Vermont Legislature SmartTranscripts:

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Okay, so we are back live. This is Senate Health and Welfare, and we're moving on to markup S-one hundred ninety and one hundred ninety seven. So Jen, thanks for coming back. You are welcome. You got us in. We appreciate your time. Got you. Who says cross that quick?

[Jennifer Carbee (Office of Legislative Counsel)]: Alright. Jen Carving, legislative council. So we are looking at S one ninety, and I do have a comprehensive, and that new amendment for you. So, I've got all of the changes from I think we've only done a as introduced. So, all of the changes when a bill is introduced are bold and highlighted. Language to be struck is bold and struck. Not all of this is necessarily consensus language among everybody, but hopefully it gives us a place to have more conversation. So, S-one 190 is an act relating to the Green Mountain Care Board reference based pricing and hospital outsourcing of clinical care. The reference based, do you wanna set it up? Thought I was. Yes. Hey, Jamie. You can't. I had it scrolling on my screen. Yes. We do have it. No. Was thanking for pointing that out when I was ready.

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: All right,

[Jennifer Carbee (Office of Legislative Counsel)]: so we have reference based pricing, no changes to begin with, but then when we start talking about hospitals and insurers expressing in their provider contracts rates as reference based pricing. Had added, so first it was for provider contracts entered into on or after 10/01/2026. The board had recommended adding contracts entered into amended or renewed. Probably makes sense, but wanted to flag that for you here on or after that date. Each hospital and health insurer shall, instead of express, we would say begin expressing, and this was part of our conversation before the town meeting break, begin expressing as a percentage of Medicare or another benchmark, if deemed appropriate by the board, the rates for items and services identified pursuant to a collaborative process between the board and representatives of Vermont Veterans. This was the piece where there was concern about an expectation that everybody be ready to go and wanting a way to identify which items and services are ready to be expressed in that case. So hopefully that works and

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: I don't know if you want

[Jennifer Carbee (Office of Legislative Counsel)]: me to stop each time or just keep going and listen until you Let's

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: go through the whole thing and then we'll help the committee and then we'll come back to decision points and we'll have the gallery Some

[Jennifer Carbee (Office of Legislative Counsel)]: of this 24 pages, it wasn't struck language, it's not all. This next provision moves out by a year from 10/01/2026 to 10/01/2027. The requirement for hospitals to get a unique NPI for intent to use on all claims filed, and this was reflecting the January 2028 implementation at the federal level, and this was a date that I believe had been acceptable to the hospital, so I don't want to forget. Okay. Then in the So I'll just identify what's still in here, some definitions. This is, I hadn't heard anything specific around including Medicare rates in the public reporting of hospital items and services. So I didn't make any changes, but you may hear otherwise. Then in the language from the bill is introduced around the board establishing a default percentage, default cap of Medicare for new service lines, or new services under the CPT codes and a default maximum percentage generally. Instead of that language, I have the board's proposal here saying until the applicability date specified in the Green Mountain Care Board rule and we settled on applicability date because I was looking for a date, some sort of a date certain so people knew when this would be starting. But the effective date of the rule may not be the same as a date when it should apply, so the board would need to include an applicability date in its rule that establishes the reference based pricing methodology. So until the applicability date specifies in the board's rule establishing the reference based pricing methodology for all items provided and services delivered in Vermont hospitals. First, a hospital shall implement any commercial reimbursement rate reduction ordered by the board under the hospital budget review by first reducing its commercial reimbursement rates that exceed 500% of the Medicare adjusted base rate, which will be a term you'll see defined in a moment, or if the hospital doesn't have any commercial reimbursement rates that exceed 500% of the Medicare adjusted base rate by first reducing its commercial reimbursement rates that are the highest in relation to the Medicare adjusted base rate, and the hospital shall not increase any commercial reimbursement rate that as of a date certain, in this case, split in 07/01/2026, exceeded 250% of the Medicare adjusted base rate. I will pause here just to say, I've seen additional, a different proposal from the Hospital Association, so this is not consensus language, this is a board's proposal. And they were great at working with me about helping clarify some of the proposed language. As used in the subdivision, Medicare adjusted base rate means the standardized Medicare payment amount for a hospital inpatient, outpatient, or professional service as determined under the Medicare program, calculated prior to the application of any hospital specific, patient specific, or policy based payment adjustments, and reflecting only the core payment methodology used by CMS to establish baseline payment levels, which include adjustments for geographic factors such as wages. Section two would be a new section added into the subchapter on qualified health plans, so these are plans offered in the Exchange, Vermont Health Connect. And it would be entitled limitations on hospital reimbursements. So it starts out with that same definition of Medicare adjusted base rate. And then it specifies that for items provided and services delivered at a critical access hospital, the Medicare adjusted base rate Medicare adjusted base rate shall be determined under the applicable Medicare prospective payment system using the Medicare payment methodology that would apply if the hospitals were not designated as critical access hospitals. So that's sort

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: of the definition there. So that just explained that eliminates critical access hospitals?

[Jennifer Carbee (Office of Legislative Counsel)]: No, it just says don't use the critical access hospital methodology for determining the Medicare base rate, use the applicable Medicare perspective payment system. And if you wanna know what all those distinctions mean, I'm gonna defer to submission. So that

[Unidentified Committee Member (Senate Health and Welfare)]: was because, I'll go back memory, what you explained, the critical care gets Yeah, critical access hospitals get more or higher reimbursement rate from Medicare. Is that right?

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: They get a cost plus reimbursement rate. So all of their allowable expenses are covered plus one.

[Unidentified Committee Member (Senate Health and Welfare)]: So that's why you're you're making that change?

[Jennifer Carbee (Office of Legislative Counsel)]: Yes. Can I make for the board that why why why does the language carve out critical access hospitals and say don't use critical access hospital payment methodology

[Unidentified Committee Member (Senate Health and Welfare)]: Right?

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Prospective payment. So we are would like to move towards a standard definition that can be applied across all hospitals. Doesn't actually change how they're paid. It's just saying we're going to use this methodology to establish the same reference point. So it's just a clean way to all be talking about the same number.

[Jennifer Carbee (Office of Legislative Counsel)]: So and and if I can just clarify. So it may be that a critical access hospital a particular hospital based on its needs gets a higher percentage of that Medicare adjusted base rate because of its needs, but it's saying in the methodology, use one Yes. Medicare method

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Good.

[Jennifer Carbee (Office of Legislative Counsel)]: For figuring out reference based pricing and then the references, the pricing itself may vary based on the hospital's needs.

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: But it gives the coordination to regulatory.

[Jennifer Carbee (Office of Legislative Counsel)]: Simple, yes. It's setting a single standard, sort of a single vocabulary that everybody's using for that, what the Medicare rate means. So you can compare office staffs. Okay, so then, so that was just the definitions. Now we're saying a registered carrier, which is what a health insurer that offers a qualified health plan is called. So in this case it's really, it comes across an MVP for their qualified health plan market.

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: I'm gonna bring up something to add in here in a little bit, so why don't we go through it and I'll go back to it.

[Jennifer Carbee (Office of Legislative Counsel)]: So a registered carrier shall not reimburse or agree to reimburse a hospital more than 250% of the Medicare adjusted base rate for any item provided or service delivered in Vermont to an individual enrolled in a qualified health benefit plan. So this would have a particular 250% reference based price caps on hospital reimbursements for people on qualified health plans. In the event that a registered carrier reimburses an option for an item or service on a capitated or other non fee for service basis, the carrier shall ensure that its reimbursement method is adjusted to account for the reimbursement limit set forth here. So, they have to still adjust the reimbursement so that it's not more than 250% after Medicare adjusted base So, I'll

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: just go up to B1. And I've had conversations both with VSEA and V5, which would be the NEA folks. And they would like to be included in B1. So not just QHPs as it is here, but also include VSEA folks and BHAB folks. So I'm just bringing that up as an addition here. It will help going forward.

[Jennifer Carbee (Office of Legislative Counsel)]: Sure there are many, many, many, many views on that. Alright, the reimbursement limit in subsection B will apply until, so that 250% cap will apply until the applicability date specified in the agreement with care board rule establishing the reference based pricing methodology for all items provided and services delivered in Vermont hospitals. So again, this is sort of an interim measure that will be revisited or modified when the board actually has reference based pricing in effect across all services. And it prohibits, so D is prohibiting a hospital or hospital provider that is reimbursed in accordance with that cap from balance billing, from charging or collecting from the patient any additional amounts other than the cost sharing amounts authorized by the terms of their health benefit plan. And then it uses some language similar to what was in May last year around the allocation of prescription drug path, and it says the purpose of this section is to reduce healthcare costs, and a hospital shall not increase the amounts the hospital charges other commercial plans or private payers for prescription drugs, procedures, tests, imaging, or other healthcare goods or services in an effort to offset revenue reduced as a result of this section. So there should not be cost shift on to account for, I don't

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: know, like 250% gap.

[Jennifer Carbee (Office of Legislative Counsel)]: Then we get into hospital outsourcing. This would strike all of the language around hospital outsourcing. So the intent language, the purpose language, the limitations on outsourcing, the specific requirements around financial assistance policies and provider taxes, and instead require that for fiscal year twenty twenty seven hospital budgets, the Green Dot Care Board shall direct hospitals to provide such information as the board may require regarding the clinical services that the hospital outsources to external entities. On or before January 15, the board, after consulting with hospitals and their contracted independent providers, and assessing the impact of outsourcing on access to and quality and availability of care, would provide findings and recommendations to this committee and house committee regarding hospital outsourcing. And in addition, the board, in collaboration with the Agents of Human Services, would report on the extent to which hospital outsourcing affects provider tax revenue and recommend any necessary modifications to the provider tax provisions to appropriately reflect expenditures for patient care at Vermont hospitals. I get lots of views, I'm sure, on that page. Excluding reference based pricing from the scope of healthcare professional bargaining, So, this is taking out the provisions of the bill that had eliminated the healthcare professional bargaining groups. That's the sections themselves are struck. So the underlying law remains the same. The repeal is struck of the section of healthcare provider bargaining groups, and instead that section will be amended to carve out preference based pricing. So, notwithstanding any provisions of this section to the contrary, the Green Mountain Care Board shall not be required to negotiate with a provider bargaining group or engage in a non binding arbitration process in connection with the board's establishment of preference based pricing in accordance with various provisions that direct the board to reference data. No changes to the language around appeals of your non care board orders or hospital audits. Data infrastructure, this is the

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: So this is what, we haven't finished a discussion on some of these things. Go ahead.

