dental Center, That is a critical component of our healthcare system. So if we can, at a state, we keep saying, we recognize the importance of primary care, and this bill goes a long ways to actually putting money in that dirt. Again, I think how we get there really matters, timing matters, and then that coordination with the other efforts that are going on in the state. So with that, I think I will turn it over to my colleague, Michael. I'm most welcome to any questions you may have.

[Sen. Virginia "Ginny" Lyons, Chair]: I do have a question. Sure. But does anyone else have a question? So would you mind fleshing out a little bit the one of your first recommendations which is to align with the state plan because. Yes.

[Sen. Martine Larocque Gulick, Vice Chair]: We just we we talk a lot here about how this a lot

[Sen. Virginia "Ginny" Lyons, Chair]: of our plans around health care sort of interdevelopmental phase and they're not fully cooked yet. So if you have another sense of that, I would love to hear it.

[Chris [last name unknown], CEO, Northern Counties Health Care]: Yeah, I think, so using blueprint as a vehicle Yeah. For moving forward this investment, I I think is a a great approach. And so how that there's talk of how the blueprint is going to be leveraged with rural health transformation funds, for example. And so I think it's important that we're just not working in silos, there's a coordinated approach to how we make investments, because this is a significant investment that we're talking about. I think the blueprint is a great vehicle to do that. And the other piece is, and we've talked to this community before about, is really being mindful of the administrative burden that may come along with that. In primary care, we spend an inordinate amount of time, and this bill does go to address some of that as well. That is non value add time for our patients. When we have providers of what we refer to often as pajama time or, you know, therapeutic providers, but they're kids today, they're working on things that really don't add value. So it's, I think, being really mindful of how the program is structured and in alignment, if we can kind of try to reduce those administrative or regulatory components, I think it's really critical to

[Sen. Virginia "Ginny" Lyons, Chair]: We're talking lot about collaboration in this room ago. Yeah. Okay. Great. Well, thank you very much.

[Sen. Martine Larocque Gulick, Vice Chair]: Great.

[Michael Costa, President and CEO, Gifford Health Care]: Good Great. Morning. For the record, Michael Costa, President and CEO of Ginny Lyons Healthcare. We are a critical access hospital with 25 beds, a federally qualified health center serving Vermonters regardless of the ability to pay, and a retirement community with a 49 bed independent living campus, 30 bed nursing home with an adult day care located in Central Vermont, located primarily in Orange County, but going from Berlin all way down to Sharon at the edge of the Upper Valley. I'm here today and grateful to do so to talk about the importance of primary care and answer any questions you may have. Before I do so, I just wanted to add one thing about the team behind me. The Bi State Primary Care Association team is outstanding and a great resource for all of our responders, including the general assembly when it comes to issues of primary care. A lot of times in public policy, and my background was about twenty years in public policy before jumping into the healthcare delivery side of it, is first let's figure out what we're talking about, what the facts are, and then make some decisions from there. And I can tell you that Tess, who is sitting behind me, people at the national levels have conversations and questions about how community health centers work when they go to tests. She is a leader among her peers when it comes to primary care associations, And so it's an invaluable resource for Vermont about how community health centers ought to work in their relationship with the federal government, an issue of particular importance right now. And so to the extent you have any questions about the evolution of America's health centers, the progression of Vermont's health centers, and how they do and do not work with our current federal administration, contest is a phrase

[Sen. Virginia "Ginny" Lyons, Chair]: to be processed.

[Michael Costa, President and CEO, Gifford Health Care]: Today, what I really appreciate about the bill is that it's focused on the right problem. To make a very obvious point, in The United States, we pay for sick care, not healthcare. And while we say lots of positive things about primary care, we tend to pay for really fancy surgical interventions. America's healthcare system is littered with bad incentives. We say that we want A, but what we pay for is B, and those are policy choices. We say we love moms and babies, and we do at Gifford with our birth center, which is open. We had 21 more babies there in 2025 than we did in 2024. So we're very proud to report. But what what insurance companies pay for is orthopedic surgery. Those are policy choices. One of my past jobs was running reimbursement for the prolonged Medicaid program, and it largely mirrors the policy values of other insurance companies, and those are things that you can change. I'm sure you've heard the phrase when it comes to S-one 197, the devil's big details, and that's true, but that shouldn't limit us to trying to make progress. I think for me, when I take a look at Mott's healthcare reform efforts over the past thirteen to fifteen years, we have been national leaders when it comes to vision, and we have really struggled when it comes to execution. And the thing about health care institutions, whether they're in Orleans or Essex County or Orange County and everywhere in between, and whether you're an academic medical center or an urgent care place in Newport, you work twenty four hours a day, seven days a week, three sixty five days a year to take care of patients. So whatever you do has to be administrable. And so as we try to push investments from acute care in the hospital side of fence into primary care, we feel real difference in people's lives, we just have to be mindful of how that's administered, and that it doesn't add to the estimable administrative burden. And Senator Gulick asked a great question of Chris of, okay, it should align with the plan. What does that mean? Let me give you one simple example, and you'd have to have folks in here from the Agency of Human Services and Blueprint talk about it. Blueprint has been a great program. It gives you very small dollar amounts for very discreet things, and it's two things to be equally true. These are great investments in primary care, and also death by a thousand paper cuts. Right? And so to the extent you're gonna make a major league investment in primary care and try to push, say, 15% of healthcare spending into it, you wanna say, hey, we're not trying to do a 100 things in a small amount, wanna say, look, this is one or two or three things that we're really trying to do. So I think it's exciting that you might be able to harmonize Blueprint's current offerings and reset it with this investment. Say, hey, everybody around the state, we're focused on these one or two or three things, whether it's hospital readmissions or well visits or whatever the clinical professions say is the right thing to do, and one of the great parts going to the bottom is we're very collaborative place for the most part, so I'm sure we'll have a good discussion about that. I think largely, even the people that work, say, in the surgical part of Hartford would agree with you that more resources need to go into primary care. They know by the time we get people in the emergency department, there are a million different ways of help from the primary care, mental health care, essential care, and we're stuck doing that. So I think for us, I think what is most important is predictability. I think of the states that look, our goal is to get to a certain point for primary care. Here's the year we're trying to do it by, and here's what it means for the other parts of the system, then we can all plan. And we're really fortunate at Kiffer to have kind of a whole health system, even in tiny form, under our own roof, because we can see the value of shifting resources from one place to another. So overall, I think we're broadly supportive of the bill It's just being clear about how it's administered and how it works with existing programs, not just layered on top of existing programs, I think would be really important. I had a lot more to say, Chris is a pretty smart guy and he covered it. I know your time is very valuable.

