Vermont Legislature SmartTranscripts:

[Virginia "Ginny" Lyons (Chair)]: You're live. All right, good, back live. This is three bills that we have before us. The one that we just looked at, which is that one between AHS and Green Mountain Care Board. And let me just share what I'm thinking and I know that I think Senator Benson expressed it very well also in higher transportation needs in different parts of the state. That work is ongoing. There is data being collected and analysis being done. The goal for the first iteration of that bill is 2028. So the decisions that work that the board and AHS are trying to make right now is in the middle of change. I honestly, I agree with them. I don't know how they're doing it. It's in the middle of change. So I do think that we should think about what you would like to see. But I would think having a plan in place, say, reaching out to the '8 or 'twenty nine and saying once that plan is in place, then AHS would provide data for decision making at the board and they would have a recommendation, so that's one. Two, that we would ask between now and whenever anything, the next step happens, the twenty ninth step happens, that the board and the agency consider how to have a public process for any service addition and reduction, so how to build that into thinking on both sides, whether it's the plan or whether it's the regulatory process. So that's what I'm thinking about. And so do you have other ideas? We can bring them together. I've been thinking about this Rosette, I think we should. Between now and whenever anything is implemented that the board and AHS can, and we, can think about how to improve what needs to be improved. That's where I am at this point, and I know that we'll all be hearing from folks at AHS and their concerns. We'll be hearing from the board. Trying to find a middle ground on this

[Sen. John Benson (Member)]: one is gonna be difficult. So one question on that. I liked your point, I think it's premature to figure out how this gets into the network when the network hasn't even been developed. But in the interim period, keeping the public notice process I think is great. But who is making the decision? Is it British Valor Care Board, or is it

[Virginia "Ginny" Lyons (Chair)]: I think there has to be a collaborative process.

[Sen. John Benson (Member)]: Even in that

[Virginia "Ginny" Lyons (Chair)]: initial In that initial, they're gonna have

[Jennifer Carbee (Legislative Counsel, Office of Legislative Counsel)]: to I sort it mean,

[Virginia "Ginny" Lyons (Chair)]: they sorted it out somewhat with Rutland. Wasn't the greatest, but they did identify a need for a public process, and I agree with that. I think the hospitals are not toilet for that. So let's think about that, and we'll try to give Jen some direction on that. Go ahead. I mean, to hold the public hearing and just yeah. Yeah. Because we know the public's gonna hate it. Yeah. The question is how are people that have been receiving that service going to receive it in the future. Exactly. I think if the I understand the hospital wants to close it because they've only got three cases in here, but where what are the arrangements that have been made to duplicate that? They probably did say that with their pediatrics. Are you thinking of having some language like that in the interim that there will be Yeah. There's no plan. We all know every hospital can't offer dialysis we all know that we probably don't have enough babies to have but it's time factor with delivering babies and so how far you know where are you going to go if the service gets cut? Seems that that would have to be the hospital would have to have some responsibility to have a plan. As part of the public. As part of the public to tell the public. And the other things I'm hearing, I learned as part of the closures is that the entire Mad River Valley does not have a pharmacy. They need to travel to Waterbury and the plan said they were going to need to travel to Waterbury for their medical primary care, I mean, care. And the hospital said, Well, you've already got you know, you get that, you already gotta go to Waterbury. She gave me the prescription pill, we're gonna offer online prescriptions. Unfortunately with the mail service in Central Vermont there have been major issues with prescriptions. Oh it's everywhere. Yes. I can't figure out when we get our mail. Yeah, and they're not getting delivered and you can't find them and the pharmacy can't reissue them because they've sent them and so that option is not viable. Well, everything you're saying is part of the ongoing conversation at AHS and within the transformation process and how we cover these things that are going away or missing or what can we add in that will build a better system at the point. What do we do in the meantime? This is the meantime, is, yeah, and I think everybody's thinking about making the vision for the future right now, and we can't do that when we're in green. Transportation.

[Sen. John Benson (Member)]: I think your approach is a good one. Two tier piece of what happens in the next three years, and then once the Yeah. Once the plan is in place, twenty nine years, the details for that.

[Virginia "Ginny" Lyons (Chair)]: Any other comments? Should we go forward with thinking about this? Yeah, no, this is something, so this is nothing for shattering, but I just think Senator Cummings brings up the point, which is that the public comment or the public hearings are a really great opportunity to educate as well as get input from folks, hear their concerns, but also educate them because a lot of folks don't really know what's going on. You can't keep up with everything, even if you're reading all of the various media outlets. But that is a great opportunity for do that.

[Sen. John Benson (Member)]: I agree, Senator. I can tell you what every single public meeting is going to the fan. I can relate. Okay.

[Jennifer Carbee (Legislative Counsel, Office of Legislative Counsel)]: I jumped in. Have agreed.

[Virginia "Ginny" Lyons (Chair)]: We'll rediscover you. This. We'll Yeah. We'll just usual suspects. Ginny? Yeah. There was another article. I don't know where it popped up. About pharmacies closing? Yes. I think I've known for years that the online prescription people were going to put our local pharmacies out of business. Yes. And it's happening. And people are having to drive long distances to find a pharmacy. I think it was up around And then

[Jennifer Carbee (Legislative Counsel, Office of Legislative Counsel)]: they got there and they got ready. Then they worked

[Virginia "Ginny" Lyons (Chair)]: her pharmacy, that's a long way. And online, you know, mail order is proving right, to be unreliable. Whole bunch of reasons. Don't know. So I I have a There is question. Canada.

[Jennifer Carbee (Legislative Counsel, Office of Legislative Counsel)]: Oh, here's a historic question coming up.