[Jennifer Carbee (Office of Legislative Counsel)]: Data infrastructure, this is the Agreement for Career Board health system performance tool, and they had requested some changes. So this would now say that it requires still the board to develop and maintain a public interactive tool displaying information on health system performance, but instead of some of the specifics in the bill as introduced, this would say including information regarding quality, access, and affordability. And then instead of requiring the board to update the information of these quarterly, it would require the board to update it on a regular basis to the extent operation would be feasible. Then this creates a new study committee. This is a new section that the, I don't think the committee has discussed. This would create the Public Employee Health Benefit Authority Study Committee. Potential for a different name to be developed by audience committee.

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: I was thinking about a new name.

[Jennifer Carbee (Office of Legislative Counsel)]: I have one, but who knows? It's slightly different from the standardized provider. For one thing, this creates a study committee, not a task force. In my mind, a task force is sort of what you do to operationalize something that's already been decided upon, versus a study committee, to, you know, do a deep dive. A study committee is really looking at an issue and making recommendations about whether that issue is worth pursuing, sort of my mental calculus on terminology. So this creates the Public Employee Health Benefit Authority Study Committee to evaluate opportunities to establish a state authority to develop and administer comprehensive and affordable health benefits for all public sector employees in Vermont. It would be composed of the following members, usually to be appointed by the entities that represent the state treasurer or designee, a member representing the Vermont State Employees Association, a member representing the Vermont NDA, a member representing the American Federation of Teachers, a member representing the Electrical Workers, a member representing the American Federation of State, County, and Municipal Employee, a member representing the School Board Association, a member representing the members of the Hounds, a member representing the State College System, a member representing the University of Vermont, and a member representing the Department of Human Resources. The study committee would consider the topics that were in this subsection and produce a report regarding the potential for establishing the Public Employee Health Benefit Authority to provide and administer health plans that would lead the healthcare and wellness needs of Vermont's municipal, state, public school, and public college and university employees and their dependents, including addressing all of the following: the manner in which health benefits are provided to public employees in other states, including Oregon and Washington the similarities and differences in level and scope of coverage provided by current health plans offered to public employees, the similarities and differences in the current service or contractual agreements negotiated by public sector employees with commercial health insurers, third party administrators, and independent clinical and analytical vendors. Uniform design, coordination, and administration of medical and pharmaceutical health plans, care networks, wellness initiatives, and medical privacy protections. Uniform standards and protocols for contract review and negotiations with hospital facilities, non hospital healthcare providers, commercial health insurers, third party administrators, independent clinical and analytical vendors, and pharmacy benefit managers, Streamlined auditable processes to confirm the integrity and accuracy of billing from and reimbursements to hospitals, non hospital healthcare providers, and vendors. Opportunities to secure substantial and sustainable cost reductions for employees, employers, and taxpayers, monitoring and management of fiduciary risk, public employee health benefit authority governance structures, deliberative processes, and equality of decision making by employer and organized labor representatives, staff positions, member and patient advocacy and problem resolution on behalf of employees and employers, uniform standards and systems for collecting, analyzing and securely transmitting data on clinical utilization, quality of care and other essential metrics to support health and management and vendor needs. Almost done with this list. Opportunities to expand participant access to primary care, mental health, and community based healthcare services. Redirect care from hospitals and their emergency departments to less costly settings, and improve chronic disease management and medication therapy adherence, and alignment of authority operations and health benefit plans with the transition to reference based pricing, global hospital budgets, and regional care transformations directed by acts of the general assembly, including various actions from 2024 to 2025. The study committee will provide recommendations regarding a detailed blueprint with timelines to design, build, and launch the public employee health benefit authority, the need, if any, for independent consultants or advisory personnel for establishing the authority, and going forward, to support its mission on a regular or intermittent basis, and the projected costs of creating and annually funding the public employee health benefit of Geordie. By December 15, the study committee would submit a report detailing the information to the general assembly, and I added in the governor. Since it deals with state government. Assistance, the study committee would have the administrative, technical, and legal assistance of the office of the state treasurer, and may engage the services of one or more consultants or firms to assist with facilitating meetings and public hearings and preparing its report. Directs the state treasurer or designee to call the first meeting of the study committee to occur by August 15 year. Designates the state treasurer or designee as the chair. A majority of the membership constitutes a quorum, and the study committee would cease to exist on 01/01/2027, after delivering this report. Requires the study committee to schedule public hearings, both remote and in person, to allow public sector employers and employees the opportunity to share their healthcare needs and concerns with the study committee before the issuance of the committee's report. Requires commercial health insurers, third party administrators, BIHI, and clinical and analytical vendors serving the public sector to provide full and timely access to the study committee with appropriate non disclosure agreements in place as needed. Access to their service contracts or agreements with relevant public sector entities and any data, including claims, actuarial, financial, and other data that the study committee requests. I put some placeholder language in here so you could decide if the members of the study committee would receive per diem compensation and reimbursement of expenses, and if so, how many meetings, and how much would be appropriated to the Office of the State Treasurer from the General Fund for per diem and compensation, per diem and reimbursement if provided, and for the services of one on one consultants or for us. Finally,

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: the actors will take effect on this and she can. Take a deep breath. Okay. So that last section is, weren't able to have testimony from what's going on in Oregon and they do have a public employee authority where they've established a system for health benefits for public employees.

[Jennifer Carbee (Office of Legislative Counsel)]: I do, I was looking at them a little bit yesterday and looking at, or Monday, and looking at, working on this language. I do think they administer state employees and school employees So there may be some combinations or some risk pooling that happens, but they do seem to have pretty different,

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: or somewhat different administration. Okay, I have talked with the VLCT, VLCT, VHI, and VSEA regarding their interest in being part of this pool process and looking at a broader risk pool and a more proactive way of acquiring insurance and health benefits. That's a lot. So let's go back to the beginning of the bill. And first of all, I'll just say I don't see a lot of people who might require for Gin, but I could be wrong there. It didn't look like it.

[Jennifer Carbee (Office of Legislative Counsel)]: It's generally people who are not compensated by their employer for their So those who are appointed by unions, for example, may not be compensated by their employer for their participation. Okay, so let's go to the

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: beginning of the bill and then walk through and we'll stop, make decisions. Know that I can see there are people around the room who want to comment, we'll do that, Then we'll get into the greater working group that's there.

[Jennifer Carbee (Office of Legislative Counsel)]: Okay. So, we start in reference based pricing, and the first change here is the board's suggestion to add provider contracts amended or renewed as well as those entered into on or after October 1.

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: So what I'm gonna ask of folks around the room is if you have a comment that you'd like to make, You don't have to comment that you like this. What would be helpful is if you have a comment that would improve the language from your perspective. So if you have that, just raise your hand.

[Devon Green (Vermont Association of Hospitals and Health Systems)]: Devon Green, Vermont Association of Hospitals and Health Systems. I do appreciate the collaborative process on this. Again, I think the Green Mountain Care Board should be doing the actual conversion. I don't understand why hospitals are required to do the conversion when we give the Green Mountain Care Board our prices.

[Jennifer Carbee (Office of Legislative Counsel)]: Is that specific to seeing here or

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: is that later? I'm looking, we're

[Emily Brown (Green Mountain Care Board)]: just looking at the Correct.

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: You're talking about the collaboration between the board and representatives of Fremont Hospitals. Emily Brown, Fremont Care Board.

[Emily Brown (Green Mountain Care Board)]: So for this one, I think I'd just like to go back to the fact that the legislature asked us to start implementing reference based pricing in FY twenty seven. If we are going to be able to do that, that requires the hospitals, insurers, everyone who is part of the healthcare system to start looking at their prices as a percent of Medicare. So, to me, they should already hospitals, insurers, everyone should already be starting to transition their contracting and how they price things and how they look at their pricing as a percent of Medicare. If they don't do that and we then go ahead and implement a rule, whether it's in our guidance, start referring to prices as a percent of Medicare and the hospitals do not have data and information that shows them what their prices are as a percent of Medicare, I don't know how we as a system are going to move towards that. We don't have all of the hospitals specific prices for every single service that they cover. We don't have that information. So I don't understand where this assumption is coming from that the Green Mount Care Board was at some point going to be feeding information out on what every single hospital charges and what the percent of Medicare is. We are happy, and I think we've done so here, provide an explanation of when we say as a percent of Medicare, what that means. But I think it's on the hospitals in the system to go back and look at their and figure out what that means as a percent of Medicare as described in this bill.

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: So just talking about the language in C. Correct. And then so you're suggesting that I disagree with it being a collaborative process. I think we are happy

[Emily Brown (Green Mountain Care Board)]: to issue guidance or provide further guidance, but I don't understand. We don't have the resources to work with every hospital and provide the technical assistance to convert their prices to Medicare. We don't. So if that was going to be the requirement or

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: the expectation, we would need more further resources to do that. So instead of collaborative process, the hospitals don't like it, you don't like it. So to

[Jennifer Carbee (Office of Legislative Counsel)]: be clear, this isn't the items and services identified pursuant to a collaborative process. So the requirement is that for provider contracts, hospitals and health insurers use, express, or begin expressing rates as a percentage of Medicare for the items and services identified pursuant to a collaborative process between the board and representatives of Vermont Hospitals. So that you identified

[Emily Brown (Green Mountain Care Board)]: items and services. I think that everything, every service, the way that things are paid for are going to have to be described as a percent of Medicare.