[Sen. Virginia "Ginny" Lyons, Chair]: You could bullet it for me because I wasn't here. Well,

[Michael Costa, President and CEO, Gifford Health Care]: I'll reach somebody and I'm sure AI can do a better job. You get what you pay for here. Number one

[Sen. Virginia "Ginny" Lyons, Chair]: good shot.

[Michael Costa, President and CEO, Gifford Health Care]: Federally qualified health centers in Vermont, as you know, centers serve one in three Vermonters regardless of affiliate pay. We serve some of the most rural areas, and I I used to work in local counties as well. They're the only damn town in the Northeast Kingdom. Primary care has historically been under financed despite people's broad support for it. And but if we're gonna move resources there, we need to do it thoughtfully and in alignment with the current transformation plans. The question from the committee at the time was, okay, there's a lot of talk about in progress work. When do we actually get to do something? You didn't say those words on adding on. Yes. And what does alignment really mean? And so then I tried to build on that and say, we have a lot of fragmented initiatives. It's okay to let stuff go. I think that's hard in Vermont. It's hard in the hospital, I've learned. It's really hard to let things go. But sometimes it's okay, given where we are right now, how do we reset this chessboard and move forward? I think what will be interesting as someone who leads a hospital that's engaged in transformation, think, there are currently a lot of ideas percolating. Eventually we're gonna have to pick up, because you can't do everything, and I think having a bigger investment in primary care that says, hey, there's been a baseline historical underinvestment in primary care that needs to be addressed, plus can we carve out any lanes to pay for innovation and what's working? I think that would be really valuable. I happen to think that Vermont, there's only two ways forward in America's healthcare system, competition and collaboration. Given the size of Vermont and the fact there's mountain range in the middle, it's mostly about collaboration, but that should be our superpower, and it is when there's flood or something else that happens. And so if you find primary care institutions like Northern Counties or Ginny Lyons or Battenkill or, you know, the good folks at Community Health Centers of Burlington, and they they do something that really works, they should be able to share that with the rest of the network and move on immediately. Like, you should be able to, like, get a return on that investment pretty quick. We did that during COVID, and it although it seems like many, many, many years ago, it was And not that much I will tell you, putting on my hospital CEO hat, we get it. We get this affordability crisis. We get we have to change, and you're starting to see some really simple changes. I was talking to someone earlier today in the building about, hey, we have a need for this much radiology service, but we have to buy the whole thing.

[Sen. Virginia "Ginny" Lyons, Chair]: There's

[Michael Costa, President and CEO, Gifford Health Care]: another Vermont hospital that needs this much radiology service, but they need to buy the whole thing. Day of owning all of this stuff is over, how do we combine it? I think the more we can do to push money to the right place, and then work on transformation from there, the better off I think we'll be.

[Sen. Virginia "Ginny" Lyons, Chair]: Okay. I am passing the pawn back on chair Lyons officially passing the gavel. Quick question, and it may be a question for another day, because it might be too big, but you mentioned that we have a disorable underinvestment in primary care, and I'm still trying to understand when we went from an affordable state to this, as you say, like an affordability crisis around home care, which is, we all agree on that, and when that happened and how it happened. I'm wondering, were we always under investing in primary care, or is that a

[Michael Costa, President and CEO, Gifford Health Care]: more recent don't know. I just want to be really careful with my answer, because I I don't have data in front of would say for fifteen years I've been working in primary care. Related to healthcare, there's always been an underinvestment in primary care, and the people I talked to said that's been persistent for a really long time. I would say, and then I'll get out of the weeds, You may remember Doctor. Chao. Oh, yeah. Oh, nice. And the creation of what was RBRBS, which is the way in which, it was a system by which to measure the intensity of clinical work and to pay more for things that require more expertise in work. And from there, it really started to weight reimbursement towards specialty care. So that was policy's decision at the federal level. Then when Medicare catches the cold, everybody else gets the flu, right? So that's how they started measuring things. Basically, everybody else measures it that way. This is a long term I think this is why we're trying to move and have been trying to move for a long time to capitated payments. Hey, this is your block of money to help primary care providers take care of the employees because the mechanics of those reimbursement systems are really hard, really hard to address equity issues with.

[Sen. Virginia "Ginny" Lyons, Chair]: Right, I know. I remember writing a little short paper back in the early 80s about the effect of the regulation on medicine and how it's done a couple of things, including increasing the number of women in medicine, but also decreasing the availability of primary care by reducing costs there. And just so the committee knows, and we should share with you, that I have put a request in for some data to look at how we might increase reimbursement rates, Medicaid reimbursement rates for primary care, what it will cost us and whether we can do it. It'll be an interesting I would make two really short comments.

[Michael Costa, President and CEO, Gifford Health Care]: The creation of America's Community Health Centers in the 1960s is part of Linda Johnson's Great Society's acknowledgment that there's been a problem with primary care access that's very, very The second thing I would say is the best time to have fixed access to primary care would have been fifty years ago, same best time is right then.

[Sen. Virginia "Ginny" Lyons, Chair]: So we

[Michael Costa, President and CEO, Gifford Health Care]: should try to get resources there. And it's not all about money. I think the investment is obviously hugely important, but there's stuff that we can do on the health care organization side of the bench. For example, Gifford over the last year has eliminated its waiting list by unclogging our schedules. Right? So two things we need to do. We need more investment. We also need to do better. And I think Vermont's health care organization is pretty motivated in 2026 trying to figure out how to do that.