[Sen. John Benson (Member)]: It was not bad. Lots of times, as we talk about, something put in place Previous. Previously that John and may not be aware of, but on on this whole planning piece Mhmm. And and I thought about this and brought it up in the discussion. So you get this master plan that says here are the services that are supposed to be provided in each of these different hospitals. That's gonna be involved. Yep. But we know that some services, they're gonna break even on. Some, they're gonna lose money, and some, they're gonna make money on is if in the whole system it said, you will provide these services, and we know they're losing money. How does that pertain percent in the hospital budget somehow that the Green Mountain Care Board is

[Virginia "Ginny" Lyons (Chair)]: That is exactly the point that the HS is making about what the board does. So therein lies the conundrum that you've got plans here and budget here, decision here, budget here, and does that upset the sustainability plan? You've got so that's why having the data and the analysis between the two is really important, and I don't know how to solve that problem. But

[Sen. John Benson (Member)]: I can see that the answer may be, no, you're still going to have to maintain that service even though it's a looser from a financial standpoint. I'm just trying to figure out what's the mechanism that makes sure the hospital stays soft.

[Virginia "Ginny" Lyons (Chair)]: We're with you. You've got it. You just put the nails on the top the head. So there are a lot of questions that need to be asked in the interim, we're going to put a dent in your stool can. Think if we can just push the final decision making out a little bit as the plan is being developed and who has the data and how it will be shared. I think that might help.

[Jennifer Carbee (Legislative Counsel, Office of Legislative Counsel)]: Good question, Martine. Yes. Far I have drafted three versions for you between last year and the amendment. Is there any of that? How does that relate to what you actually want? Here's what my suggestion.

[Virginia "Ginny" Lyons (Chair)]: We have all, we have three different drafts now? Well, mean,

[Jennifer Carbee (Legislative Counsel, Office of Legislative Counsel)]: I'm looking at the existing law, the past last year, Bill has introduced the strike all amendment

[Virginia "Ginny" Lyons (Chair)]: that we have that's right. I have on slide one. Maybe what we do is we give ourselves an opportunity to read this one more time, think about what we've been discussing, and then we'll come back with some endpoint decisions. Senator, go ahead. I have this question for you, Madam Chair, which is, number one, is doing nothing an option? And number two, if we do nothing, what will consequence the We'll have more and more ons. I mean, the least that we can do is to have a public hearing and some public process. Think that the hospitals are suggesting and others are, and I see Jill is just dying to speak.

[Devon Green (Vermont Association of Hospitals and Health Systems)]: I am, apologize. My eyebrows moved. They do. Jill Wilson. I just wanted to clarify one thing.

[Jill Wilson]: If you do nothing, the existing law remains in place, which is the Green We

[Virginia "Ginny" Lyons (Chair)]: understand that. What the proposal did was to move it from Green Mountain Care Board to AHS and that's the conundrum and who has the data and how are the decisions made relative to the budget. We get

[Sen. John Benson (Member)]: all that.

[Virginia "Ginny" Lyons (Chair)]: So now we're gonna go through and we're gonna read what we have and then we're gonna come back and we'll try to sort out a step forward. We don't wanna, you know, staying the same will result in what we have seen in Rutland when the kid beds were cut. I'm not interested in having the community go through that again. That was deadly to some parents and some kids. So let's this group right here, we're thinking about this. So we'll with yes. No. I'm I'm looking at the bill that's been published in newspaper for general circulation. Yeah. Other than the Burlington Free Press, there is no news paper of general circulation. Do not have any more. Gonna have to answer that one. We're gonna press you right here. That's an issue. That's true. We've always said that. Public noticed, even to local communities. Right. It's all local and general, I think. I I Yeah. Everybody who's the two parties who are interested in this, I understand. We're problem that is now. We're gonna solve it. I understand also, and we're in a moment where public trust is so compromised and so broken, and this if we don't do anything, it exacerbates the lack of trust the public has in all of these entities and all of these institutions. And to your point, we are the health and welfare committee. We are responsible for the health and welfare of Vermonters. And it's really important that we act and do something to protect people. You're with it. Yeah. It's well taken. I'm looking at this. Highlighted and struck out. Yeah. Oh, it is a lot going on. Oh, this is exactly why. The highlights that it struck out.

[Sen. John Benson (Member)]: I'm on 1.1.

[Virginia "Ginny" Lyons (Chair)]: We go through 1.1, frankly, so we know what we're thinking about? Sure. But to be clear,

[Jennifer Carbee (Legislative Counsel, Office of Legislative Counsel)]: I think 1.1 is maybe the AHS compromise proposal, is that accurate? Yeah,

[Virginia "Ginny" Lyons (Chair)]: it's fine Okay. To look It might be an interim step. This is a thing I'm thinking about.

[Jennifer Carbee (Legislative Counsel, Office of Legislative Counsel)]: So, this is S-one hundred eighty nine draft 1.1. Says Dracoll, but the highlighting is showing you what's changed from the bill as introduced. Would create a section in Title 18 on hospital service reductions, but requiring notice, approval, so it strikes out language from the bill as introduced that would say a hospital shall not reduce or eliminate any service without approval from the Secretary of Human Services. It would require a hospital that proposes to reduce or eliminate any service to provide a notice of intent to the Agency of Human Services, Green Mountain Care Board, Office of the Health Advocate, and the legislators from the hospital service area. I know there had been some discussion while we walked through this before about maybe adding some legislative committees. Not less than sixty days prior to the proposed reduction or elimination, That notice would explain the rationale for the proposed reduction or elimination, describe how it's consistent with the statewide healthcare delivery strategic plan once established, and the hospital's most recent community health needs assessment conducted pursuant to state and federal law. And then before you scoot ahead, I'm looking at the word any for service. Yes, I mean it

[Virginia "Ginny" Lyons (Chair)]: was an IGG Well, to no, I'm thinking any service, and so what does that mean exactly?