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: I don't know how you then take a identify a subset of that if we're trying to regulate prices across the system. So are you is it better to think that it's initially a collaborative process? I'm I'm thinking that this is like There's no benefit. Yeah. There's no benefit, Elena Bear Beadrick Okay. Go ahead. To doing just a subset. Think if hospitals are going to have to do this, doing it for all services is really just do it once, Then we know where we stand. I think we know where hospitals stand as a basis of Medicare. It's a really important baseline information to have as we move forward so we know how things are changing. Okay. And it does say earlier in the paragraph, Each hospital and health insurer shall begin expressing. So there is an implication there that it's a process. It's not gonna happen, but it begins October 1 and it's going to affect 27. So, and then it's the rates for items and services identified in a collaborative process. So it's the collaborative process that is in question. I'm trying to get the wordsmith there.

[Devon Green (Vermont Association of Hospitals and Health Systems)]: The green from buzz. We're this does feel like a matter of resources. Fremont Care Board says that they don't have the technical assistance to help us do these calculations. We also don't have the resources to do these calculations necessarily with what is happening. And so we would be interested in a collaborative process and beginning to look at this. We can work with this language, but we're we were also just trying to figure out the reasoning for the language.

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Senator, do you want to ask?

[Unidentified Committee Member (Senate Health and Welfare)]: I hope chair. So the rates for items and services identified pursuant to a collaborative process between the board and representatives of the rural hospitals, that can be a tremendous amount of services, right, or it could be smaller amount of services. And would it be better off to set up some common services that every hospital provides that's known, measurable, that's easy to do, and then continue to move that forward as far as services?

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Can I say something here?

[Emily Brown (Green Mountain Care Board)]: Do do not.

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: We don't wanna be the regulators. That's something the board will do. So yeah. Think about it. Once we start down that pathway

[Unidentified Committee Member (Senate Health and Welfare)]: Right. Yeah. But the way, like, look, the way this is worded doesn't prevent the collaborative process to do that between the hospitals and the Great Mountain Care. Mhmm. Yeah. I just don't know what services means. They're gonna figure out, I guess, what services means.

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: It's a collaboration, you see.

[Jennifer Carbee (Office of Legislative Counsel)]: You know?

[Paul Robinson (Vermont-NEA)]: I don't

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: know if it is. Hospital.

[Unidentified Committee Member (Senate Health and Welfare)]: We

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: can't do this one. This is too complicated for us and it'll take us too much time. Like give us four months to come back with that one. Let's do this one. Yeah. You know, honestly, when I hear from hear from patients after we talked about this and I've talked to some folks over the break about, you know, I get my bill and it's got everything itemized perfectly based on all the stuff that's going on. So how come I'm hearing that the hospital can't sort that out for the regulator? And then I hear why can't the board move faster on this? I'm hearing all of it. Okay. So, committee, around this table, how does this all sugar off for you? I'm fine with it. I think that it makes sense. It puts some responsibility on both sides of the fence here and people have to work together to get to it. Yeah, I get my insurance and Medicare saying, this is what they charge, this is what we pay. Somebody know I mean, the hospitals know what they're getting paid by Medicare patients, and that I assume is the Medicare Right. It would take some doing, and I can see where given I'm sure there are a million billing codes or more, where it's gonna take some time to work it through. And maybe you start with the ones that we saw are the most egregious, which is relapsed and outpatient things. Maybe. I mean Maybe.

[Unidentified Committee Member (Senate Health and Welfare)]: But Up to them, you can't regulate.

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: But I think with the collaborative process, the goal being that we're going to have all of it that way, and I don't know that we need to say by next year, but within x, no. They're beginning. Yeah. It's a beginning. It's a beginning. It's a beginning. It's a big process.

[Unidentified Committee Member (Senate Health and Welfare)]: So do you think they're going to collaborate?

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: They have it on the path. Okay. I need to be honest. They do. Depends on people's attitudes. We can't we can't legislate behavior, but we can suggest the way.

[Emily Brown (Green Mountain Care Board)]: I apologize. Emily Brown again. So regardless of whether this goes into statute or not and there's a collaborative process, going back to my comment, if the expectation that we are going to be doing reference based pricing and enacting a rule that is probably going to be effective and require hospitals to be offering prices as a percent of Medicare, then it doesn't matter what services we identify. They are going to have to know what their services and what the prices are as a percent of Medicare. And if we don't require it here, which is your choice, they are still going to have to do it because then how are we If we can't say hospital X, you need to be priced at X percent of Medicare and they don't have the data, and then they come back to us and say, we can't do that because we don't have the ability to do that, then that's a larger problem. We get it. Yeah. Okay. Thank you.

[Unidentified Committee Member (Senate Health and Welfare)]: I mean, my only comment is if you don't do a collaborative process and you put rates in place, it's gonna be one of these. And so both sides have to work together in order to come up with things that they feel are workable. Yeah. And I'm sure we'll hear about it.

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: One last comment. Part

[Devon Green (Vermont Association of Hospitals and Health Systems)]: of the calculation piece is the definition of the Medicare base, which is different than what hospitals are receiving now in this legislation.

[Jennifer Carbee (Office of Legislative Counsel)]: So it would be a different conversation. So we'll

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: go, we'll look at that language. I know you said this was, Jen had said this was different from what the hospitals had suggested. So we need to look at what the hospitals had suggested and then we'll try to make our decisions about that. Nothing is So let's move on. I think we're gonna leave this the way it is now, and then we can move ahead.

[Jennifer Carbee (Office of Legislative Counsel)]: Okay. The next piece is having, giving hospitals until October 2027 to apply for, to use, and unique NPI for services delivered off campus.

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: There's a little bit concern about that. Then

[Jennifer Carbee (Office of Legislative Counsel)]: there is the change, or the language here saying, until the Virginia Gore Board rule applies on reference based pricing, hospitals will implement commercial rate reductions ordered by the board under their hospital budget review authority by first reducing the hospital commercial reimbursement rates that are more than 500% of the Medicare adjustment. Or if they don't have any of those, then targeting the highest service, highest reimbursement rates in the region for Medicare adjusted base rate, and prohibit any further increases to a commercial reimbursement rate that was more than 250% in Medicare adjusted base rate as of 07/01/2026. And going along with this is the definition of Medicare adjusted base rate. Just want to confirm what the board was at, just to add this critical access curve out there as well? Did I just drop that?

[Unidentified Committee Member (Senate Health and Welfare)]: I think that makes sense.

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Yeah. Okay.

[Jennifer Carbee (Office of Legislative Counsel)]: So I was supposed to have the second piece that you saw in the next section that says, it's critical access, don't use the critical access specific methodology, because we're trying to put everybody on the same same methodology. Okay. So that was my mistaken.

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: So go through that again, Jen.

[Jennifer Carbee (Office of Legislative Counsel)]: Just the, there should be a second part of this definition of Medicare adjusted base rate that mirrors the version in section two that says if it's a service at a critical access hospital, still use the same consistent Got it. Payment system and not the hospital's own specific critical access methodology when the exception, what the Medicare adjusted base rate is. Okay. I'm not saying what the price has

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: to be, but just.

[Unidentified Committee Member (Senate Health and Welfare)]: So 500 over you're trying to get that below that, and then if they try to increase by $2.50.

[Jennifer Carbee (Office of Legislative Counsel)]: Right, so targeting anything over, first targeting anything over 500, or the highest ones, and not be further in

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: for That one treatment to go for two

[Jennifer Carbee (Office of Legislative Counsel)]: is what the language here says. This is

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: a proposal from the board. So, this is where the hospital may look.

[Devon Green (Vermont Association of Hospitals and Health Systems)]: Sure, that would be from us. We actually really appreciate this proposal. We've been wanting to address our high prices for a while. We want to work on it, and this provides a good framework within the budget process to do that work. So, we appreciate this proposal. We would even offer to come forward in the budget process with our proposals in that spirit of thinking about it and being transparent as opposed to doing it after the fact that the budget's in place. Where we are concerned is on the definition of the Medicare adjusted base rate and how that comes into play. Our understanding is that places like Oregon have used the full Medicare payment. And like I said, hospitals know what they get paid with their adjustments. So, that consider the fact that there's the wage price index or just policy decisions for those hospitals, we know we're getting there, and we think that those should carry forward.

[Emily Brown (Green Mountain Care Board)]: Emily, for Ann, the pre master board. I don't want to jump ahead, but I think there is some relevant language in section two. While we were going through this process with developing this with Jen, I think there was some overlap happening here. So the intent of the proposal in section two, which was directly related to the QHP market and setting that at 250%, I think the board would prefer So the goals here are to first apply the So there is a budget process that will be happening concurrently with this adjustment.

[Devon Green (Vermont Association of Hospitals and Health Systems)]: And I

[Emily Brown (Green Mountain Care Board)]: think it's the board's preference that the savings accrue to the QHP market. In place of the language we have here, I think we'd prefer that the QHP market be set at 250%. We're assuming that in many instances that will allow the hospital to meet its budget guidance of negative 1%. In some instances, it's a little higher. Then if the hospital is not able to meet the budget guidance with applying the QHP market rate of 250%, then we would like them to target the savings at the higher services as outlined in section F, little I, one, I think it is. Because again, I think that the idea is to have the savings accrued in the QHP plan, which right now, as many of you are aware, is in a very vulnerable state. But we also want, I think this section two, which was essentially a freeze on prices over 250%. We are concerned that if you have that additive to the QHP market adjustment to two fifty, that that will be too much money out of our hospitals.

[Unidentified Committee Member (Senate Health and Welfare)]: So cost from hospitals to the QHP from savings, basically.