[Sen. Virginia "Ginny" Lyons, Chair]: And you are, and thank you for the work that you're doing, and I said Chris has his hand up behind you. Got me to say it.

[Chris [last name unknown], CEO, Northern Counties Health Care]: I'm calling for someone to say what Michael meant to say.

[Sen. Virginia "Ginny" Lyons, Chair]: I meant to say if I can. Go ahead.

[Chris [last name unknown], CEO, Northern Counties Health Care]: Thank you, Chair of the Hines. I just wanted to kind of piggyback a little bit on what Michael was talking about as it relates to workforce, because as I mentioned in my testimony is that we can't do this in a silo. We very much support the bill. We can't lose sight of the workforce component, and I realize we're here talking about S197, but also support s one forty two, which is the bill to provide a pathway for internationally trained providers. And so I do think that that is critically important too as we move forward, as well as restoring our investments in AHIP. If we're going to increase investment in primary care, we need the workforce to be able to do that. I was chatting with the governor this morning and others at the coffee hour that we've been looking, as I said, we're the only provider in Essex County. We've been looking for almost two years for a physician in Island Bonds. We need to have a solution to do that. The Maple Mountain Consortium, I think, is gonna go a long ways in helping to address that, but I also think that S-one Hundred 42 could also provide a pathway there. And I know Stephanie, Mary Kate introduced, has a lot of experience in recruiting in the state as well. And so I think BioState is well positioned to help in those efforts.

[Sen. Virginia "Ginny" Lyons, Chair]: Thank you. Thank you for those comments, because we are looking at 142 very seriously and doing some markup on it, and then when we get closer to budget times, AHEC will become a top of the list discussion. I see. Thank you. Just can I tell them something I'm working on in finance? Sure. I know. Good. I no. I've I've I've listened, talked with Michael. I've listened to people from North Country about the difficulty of including positions. Finance, we're looking at the tax code. We have one of the highest top tax brackets in the country, and it starts at 300,000 for a couple filing jointly. New Hampshire and Dartmouth is going there and they don't have an income tax, and that's gonna pick up physician, physician with a working spouse or partner. So I'm trying to raise that bottom rate. So maybe put the fifth bracket back in and try and eliminate some of the tax burden. Property taxes are a little harder,

[Chris [last name unknown], CEO, Northern Counties Health Care]: I over appreciate that. Like Chris Gifford supports S-one 142, I know the medical society has some objections, I assume we've worked through those because the supply and demand curve of workforce is nowhere close to be, if it would be in all of the above approaches. On the top tax rate, we compete with Dartmouth, period. I will tell you, and this is true in Northern Counties, that once they recruit someone to run FQHC, they stay. They love the condition, they love the patients, they love the community, they love the state. Getting them in the door when they're doing that analysis, wait a second, I can keep this much of my salary by living on the other side of the river, challenge himself. That should be

[Sen. Virginia "Ginny" Lyons, Chair]: You've got medical school down.

[Chris [last name unknown], CEO, Northern Counties Health Care]: Yes, and so we appreciate any efforts to make Vermont more competitive.

[Sen. Virginia "Ginny" Lyons, Chair]: One last question, and then we need to move on. Two last questions. And we'll move on. And I'd say two short I

[Chris [last name unknown], CEO, Northern Counties Health Care]: would do my best to be quiet.

[Sen. Virginia "Ginny" Lyons, Chair]: A few comments actually. One, just that I had really nice talk with the CSG folks last night and I think it was interesting getting a New Hampshire perspective because we tend to think everything's worth zero over there and that was not the story that I got. That's number one. But number two, Chris, I just wanted to say that I remember the Vermont Public story about that primary care doctor leaving Island Pond, and it was such a great story, and it's thirty something years. It's really interesting to hear now what's happening, and it sounds like they have not found a replacement. So, thank you for sharing that. One last question over to Ervin. So I just want to

[Sen. John Benson, Member]: roll this back to 01/1997, and I heard both of you say the devil's in the detail. So we have a bill in front of us. We're trying to move that bill. We all want to look at how to bolster primary care. So I'd be interested in any suggestions or thoughts that either one of you have as you look at the bill of things that you think are either impediments to getting to the to that end result or things you think that should be added to the bill or modified that from your perspectives would make the bill better. Because we have limited time here before crossover, and so we wanna get it right, obviously.

[Sen. Virginia "Ginny" Lyons, Chair]: So I will concur with that comment. I will say that we will be looking at some changes to the bill, So it might be helpful to look at the bill that comes before us after town meeting week, because our Legion Council's been working as we had asked outside of committee to put some language together. I did meet with her last night. So this is a good question for anyone in the room, comment on the bill, the next draft that comes up. There are some differences. And I'm going to end the conversation at this point. It's a really good one. Don't like to do that. It would be great to keep you all in the room. We could go forever because I know that our sister treasurer is here. Great.

[Chris [last name unknown], CEO, Northern Counties Health Care]: Thank you. Thank you so much. Thank you.

[Sen. Virginia "Ginny" Lyons, Chair]: I really appreciate your time.

[Sen. John Morley III, Member]: Thank And

[Sen. Virginia "Ginny" Lyons, Chair]: we'll we'll provide some testimony on that. That would be great. I'll I'll seriously we'll just write some good.

[Chris [last name unknown], CEO, Northern Counties Health Care]: Thank you, senator.

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

[Chris [last name unknown], CEO, Northern Counties Health Care]: Take care.

[Sen. Virginia "Ginny" Lyons, Chair]: Good luck. We're gonna try and get you one. We can't we can only do so much.

[Chris [last name unknown], CEO, Northern Counties Health Care]: Appreciate it. Good. Take care. John will be in. You got it.

[Sen. Virginia "Ginny" Lyons, Chair]: You are. Amy, you're. You. Really. Welcome.

[Sen. Martine Larocque Gulick, Vice Chair]: Thank you very much.

[Sen. Virginia "Ginny" Lyons, Chair]: Thanks for being here. And for the record.