[Jennifer Carbee (Legislative Counsel, Office of Legislative Counsel)]: Well, know you've heard some discussion, I think, about sort of what level of reductions should trigger process. I know eliminations, I think, seemed easier, reductions, but I've heard concerns about, you know, what happens if a provider leaves a provider hurt? Is that a reduction if you have less availability? Does that need to go through this process? Was one

[Virginia "Ginny" Lyons (Chair)]: of the Johnson's psychiatric counseling episode because the provider was right with them. Okay. But could serve either no service? Could service include, like, IT services or phone services or or is it just I

[Jennifer Carbee (Legislative Counsel, Office of Legislative Counsel)]: think that was the, I think it was a clinical service. Clinical service might be a test.

[Virginia "Ginny" Lyons (Chair)]: Right, don't know. Okay. I mean, we can certainly have it the buyer. It's service could be possible. So unless there's providing.

[Jennifer Carbee (Legislative Counsel, Office of Legislative Counsel)]: Right, it's really a, you know, a medical or health care service, but Provide.

[Virginia "Ginny" Lyons (Chair)]: I think this is something. I feel like the girl who kept me licensed. Okay.

[Jennifer Carbee (Legislative Counsel, Office of Legislative Counsel)]: Okay, so some options for that. So this is to provide notice, post the notice of intent on the hospital's website on or before the day on which the notice is provided under subdivision one, published the notice in a newspaper of general circulation in the hospital service area, so it's not necessarily statewide, but this has been part of our notice process in the past. I don't know if it makes sense anymore or not, but but it seemed better than saying, you know, put it in front court form or something. Well, we might say, it

[Virginia "Ginny" Lyons (Chair)]: may apply to various media. It's not news. So, part of the state has a little bit more. I think most of them have, like

[Devon Green (Vermont Association of Hospitals and Health Systems)]: Weekly. A local volunteer. Yeah. That's right. But,

[Jennifer Carbee (Legislative Counsel, Office of Legislative Counsel)]: yeah, there's a can certainly modify that. I don't think that's the sticking point.

[Virginia "Ginny" Lyons (Chair)]: The world is changing and we haven't changed our standards.

[Jennifer Carbee (Legislative Counsel, Office of Legislative Counsel)]: Conducted a public engagement process, including holding one or more public hearings and then counting with the hospitals located, and soliciting and responding to public comments regarding the proposed service reduction or elimination. Public engagement process can start before the notice goes out, but it must continue for not less than thirty days after the notice. These are all just, you know, placeholder dates and times, everything. At the hospital, she'll provide a summary of the community's response to the proposal, including the public comments received to the Agency of Human Services, and this would change from weekly during the public engagement process and Bill is introduced to following the conclusion of the public engagement process. So strike the language about the agency of human services reviewing the proposal, considering the impact of the proposal, and approving if the agency determines it's not inconsistent with a statewide strategic plan, community health needs assessment, doesn't ambly leave burden access to care, food services, and the pros outweigh the cons. So that whole AHS verbal piece comes out in this draft. And then, yes.

[Virginia "Ginny" Lyons (Chair)]: Right, so that all comes out. My suggestion is relieve it in and it goes into place after the plan is in place. All the other things that we're talking about we do in a preliminary way. We do this stuff in the interest. That's what I'm talking about so that there's some pressure on everyone to work together and make decisions. And I'm very clear on the open back. The

[Devon Green (Vermont Association of Hospitals and Health Systems)]: recommendation.

[Jennifer Carbee (Legislative Counsel, Office of Legislative Counsel)]: Right, and there was talk, last time we went through this about a recommendation rather than an approval. I don't know if that's where the And I don't know if you were thinking recommendation in combination with the delayed effective date for this piece or recommendation until the plan and then approval. In the interim, it's gonna have to be

[Virginia "Ginny" Lyons (Chair)]: a collaborative process, I do think, unless I hear differently, but recommendation would go in Labor condition? What? I don't,

[Jennifer Carbee (Legislative Counsel, Office of Legislative Counsel)]: I didn't. You didn't understand I didn't understand We

[Virginia "Ginny" Lyons (Chair)]: have the public notice and we have some communication between AHS and the board about what's happening in the transformation process. At the end of the lobby, after the county beds, this stuff goes into place with the word recommendation. Recommendation instead of Yeah, the otherwise. Okay.

[Jennifer Carbee (Legislative Counsel, Office of Legislative Counsel)]: So when this information, in the shorter term, when this information is, if the hospital's providing a summary, this is where you want AHS and the HORT to

[Virginia "Ginny" Lyons (Chair)]: be somehow sharing. This is what we haven't heard anything about. That could come from AHS. Wow, this is brand new. Or golly, Ned, we've been working on this, and that makes some sense, and they can communicate as much as they can tolerate. Okay. So then, recommendation with the latest CTAP. Okay.

[Jennifer Carbee (Legislative Counsel, Office of Legislative Counsel)]: Then, in this version, so if the agency approves the service reduction, that would come out, because no approval, think that still carries through in your revised version. But if a hospital elects to proceed with reducing or eliminating a service after completing the process, then they have to notify the board within five business days following the hospital's decision to reduce or eliminate the service so the board can review the impact on the hospital's budget.

[Sen. John Benson (Member)]: Think what we want is notification to both the board and AHS, right?

[Virginia "Ginny" Lyons (Chair)]: It's on the- Oh yeah. There? Well, it

[Jennifer Carbee (Legislative Counsel, Office of Legislative Counsel)]: this specific piece, I mean, the agency is providing a recommendation, but-

[Virginia "Ginny" Lyons (Chair)]: But I think,

[Jennifer Carbee (Legislative Counsel, Office of Legislative Counsel)]: this just says the board, but we could certainly add AHS and then be clear evidence. And maybe that, also, we could time to notify AHS to inform its ongoing work on the strategic plan and the board so it can evaluate for the impact on the hospital budget.

[Virginia "Ginny" Lyons (Chair)]: Yeah, I mean, it does make sense. If the board might be considering a CON from somewhere else, we didn't let him re generate, we don't know.

