Vermont Legislature SmartTranscripts:

[Sen. Virginia "Ginny" Lyons, Chair]: You're live. Okay, good morning. This is Senate Health Welfare. It is March 12 and it's a day before crossover, which is really good news. Because the sooner we get through all those bills in front of us, the happier it will be. So And I know everybody wants us to do everything all at once, but that's sometimes not possible. In fact, I don't think it's ever possible. We'll do what it can do in order. So, we don't have Lich Council with us until 09:30, but I thought it would be helpful to look at S-one 194. It is a bill that we started talking about during the BAA process and makes sense to look at it. We do have written comments coming in from the agency, so we'll look at those. So we may not get anything accomplished on the bill until tomorrow. And if we can't do it by tomorrow, we'll also have an opportunity to put some language into the big bill or into another bill at least. But we'll we do wanna pay attention to this payment methodology issue. S194, I think we've went through briefly, previously. I'm gonna follow a friend. Kelsey, you're here. I'm you to provide your testimony on the bill. It may be that it comes in before some folks are fully aware of all the details in the bill. So just so you know that, it's obvious offer as much clarity as possible if you're going along. And do we have your testimony in writing?

[Kelsey Stabseath, Executive Director, Northeast Kingdom Human Services; Co-President, Vermont Care Partners]: No, I have a PowerPoint that I'll use to and guide the then Amy Johnson has some written recommendations for follow-up that we'll use. But I wanted to give, my intention is to speak to the bill, give kind of the reasons and overview and then answer questions, if that'll be helpful.

[Sen. Virginia "Ginny" Lyons, Chair]: And just so you know, we're gonna try to finish up this bill by the morning after nine and give ourselves ten or fifteen minutes on S-one 154, the Biohonza bill. It's the end of the sessions, end of the crossover, so it got taken off the agenda accidentally. We'll put it back on. That's happened to several bills. Everybody gets all upset. Here we are. Okay, go ahead, Chelsea.

[Kelsey Stabseath, Executive Director, Northeast Kingdom Human Services; Co-President, Vermont Care Partners]: Great. For the record, my name is Kelsey Stabseath. I'm the executive director at Northeast Kingdom Human Services, which is the designated agency that covers the three counties in the Northeast Kingdom, And I'm also co president of the Vermont Care Partners So I will, and I'm here to speak on S-one 194 about payment rates for providers of community based services. Let me share my screen here. Okay, that should be full screen.