[Deputy State Treasurer (name not stated in transcript)]: For the record, it seems

[Sen. Virginia "Ginny" Lyons, Chair]: You you know everyone, do you or not? I'm not.

[Chris [last name unknown], CEO, Northern Counties Health Care]: I believe I've met most people,

[Deputy State Treasurer (name not stated in transcript)]: but I'm not sure if I've met anyone.

[Sen. Virginia "Ginny" Lyons, Chair]: Well, let's go through it then. So Senator Biden start. John

[Sen. John Benson, Member]: John Benson from from the the Orange Orange District. District.

[Sen. Virginia "Ginny" Lyons, Chair]: Ginny Lyons, Chittenden Southeast District. One, two, three. Good to see you. Ann Cummings, Washington.

[Sen. John Benson, Member]: Good to see you.

[Deputy State Treasurer (name not stated in transcript)]: And favorite chair, deputy treasurer. Thank you for having me this morning.

[Sen. Virginia "Ginny" Lyons, Chair]: So and I did reach out to the treasurer's office, and I I did talk with Peter yesterday, and there is a section in the bill that names a treasurer to be involved with reaching out to other Northeastern states, and there may be other parts of the bill that you're interested in, so we'll listen to your testimony.

[Deputy State Treasurer (name not stated in transcript)]: Thank you very much. I'll I'll keep it relatively brief here. I'll start by focusing on section seven where our office is named and then have a few general remarks on the broader bill, but not diving into too much detail. With respect to section seven, we are certainly happy to do the work that has been outlined for us in that section. That's agree that it's an important area for us to explore a little bit more in terms of broadening out the base that would be involved in universal primary care systems. The concept makes sense. Obviously we could reach out to other states and see whether that is gonna be plausible from their standpoint and see what legal and regulatory challenges there will be, which there will be some, but that's something that's the scope of work that we're happy to take on. So we're happy to remain as that has stayed at the mill right now.

[Sen. Virginia "Ginny" Lyons, Chair]: Good. Thank you. That's great. Of course. And if there's any change to the language that you would you think would help, you can send that in and we'll include it in the next draft.

[Deputy State Treasurer (name not stated in transcript)]: Thank you. We'll take a second look and let you know if that strikes us. With respect to the Bonnerville, I won't dive into details. Obviously, our office isn't named or involved in a detailed way, I did just want to pass along the Treasurer's appreciation for the committee's focus on it. Obviously, healthcare costs, as we all know, are serious concern in Vermont that impacts a lot of scenarios of life and impose economic challenges on us all. In primary care, in particular, it's an area that needs critical investment to help tackle those broader costs. So the treasurer just wanted to make sure the committee understood that he appreciates your work. He's working, you know, he has a a different bill that's lining his way through the other side that would hopefully have a little bit of an impact on health care costs, but this is another area critical focus and he appreciates the work on it, I was happy to be helpful. That is my testimony.

[Sen. Virginia "Ginny" Lyons, Chair]: But that's okay. We are working on another bill, and I think that the next question belongs in the other bill, but it's actually a question about at having the treasurer developed in a task force to something that I've been interested in and the committee has been interested in and that is bringing together some of our public employees into a single risk pool, having a task force that might look at that, how could we do that, how could we call it, know, Vermont, employees health, you know, something like that. And I've asked Jen to draft some language that we can look at the idea. So I'm wondering, and I put the treasure in there. And I think I mentioned it to Peter yesterday. So it's something as it comes up it would be helpful to have you look at that.

[Deputy State Treasurer (name not stated in transcript)]: We'll be happy to take a

[Sen. Virginia "Ginny" Lyons, Chair]: look that. Okay, and then the third one, the other one is also probably not directly the treasurer, but looking at some kind of actuarial analysis of the primary care model as it comes out and whether or not the treasurer could be involved in that. There's a whole different world of that. So we will be looking at some language. How can we move this forward? But we're going to need some study and some analysis. We can't just do it. Everybody would like to suggest you do it whether that tags or something else, and so we need to know, because there is some funding and fundamentals of this, so we'll keep you posted on that.

[Deputy State Treasurer (name not stated in transcript)]: Please, thank you. Happy to be involved.

[Sen. Virginia "Ginny" Lyons, Chair]: I was gonna say, I'm talking with other states. My other half, health insurance, you think. We could work collaboratively and share our insurance with people and make it larger around Right. Do what that means? That yes. That's That's the point. Would be helpful. Yeah. We work collaboratively with Maine and then other states while trying to get a handle on pharmaceutical costs. Well, yeah. Frederick was all over that. I know. I know. Then Maine elected the governor who didn't want to do it, and the whole thing kind of fell apart. But that collaboration of small states may be our future salvation.

[Deputy State Treasurer (name not stated in transcript)]: Right. Right. Now, realize the concept makes a lot of sense and there are some legal regulatory, Yes. You But we're happy to take a look at that. Yeah. Mean,

[Sen. Virginia "Ginny" Lyons, Chair]: while you're talking to them.

[Deputy State Treasurer (name not stated in transcript)]: Exactly. Yeah. Well,

[Sen. Virginia "Ginny" Lyons, Chair]: thank you. I mean, well, one of the things I don't know whether it's in section seven or not is a communication fact to health reform oversight or this Yes. That's I don't is it in the is section seven? Yeah. Yeah. That's good. Yeah. We didn't forget that.

[Deputy State Treasurer (name not stated in transcript)]: No. That's in there and

[Sen. Virginia "Ginny" Lyons, Chair]: we'll we'll be happy to get rid Okay. Of Yeah. Thank you. Alright. This is great. Yeah. It's time I think senator Cummings hit the nail on the head. You know? Gotta expand Exactly. The pool of god. Great. Thank you.

[Chris [last name unknown], CEO, Northern Counties Health Care]: Alright. Thank you.

[Sen. Virginia "Ginny" Lyons, Chair]: It's good to see you.

[Deputy State Treasurer (name not stated in transcript)]: Good to see you, sir.

[Sen. Virginia "Ginny" Lyons, Chair]: I'm I'm glad that you were patient and waited so that I

[Deputy State Treasurer (name not stated in transcript)]: can Oh, it's no problem at all.