[Sen. John Benson (Member)]: That's not interesting. Could the Say it was too expensive to provide a certain service at one hospital, and they want to get rid of it anyways, the hospital does, and move it to another location that seeks to fit the community better, whatever like that, would the Green Mountain Security Board be able to force a certificate of need to that hospital for a certain type of service?

[Virginia "Ginny" Lyons (Chair)]: I don't think so. I mean, it, well,

[Jennifer Carbee (Legislative Counsel, Office of Legislative Counsel)]: if the hospital is planning to stand out of the service, Yep. And it triggers the jurisdictional thresholds and the certificate of need law, then, yes, they would require a certificate. I mean, the agreement with care law wouldn't be forcing it. It would just be by operation of the existing state Okay. But the triggers were increased fairly significantly. Yeah, we did that last year. Okay. Increased.

[Virginia "Ginny" Lyons (Chair)]: Does that sound nice to you? Okay. Thank you. Right here. You can tell him if it is. No, that's okay. That's a good question.

[Jennifer Carbee (Legislative Counsel, Office of Legislative Counsel)]: Later going. Alright,

[Virginia "Ginny" Lyons (Chair)]: they'll make it

[Jennifer Carbee (Legislative Counsel, Office of Legislative Counsel)]: work on some language there, and then Green Mountain Care Board to this would take out the existing law process that was established in 1968, and instead change this to upon receipt of notification, and then it's not coming from agency community services, it's coming from the hospital, that the hospital intends to reduce or eliminate service after completing the process, Then the board reviews the impact on hospital's approved budget and can adjust the hospital's budget as necessary, which may include directing any savings related to the reduction or elimination of return to payers and promoters to address affordability concerns or reinvest it in primary care prevention and other community based services. And then just modifying language a little bit around for its collaboration with DFR and the monitoring the implementation. And that's that section.

[Sen. John Benson (Member)]: Jerry, would just use that. Something that was so you say, if we don't do this, we think we're gonna have more problems. With the Rockland experience, I'm not sure you would have the same problem. Sure.

[Virginia "Ginny" Lyons (Chair)]: Not sure what?

[Sen. John Benson (Member)]: No. No. I'm not sure you'd have the same impacts as Rockland. Oh. So my only question is because of all the flux of where we are and the transformation and all that stuff, no, this this bill's really needed, and I hate to say that. There's gotta be a process now that that's kind of in place without this bill, I don't know what it is. Don't know what

[Virginia "Ginny" Lyons (Chair)]: it No, it's the only process in place, this underlying statute, which resulted in rob. There is no public hearing required. There is no public notice requirement. Right. The transformation plan doesn't have an effect unless it's a willing player. So do nothing. No, so it's I'm not, you know

[Sen. John Benson (Member)]: I am for the public process.

[Virginia "Ginny" Lyons (Chair)]: Yeah, no, What I'm thinking of is putting the public process in that would ameliorate some of the problems that we see. In the meantime, AHS is working exceedingly hard at collecting data, working with doing transformation, helping community. And once that gets in place, there might be a firmer understanding of what's there, what's not there, and what would influence budget. That's why I say put it out there, but let's put something in that helps. It'll be reassuring, I think.

[Sen. John Benson (Member)]: One option would be because it's don't look at the longer term plan at this school.

[Virginia "Ginny" Lyons (Chair)]: And that will never change. It will come back in in three or four years, and now it's gonna be it'll be the same battles. Very true. Only problem difference is we'll

[Sen. John Benson (Member)]: know more about what the strategic

[Virginia "Ginny" Lyons (Chair)]: plan And we will. And within this timeframe, we ask for information about how to improve this process. We do exactly that.

[Jennifer Carbee (Legislative Counsel, Office of Legislative Counsel)]: All right, so I feel like I have enough guidance to get you a new draft on this. Glad you knew. Well, if you're not seeing Although I do think, you know, there are a couple things to think about around whether you want to put supernavers on what it means to, what a reduction is that would trigger this requirement. Yeah, I agree with that one. And if you wanna do something about the reduced paper based.

[Virginia "Ginny" Lyons (Chair)]: Regional media. That'll be our last step.

[Sen. John Benson (Member)]: Yeah. What is the reduction?

[Virginia "Ginny" Lyons (Chair)]: Well, size of the service reduction, I think, and the type is really Yeah. Wow. It's gonna be important.

[Jennifer Carbee (Legislative Counsel, Office of Legislative Counsel)]: Yeah, and I don't know if that's something that the hospitals can help us think through. Know that had examples in the past of like, you know, what if somebody retires, do we have that, and it reduces service, is that? And I don't think that's what you want, but are there particular sort of lines you can draw around what it means to sort of significantly reduce the

[Virginia "Ginny" Lyons (Chair)]: service. Don't know if I can Maybe a patient can help with that. Help me get through that one. Care of course, yeah. So, But it'd good. Thank you. K. That's it. What's next? Okay. What's next? Pill are

[Jennifer Carbee (Legislative Counsel, Office of Legislative Counsel)]: we doing at one ninety or one ninety seven?

[Sen. John Benson (Member)]: Hopefully, we're doing. We were one ninety.

[Virginia "Ginny" Lyons (Chair)]: We were doing one ninety. But let's go back with that. K?

[Jennifer Carbee (Legislative Counsel, Office of Legislative Counsel)]: Alright. So next up, we have s one.

[Virginia "Ginny" Lyons (Chair)]: Do I do we have nothing? Nope? Yep. Got it. We've started a little bit to talk about,

[Jennifer Carbee (Legislative Counsel, Office of Legislative Counsel)]: but you've gotten testimony from a variety of people. So this is the Green Mountain Care Board reference based pricing, hospital outsourcing, and clinical care. We've had some proposals around, from the board around reference based pricing. You've had some proposals from hospitals. Great job of remembering who else you heard from.

[Virginia "Ginny" Lyons (Chair)]: Oh, I heard from insurance companies.