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

[Kelsey Stabseath, Executive Director, Northeast Kingdom Human Services; Co-President, Vermont Care Partners]: I'm sure you all know this, but Vermont Care Partners represent 16 agencies, so designated and specialized support agencies across the state, and so we represent every county and provide mental health substance use, emergency services, developmental services, as directed by Dale and DMH. For the framing of this, I think it's really important about how we think about the DA and SSA system, and so really saying we provide expertise, and I really do feel like we're the experts in community based mental health, substance use, and developmental disabilities. We often get referrals from primary care, hospitals, first responders, including law enforcement, and saying, we can be the last stop before inpatient or higher levels of care, like residentials for children or out of community placements for therapeutic schools. And so we're trying to do everything to keep the Vermonters we support in their communities, and I think we do a pretty good job. So S-one 194 we feel like is really getting at is like saying, look, what issue are we trying to solve? And really it's saying what services do Vermonters need to be successful in their communities. And we know that some of the supports folks need to one, keep themselves safe, keep our communities safe, to support them to be valued and contributing members of their communities requires expertise, therapeutic support, case management, and other supports that help people live the life that they want and also contribute to their communities. Just as an example for us, one of those is transportation, as we know and talk about, and so being the ruralest area in a rural state, last year we drove over a million miles to get people to their jobs, to get people to their healthcare appointments, and so it's critical that those costs are taken into account when we're providing services. And so the bill I think is addressing what is the total cost of providing services to get the outcomes we want. And I want to frame this saying there are lots of things happening. So Act 167, we know that health insurance costs are high, some of the highest in the nation, that that is putting downward pressure. We feel that specifically as an organization that provides robust benefits, healthcare benefits, that goes up every single year and puts pressures on our costs, but also our ability to pay higher rates to attract people to do the services. It also means that when we can't recruit or provide the services that we are hired from DMH or Dale, the unintended consequences is often that people go to other services that can be crisis and not fall through, like hospital emergency rooms, which can be more expensive than if we right size our payment rates. And so we are working on CCBHC, recently went through DS payment reform, and so there's a lot to be worked out, but what we're finding is that we are struggling to cover costs for things like residential care, in DS and in other areas and so we have not had a formal sit down to saying like what are the true costs of the services to get the outcomes that we want and so this bill helps to establish that formally and would guide AHS in setting rates that allow us to fulfill our mission. Okay, so here's a couple things that are going along. I think you're all well aware of this, but CCBHC, there are some designated agencies headed towards CCBHC designation. Two are currently in there. Four more are going in the summer. We've also been transitioning to DS payment reform and conflict of interest, and saying, we did work closely with Dale, and appreciate that they continue to work on this. We're about six months in and finding that the transition has impacted revenue for a number of organizations. It has the potential to destabilize some pretty significantly who are working with the department to figure out how to stabilize their organization. And it's also not adequately covering the residential costs for folks who need medical care, who need staff living, who need long term care. As you know, we have an aging population, and when combined with complex care, like medical needs or mental health needs, it can become expensive. One thing I want to highlight about DS is that I feel the network does a really good job of supporting people in staff living to a nursing level of care. And so one thing I actually think that this could benefit from is saying, we do a good job, we have nurses that designate lay people to do specialized care procedures, and we support folks with developmental disabilities that also have complex medical needs and we do that in the community with staff that are not technically trained but overseen by a nurse and I actually feel like that is a savings to the system, but if it's not paid enough to keep those people coming in or keep our nurses on staff, then you start to get folks who are gonna need inpatient levels of care or gonna be languishing in hospitals or nursing homes that don't feel equipped to do this. So without investing, I think we can bring investment up without it costing more than other higher levels of care, but can balance the need of capacity in our community. And so this process would help align costs with higher level system goals. And so this isn't built into the or sorry, this isn't built into the bill saying like this must happen, but one of the things that we would be in support of to figure this out is a study and so I think it's important that we have a robust study. We've done that with the hospitals. I think it's important to consider the designated and specialized service agencies and the community based services into healthcare reform. If we can keep people in our communities, if we can keep them out of higher levels of care, we can not only provide better services where people want them, but we can also save money in a healthcare system that is costing more and more every year. And so what we would be open to and would like to consider is a more formal study of the system to saying what services should be core and provided and available to all Vermonters. We have started that process a couple years ago, but there's a lot going on, and so we want to make sure that that could potentially be formalized and completed, and saying how do the DAs and SSAs fit into things like Act 167 and healthcare reform. Oftentimes what happens when we don't have a formal strategy about how these things all fit together. We can get piecemeal situations where maybe that looks good for the program, but when you take it as a whole with added informal expectations, the costs outmatch the resources, and then you get a watered down system that's not fulfilling its obligations in meaningful ways to Vermonters, which not only impacts the people receiving services, but then has system impacts that weaken the entire system. So reasonable and adequate. Again, to start, why we said we're the experts is that we often get referred the most challenging. And so for adults, we talk about SMI, serious mental illness in children, severe emotional disturbance. That's the language that's used by SAMHSA. But what we can find that happens is saying we not only bring people in, we license them, we supervise them with our clinical licensed folks for free, which we're adding capacity to the system, but once they get licensed they can make more money in private practice, in primary care, in the hospitals, and then what happens is lose our most talented folks, they go somewhere else, and then they refer the most challenging cases back to us. And so we're put at a disadvantage to fulfill our mission of the most complex situations without being able to pay rates that are competitive for the expertise that we provide, which creates an inversion in the system, which I think actually puts more pressure on the system at large, and which costs more money. So prospective payment methodology stabilization, so like how are these rates structured? It has been challenging to saying, well, we think this is best guess, we're gonna try it, we have worked with the departments to make sure this works, but oftentimes we're not sure how it works until we're well into it. I think DS payment reform is a good example of that saying in the residential piece, it is looking like over the six months that the rates that were paid are not covering costs. And so what that requires us to do is subsidize important services that we have to provide with other programs. And so that creates an unnatural strain on the system. Full of time here. Okay, so I'm gonna stop there just so we have a few questions or if there are a few questions, I know we're trying to end at 09:20, but in general, we're supportive of the bill. I think Amy Johnson, our Director of Policy and Legislative Advocacy has some suggestions that can be passed along, but wanted to talk about, or just give a high level overview of where we stand as a network.

[Sen. Virginia "Ginny" Lyons, Chair]: Thank you. I do have two questions for you. So in addition to your contracts with Dale and DMH, do you have other contracts outside of your state responsibilities?

[Kelsey Stabseath, Executive Director, Northeast Kingdom Human Services; Co-President, Vermont Care Partners]: We work with the Department of Substance Use under VDH currently, and so we do provide substance use services, but I would say that a majority of our work is through the state. We do have other grants, those often enhance the work that we're doing with the state, and so I would say that almost all of our services are focused on DMH and Dale requests.