[Emily Brown (Green Mountain Care Board)]: Essentially focusing the hospital budget savings to the QHP market. And then if there is a hospital that, for some reason with that market adjustment for the QHP, it doesn't reach the budget guidance, then we would like them to focus the savings at the higher priced services. But I think we don't agree that with section two, which says a hospital shall not increase any commercial reimbursement exceeding 250%. That's essentially a price freeze. And I think, again, we're concerned that if you do that additive to the QHP changes, that will be a larger financial implication to the hospitals that wasn't part of our original analysis when we brought forward the QHP market changes. Again, I think we were viewing it as the QHP adjustments and then if needed, targeting the higher prices than the rest of the market.

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: You're suggesting taking out the non increase anything above 45%? Correct. Yep. And then, is there a reference in here to the POHP?

[Jennifer Carbee (Office of Legislative Counsel)]: Is there clarity? No, I have to fix that again.

[Emily Brown (Green Mountain Care Board)]: We would have to fix it again. Apologies to Jen, we didn't catch this. But it would essentially be in many ways combining the provision of section two, which has the q the relevant QHP provisions. Mhmm. And then having that be the primary function of the hospital meeting. Understood. Good. Okay.

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Thank you. That's that's helpful. Yeah. It might help the hospitals. Me.

[Devon Green (Vermont Association of Hospitals and Health Systems)]: I'm always going. So from Buzz, we are concerned about the 250% for the QHP implants. We understand the goal of helping that market. So, we do see that. I think what we're seeing now is other groups wanting to get into this 250% base already, which could have a negative impact to our hospitals. When you look at reference based pricing in other states, Oregon does it for its employees. It's something like 30,000 people.

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: The other We haven't got a lot of those.

[Devon Green (Vermont Association of Hospitals and Health Systems)]: Right. But I'm We just saying do. The other states that do this, do this for maybe 1% of their population, a very small percent of their population. And so I would want to be very cautious because I think there's a scenario, I appreciate the Green Mountain Care Board saying 250% will get you to your budget, But I think there's a scenario where the 250% for a hospital that has a large amount of Medicaid and QHP plans could really hurt their budget more than what's expected. Instead of going down by negative 1%, they're going down by negative 5%, and I would say that's more the vulnerable hospitals in the state.

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Well, this is exactly why it's important to leave it up to the treatment of care board and not up to us, but I know the board, do you want to comment back? Yeah. This is a good discussion.

[Emily Brown (Green Mountain Care Board)]: Yeah. So I think I hear, right, the the the concern about hospitals being impacted in different ways depending on what where their QHP population is. I think the reason why we chose this approach is because we regulate the rates in the QHP market. Right? And there's a desire by the board over the past several years to keep those rates lower. There could be a scenario where we don't do anything to control the underlying costs of of the QHP costs, and then the board approves a very aggressive rate reduction for QHP plans or or doesn't offer the full QHP requested rate increase. We wanna get away from the situation where we are relying on our on our insurers, our domestic insurers specifically, to, in that situation, subsidize a decision to decrease rates. We also wanna stabilize the QHP market so that we don't have this year over year issue with QHP prices growing and really not a mechanism to effectively control that outside of Fed cutting a hospital's budget.

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Understood. And so we get it. I know that there are 2,000 less people signing up for two AAP and that's one of the big concerns So, of all of So, we're taking out let's remind us where we are. Taking out

[Jennifer Carbee (Office of Legislative Counsel)]: so we're taking out one thing. We're moving another one.

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: We're taking out little I I. Yes. So you would so basically be taking

[Jennifer Carbee (Office of Legislative Counsel)]: we're gonna move, I think, all of this elsewhere. Right. Okay. So, because when we're combining what is now, we have one here, and the targeting the highest reimbursement rates as to, to, as sort a, of an, an order of operations after application of the 250% reimbursement limit for QHPs. And then saying if there is still room for reductions to meet the hospital's budget, then apply commercial reimbursement rate reductions to the find over 500 org highest. Mhmm. Taking out two here, I think the overall cap, and then we don't need a separate definition as it'll all be in one section and I have

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: to think about red eyes. Okay. Yes.

[Unidentified Committee Member (Senate Health and Welfare)]: Yes.

[Devon Green (Vermont Association of Hospitals and Health Systems)]: Having re infamous, I am concerned that there is actually nothing in here about making QHPs more affordable by doing this.

[Jennifer Carbee (Office of Legislative Counsel)]: Making what more

[Devon Green (Vermont Association of Hospitals and Health Systems)]: UHP, the qualified health plan.

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Right, there has to be that link. I agree. You need some link there. It can't just be I agree.

[Emily Brown (Green Mountain Care Board)]: Doing this. I agree that there should be an expectation on savings, Emily Brown, that those savings are passed through to To the consumer. Consumers for premium reductions. Correct.

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: That that that that has been my biggest recent my biggest recent comment. I met with some folks in Bennington a week or so ago and the one thing I said was if we do all of this work and it doesn't translate to keeping premiums loads of people and money out of their pockets, it doesn't do any good at all. So we can't just send it off to insurers or others, period.

[Emily Brown (Green Mountain Care Board)]: And Emily Brown again, I just also, want an opportunity to address the comment that was made about BIHI on VSEA and We're not there yet. Okay. I'm sorry.

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: My apologies. I just We're not there yet. Are you gonna talk about the same thing?

[Unidentified Committee Member (Senate Health and Welfare)]: I was gonna talk about the link between the pre

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Oh, let's talk about the link.

[Unidentified Committee Member (Senate Health and Welfare)]: Yeah. The

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: record

[Unidentified Committee Member (Senate Health and Welfare)]: For the record, Michael Barber, general counsel, to to understand the impact of a a cap such as this on those premiums, the insurers and the hospitals, they'd have to know what the Medicare adjusted what their rates are as a percentage of the Medicare adjusted face rate, and so we could factor that in, right? So, it has to be quantified. Alright, understood. Okay. Alright.

[Devon Green (Vermont Association of Hospitals and Health Systems)]: Devin Green provides just for the records. We are opposed to the 250%. I know that I made the suggestion about the affordability, but I just want to make sure that we're clear on that.

[Unidentified Committee Member (Senate Health and Welfare)]: Understood.

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Understood. I think there are some conditions in here that might ameliorate your concerns, but and I you know, sometimes they have to lean one way or the other, and we're if if good faith and trust don't hold forth, then we'll come back to this. The goal of this is that some control of cost, but it is not to put any hospital under. So I assume that if the numbers come in and two hundred and fifty percent is gonna bankrupt the hospital, that adjustments will be made. And, I mean, that to me is just the underlying It is. I mean, we're we're spread.

[Jennifer Carbee (Office of Legislative Counsel)]: So you may wanna include some, sort of a relief valve here allowing the board to modify the 250% if it's That's a good idea. I would I like to think two fifty percent I more on

[Emily Brown (Green Mountain Care Board)]: think we need the data. Then I also I think there was similar language in Act 55 that they could apply through the budget process for some Yes. Type of There was. Yeah. So I would recommend that it not necessarily be that you're adjusting the I think it could get messy if you were adjusting the two fifty. I think it could be part of the budget adjustment process.

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: I think that's really helpful. I mean, we we we don't want a hospital to go under them at all. We need to a. That's what started this whole.

[Jennifer Carbee (Office of Legislative Counsel)]: Okay, great. What I think I'm doing then is I am, as we've talked about, combining the 250% for QHP as the first go to for commercial rates, and then if there's any room left for commercial rate reductions within the hospital's budget, they would apply to the services over 500% of the Medicare rate or the otherwise highest priced services. We will add potential budget adjustment language, language allowing the board to modify a budget, like in Act 55, where the hospital is in dire straits because of the application of that provision, and also specify that the board needs to ensure that these reimbursement limits are reflected in QHP grades.

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Yes. And are we at QHP? Where are we now?

[Jennifer Carbee (Office of Legislative Counsel)]: Yes, we are, now that we've sort of combined them, are in the QHD setting.

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: So, and I would like to add, VHI and VSEA, and there are reasons for that. We hear consistently about how our taxes are going up because of healthcare costs, and this is just one more step to take that will help people in our communities. We talk about getting the money back to the lowering premiums. This is one way to do it. I mean, suggesting that.

[Emily Brown (Green Mountain Care Board)]: Can I It's Emily Brown, a clarifying question? Are you talking about applying the two fifty to the VSEA and the VHI plans or incorporating VHI and VSEA into the QHP?

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: I don't think we can just categorically put them under QHP. I I'm just asking for Not yet. Yeah. It might lead that direction. Okay. Might lead to a larger group, but I'm thinking this is really to keep them in the two fifty. Okay. Alright. So this is a plan, so we would

[Jennifer Carbee (Office of Legislative Counsel)]: be adding them to section two to apply the 250%

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: They'd be in the pool?

[Jennifer Carbee (Office of Legislative Counsel)]: No, they wouldn't be in the pool, it's just about how much the hospitals get paid for the services that they deliver.

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: And there's still the off ramp during the budget process. So,

[Emily Brown (Green Mountain Care Board)]: Emily Brown, Care Board. So, we do not regulate VHI and VSEA rates. VHI rates are regulated by Department of Financial Regulation. VSEA rates are non regulated, it's my understanding by anyone. The Green Mount Care Board would not have any authority to essentially effectuate those cost savings to the plan members. I also would like to highlight that I think currently the small group market, which this 250% of cap would apply to, is open to small groups. So if there are municipalities, I'm not sure of the ability right now of schools to have the option to buy QHP plans, but it would enable small employers who would like to have access to that preferential pricing to enter into the QHP market if they would like to. I I am also concerned that adding the additive of the VSEA and the Mihai to the 250% budgetary for hospital impact would be way beyond what we had originally estimated for the impact of doing this in the QHP market. Also want to point out that the board is working on the system wide reference based pricing, which would then in the future impact the VSEA and BI plans. So the point of doing and focusing this on the QHP market this time is because that market is a very in a book, very vulnerable state with all the federal changes that are happening. And so because the board regulates those green masons, it would it made sense to us to start there to try to shore up that market and strengthen our regulatory market that we have. Declining. Correct. So So I I'll end my comments there.