[Jennifer Carbee (Legislative Counsel, Office of Legislative Counsel)]: Right. And as far as what proposals you have heard that you already submitted?

[Virginia "Ginny" Lyons (Chair)]: Oh, on reference based budgeting, I think we were thinking about looking at high cost, high segmentation, that information. We were also So we ran chair boards proposals. Yeah, but thinking about it, right. Not interested in diving into specific services necessarily. Like the insurance companies brought up laboratory and others and veterinary Oh, right. Not our job. Not our job.

[Jennifer Carbee (Legislative Counsel, Office of Legislative Counsel)]: Yeah, and I think, you know, in that language it may flag some of the same services the hospitals were talking about with that name.

[Virginia "Ginny" Lyons (Chair)]: One of the things that's come up from time to time with this is if a hospital size, and so academic medical centers versus critical access versus maybe our larger hospitals, and whether there's a differential that we can place depending on the hospital's organization, Or is that some, and that's something that the board should be charged with evaluating in the reference based pricing model? I can't remember the difference between critical access hospital can cause it.

[Jennifer Carbee (Legislative Counsel, Office of Legislative Counsel)]: Clinical access hospital is a subset of hospitals, but I would love to let

[Virginia "Ginny" Lyons (Chair)]: them Oh, have the hospital. There are different, six of them. Could see them wind up, but I can't remember.

[Devon Green (Vermont Association of Hospitals and Health Systems)]: Yeah, actually we have eight of them. Devon Green, Vermont Association of Hospitals and Health Systems, we have eight critical access hospitals. They're a federal designation for purposes of Medicare payment. You have to have fewer than 25 beds and sort of like a geographic component in terms

[Virginia "Ginny" Lyons (Chair)]: of this

[Sen. John Benson (Member)]: That's critical, okay. Yeah.

[Devon Green (Vermont Association of Hospitals and Health Systems)]: So, it's all about So long. Creating Yes, yeah, and secure.

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

[Devon Green (Vermont Association of Hospitals and Health Systems)]: Yeah, access hospital.

[Virginia "Ginny" Lyons (Chair)]: And then we have larger hospitals. Can you speak to that?

[Devon Green (Vermont Association of Hospitals and Health Systems)]: Yes, the larger hospitals are, they're another Medicare designation, but I would say we have Rutland Regional Medical Center, UBMMC, CPMC, Southwestern Vermont Medical Center. Brattleboro Memorial Hospital is a little funky.

[Virginia "Ginny" Lyons (Chair)]: Now a critical access for sure.

[Jennifer Carbee (Legislative Counsel, Office of Legislative Counsel)]: No, not credential. Participating in a federal model that sort of, he'd like a critical access hospital, but it's not

[Virginia "Ginny" Lyons (Chair)]: a critical

[Devon Green (Vermont Association of Hospitals and Health Systems)]: It's critical access not

[Virginia "Ginny" Lyons (Chair)]: But you guys addressed academic medical center is a separate category of white

[Devon Green (Vermont Association of Hospitals and Health Systems)]: Yeah, that's a tertiary care hospital, so that's major trauma, And then it's also an academic medical center, so it's a teaching hospital.

[Virginia "Ginny" Lyons (Chair)]: And it gets a higher insurance reimbursement because it is an academic. That's good. Right. So it's all about things to consider.

[Sen. John Benson (Member)]: So not even Medicare. Not even Medicare is the same than going to hospital? Correct. Right. Oh my Lord.

[Virginia "Ginny" Lyons (Chair)]: They get facility fee reimbursements to support their facilities at different levels. And they complicated set forth at CBA and Tribe, a $200 facility fee to UVMs. So which is why And they're buying up. There are differentials across the world.

[Jennifer Carbee (Legislative Counsel, Office of Legislative Counsel)]: What's quarter? Quarter

[Devon Green (Vermont Association of Hospitals and Health Systems)]: is critical access hospital.

[Jennifer Carbee (Legislative Counsel, Office of Legislative Counsel)]: That's all

[Virginia "Ginny" Lyons (Chair)]: they're pulling out. Cobbly is critical access. Southwest is, I call it regular.

[Devon Green (Vermont Association of Hospitals and Health Systems)]: So Northwest certainly. So, Rutland, Northwest. Northwest is regular.

[Virginia "Ginny" Lyons (Chair)]: Right, what about St. Johnsbury?

[Devon Green (Vermont Association of Hospitals and Health Systems)]: Critical access.

[Virginia "Ginny" Lyons (Chair)]: Critical access. Northeast Kingdom? Critical access. So all of that, they're all critical So

[Sen. John Benson (Member)]: they're different, Medicare and Medicaid rates? Or just Medicare? Medicare. Just Medicare.

[Virginia "Ginny" Lyons (Chair)]: As far as we don't. Medicaid. Medicaid is in terms of rates. Yeah.

[Jennifer Carbee (Legislative Counsel, Office of Legislative Counsel)]: Okay,

[Virginia "Ginny" Lyons (Chair)]: so let's just go through one ninety and we'll identify some places where we have decision points to be made. One of them was the reference based pricing on high cost, high utilization. Also were talking about differential pricing based on Tyvaso Hospital.

[Jennifer Carbee (Legislative Counsel, Office of Legislative Counsel)]: Yeah, and I think that may be inherent in the existing reference based pricing language. That's what I was wondering. Think it

[Virginia "Ginny" Lyons (Chair)]: was, it is. I don't know if that I think I have a gene ID.

[Jennifer Carbee (Legislative Counsel, Office of Legislative Counsel)]: You had the request from the hospital association to delay the NPI.

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

[Jennifer Carbee (Legislative Counsel, Office of Legislative Counsel)]: Separate NPI for off campus services to align with federal timing, or are you So, it's

[Virginia "Ginny" Lyons (Chair)]: in the bill as twenty sixth? It's in the

[Jennifer Carbee (Legislative Counsel, Office of Legislative Counsel)]: bill as 10/01/2026, and the Hospital Association of West Hartford, 01/01/2028.