[Sen. Virginia "Ginny" Lyons, Chair]: Okay, thank you. And then conflict free, if you could talk a little bit about the separation of the case management and the actual delivery of services. So the federal rule that has put us in this place. Just really twenty seconds.

[Sen. John Morley III, Member]: Okay, I'll try my best.

[Kelsey Stabseath, Executive Director, Northeast Kingdom Human Services; Co-President, Vermont Care Partners]: So the state of Vermont needed to come into compliance with the federal government through CMS and what they're calling conflict of interest free case management. And so essentially what that's doing is separating the organizations that provide direct services from the people who determine people's treatment goals, we call those ISA, NDS, and the funding. And so what the government is saying, there's an inherent conflict if you're assessing folks and determining what their treatment should be and what they should get paid and then providing that. And so that uncouples funding from service delivery, which in theory is good. I think what Vermont had developed is a vertical integration that allowed for thoughtful and quick flow through the system to provide services quickly to folks. And so that has been decoupled. We brought into external to the state case management organizations, another organization external that is doing the assessments. And so right now that's putting some pressure on all of those organizations to learn a system and it's creating bottlenecks and challenges, which we are supporting with, but have essentially carried on the same duties that we had before to make sure that people are getting the services they need.

[Emily Brown, Green Mountain Care Board (GMCB) staff]: Okay,

[Sen. Virginia "Ginny" Lyons, Chair]: Thank you. That's helpful. All right. So we'll keep going because I know, I'll tell you that I know that Legg Council will be happy if we go over this a little bit. Amy, why don't you do you have specific testimony that you're gonna offer?

[Amy Johnson, Director of Policy and Legislative Advocacy, Vermont Care Partners]: Amy Johnson, Vermont Care Partners. I don't have specific testimony, but I do have language suggestions for the study and supporting a work group for the facilitative and rehabilitating. Why don't you come up and offer that? And then I know that

[Sen. Virginia "Ginny" Lyons, Chair]: Dale was interested in commenting.

[Amy Johnson, Director of Policy and Legislative Advocacy, Vermont Care Partners]: Do we have it? No. I haven't sent it yet.

[Sen. Virginia "Ginny" Lyons, Chair]: Okay. Well, maybe do that. I will. Yeah. Sorry.

[Amy Johnson, Director of Policy and Legislative Advocacy, Vermont Care Partners]: I have sent it a few days ago, but it wasn't formalized. If you have a formalized version that I will send to the committee. Go ahead do that. So we're looking to have a study that will look at our entire DAA SSA system of care. So, Kelsey spoke to it kind of briefly, but we want to review the services currently provided by the DAAs and SSAs, including identifying what is essential, what are our specialty services that are being delivered on behalf of the state, review statutory, contractual, and administrative frameworks guiding the DAs. Did over there, but I can move again there. Amy Johnson, Vermont Care Partners. An analysis of emerging needs, pilot initiatives and system transformations, and how they've expanded or altered agency responsibilities over time. Consideration of the system's sustainability, including workforce capacity and strengthening, addressing administrative burden and strengthening the long term stability of the system. So, we're interested in, I've created a group that we can add members to, but we do have a designee from, the agency of human services, Department of Mental Health, Dale, as well as the Developmental Disabilities Council, individuals receiving services, a family member of individuals receiving services, and of course, our folks. So, we, we didn't add, we try to keep this pretty basic and simple because we want to be able to work in collaboration with the administration to guide this process. We don't have funding attached to it or specific dates, but I think what we're seeing is there are gaps in the system, there's things that we're required to do, and often there are things that are added onto our plate, not necessarily with increased funding or contractual agreements. So we're really looking to see what is our capacity, what are the essential duties? What are the gaps? And really looking at where the system is now and where we should head, and how that fits into healthcare reform. So that's the study.

[Sen. John Morley III, Member]: I think it's helpful. John.