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Thank you. So what I'm hearing you say is, oh, it's in the future to do this anyway. Correct. Why can't we reference that? And so what I'm thinking about is, do we have to come back here every time the board needs to take another step? This is bothersome to me in the biggest way.

[Emily Brown (Green Mountain Care Board)]: I percent agree with you. And I think what we've heard loud and clear from this committee since the beginning of the session is that we need to move faster. And we are moving as fast as we can. Have RFP. We get that. And my point being is that we are not planning on asking for every single step. We are going to implement a rule that is a system wide approach. I think what we see right now is a market that is at a high risk of increasing premiums and really just a market of last resort, which we do not want from a policy perspective. So again, if we have the ability to create an immediate fix that applies to a market, which again, we regulate the rates on, I think it makes sense to do that as immediately as possible while still focusing on our larger health care Understood. Okay. Thank you.

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Okay. What I'm asking what I'm suggesting Yeah. Is that we referenced the role of DFR in working with regulation of other entities and include some future steps for the Green Mountain Care Board that would be involved with that and that would include VSEA and VHOD. Because I think if that's something that's in your future, then why can't we just reference it now and point in that direction? Because I think it's huge. I think that's like 60,060 lives that could be brought in to this, understanding that it will have an effect all over the place. But if it's a next step, why not reference it as a next step? I'll idle yield on putting it in immediately into the QHP. Having it next step might be something we could do, and I see that following up here. Yes,

[Paul Robinson (Vermont-NEA)]: Paul Robinson, Vermont and Yeh, appreciate the conversation, and support the suggestion as originally presented around the beehive pool, which covers about 35,000 lives and I understand the reason the SCA is supportive of that. I do just, cause I know folks' time and knowledge changes quickly as calendars march on, but the Senate added language to the budget bill in '28 or '24 that actually had the Green Mountain Care Board do an analysis and study of taxpayer savings that would be realized by moving to a reference based pricing system for the VHI pool and the state employee pool, including specifically the number 250% of Medicare. And I don't mean to tell you all that conversations about the cost of education and specifically how healthcare costs, as Senator Cummings mentioned, have impacted that. And the last full year of analysis presented in the GMCV report released in December 2024 showed that 250% of Medicare just in the VHI pool would be $27,000,000 in savings to property taxpayers. I also just want to clarify, my understanding is Oregon, which does have RPP for public sector workers, that covers 300,000 workers in the state of Oregon. So a very sizable portion of folks. So definitely understand and appreciate the cadence that the board and this committee is working on. I think as it specifically comes to the intersection on healthcare affordability in the QHP market, as well as tax affordability, property tax affordability specifically, it seems like there's real opportunity with this work of the committee and the work of the board in this transition moment to actually take an affirmative step and apply the two fifty to the BHI pool, specifically in this moment and potentially the same thing.

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Okay, so I'm gonna suggest that we pull the final decision. I've given two options. One is immediate inclusion and the other is referencing it for going forward in 2728 future. So I wanna leave that, but we're gonna have to get to another bill in a few minutes, but I wanted to go through this, the rest of this bill. I mean, the frustration has been, ever since we started talking about this, if we go too fast, I think we need to remember that the majority of our hospitals seem to be in various shades of pink or red, our most prosperous hospitals. They're just off the line of adequate. That if we go too quickly, we might find people having to drive a 100 miles to deliver a baby. That's the balance, that even though there's an urgency to cut drivers and you know, the BI is negotiating contracts. They they could try and negotiate with hospitals. I think the goal is to go there, but the goal is also not to put hospitals under where to cause undesirable cuts in services so that people need to drive long distances, which goes against our environmental goals to receive health care, in some days it's absolutely impossible to do safely in this state. We see if it wasn't. Nonaging.

[Jennifer Carbee (Office of Legislative Counsel)]: Yeah. And I just corrected

[Devon Green (Vermont Association of Hospitals and Health Systems)]: the record on something getting read from us real quick? You're right, I was wrong on the Oregon piece. I was thinking Montana, it was only 30,000. Oregon would actually exempt all our hospitals with the way they do it, because they keep critical access hospitals out, they keep household community hospitals, hospitals with Medicare comprising over 40% and hospitals with 50 or fewer beds.

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: They have lots of hospitals. And

[Paul Robinson (Vermont-NEA)]: thank you for that clarification. I will say in previous conversations around this, the recognition of critical access care hospitals and it was something that obviously we understand as well, and you know, if there's language related to that, then we would need to incorporate this understood and

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: make sure. So that's a third option. It is put it in immediately and then reference critical access hospitals. Okay, Let's do this. We're going to come back to this pill. We've made a lot of important decisions. We're coming back to it to you. Say that thing.

[Unidentified Committee Member (Senate Health and Welfare)]: Ready for Monday. Yeah. That's okay.

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Looking at Wednesday.

[Unidentified Committee Member (Senate Health and Welfare)]: Yeah. The voltage.

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Yes. Thursday. We'll back to it. So let's do some thinking about this. Right now I do want to include some language on this. I know it's, you know, that report that we got from the Revant and Care Board was very compelling and it's one of the things that has driven this whole process. So there's 60,000 people sitting out there with savings that were approved to people who are paying, can't pay their premiums. And many of them have stocks. So I think we should have something in there on that. Please do some thinking on this committee and we'll come back and we will talk with Jen about having some options on the table for us. I know everybody else would be like, well, this is what we do. Okay. Are there any other major decisions that we Oh, lots. We're at the cage box. Yeah. Okay. But the others don't seem as may have

[Jennifer Carbee (Office of Legislative Counsel)]: to decide what you wanna do on outsourcing. And

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Yeah, I think the language is fine that we have put in reporting.

[Jennifer Carbee (Office of Legislative Counsel)]: Well, don't think the board thinks it's fine. I'm not just being more than that. That's your brief on

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: the board and then we'll go to 197.

[Emily Brown (Green Mountain Care Board)]: Emily Brown, Green Book. I think we appreciate gathering more information. I think our position still stands that we do believe that outsourced services should be captured within our hospital budget process and subject to all the same regulatory levers as other services that hospitals offer. We don't want to outlaw or ban outsourcing. We just want it to be integrated and hold hospitals accountable for that cost that is going to insurance premiums and consumers.

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Okay. Understood. I don't think that's a bad idea, looking over at that. To have outsourced services included in the budgeting process.

[Devon Green (Vermont Association of Hospitals and Health Systems)]: Uh-huh. Dana Green from Vaz. No. That is back to the original proposal. And that's regulation of outsourced services. We are worried about access and losing those outsourced services. We would like to gather the data on this and make informed decisions before we miss losing things like emergency department services.

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Okay, so we'll think about this one. Some of these things don't get resolved without

[Emily Brown (Green Mountain Care Board)]: breaking the chain.

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: We're gonna come back with three things then. We'll come back to the audit report, the outsource stuff, the QHP conclusion. How about the study committee? The study committee and the study committee. Yep. Okay, we're gonna have to go back to it. K. So let's move on to one ninety seven. And do we have we do.

[Jennifer Carbee (Office of Legislative Counsel)]: The one ninety seven, I have language that's still a fit, a little bit in flux, but that I've been working on with AHS and the Society. I don't think it's posted yet, but if you want it to be posted, hit candy plus it has it.

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Ordered it. Let's look at it, and we can decide whether to put it up permanently. We can put it up temporarily just to go. So do you want

[Jennifer Carbee (Office of Legislative Counsel)]: her to post it for now? Yeah. And then we'll depost it

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: because it's a work in progress.

[Jennifer Carbee (Office of Legislative Counsel)]: Well, we largely, there's one piece of it that I think is is still open. Okay. You can send your So I'm not

[Unidentified Committee Member (Senate Health and Welfare)]: And you let me change this. You you make changes?

[Jennifer Carbee (Office of Legislative Counsel)]: Yes. I think it's just getting posted now. Okay. It's only for sections one through three, so the rest of it, if you have not used.

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: We were going through making some good progress, as I recall, on this one. And so we probably should look at what you have, one through three, and then go back and go through the bill look at our decision points.

[Jennifer Carbee (Office of Legislative Counsel)]: Yes, and some of them I don't know based on what's in one through three of those, they'll still open. Okay. All right, so we are looking at some potential revised language for sections one through three of S197. S197, by way of reminder, is an act of establishing a primary care payment reform program. So the first is, some of this I've done in market, but some of it is just replacing. So I've marked up section one, modified based on AHSVNS work. So it would now say, is the intent of general assembly to invest in primary care, and then instead of by establishing a streamlined primary care payment system, you would say, through streamlined primary care payments that build on the blueprint for health, and will promote, and it still says the rest promote the public good by increasing access to primary care in order to help the Vermonters and reduce those risks and costs. Section two would replace Section two, sections two and three of the bill as introduced. You remember, bill as introduced set up a primary care payment program that would aggregate money from payers and provide phone number per month, habituated payment to primary care practices.

[Unidentified Committee Member (Senate Health and Welfare)]: We can do something with Medicare on that.

[Jennifer Carbee (Office of Legislative Counsel)]: With their when they participate. So they have historically participated in the Blueprint for Health Ages.

[Unidentified Committee Member (Senate Health and Welfare)]: Okay. So that's where you're

[Jennifer Carbee (Office of Legislative Counsel)]: But they have participated

[Unidentified Committee Member (Senate Health and Welfare)]: in If the

[Jennifer Carbee (Office of Legislative Counsel)]: we participate in the head model, I think they're back in at that point. Yes. But it has to be met there.

[Unidentified Committee Member (Senate Health and Welfare)]: They're

[Jennifer Carbee (Office of Legislative Counsel)]: blessed with pretty much. Yes.

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Yes. And they're active participations.

[Jennifer Carbee (Office of Legislative Counsel)]: So this would amend the blueprint chapter. We may need a few more updates as we go along, but it starts out with some definitions. We've been clarifying that health insurance plan is a major medical insurance plan. Basically it's the same, you plan to go to

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: the best schools before it's updated.