[Virginia "Ginny" Lyons (Chair)]: That was the board who's gone over that, there's also what?

[Devon Green (Vermont Association of Hospitals and Health Systems)]: Devin Green was, when we talked with the insurers, they said 10/01/2027 would be optimal and we're amenable to that, we could do that.

[Virginia "Ginny" Lyons (Chair)]: Okay, so let's decide on that.

[Sen. John Benson (Member)]: Can't believe it.

[Virginia "Ginny" Lyons (Chair)]: We did something. Something good. It is time for spring break. So, the hospital association

[Jennifer Carbee (Legislative Counsel, Office of Legislative Counsel)]: also asked for language in C here, then have the Green Mountain Care Board expressing rates for items and services as a percentage of Medicare amount. I'm entirely sure I understand this request since it's provider What's the request? It's provider contracts, so it's like hospitals and insurers. Oh, they make the contracts first and then, I know how the people see that playing out.

[Devon Green (Vermont Association of Hospitals and Health Systems)]: Having don't have a Green Vermont Association of Hospitals and Health Systems, I think where we were at with that, it's the Green Mountain Care Board gets our prices anyway. So my understanding is from legislation last year, I could be wrong on the contracts piece, but that they do get our prices. We're concerned, it's not easy to do the calculation of the percentage of Medicare. There's a lot of factors that can come into play. We've often heard the Green Mountain Care Board express frustration around us not having our budgets standardized as much as they could be. And we're worried that we're going down the path of people calculating things slightly differently. We don't understand why it's hospitals doing the calculation and not the Green Mountain Care Board doing the calculation.

[Virginia "Ginny" Lyons (Chair)]: Okay, so what line is that?

[Jennifer Carbee (Legislative Counsel, Office of Legislative Counsel)]: We are literally at C here, it's harsh with it, because it goes across two pages, but for provider contracts entered into on or after 10/01/2026, and the bill, as introduced, says each hospital and health insurer shall express the rates for all items and services as a percentage of Medicare or another benchmark, if that's I want to turn

[Virginia "Ginny" Lyons (Chair)]: it into that one. And so I think

[Jennifer Carbee (Legislative Counsel, Office of Legislative Counsel)]: what you're hearing from the hospitals is we are not sure we're all gonna be using the same calculation. Think for Medicare so please don't put this on us. And my question is, is the board, the board isn't involved in the provider contract still afterwards, so I'm not sure if the request is for the approval the thousand. Okay. So I'm not sure, you know, what you

[Virginia "Ginny" Lyons (Chair)]: wanna do. I see two things in this. 200 things in this? I've just gotten knocked out of my head. Let me just go back. The board should be establishing reference based pricing based on service and certain codes. That's the board's job and the hospitals then use that in a rate setting. I don't know why this is happening through contracts at all. Can I get clarification? The board has I don't understand that. Okay, well,

[Jennifer Carbee (Legislative Counsel, Office of Legislative Counsel)]: then I understand And my sort of general read on this, the board would like things to start to be expressed as percentages of Medicare so that if the company is using the same Exactly,

[Virginia "Ginny" Lyons (Chair)]: I feel like, oh thank you, you brought me back out of my mind. Go ahead, Shannon. I'll say Diane Lane for In the Medicare preparation for the continuation report for the reference based pricing, we're going to need to have the data expressed in for best in the Where they currently are. Right. So we need to know that it's 500% over or 200% or whatever. Okay, thank you. That's good. Now, why do we need to invoke why do we need to I gotcha. Why do we need to invoke provider contracts in that? Why can't we simply say hospital and insurers shall express? So why do we put the contracts in the middle of it? The contracts are the contracts between the two entities. They are supposed to be trained. They are transparent, but what we're trying to see is just what's the bottom line. Am I missing a point? I think you're right, madam. Like, we wanna see what the bottom line is, not just what it might be, but what is in the actuality of the contract. I'm the director of the hospital say, just like everybody kind of classifies things in their budget slightly differently Yes. That they calculate Medicare, those payments slightly differently, or is it just you've got three services being delivered to one person at the same time? You've got a bulk rate and you've got to divide it out. Is that

[Devon Green (Vermont Association of Hospitals and Health Systems)]: Yeah. So, have a green from both. So, it's, what we're hearing from our chief financial officers is that, A, we're not sure what the methodology is yet, and so we don't want to be in a position where everyone's, you know, and applying it we're getting different answers. We want it to be uniform. We want one source of truth, and then B, this is actually administratively burdensome for us to do, and this is a difficult task, and so we're not quite sure how to do it, and we think it will take resources.

[Virginia "Ginny" Lyons (Chair)]: So what do we wanna know? It would take, if it's difficult for one hospital within their own system, which I would defer that it might be, I don't know that for sure, but I can't imagine how much more difficult it would be for us to do 14 of them without the insight that a hospital would have on its own system. Maybe To be able to calculate all their prices. So maybe because reference based pricing isn't going to go in all at once, maybe the board requests of the hospitals specific Medicare related services as a percentage of Medicare. Maybe we put in that the board will ask for specific services the over time, within a specified period of time, so the board could ask for orthopedic services and all pediatric services. Just, I'm hypothesizing. I'm not saying which services. That's something between the board and the hospital, and then you break that those things could be broken out on a gradual basis. Yes, it's administratively burdensome, but I agree with the board. Doing 14 of those all at once is massive.

[Devon Green (Vermont Association of Hospitals and Health Systems)]: I agree from Bob. The board has received funding to do this work, though, and physicians to do this work, and hospitals have not.