[Sen. Virginia "Ginny" Lyons, Chair]: Yeah. Thank you. Is there anything else I need to know, senator? We did do a vote on s 19710, but I'm sorry. MH 237. We held it open for you. So if we wanna sort of put a timeline on that. Alright. Yes. Yes. So that vote is four one zero two. Can I ask the vote again? You. That's all good. Alright. Thank you. That was page two thirty seven, an act related to prescribing by doctor level psychologist. Okay. Thank you. Thank you. Mister chair roll with amendment. Is there a reporter? No. Okay, so Jen is here. We have some time to, Jen, to talk about, to continue the committee discussion where we were with me at January or when I was seven years ago. January. And what I'd like to do is just spend just like fifteen minutes on that, and then we'll take a break and come back for one hundred eighty nine. I think we've got to do a

[Sen. John Morley III, Member]: second one. It's dated your own section two.

[Sen. Virginia "Ginny" Lyons, Chair]: It's 237. Jill. Jill. Jill. Jill. Sorry. I'm doing three things. If you leave, we can dive right into S-one 189 and read your testimony. Okay. Way we can consolidate our committee discussions around the board. Okay. I'd be happy to do that. If you don't mind, I need to inform the people I'm on a conference call with that I'm hanging up. It is this looks not great. That would be true. Okay. Well, we have the board here. You're not on vacation like everyone else, and we have different services here, so that's good. Okay. Apologies. I now I am now present. And we're talking about one eighty nine, and I know that we had talked about having the two organizations get together and come back with recommendation. How do we wanna do that? If you would like to go first, guess I'll I have you Jill and then Jessica in that order. Have a preference? No, go for it. You have go first. That's great. Okay. Sorry.

[Jill Olson, Medicaid and Health Systems Director, Vermont Agency of Human Services (AHS)]: Have the right in front of me yet. I'm Jill Olson. I'm. Medicaid and Health Systems Director for an agency of tumors. I actually trip over it every time. There's something about it that's just doesn't go off my tongue. Thank you so much for having me today to talk about this. So I'm going to just sort of spoiler alert. I don't expect that AHS is going come to agreement on this. So we just don't really see this problem the same way. Think that, just I'll turning around to make sure Jess isn't isn't saying something different. We're in agreement of disagreement. Yeah. So in my view, in our view, I think the the amendment that you looked at the last time was a reasonable compromise. So backing way up, just to remind everybody where we are with this bill and what what how where it came from and how we got to this amendment. Last year, I think it was very reasonable, serious concern about hospital reaction to budget orders that reduced their revenue. And so we had one major hospital that actually cut a whole bunch of important services suddenly and without any process. And so I do think that the concern and reaction to that was totally correct. We were all concerned that that could just be allowed to happen without any sort of being processed at all. I think that that makes sense to me that we were concerned about that. And it's a problem that will, I agree, will persist because some of the services that are really important for access also in our current payment world, much of which we don't control, because a lot of it's controlled by Medicare, some of the things we care about a lot, or spread Medicaid too, areas of loss for hospitals. And so as they get squeezed, they're naturally going to look to areas where they're struggling to make the dollars work. So that's just the reality that we live in. So the bill that was passed last year creates a regulatory process with the Green Care, mostly with the Green Man Care Board, that requires them to review all of these service reductions. It actually is reductions and eliminations. Reduction is a really good category. We had the example of the Rutland Pediatric Unit. Rutland announced that they want to close that pediatric unit, which I'm actually grateful that it happened because I think it gave all of us, both AHS and the Green Medicare Boards clarity on, frankly, how non workable the legislation was. I think we actually agree on that. It was not workable. So it created all this confusion at very short timeline for the Green Man Care Board to review it. I think, I'm sure they'll testify to this, I think fairly, they felt like they don't necessarily have all the clinical expertise to think about these problems. So it definitely created something that we, I think we could all agree it didn't work. The remedy is where I think we're having the disagreement. So, the bill that was introduced essentially just moves the regulatory work from the Green Banker Board to AHS. That's essentially what it does. So it creates this, so the problem persists of having needing to do this sort of detailed regulatory process on every single service reduction or elimination. And as I testified before, the agreement, the AHS rule under the current law that sits on the books today is that if work is being done as part of our transformation efforts, it's exempted from the process. Also squishy and a little, sort of like, how do we functionally make that work? We would be actually in charge of a regulatory process. So we really are committed to transformation, to working with hospitals in a detailed way, to help think through how some of them might become a different organization in order to survive in the environment that we find ourselves in, right? It's really important work. And it is close work. It is technical assistance. And so you've heard me say all this before. Technical assistance. It's providing ideas. It's actually providing some anti trust assistance by hearing from one hospital about something that they might want to engage in another hospital about something that might fit, and then we can bring that together in ways that they can't talk to each other. So we are hoping to develop these plans. And in our view, we cannot then regulate something we helped make. And that is what the bill has introduced, we would have to regulate something that we helped create. We don't think that's our goal. And we think our transformation role is really important, and it's frankly just starting to gain traction, and we're starting to make progress. I don't want to see that disrupted, and I do think that the bills introduced were disrupted. The amendment that we looked at the last time, I think, is a very reasonable compromise. It eliminates well, what it does is it makes sure that if there shouldn't be a service, it actually is reduction or elimination, I would probably focus on eliminations only, if there's gonna be a service elimination, there has to be notice to the Green Healthcare Board, to AHS and others, which I think is correct, we want to know, And the hospital has to engage in a public process. That's new. They never had to do that before. And so that's how they were able to just like, we're gonna do this, and it was happening. This would require a public process. We would get notice of what the process sort of resulted in, like what they learned from the public process. And in my view, both the Green Medicare Board and HHS, we other, we have regulatory levers. Sometimes we have NHS hospitals interested in stabilization, and so we're able to connect dots between transformation and stabilization, or we can say, if you want, we need to see evidence of meaningful transformation in order to, say, provide stabilization. So we have levers that aren't necessarily the sort of step by step, gotta do the same regulatory process every single time. We are really not the regulator of hospitals, Blue Med Care Board really is. And it's their budget process that is sort of creating some of this tension. Not all of it, some of it's the environment. If a hospital has to keep something open, they are gonna have to have a budget that supports it. Like, is sort of another question, is like, we say no, then what?