[Jennifer Carbee (Office of Legislative Counsel)]: Health insurer, I've largely pulled in the definition from section 18 USA 9,402, so it's a broad definition. Any person that offers issues for news or administers a health insurance plan or other health benefit plan in this state, and includes, to the extent permitted under federal law, third party administrators administering a health benefit plan offering coverage in this state, or providing administrative services only for a health benefit plan offering coverage in this state. So that includes self funded to the extent that we are permitted under federal law. Section seven, and then it jumps to existing section seven zero six of Title 18 and adding into health insurer participation payments to practices. So under existing law, health insurance plans must be consistent with the Blueprint, and health insurers must participate as a condition of doing business in this state. This would add language saying, in order to facilitate development of the sustainable payment models necessary for the Blueprint's success. Health insurers must submit to the Agency of Human Services at least quarterly or more frequently upon the agency's request. All information the director of the Blueprint deems necessary to perform a comprehensive fiscal analysis of the total cost of care in the state, and to implement more and more payment models addressing healthcare capacity, quality, and clinical outcomes. Change some language a little bit, here, so under existing law, says the Blueprint payment reform methodology shall include person per payment months to medical home practices. This would expand that to say participating practices, including medical homes and primary care providers. And then under existing law, and keeping it here, says by each health insurer and Medicaid for their attributed patients, and for contributions to the shared costs of, and again, expanding from just community health teams to operating blueprint initiatives. Under existing law, a person per payment, PMPM, payments to practices must be based on the official National Committee for Quality Assurance, NCQA's, physician practice connections, patient centered home score, although some of this terminology may be getting updated, believe, to Jessa, but I think there's just some terminology updates reflecting changes at NCQA. Or another quality standard, this would add, or another quality standard identified by the Blueprint director in consultation with the Blueprint's payment implementation work group, to the extent practicable, so based on NCQA score, or another standard identified by the director, to the extent practicable. Provided in addition to, and just updating some language to be a little bit more clear, a practice's typical fee for service, not their normal fee for service, or other payments. And then this would add, Ann, from health insurers, it amounts at least equal to Medicaid beginning in 2027, and don't worry about the statutory language, this is what I'm continuing to work with the stakeholders on. So, currently, it's my understanding Medicaid payments are more than insurers, so looking to equalize those. Then, just some reflection that the Blueprint is no longer in the Department of Homeland Health Access, but is within the Agency of Human Services at Central Office, so changing references to the Commissioner of DIVA to the Secretary of Human Services, taking out the specific requirement that enhanced payments to healthcare professional practices are those that operate as medical home, saying including medical homes and primary care practices. This is striking a reference to naturopathic physicians, not because they aren't included being eligible to receive these payments of their primary care practices, because there's broader language elsewhere that just says they're in as primary care practices, so we don't need to pull them out here.

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: We will do that.

[Jennifer Carbee (Office of Legislative Counsel)]: It has been expressed offline to the representatives of the natural pet physicians, so they are not worried. Then in formulating recommendations, this new language would say the director shall strive to achieve or maintain parity across payers and deem up methodologies. Then it keeps existing Blueprint language,

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: and then

[Jennifer Carbee (Office of Legislative Counsel)]: under appeals, adds references to the Secretary of Unique Services instead of the Commissioner. Then this would add a new section in the Blueprint chapter on primary care spending targets, directing the agency of human services to establish a target for the amount of per person per month spending on Vermont residents that should be for primary care services, and develop a transitional schedule that increases that target over time, so this will replace language in the bill on primary care spending targets. It allows targets to be adjusted to reflect payer specific differences, such as age and health status, and it requires the increased spend to the per person per month payments in that new updated Blueprint section. Then there would be a report. So new section three, saying on or before 01/01/2027, the director of the Blueprint in consultation with the Blueprint Executive Committee and the Vermont Standards Committee for Comprehensive Primary Health Care, established in last year's Act 68, shall report to this committee and the House Health Care Committee regarding changes to the payment amounts or payment method of reform methodologies, or both, that are necessary to transition the blueprint's PMPM payments to primary care practices to include payment for the routine primary care needs of attributed patients who are covered by participating health plans. So kind of looking at how to continue to build on the blueprint for all primary care, routine primary care payments. The report would define which services should be considered routine primary care, address any differences in methodology for different practice types, make recommendations on risk adjustment and attribution methodologies, describe the ways in which the methodology will balance capacity, volume, quality, and outcomes, Include mechanisms for ensuring that health plans make accurate and appropriate payments to primary care practices in a timely manner. Make recommendations on participation or quality measurement requirements or both. Provide an analysis of including cost sharing amounts for individuals covered by participating health plans in the methodology, including the extent to which such inclusion would be permissible for a high deductible health plan without losing its eligibility to be paired with health savings accounts. Provide an analysis of ways to incorporate a primary care spending allocation target into the methodology, and provide an operational plan and description of any additional legislation needed to implement the methodology not later than 01/01/2028. The new section, which I called tier 3A, just because we were striking sections one through three of the bill as introduced, that would require also by 01/01/2027, the agency of human services, the consultation of the non care board, report to the same committees, the baseline per person per month spending on primary care services for Vermont overall, and by each health insurer, third party administrator administering a health plan or providing administrative services only for a health plan. Medicaid and Medicare, it would require the agency to use the definition of primary care providers and services from the AHEAD model, or the definition used by the New England States Consortium Systems Organization, NSC. Section 3B, via subreport, due by 01/01/2028, so a year later, from the Agency of Human Services to the same legislative committees, with the per person per month primary care spending targets developed pursuant to that new section ATVSA seven ten added by section two of this act, as well as the proposed transitional schedule for increasing that target over time, any recommendations for payment specific adjustments to the targets, and any additional legislation needed to implement and enforce those spending targets in that section. So that is the language proposed to replace sections one through three of the bill S and T. Okay. Any time this is dispersed to the stakeholders, to explain to you their rationale. Just getting their ideas on it.

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: So I know that Doctor. Cheroian is up on the screen and Jessica Barnard is here. You each wanna make a comment on the first three sections.

[Jennifer Carbee (Office of Legislative Counsel)]: And talk it to in whichever order you desire.

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Go ahead, Doctor. Saroyan. Welcome. Thank you. I've completely lost my nose. K. Well, we're we're our ears are open. Do would you rather that Jessup Barnard went first, or how do you want okay. Go ahead. From the side is fine? Or Oh, do you want Is that okay? Yeah. We can move up here if you want. I can wherever you look. Let's show. Perfectly. Okay. This has been a process. This has been a collaborative process. Thank you. Yes. Jessa Barnard with the Vermont Medical Society. We really appreciated AHS's openness to- to work with us and talk this through and come forward with a proposal that we hope, not only really starts to move the needle for supporting primary care practices, but is also accomplishable and implementable, which is important. So really, it's a it's a transition. You know, we always, in bringing forth the bill as introduced, always envisioned that it could really work with the blueprint, but this just makes it really explicit that this is building rather than creating something new or some other pathway of paying primary care.

[Jessa Barnard (Vermont Medical Society, Executive Director)]: This is really building off of and strengthening the existing per pay per member per month payments that already go to the Blueprint. They already have a lot of that infrastructure and that payment model in existence. I'll just highlight some of the sort of bigger changes or how it works, would work differently or what this accomplishes. So a couple things that are really important to our primary care practices and members. It would, first, we hope, allow a opportunity to bring in all payers since all patients in Vermont are eligible to receive Blueprint services. It's a payer agnostic program. So patients of third party, you know, large employers, third party administrators are already receiving those services. So this attempts to say all insurers participate and fund the program equally. That's important, and that could increase payments to practices without putting additional burden on our QHP and regulated plans and prolong, which I think is important to all of us as a state. Totally. So so it's right. Yeah. So it gets it gets more payers in and then it also tries to equalize how payers are contributing. So saying that all payers should contribute equally to Medicaid. And then the next step is how do we, over time, increase that payment to not only cover right now, if that's an add on payment. In addition, do you bill the practices bill their payers, they get the fee for service reimbursement for whatever services they're providing, plus they then get this per patient per month kind of add on. So we're saying first, let's look at can we increase that sort of add on payment? But really then the ultimate goal with the report later on in these sections is can we look at can that PMPM actually become more comprehensive start replacing fee for service payments? Can we actually include some of those routine primary care services within that so that practices are getting more of a flexible chunk of payment to take care of their patients. So those are some of the components and looking at in that analysis of could we include other services? Could we address patient cost sharing for primary care services in that analysis? Could that be something that premium dollars sort of are adequate and go to that payment in an amount that then patients wouldn't have as much out of pocket costs for primary care services? And then it has the components still establishing a goal for what our state is spending on primary care services. One thing you'll notice, this language takes a different approach rather than a sort of a percent of total cost of care that should go to primary care. It actually looks at establishing a per person per month spending amount on primary care. And the reason to look at it that way, we collectively did some further thinking and research about this, it's a way to make it a more comparable measure for different payers because if you're looking at a percent of spending going to primary care, it actually depends on how much that payer's costs are overall. So as that payer's overall spending on care changes, that alone could change the percent of the proportion going to primary care. So instead this is more of a flat per person per month amount that is not as dependent on that payer's overall, cost of care. So that's why the transition and how that would be measured. And I think that really highlights the direction we went. I'm happy to answer other questions. And again, really appreciate the collaboration with, AHS and Diva and the Blueprint team. I know this required a lot of work on their behalf thinking about it as well. I think the one outstanding issue at the, top of page three, there is still some highlighted language. Well, there is highlighted language about equalizing the payments, between health insurers and Medicaid. We would, like, we are working to see if we can get to a common understanding or agreement with AHI about also looking at an annual assessment of the amount of those add on PMPM payments going to practices to make sure it's keeping up with the cost of, confined with blueprint requirements, maintaining patient access to care, all of that. So we know we have to be careful about how that's worded in terms of state directed payments and things like that. So we're working to see if we can finesse some language that would at least ask for an annual review of what that payment amount is. Good. That's good.