[Virginia "Ginny" Lyons (Chair)]: So, the board could work with hospitals to do that. That's what we're saying. So, now the board can work with the hospitals to do selected services and the hospitals will provide needed information. Don't see. Ag sixty eight collaboration. So, how does that make sense or not? I see a yes from the board. I would say that we would probably need to go back to, I'd have to go back and find out what the problem would be or what our reaction would be to them.

[Devon Green (Vermont Association of Hospitals and Health Systems)]: Ann, just, sorry, one more.

[Virginia "Ginny" Lyons (Chair)]: Yeah, go ahead.

[Devon Green (Vermont Association of Hospitals and Health Systems)]: So, Devin Green from us. We sort of ran into this already with the prescription drug price cap and how we were supposed to implement that. And we asked the board for just give us, just post the price, and we did not get that response. And so we would really appreciate in this moment of transition something, one source of truth that's standardized, clear, easy for us to follow, as opposed to 14 different calculations or

[Virginia "Ginny" Lyons (Chair)]: How would you say?

[Devon Green (Vermont Association of Hospitals and Health Systems)]: I would say that the board could do these calculations, and we are happy to post those. We understand the transparency aspect and wanting those prices posted. We are happy to be transparent. We're happy to give them the data. They already have the data. We're just not sure why they can't do the calculations.

[Virginia "Ginny" Lyons (Chair)]: I would say we haven't done an analysis on what it would take to be able to do that. So we don't have an answer to say, if we did do that, how many man hours and what information? So we would need to be able to figure that out first before we could even decide what we do. Okay, but you have a provision in here that I think came from the board in the first place that is putting administrative burden all over the place. So we need some language here that will have some graded response and collaborative work together. We could put a lot of money into the board for the work, you know that, physicians. So, okay, all right. Jen, you've got a question mark, I need to say that. No, but not really. It is the work of the board with the hospitals to make sure this happens and maybe to identify specific services. And they need to accomplish reference based pricing, and global budgeting will be coming up very soon. So there's a timeframe in here. Always forget the time, but there's a time frame right here. Okay, we're not dropping global budgeting. Now, who want to do that first? Let's work on reference based pricing too.

[Jennifer Carbee (Legislative Counsel, Office of Legislative Counsel)]: Okay. So, are you wanting, first of all, are you wanting the provision to take effect for contracts entered into on or after October 1 year? And if so, do you want, or in any event, do you want to say that hospitals and health insurers will express the rates, percentage of Medicare based on information received from the board, or something about the work between the board and the hospitals to categorize

[Virginia "Ginny" Lyons (Chair)]: specific services as a percentage of Medicare and that the board shall identify those services. So there's a framework for them to look at just a few services.

[Sen. John Benson (Member)]: It'd be

[Jennifer Carbee (Legislative Counsel, Office of Legislative Counsel)]: Okay, that's different than express the rates for all items and services. Right.

[Virginia "Ginny" Lyons (Chair)]: Yeah, well, ultimately, it's all items and services by such and such date. What date do we put in there? I'll leave it at '20 '6. I'm happy leaving it at '20 '6. I don't it sounds like a Herculean task by '26.

[Sen. John Benson (Member)]: That's right.

[Virginia "Ginny" Lyons (Chair)]: But I'll just leave it. I just leave it.

[Sen. John Benson (Member)]: I think what I heard is that the responsibility for developing the actual rates would lie with the board through consultation with the insurers and the hospitals. Right?

[Virginia "Ginny" Lyons (Chair)]: Yeah, we wanna know what the bottom line is, what's the payment model for what is the hospital being paid for that services if it's bundled with x rays and labs and everything else, we pull it out and you look at those costs and that's the hard part right here.

[Jennifer Carbee (Legislative Counsel, Office of Legislative Counsel)]: So is part of the issue that the board needs to develop sort of a master list of Medicare benchmarks so that everybody can do the math.

[Virginia "Ginny" Lyons (Chair)]: I'm trying figure that out too. Would happen if you did it by bundles? I mean, bored, what would happen if you did it by bundles? And then they've also got those great big bubbles out there with labs, and you're have to sort that out at some point, but if they did it by bundles for knee replacement surgery or cardiac surgery or I need an answer from the board, so we'll have some fun. Okay.

[Sen. John Benson (Member)]: Well, I

[Virginia "Ginny" Lyons (Chair)]: think we've been in Oh, yeah.

[Sen. John Benson (Member)]: Looking at that date. I guess I'm looking at the the two two groups right here that are responsible for actually developing this. And is that really a realistic date? Should that be further out if we do it in status? You know, so we understand how does this really work, and and we go to reference based pricing instead of it all happening at once. And so over a period, we can see where we made our mistakes and have time to correct those.

[Virginia "Ginny" Lyons (Chair)]: But Senator Benson, I'm going to tell you that we've been talking about and working on reference based pricing now for quite a bit of time. Asking for that date out there is an extension of a problem that we've been facing and have been working on. So, right now, unless I hear compelling information, we haven't heard from the board, we're hearing something from the hospitals, might not leave the date, we know we'll sort it out.

[Jennifer Carbee (Legislative Counsel, Office of Legislative Counsel)]: And I'm putting some potential notes in here, like, that you shall begin expressing as a percentage of Medicare based on a collaborative effort between the hospitals and board to determine sort of which items and services. And how.

[Virginia "Ginny" Lyons (Chair)]: It could be bundled. That might ameliorate some of the difficulty. Yes, but I think

[Jennifer Carbee (Legislative Counsel, Office of Legislative Counsel)]: that only works if the services are delivered with S. The

[Virginia "Ginny" Lyons (Chair)]: same way, exactly.