[Sen. John Morley III, Member]: I think you're going to question me.

[Jill Olson, Medicaid and Health Systems Director, Vermont Agency of Human Services (AHS)]: That's okay. Yeah, yeah.

[Sen. John Morley III, Member]: And that is, I think public processes is in the building. Say the hospital wants to reduce or eliminate every offer of service, And then they go through this process, and the public says, No. I'm just curious if they say, No.

[Jill Olson, Medicaid and Health Systems Director, Vermont Agency of Human Services (AHS)]: We supported it here. We

[Sen. John Benson, Member]: want the service.

[Sen. John Morley III, Member]: How do they get the money? Or how do they maintain that service?

[Jill Olson, Medicaid and Health Systems Director, Vermont Agency of Human Services (AHS)]: I think that is the challenge, and that's part of what, that's what we're trying to figure out with transformation. How can we help hospitals figure out a way to do the things that are critical while remaining viable? And there's no easy answer here. There's no easy answer. And some of the pressure is from federal pressures, like how much Medicare pays for what, that absent a payment model that includes everything, which we don't have right now, right, between federal agreements, it's not gonna be so easy to solve. So, yeah.

[Sen. John Morley III, Member]: I'm just curious if that does occur. This bill doesn't fix that problem.

[Jill Olson, Medicaid and Health Systems Director, Vermont Agency of Human Services (AHS)]: No, it doesn't fix that problem. And I think our view is if you really think there should be a regulator involved, it should be the one that's in charge of the budgets. So, if you really think there should be a regulator in the mix on saying no, I think it has to be the regulator that has control over the hospital budgets. Okay, so now we have But we don't agree. And I would say again, I liked your amendment because I thought it was I thought it sort of created a framework where the most important things happen, the notice.

[Sen. Virginia "Ginny" Lyons, Chair]: Okay, we get it. We got it. So we understand the AHS position. We understand that AHS did not come to some agreement with Prevent Care Board. We also understand this is the board's proposal in the bill, so we'll come back now. Bring the board up. And we also stand the conundrum that exists all around us with the planning, transformation, the regulation, the implementation, etc. We get it so we're good. Thank you. Now we'll hear the board side of this and then we'll Happy May. It's of the rock in the hard place that we hope it gets pushed into. I think it's clear. Welcome, Jessica. Do you know everyone? I don't. So we'll start with introducing.

[Sen. John Morley III, Member]: John Morley from Orleans District.

[Sen. John Benson, Member]: Nice to meet you. Nice to meet you. John Benson with the Orange District.

[Sen. Virginia "Ginny" Lyons, Chair]: It's wonderful. Yeah. Morley and the rest of us. Yeah. Would you like me to start?

[Jessica Holmes, Member, Green Mountain Care Board]: Please. Wonderful. It's wonderful to be back here. So thank you for inviting me. My name is Jessica Holmes and I am one of the board members. I'm also an economist by training, so that's my background. And I'm here on behalf of Sharon Foster, who couldn't be here today. So the clarity that I'd like to bring is we actually support S-one 189 as introduced, as originally introduced. S-one 189 requires hospitals to provide public notice and obtain written approval from the agency community services before reducing or eliminating any service. If AHS grants that approval, then the Green Mountain Care Board would do our regulatory responsibility to adjust the hospital budget accordingly if needed. So my understanding is there tends to be broad agreement on the public notice requirement and on the importance of giving communities an opportunity to comment. I understand we agree with that. Think the central question seems to be if and which state entity should have final approval of service line reduction in any one patient's surgery. So first of all, I want to emphasize that the Board's position is that state oversight over hospital service lines is critical. We do not agree with the amendment notice only. We do think that there needs to be state oversight here. If we want to ensure that access to high quality affordable care is preserved and safe, A community open meeting is not enough to ensure adequate access. It's necessary, but it's not sufficient. The Copley community had opportunity to comment. There was the public backlash against closing their birthing center. It might have been the right decision to close that birthing center. But we don't know because there was never a system wide analysis to evaluate that. Birth and properly service area are probably now happening at the UVM at a higher cost. Right? So much more expensive sending to your broker. It may have saved thoughtfully some money in terms of on their on their books, but it likely increased cost in the system, which will show up in higher premiums and higher property taxes. That's the reality of not having a system wide view. And I think, to result to this point, financially strained hospitals are gonna be tempted to close low margin services. Services that we all think are essential. Birthing, mental health, primary care, pediatrics. Right? And the financial headwinds are growing right now. We're seeing it in the federal subsidies being sunset. We're seeing it in a shrinking commercial population because of our aging population and Medicaid eligibility changes that are coming from the federal level. So more reductions and more eliminations are likely. We need to have state oversight. That is what's in the best interest of Vermonters. If you wanna go with the proposed amendment where nobody approves, and it's just noticed in a public meeting, you're going to see reduced access, you're gonna see potentially higher costs and care visits. I implore you, please don't do that. So who should do it? Right? So S-one 180 nine's approval standard is fundamentally about whether a proposed service line reduction is consistent with Vermont's healthcare delivery system strategy. So state review and oversight is really about ensuring that no one hospital's financial decision has negative impact on access to the system, cost to the system, quality elsewhere in the system. AHS is uniquely qualified to do that system wide assessment, and I'm gonna tell you why. First of all, you know why, because the legislature has already entrusted IHS to do this work. Through Act 51, through Act 68, you charged IHS to lead the development of a statewide healthcare delivery system strategic plan to coordinate transformation planning across providers and regions to assess the impact of individual hospital transformation decisions on costs, premiums, access, and health outcomes, and to track whether those decisions collectively move Vermont Cove's lower costs, improve quality, reduce inequities, and increase taxes through essential services. If the statutory test is for approving these service tests is alignment with the state's delivery system's strategic plan and community health needs, the entity responsible for delivering, developing,