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: You very much. I have one.

[Unidentified Committee Member (Senate Health and Welfare)]: Primary care, I'm trying to get my head around it, I used to go to my primary care physician, it wasn't at a hospital, it was separate, then that facility got bought, I think, by hospital. And so you've got either independents out there or is, or the majority of primary care institutions, or I don't know what we call them, institutions, but are they hosted, owned, controlled by hospitals?

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: So primary care in Vermont, there's still certainly strong robust independent primary care. There is hospital based primary care and can't forget our strong federally qualified health center system of primary care in Vermont. So really three kind of models. I I should have, I don't off the top of my head have which percents,

[Paul Robinson (Vermont-NEA)]: you know, have the numbers. It seems like it's trending little one way though, to me, maybe not.

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: You know, it's actually interesting. I would say that was a trend. Some of the more recent transitions have actually been from hospital owned to independent or LGC in the past two, three years. What? As primary care, for better or worse, loses money in many places. The reimbursement rates don't always cover the cost of providing primary care and it's become harder and harder for hospitals to maintain that service. There have been a couple instances recently of both going to independent and going to QAC. But there was a big trend for not just primary care practices and general specialties as well in the you know, 90s, 2000s, of mood for short

[Unidentified Committee Member (Senate Health and Welfare)]: term I think UDM, would go with Burrow. It just seems like UDM is buying

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: up a Almost dead.

[Unidentified Committee Member (Senate Health and Welfare)]: Right, it's And

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: they're still independents. Mhmm. Yep. Few guests. Okay. So, I'd like to turn to the folks on the screen, and then we'll bring Jen back up. So, you wanna stay while they're talking?

[Jennifer Carbee (Office of Legislative Counsel)]: It's up to you. Stay focused. Okay, I'll stay focused. Okay,

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: so who do we have up on the screen? Mara?

[Mara Krause Donahue (Assistant Director, Blueprint for Health)]: Hi. I'm Mara Krause Donahue. I am the assistant director for the Blueprint for Health, and I'm speaking on behalf of John today,

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: or Chad today as he has no That's a really good thing. Don't want to make it worse. Go ahead.

[Mara Krause Donahue (Assistant Director, Blueprint for Health)]: So I'll just go ahead with a general statement that we're extremely appreciative of all of the feedback from VMS and the other stakeholders, very appreciative of the willingness of the committee to work to modernize and build upon the blueprints foundation. I think that, you know, we've been working hard to coalesce around some of this language. And I think that's been very successful. I

[Unidentified Committee Member (Senate Health and Welfare)]: would

[Mara Krause Donahue (Assistant Director, Blueprint for Health)]: say there are still, as Jess already mentioned, I think there is still some language that our team needs to review within AHS in terms of the annual updates and the state directed payments. So I would just flag that as an area under review for us currently.

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Perfect. Thank you. That's helpful. And so the the flagging is good. The timing is tomorrow. Just so you know. We're on such a short timeframe right now.

[Paul Robinson (Vermont-NEA)]: And this was voluntary

[Unidentified Committee Member (Senate Health and Welfare)]: and then it becomes mandatory, right, as I recall somewhere in here.

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: The proposal in front of you does not transition anything to mandatory presentation at last time. The bill I introduced, send the other line bill. Oh.

[Unidentified Committee Member (Senate Health and Welfare)]: Thank you.

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: I will yield.

[Unidentified Committee Member (Senate Health and Welfare)]: Alright. There's one question here is how is it determined what patient goes to what primary care physician? Is it the physician who says, is it the insurance, and then if we're to, how is that hard to get dealt with?

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Yeah, so currently it is completely the patient's choice where they, and would continue to be. The patient could choose whichever, obviously, you know, it may be hard to get into the But back

[Unidentified Committee Member (Senate Health and Welfare)]: there's no,

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: there's nothing that would change currently or in the future where the patient goes for their primary care services. The tricky piece then, or the next step, is then the term is attributed. To which practice does that patient count for which practice gets the payments linked Right, to that's what I was asking So there is, and I will defer to Mara, but typically, you know, whatever kind of value based program it is, whether it's through an insurer, the old ones through the ACO, or through the Blueprint, there are definitions of how do you link this patient to this practice for, for the funding. And, you know, usually it's where have they gotten an appointment, a visit in the past twelve months or something like that. Mara could probably give the, for the blueprint purposes, how they currently attribute to a practice.

[Mara Krause Donahue (Assistant Director, Blueprint for Health)]: I'll go ahead and just jump in with that to the best of my knowledge. The Blueprint has a two year look back, and during that time, we look at claims. There's a set of codes that are generally agreed upon, but we do update them every year of primary care codes. Then those would be filed based by a patient centered medical home by a blueprint provider. The provider that has the majority of that individual's primary care claims over that two year look back period is the provider to whom the individual is attributed for our purposes and for payment purposes. That is done based on claims, based on actual experience with a two year look back, and using a generally agreed upon methodology. We generally don't have issues with that, but there could be, as you can imagine, a situation where a provider may say, Oh, I saw this person eighteen months ago. They're one of my patients, but actually then they started receiving more care from a different provider. If the majority of their care is given by a provider, that's the provider to whom they're attributed.

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Thank you. I think we're going to move right along because we need to look at the rest of the bill. I am going to ask Mara and John this question. I asked yesterday in appropriations when AHS was in, I know that the eleven fifteen waiver is coming up for review going on this next year. And I asked for information about how much money we'd have to put in the budget to increase reimbursement rates for primary care across the board by 1%, by 2%, by 5%, just to getting a picture of that. Would come from Diva. I don't know who does that. Maybe Ashley Berliner or someone else. But I'm asking for that data. I've asked for it three times now, and I'm hoping that the third time will be the time that I hit the ball into the field and not strike out. Oh, there we

[Unidentified Committee Member (Senate Health and Welfare)]: go. Thank

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: you. Alright. So, Jen, we're we're not gonna go through the rest of field. Is my day. Right? Not. It's okay. We're gonna have And to FYI, before we do that committee, I'm thinking we will not start at 08:30 tomorrow. There have been some changes in the cannabis bill, and I'm not sure we need to look at it right away so I'm going to say that we'll cancel that part of the agenda at 08:30 on the cannabis bill. We're gonna hold off on that.

[Unidentified Committee Member (Senate Health and Welfare)]: That one's hard. It will start

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: at nine. 09:00, and I know. Know. Daylight savings. I thought she was there already. Know.

[Emily Brown (Green Mountain Care Board)]: That's what they said before you came in. I'm working

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: on it. We gotta get rid of it. It's just rushed. Okay. K. So we go back to the original bill. Yep. Back to the original bill.

[Unidentified Committee Member (Senate Health and Welfare)]: She'll he'll see it, though. We start on section four.

[Jennifer Carbee (Office of Legislative Counsel)]: Exactly. Section four, not page nine. This is the that's having the agreement. Care board updates reports and updated version of the what page it's about tonight? No. Of the Vermont Clinician Landscape and Site Control Reimbursement Reports.

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Got it.

[Jennifer Carbee (Office of Legislative Counsel)]: I don't think I've got any direction on anything different here.

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: That's kind of a general question. We're reporting back to the major jurisdiction. Does it make sense anywhere in here to put health reform oversight committee or no? Because they're all coming in like in January, so I'm Right,

[Jennifer Carbee (Office of Legislative Counsel)]: so if they're coming in when the legislature's in session, don't throw a bit of subs. I think even the members who are not Yeah, on so what All of the committees of jurisdiction, but are on the health and oversight committee are probably Okay. Busy with their subject matter Section five is a report on transitioning care to community settings. It's the agency of human services report on what's English means here to community settings.

[Unidentified Committee Member (Senate Health and Welfare)]: Yeah, that's

[Jennifer Carbee (Office of Legislative Counsel)]: And so, agency, my notes says, AHS says they should, or maybe you said AHS should incorporate into the healthcare strategic plan as appropriate. Uh-huh. I don't know if that's instead of this section or in addition to this section.

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Well, I'm putting it in. Okay.

[Jennifer Carbee (Office of Legislative Counsel)]: Section six, I'm not sure of the extent to which it is needed. This is language directing the agreement in the care board in collaboration with the DQHC, World Information Exchange Steering Committee, and Advocate. To look at existing regulatory structures for access to information from GE Cures and BUDS, the Uniform Hospital Discharge Data System, and recommend ways to improve access to the information for quality improvement purposes while preserving appropriate protections for patient privacy. There's also a piece about the board in consultation with the VPHC recommending any changes needed to the in the VPHC bill back statute that I think what you've heard is

[Emily Brown (Green Mountain Care Board)]: not necessary.

[Unidentified Committee Member (Senate Health and Welfare)]: I don't know what that means.

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Well, that's how we're funded.

[Unidentified Committee Member (Senate Health and Welfare)]: I know. But Yeah. So you're you're chain you're changing it?

[Jennifer Carbee (Office of Legislative Counsel)]: I so I think this I don't know if there was miscommunication or mis understanding or something, but I'm I think this it's so it's the Department of Health that has the contract with the, but I think the Green Mountain Care Board handles the actual bill back because the health department doesn't have

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: You build back regulated entities. Right?

[Jennifer Carbee (Office of Legislative Counsel)]: You do. But I think I

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: need something from Gene and, you know, Nolan about who

[Jennifer Carbee (Office of Legislative Counsel)]: actually does what. But I'm not I'm not sure. Wish Nolan was still here. I think he's gonna see all the patients, and I'm

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: not sure that this language is needed. I'm thinking that I'm probably busy needing it after having conversations with folks. Okay. The only question asked is one of the things that we've heard loud and clear is the need for quality measurements for primary care and blueprint as we go forward. Right, which I think was included in the language. Included in the language in section once again.

[Jennifer Carbee (Office of Legislative Counsel)]: I don't know if still a live issue around access to features and best data for quality improvement purposes.