[Kelsey Stabseath, Executive Director, Northeast Kingdom Human Services; Co-President, Vermont Care Partners]: Just to speak to that as saying, you know, one of the challenging things that we've navigated is also saying we are in state statute. You know, I think it's fair to say that the designated and specialized service agencies are the action arm of the departments and so these are required services for Vermonters and saying every single year we've had great allies in the legislature, which we so appreciate here and in the house, but we have to come back every year to ask you for rate increases to cover things like cost of living. And so that is automatically passed through in the state, which we also support knowing that things cost more every single year and that's been exacerbated in the last few years. But if that's not guaranteed or at least meeting inflation, then you're talking about service cuts every year. And what we have seen is that the need has been increasing and that doing services upstream preventative, especially in early intervention with children is going to have the long term impacts that we want, not only for keeping people and children in their communities, but alleviating pressures on higher levels of care, which is where people go when services are not available. And so I do think that the bill as put forward in the study helps address saying like, what are the outcomes we want and what would the cost be in the context of healthcare in Vermont? So I think we're trying to emphasize the fact that we are here to fulfill a required required work of the state that is important to Vermonters.

[Sen. Virginia "Ginny" Lyons, Chair]: No, that's good, yeah, understood. And so the analysis of where we are today, I'm really pleased to hear that you're including the state planning process because that is a big part of transformation that's ongoing. And it probably shouldn't be separate. Yeah, exactly. Yeah, so thanks for that. And you will get us, send it to Calista if you haven't already, because we need to see it. I'm also posting a letter from the administration that talks about the bill as it currently stands or the provisions of the bill and one would put us in jeopardy in terms of Medicaid. Right. And so there's some changes that we'll have to look at. If the study goes in, it might be that that's what goes in, and it makes more sense to do the study before we decide to change everything. Right. And I know Senator Morley's gonna ask a question. So

[Sen. John Morley III, Member]: I'm looking at the bills introduced, and so you'd be adding the study somehow into We'd amend it.

[Sen. Virginia "Ginny" Lyons, Chair]: Yeah, we'll amend it.

[Sen. John Morley III, Member]: So this reminds me a lot of the primary care bills, madam chair, Uh-huh. Because it's per member per month. Yep. Yep. And so is the study going to be also looking at how it's going be paid for. So I mean, there's going be, you're going be looking at Medicaid, you're going get private insurance company, you're be looking at a whole, I think, I hope your stuff is going to do that. Not just outcomes as far as, you know, there's two there's two sides of this. Right? You've got, your side providing the services Right. That you guys look at. How are we gonna

[Sen. Virginia "Ginny" Lyons, Chair]: What's needed? Right. Exactly. Yeah. What's needed?

[Sen. John Morley III, Member]: But then you gotta also figure out Yeah.

[Sen. Virginia "Ginny" Lyons, Chair]: So that you you pay for it. Exactly.

[Sen. John Morley III, Member]: Well, I don't know if your study's gonna include anything.

[Amy Johnson, Director of Policy and Legislative Advocacy, Vermont Care Partners]: Ideally, it would do a robust analysis of what's happening and the funding that's needed to cover the cost of those essential services through their monitors. And we do have payment methodologies. We talked about CCB, CT's payment reform. So these are big reform processes that are actively happening on the adult and children's mental health side that happened a handful of years ago. So we have had these reform efforts, but how do they all fit together? How are they all impacting each other? Where are the shortfalls? Because we know that for some of these efforts, the cost is not, what we're getting is not matching what the cost of care actually is. And obviously we don't receive the inflationary increases that are needed. CCBC does have that baked into that model, but not all the models have that baked in so often we come to the legislature for those inflationary increases.

[Sen. John Morley III, Member]: So this will help them alleviate some of that. Ideally, ideally. Bringing from what you would like. Yes.

[Sen. Virginia "Ginny" Lyons, Chair]: Okay. Other questions? Go ahead.

[Sen. John Morley III, Member]: As I understood it, you have some specific language for setting up this study that you're going to submit.

[Amy Johnson, Director of Policy and Legislative Advocacy, Vermont Care Partners]: Yes, I will send it.

[Mike Rollo, American Cancer Society Cancer Action Network (ACS CAN)]: And

[Sen. Virginia "Ginny" Lyons, Chair]: the memo that comes from HHS, agency human services, does address the bill and also the willingness to work on a study and stuff like that. So we have today and tomorrow. We'll see what we got. If there's language forthcoming from both sides we can evaluate it and put something together ourselves and then try to move it along in a way that the house will be

[Sen. John Morley III, Member]: able to pick it up and improve it.