[Jennifer Carbee (Legislative Counsel, Office of Legislative Counsel)]: And that's, again,

[Virginia "Ginny" Lyons (Chair)]: statement every month, couple months from Medicare telling me what I was charged and what they paid for what service, and I get another one from my Medicare supplement. So somebody's breaking

[Devon Green (Vermont Association of Hospitals and Health Systems)]: Right, it

[Jennifer Carbee (Legislative Counsel, Office of Legislative Counsel)]: I mean I think that the insurers know what they've paid, they send you an explanation of benefits as well. Think it's just a matter of getting everybody using the same Medicare definitions, including modifiers Gotta align all of Alignment. This. Are Yeah, Medicare has modifiers, it isn't don't, honestly I don't know enough about how Medicare But I know there are lots of variables that when, and I think even in some of the language that the board provided, they're talking about the Medicare adjusted base rate. Based on the definition, I think this may help just to understand the different variables that are involved based on the board's proposed language. They define Medicare in their name, what they submitted as testimony. A Medicare adjusted base rate means the standardized Medicare payment amount for hospital inpatient, outpatient, or professional service as determined under the traditional Medicare program calculated prior to the application of any hospital specific, patient specific, or policy based payment adjustments, reflecting only the core payment methodology used by the Centers for Medicare and Medicaid Services to establish baseline payment levels, including adjustments for geographic factors such as wages. And then some additional stuff for critical access hospitals. So that's why you can't just say, ah, the Medicare rate. Yeah,

[Virginia "Ginny" Lyons (Chair)]: happy stay on sympathy for oxygen.

[Jennifer Carbee (Legislative Counsel, Office of Legislative Counsel)]: Where are we? I think we can potentially call ourselves through reference based pricing for the moment based on all mixed changes from the board's proposals and some of what you've decided so far. Hospital outsourcing. So,

[Virginia "Ginny" Lyons (Chair)]: you gonna call me through just to use this? There we are. We've taken testimony on it. We'll look at that testimony. Maybe we can put something together for folks to town meetings and look at this gym. So we have a comparison. We were thinking about a study for that, weren't we?

[Jennifer Carbee (Legislative Counsel, Office of Legislative Counsel)]: I think you were talking about reporting. Yeah. Some reporting. We

[Sen. John Benson (Member)]: got conflicting information.

[Jennifer Carbee (Legislative Counsel, Office of Legislative Counsel)]: Yes. You did. Yeah. And there's conflicting information.

[Virginia "Ginny" Lyons (Chair)]: I had a lot of questions. You could outsource well, every yeah. Some people outsource all their lab work. Some of them may outsource specific kind of lab work. I think when we were doing COVID there was a problem at a Massachusetts lab and none of the tests came back and it's kind of I think it was Cigna that said, you know, if you outsource, like, to one person, but if you outsource whole departments, emergency rooms, there's private businesses coming in. I was at Springfield, who's going belly up, all their emergency room doctors came from a company in Chester, Vermont. So I assume they have an office there somewhere but that was a whole part that was And radiology is another one that, least nationally, gets outsourced.

[Jennifer Carbee (Legislative Counsel, Office of Legislative Counsel)]: Right, think labs and imaging, radiology, there's a lot of outsourcing and then what was getting explored more recently was the direct patient care, the emergency department anesthesia. We're also hearing conflicting,

[Virginia "Ginny" Lyons (Chair)]: so that's all our So, it'd be nice to have some more clarity on that. Thank you. Five years ago. So, going back, we're thinking about having some data brought, some information brought back to us on this. So,

[Jennifer Carbee (Legislative Counsel, Office of Legislative Counsel)]: I think and the medical society had recommended replacing the language in the bill with a requirement that the board require reporting on outsourced services for the next year's hospital, for FY 27 hospital budgets, so the ones that will be submitted for

[Sen. John Benson (Member)]: So then you'll get the information. And

[Jennifer Carbee (Legislative Counsel, Office of Legislative Counsel)]: then the board could make some recommendations after contracting with hospitals and their contracted providers assessing impacts on access quality and affordability, the board can make recommendations to the legislature by next year. That

[Virginia "Ginny" Lyons (Chair)]: think is solves us. Right.

[Sen. John Benson (Member)]: It

[Virginia "Ginny" Lyons (Chair)]: the language as it was written. I know. Yeah. Yeah. Oh, okay. Okay. I know. Everyone is you wanna do what you can out here, but you know that to get there. That's what I'm going to suggest, what page are we on? Yes.

[Jennifer Carbee (Legislative Counsel, Office of Legislative Counsel)]: And then, I mean, is Our actual assistance. Money. Watching.

[Virginia "Ginny" Lyons (Chair)]: Yes. We might wanna put some Requesting here that they report any impact on provider taxes. That's major concern. Thank you, Nolan. Thank you your help. Coming to Yeah. Because that would impact our ability to Resuscate. What page are we on? Because we're gonna have to write here. Right,

[Jennifer Carbee (Legislative Counsel, Office of Legislative Counsel)]: so is that what the hospitals are telling the board or what the board is telling the legislature

[Virginia "Ginny" Lyons (Chair)]: or both? The board should tell the legislature. Yeah, we'll have to, so they

[Jennifer Carbee (Legislative Counsel, Office of Legislative Counsel)]: have to consult with the AHS. So

[Virginia "Ginny" Lyons (Chair)]: then we're up to the healthcare professional bargaining group? Yes, and I think what the BMS had requested was appropriate.

[Jennifer Carbee (Legislative Counsel, Office of Legislative Counsel)]: So carve out the reference based pricing at the BMS proposal?

[Virginia "Ginny" Lyons (Chair)]: Yeah, we can look at that with everything else. Okay. And then, what? I don't remember. Payment amounts methods. Hospital oh yeah section pay fee can we end the oh then

[Jennifer Carbee (Legislative Counsel, Office of Legislative Counsel)]: it should repeal that's the bargaining group stuff so then it's like your nine foot four

[Virginia "Ginny" Lyons (Chair)]: appeals let's end here okay complicated and we're going

[Jennifer Carbee (Legislative Counsel, Office of Legislative Counsel)]: to take a break and our brains

[Virginia "Ginny" Lyons (Chair)]: have done good work. This is great. This is a good way to get this done.