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: I think we have a process where researchers and other state agencies can get access. Yeah. This is specific for BLUEPRINT over what you No.

[Jennifer Carbee (Office of Legislative Counsel)]: This is specific to BPQ. Oh, no. This is the

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: the language that's here is. Yes. My my concern is having data for blueprint outcomes. The auditor's report was pretty critical about not having that evaluation done. So my concern is that we have some language that directs our quality assurance folks for doing and our blueprint folks for doing some outcomes, data collection and analysis so that we can change that auditor's report. That's, I mean, so really making sure that we do get the clinical data that we need. I also understand in talking with my primary care friends that there is a huge administrative burden placed on primary care docs that really intervenes with their ability to work with patients. So we don't want whatever we have here to complicate that. So I'm looking to see. Jessa, I'm Bill Barner with the Medical Society. Do think there's, so there's language in the new sections, proposed sections on page two around ensure providing more information to AHS at least quarterly. The director of the blueprint to perform both the fiscal analysis and addressing capacity, volume, quality, and clinical outcomes. So that was new language suggested by the staff, but I think more directly gets at the blueprint access to data than sort of they do the analysis. I believe so, and not to speak for the blueprint to whether that's all of the data they need or are seeking, but I will just say that, and I don't know if they're still on, but they did, this was language that they suggested to add to the- Mara is on. Mara, do you want to comment? And John?

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

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: John, did you want to

[Mara Krause Donahue (Assistant Director, Blueprint for Health)]: You're on mute.

[Dr. John Saroyan (Blueprint for Health, Medical Director)]: I agree with Jessa.

[Mara Krause Donahue (Assistant Director, Blueprint for Health)]: Okay, John agrees with Jessa.

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Okay, this is good. Thank you. That's not great. And I think that what we could do is take out that BPQH section that's there.

[Jennifer Carbee (Office of Legislative Counsel)]: The whole section?

[Emily Brown (Green Mountain Care Board)]: Okay.

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Well, we we could we could have recommendations about any changes to practice that we

[Jennifer Carbee (Office of Legislative Counsel)]: I don't know. I don't know if anybody is I have

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: anybody about that?

[Emily Brown (Green Mountain Care Board)]: No. With Emily Brown, I think we we have we don't understand.

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Okay.

[Emily Brown (Green Mountain Care Board)]: Don't really think this is necessary unless there is some outline issue that we're not aware of, but we're not aware of.

[Jennifer Carbee (Office of Legislative Counsel)]: They're asking the board to do a lot of things, and maybe

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: they don't. That's fine. I'm happy to have a strike for section six. Alright. Okay.

[Jennifer Carbee (Office of Legislative Counsel)]: So then we get to Section 7 and having the treasurer's office and have a collaboration with AHS, or consultation with AHS collaborate with other Northeastern states to explore the potential for a regional universal primary care program

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: report them. So then the other thing that we heard about yesterday was having some analysis of how to get more groups included moving forward with primary care. So, there would be some, it would cost money to do that. We'd have to send an RFP out. We'd have to do an analysis of if we have to pay for universal primary care. So it's really looking at

[Unidentified Committee Member (Senate Health and Welfare)]: how do we pay for it, how do we

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: make it cost effective, how do we draw in more small groups and large groups, period. So the question is that.

[Paul Robinson (Vermont-NEA)]: How do

[Unidentified Committee Member (Senate Health and Welfare)]: the creditors involved in this?

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: He was he does a lot of work with other states, and he's worked hard on prescription drugs, so we asked if we would do it rather than send it out to AHS, being on care board, everybody's swamped.

[Unidentified Committee Member (Senate Health and Welfare)]: No AHS, I'm just curious.

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Yes or me? If you just comment on the stakeholder engagement piece, I want to make sure the committee has not forgotten that you created a comprehensive committee or a committee for comprehensive primary care last year that is charged with gathering a lot of stakeholder input and discussing the future of paying for primary care. They had a meeting on primary care payment reform last night, and we did reference that the Blueprint needs to consult with them in designing the next steps of any expansion of the PMPM program. So just a little hesitation about fragmentation with another primary care sort of stakeholder process when I think we have a pretty robust committee going. I'm sure you could hear from that. And you actually heard from Faye Homans, who's their chair, testimony when you first started taking up 01/1997, and they're working on priorities, their priorities for sort of the future primary care and her mom. So I'm wondering if there's a way to really just tap and work this with is helpful. Yeah, no, and obviously work with people and it's been very helpful to us in this process.

[Jennifer Carbee (Office of Legislative Counsel)]: Do you want me to put up the language around that story with me? Is that what you're about? Yeah, can't do that.

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Here's the thing. There are, right now, there's a Vermont Business Roundtable and there are other small business groups that are very interested in being a part of this discussion and they're concerned about being shut out because of cost and they're very concerned about the cost increases they're seeing. So trying to, that's what the sort of working group idea, that's what that working group idea comes about. If we can better integrate with what's already happening, I'm totally for that. I see that Elizabeth has her hand up. Go ahead.

[Elizabeth Poggin (Agency of Human Services)]: Elizabeth Poggin, Agency of Human Services. We agree with BMS regarding not creating redundancies and to use our existing resources in order to guide this one. So, existing resources?

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Oh,

[Jennifer Carbee (Office of Legislative Counsel)]: I was

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: also gonna say there's also the executive blueprint, which is pretty broad and includes payers and other stakeholders. And they are also tasked with being involved in this part of the meeting.

[Jennifer Carbee (Office of Legislative Counsel)]: The other piece I just wanted to flag in the bill, S-one 187 itself, is there's also a section eight would remove the sunset on the educational assistance program, scholarships for primary care students at the UVM College of Medicine. And I think there's language in the Virginia, don't remember if you know if it's in the budget, but I believe that is in the budget that would do the same thing and specify there's money remaining. So it doesn't necessarily require new money to be added, although I'm sure people in that area would appreciate it. But but there is existing money that because of this sunset would not be able to be spent in time. And so I think there's language similar that the the same removal of the sunset plus actually, I don't think we had to put anything else in because of existing carry forward language. So this would do the same thing. You may wanna put it in both places if you are prioritizing it, but this would remove the 2027 sunset on this education scholarship incentive program for primary care, for medical students going into primary care who commit to a service obligation in a more rural part of the state.

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: I'm fine for that. I just wanted to remind folks that I was in here that'll be an automatic sent down.

[Jennifer Carbee (Office of Legislative Counsel)]: It's in the budget anyway, but it doesn't require any money. The money is there. Money is already in the account. It's already been appropriated.

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Before I call on anyone else, I have two things I want to talk about including in this bill. And one is the extension of the prior authorization for primary care. No, nothing is happening. It's not ending? Thought it was ending this year. Was it next year? I don't think there's a sunset on that. Alright, good. I don't want the extension

[Jennifer Carbee (Office of Legislative Counsel)]: for primary care. Not aware if you have an extension. I might have a sunset. There was some language in a House bill that would further limit the scope and that language has been

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Oh good, okay, that's what I was worried about. So we don't have

[Jennifer Carbee (Office of Legislative Counsel)]: to worry about that one.

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Then the other one is that when an insurance company cancels its coverage for a specific prescription drug that patients are notified by at least thirty to sixty days because it can't be categorical that your drug is going wrong. So that's one I think is really important. I'm hearing about that from people on GLP-one, for example.

[Emily Brown (Green Mountain Care Board)]: Emily Brown, I believe there is existing, putting on my insurance hat, there is existing legislation that is Like

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: statute? Correct.

[Emily Brown (Green Mountain Care Board)]: That I believe was passed maybe a few years ago that required notification.

[Jennifer Carbee (Office of Legislative Counsel)]: Oh, change in formulary?

[Emily Brown (Green Mountain Care Board)]: Change in formulary. Yes. So formulary. And DFR would probably be able to better answer that question.

[Jennifer Carbee (Office of Legislative Counsel)]: Yeah. So we

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: may I just need to pull up the extension,

[Jennifer Carbee (Office of Legislative Counsel)]: but we may already have existing law on Oh, you you did that. Yes. Think we did that.

[Emily Brown (Green Mountain Care Board)]: I think we did. Yeah. I I can't remember the citation.

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: I don't remember the notice provision, and I'm hearing from people that they didn't get they didn't know.

[Emily Brown (Green Mountain Care Board)]: There might be, some self insured or unregulated plans that are not subject to that statute. That's always the That's the point. That's always the issue.

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Got it.

[Emily Brown (Green Mountain Care Board)]: I did have I'm sorry. I did have one comment before we leave the s one ninety seven on section four. I think we support doing that work. I I have been informed that the last time we did that, we had a full time staff positioned for that. So I I just wanted to highlight the resource issue.

[Jennifer Carbee (Office of Legislative Counsel)]: For this piece of Section four. Both parts or the

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Particularly, the first one was a series of focus groups and a lot of stakeholder engagement that required in-depth. It's not just aggregating data. Was That's what I'm saying.

[Emily Brown (Green Mountain Care Board)]: And wondering too, the just earlier points, is there a way to integrate that into existing working groups or open to that suggestion as well? I don't know if there's resources, other places that we could pull from.

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: So

[Jennifer Carbee (Office of Legislative Counsel)]: as far as formulary changes, there is a requirement under existing law that on a periodic basis, but not less than once per calendar year, each health insurer must notify all individuals covered under its health insurance plans of any changes in pharmaceutical coverage and provide access to the preferred drug list. So that was negative for if it was negative for

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: the PPM. Think it was Anyway, let's think about that one. Okay. Last comment is

[Jennifer Carbee (Office of Legislative Counsel)]: I just want to add as a caveat to my earlier testimony that while AHS does not want to create redundancies, AHS still does have concerns about Section seven of the setting.

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: Section seven is? The setting.

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

[Senator Virginia "Ginny" Lyons (Chair, Senate Health and Welfare)]: So we are gonna go offline. It's been a very lively day.