[Sen. Martine Larocque Gulick, Vice Chair]: and

[Jessica Holmes, Member, Green Mountain Care Board]: stewarding that strategy should be the decision maker. The legislature has also provided any adjustable resources to do the sort. More than $4,000,000 in state funding for transformation this year. I also want to bring out the federal Rural Health Transformation Program dollars. AHS has just been awarded a billion dollars over five years to lead transformation of our healthcare system. For this year alone, and this is some of the data that I have that was made available online. For this year alone, HHS is allocating $15,000,000 to, and I quote, hire a vendor to gather and study data that will inform hospital and regional transformation planning over the next five years and to provide models to assess the impacts of proposed reforms on cost, quality, access, and sustainability across Vermont's hospitals and regions. It's $15,000,000 for a data analyst consultant. That's exactly the modeling that needs to be done to make the decision on whether a proposed service line change at one hospital doesn't harm access, cost, sustainability, and quality elsewhere. We don't currently have at the Green Mountain Care Board the analytical capacity to do that system wide review, and we don't have the $15,000,000 to hire somebody else to do. My understanding is that AHS is allocating another $2,500,000 to go hire a consultant to develop and implement a system wide healthcare strategic plan for Vermont that will, I quote, provide a roadmap for healthcare delivery system reform, promote access to high quality cost effective services across the system, and ensure, it's important, a coordinated, data driven approach to organizing and sustaining Vermont's healthcare delivery system statewide. So again, whether you call it innovation, transformation, healthcare design, EHS is building the roadmap. They're building the roadmap about where hospital services should be. And they have millions and millions of dollars to do it. So it's really important, they're building a roadmap. Finally, my understanding from this document of the Rural Health Transformation Funding is that HHS is allocating potentially $27,000,000 to supporting health providers in adopting tactical regional care strategies that will shift appropriate services from hospitals to non hospital settings to create regional hospital services and betters of excellence. If AHS is allocating the $27,000,000 towards strategies to move care out of hospitals, they're gonna have to allocate those dollars effectively and they're gonna have to evaluate and decide whether they're proposed to end of services, reduces costs, improves volume, and retains access. They're gonna have to do that. So again, they're doing this work. So our position is that state review and approval needs to happen, and that the decision making authority should lie at the entity that has the most statutory responsibility that's already been given to them, and the financial resources to assess these existing wide impacts. We have access to over $45,000,000 this year alone to do the data analytics and transformation work and design of system. I also wanna add, AHS is also the payer, a payer. And that matters because many of the essential low margin services we're most concerned about losing, birthing, primary care, pediatrics, dialysis, mental health, depend heavily on Medicaid for sustainability. So if the state determines that preserving access to those services is necessary, then doing so may require some action, a targeted increase in reimbursements, a stabilization grant to help that hospital, or some other programmatic response. AHS is in a really good position to do that work. Green Mountain Care Work does not have resources to allocate. We are not a payer. In fact, with due respect, the question was a good one. And if you listened to Ms. Olson's answer when you said, What happened when a hospital wants to close the surface? Ms. Olson said, Well, that's the work of transformation. Exactly. That's why IHS should do this. Think I she answers the question. So in short, analysis and approval should really rest with the ends of being responsible, has the finances, and has the programmatic capacity to not only estimate and evaluate system wide impact, but frankly to coordinate a response. Okay. Should I just say one more thing? Yeah. We go to questions, I have ask. Yeah, more thing, because I think it's really important. They also have more detailed information on quality than we do. So serious reportable events are reported to the agency of treatment services, the Department of Health. We don't have access for that. And I just wanna end with, it will be incredibly wasteful of taxpayer dollars, right, for us to have this authority, we will be having to duplicate the expenses that are already being made to do the analysis that we would need to make these decisions in an evidence based way. It would be absolutely, you know, bureaucratically wasteful and counterproductive for the Green Mountain Federer to come in and second guess to AHS's strategic planning decisions, their transformation work, what happens if hospitals, AHS, and other providers are spending huge resources coming up with these plans, and then the Green Mountain Pibbler comes in at the last minute and says, oh, we think that we should have a different process here. When there are different processes, we think we should cut this service. We're not gonna allow you to cut this service. Right? They're leading transformation. They always have. Deciding what service lines are where are part of that responsibility. Okay, thank you. If you could provide your written test, it will be. I can. You want me to hand it to you? Or email it to you. I can, thank you. Okay, so here we are. Wait, do you have any more questions, I think, Jessica? Oh, yeah? Okay. Still in the hot seat. Go ahead, Senator Morley and Senator There

[Sen. John Morley III, Member]: are so many questions. I

[Jessica Holmes, Member, Green Mountain Care Board]: just will say one thing. I will point out what we I remembered yesterday, and that is Act 68 says collaboration. And collaboration comes in many different ways. Either it could be a hallway conversation that's happening, or it could be the way that the responsibilities of two entities come together in decision making. So, and that we have written into statute already, but we're also listening to make improvements to what we have done in the past, and I'm hearing you loud and clear, both of you. Thanks.

[Sen. John Morley III, Member]: So I kind of think of this as you're kind of a quasi judicial board of the state. So we'll go back to my exam and say that AHS makes a decision, listening to the public, listening to the hospital, all the information they've got, they say, Okay, we're going to eliminate X, And then you're gonna have to decide, I take it, whether or not ultimately you're going to give more money to keep that or don't keep it, they go somewhere else.

[Jessica Holmes, Member, Green Mountain Care Board]: No. If they decide the one day is okay, we would just adjust the budget accordingly. They've made the decision. Okay. They have done the system wide view, right? They have assessed whether that reduction, what impact that reduction will have on access in that hospital service area and elsewhere in the system. They will have done the analysis whether the costs are rising elsewhere. Once they've made a decision, we would adjust to the budgets accordingly.

[Chris [last name unknown], CEO, Northern Counties Health Care]: Okay.

[Jessica Holmes, Member, Green Mountain Care Board]: There's revenue that no longer is coming into the hospital from that reduction of service to be adjusted.

[Sen. John Morley III, Member]: So then why, that's another question, why aren't they the ones that are determining whether or they're going to get the increase or the decrease?

[Jessica Holmes, Member, Green Mountain Care Board]: The increase or decrease in hospital budget? Yeah. They can certainly make a recommendation. Ultimately, that is our authority. We do hospital budget adjustments. We decide hospital budgets.

[Sen. John Morley III, Member]: So then another step.

[Jessica Holmes, Member, Green Mountain Care Board]: I think the problem would be if they do all the analysis, design all this transformation, and it comes to us, we have to then do the exact same work. That's duplication of effort. Taxpayer dollars. My point would be, they're already doing it. That's what's been charged. That's where they have allocated resources. They're already doing it. Having us do it on top would be duplicative and wasteful, and potentially counterproductive therapy. You see,

[Sen. John Benson, Member]: there's some other problems here, but in terms of this one, as I hear both parties, We have one that considers themselves the planning tool, the AHS and Green Mountain Care Board has more of a regulatory oversight rule. And we're developing a process here that talks about how we need either reduce or eliminate a service in a hospital. So to me, if you go to the planning group, their responsibility in the hospital wishes to eliminate a service or reduce it, they do the analysis. They look at how it affects the statewide operation, what it means in terms of cost and They so provide that information to you. You are the regulatory side, and with that information, with the public information, with the hospital's information, you should be able then to make an intelligent decision whether this makes sense for the hospital to eliminate that service or if it needs to maintain its service because what AHS has told you is that will be very disruptive to the overall state network. So I I don't see the big problem here in terms of the defining

[Sen. Virginia "Ginny" Lyons, Chair]: If I may

[Sen. John Benson, Member]: equipment services.

[Sen. Virginia "Ginny" Lyons, Chair]: I'm me ask a question. So or let me answer that with a question. So when the Rutland case came before us, we had to evaluate. We were, you know, they they pulled at the last minute, but there was a request for a reduction or an elimination of pediatric inpatient. Right? We requested an analysis from AHS. We really didn't get it. So we did not have, what we would need is an analysis that they have the resources and statewide view on, is this consistent with your strategic plan? What would be the impact on access to care in the service area and also other areas, right? Other areas, are weight types We're going to go developing

[Sen. John Benson, Member]: the process that we would define in the process that that is AHS' role. So when you say you didn't give information, it's because we didn't have a process defined as we are defining it now, but if we define the process and we assign different roles to the different entities, then you would get that information because that is part of the process. That's what it says. Well, HS will provide X, Y, and Z.

[Sen. Virginia "Ginny" Lyons, Chair]: May I share what I think analysis needs to be? Okay, I would say it has to be, there has to be an analysis on whether this is consistent with the strategic plan. There would have to be an impact analysis on that reduction or elimination on access to care in that hospital service area and other areas in the state. Is this gonna add wait time somewhere else? And can they handle it? Is there a feasibility to absorb this care somewhere else? What is the impact of that reduction and elimination on the cost of care in that hospital service area and also other areas in the state? What is the impact of that reduction and elimination in quality of care that's gonna happen for the patients that live in that hospital service area? Are they moving to an area of higher quality? We're gonna have to move. What is the impact on population health? Will closure impact mortality rates, for example? What's the impact on network adequacy rules? I would also ask, what is the feasibility of transport? This came up in Rutland. AHS is working on redesigning transport and thinking through different EMS systems, to my understanding. So what's the feasibility of transport? Is there enough private transportation? Do people in that community have the ability to get to wherever the care can go? Will EMS have the capacity to deliver the patients that are gonna end up in their ED to the other side of care, that alternative side of care? That's the analysis that has to be done. Could have Medicaid reimbursement rates been adequate for that particular service line, and was there an analysis to be done, whether an enhanced payment would have helped? These are the types of things that AHS has the ability and potentially with all of these resources to do. That's the type of analysis that needs to be done. At the end of that, they should know the answer to whether or not it should be approved or not.

[Sen. John Benson, Member]: Yeah, but what I, I'm just trying to look at how we could move forward is, well, that's great. You could lay that out for us and say, this is what should be in the bill. This is what AHS's role should be. So you get the information you need to make the proper decision. Supposed to us fighting back and forth over.

[Sen. Virginia "Ginny" Lyons, Chair]: Well, is not an unusual place for all of us to be. So I will say this. I know that one of the concerns that I've heard is which services and how street a line item would that involve. So major services, services that have gone through a CON, you know we haven't talked about CON because the board also does do CON and that's an assessment of need. So somewhere there's a balance there. So those are the kinds of questions that have to be answered going forward. So we're good. I'm gonna another think, Greg, that you're gonna you have one question. It's a quick question. Quick question. I believe It's not a discussion. It's a question.

[Sen. John Benson, Member]: Question is still very valid is what happens when we tell a hospital they need to maintain a service, how does that get paid? I think that's a big missing.

[Sen. Virginia "Ginny" Lyons, Chair]: Yeah, well I would say that through some of this, some of the stabilization grants that HHS has through their Medicaid reimbursement policy, we're moving to Medicaid global budgets. There may be mechanisms that HHS has to support, you know, retaining essential services. That's why it's imperative that they are involved in this decision. Okay, thank you. Good. So we've resolved that problem. And so what we're gonna do is we're take a break for seven minutes. And we'll go back and we're gonna have a, we'll have to have a more robust discussion about S-one 189, set of recommendations that we're hearing both from the AHS and Pre Men Care Board. It does sound like what AHS is doing would provide the data that the board needs. One problems of is right now, we're in a huge, airtime of limbo and transformation. So it makes it really difficult to pin this all down for either the board or for AHS, thinking maybe there's a timing piece to all of this because there is a timing piece to the statewide plan. So, you know, it's a matter of, know, how are we juggling all of this? Not me. How are you juggling this in the interim when we don't know the outcomes, we don't know what the regions are gonna look like and which hospital is going to give up or which one's gonna do this. So making this decision for right now is stepping into the middle of the cake in the middle of being made. We'll have to