[Amy Johnson, Director of Policy and Legislative Advocacy, Vermont Care Partners]: I do have one additional piece that you'll see in what I'm sending to Calista and I know that Brad's on my head. So, the additional pieces, and I just wanna talk about conflict of interest free case management on the mental health side. One of the things that was put into place ended up creating a situation where adults with serious mental illness, again, that's a SAMHSA term, are moving from debilitated to rehabilitated. And so, we're taking folks who have really high acuity, high needs, and they're flipping from rehabilitated to rehabilitated. What this means is that they can only be in these residential settings for a certain number of years and then they have to move on from them. And for some folks that will work, but some of our highest acuity folks, especially our aging population who meets the criteria for serious mental illness, would end up essentially or potentially being exited to homelessness. And so we're asking for a work group to figure out for that small subset of the population who meets that criteria to figure out what we are going to do with that small subset of the population. And that's gonna be

[Sen. Virginia "Ginny" Lyons, Chair]: a working group with DMH Dale's similar partners. Good. Thank you. That's good. So we'll see that. I don't see that.

[Sen. John Morley III, Member]: So now we got it.

[Sen. Virginia "Ginny" Lyons, Chair]: Got it. Those are the two examples. Thank you. Because it's good. This is a good setup for tomorrow. We actually get a chance to make decisions. Okay.

[Sen. John Morley III, Member]: We think

[Sen. Virginia "Ginny" Lyons, Chair]: who knows?

[Emily Brown, Green Mountain Care Board (GMCB) staff]: I I need more. Think I need to be down.

[Sen. Virginia "Ginny" Lyons, Chair]: Oh, this Yeah. Dude is going crazy with all of the changes.

[Sen. John Morley III, Member]: Oh, I think that you can give,

[Sen. Virginia "Ginny" Lyons, Chair]: but she's doing good jobs. I thought we weren't sure everybody.

[Sen. John Morley III, Member]: No. Sorry to call.

[Sen. Virginia "Ginny" Lyons, Chair]: That's what I thought. Okay. You're not late. Only your usual. I just wanna make sure I have a brother just like that. Think I'm going up next week because I have no idea how many bills are headed to me. Well along. So we have folks in here to remind us about S-one 154, the biomarker bill, which came from finance and it would be safe for us if we could at least get it back in some condition to finance, because I'd have another week to And look at we have two folks here who can speak to 154 briefly. Can you do that? So, it's up to you how you wanna direct it.

[Mike Rollo, American Cancer Society Cancer Action Network (ACS CAN)]: Thank you, Senator. I'll reach the student's call. Mike Rollo, American Cancer Society, Interaction Network. I did email testimony in, and I actually have it printed out, apparently everything else printed like that, so

[Sen. Virginia "Ginny" Lyons, Chair]: I'm apologizing, I'm using my phone. No, that's fine.

[Sen. John Morley III, Member]: But I apologize.

[Mike Rollo, American Cancer Society Cancer Action Network (ACS CAN)]: But on behalf of ASUS Canada, want thank you for taking this up. So the timely access to guideline indicated comprehensive biomarker testing will enable more patients to access the most effective treatments for the disease, and can potentially help achieve the triple game of healthcare, better health outcomes, improve quality of life, and reduce costs. Progress in improving cancer outcomes increasingly involves the use of precision medicine, which uses information about a person's own genes or proteins to prevent, diagnose, and treat diseases like cancer. Biomarker testing analyzes tissue, blood, or other biospecimens to identify mutations that may impact treatment decisions. This testing is an important step in accessing precision medicine, which includes targeted therapies that can lead to improved survivorship, better quality of life, and better quality of life for cancer patients. Unfortunately, not all communities are benefiting from the latest advancements in biomarker testing. These include communities that have been traditionally marginalized, including communities of color, individuals with lower socioeconomic status, and people in rural communities, those receiving their care from non academic medical centers, are all or less likely to benefit from the benefits of biomarker testing. I'm trying to skip anything, I don't want to price for time, but I want to be clear. Biomarker testing is not indicated or appropriate for all cancer patients. We are not advocating here today for universal biomarker testing. Rather, this legislation before you was tied to regular sources of medical and scientific evidence a guy who should receive his testing. When patients forego unnecessary care, there are direct and immediate results in the individual's out of pocket costs, system wide costs, and often in terms of improved quality of life. Avoiding unnecessary side effects or ineffective treatment can also result in cost savings, and can better support a patient's ability to work, support their family, and engage in their community. The power of access to biomarker testing is truly a game changer for cancer patients, And that's why I'm taking forward, make it possible for all patients to get the right treatment at the right time. I want to thank you for your time this morning. I also wanted to draw your attention to one of the handouts I emailed you, and if you need another copy, I do happen to have some in front of me. But it's about biomarker testing and cost savings. There are cost savings to the individual, and there are cost savings to the system and to the care. One study has indicated that, at CVS Healthcare, actually looked at total cost for care for non small cell cancer patients who receive a broad panel biomarker testing compared to a narrow panel biomarker testing. The cost to the carrier was $1,200 However, they saved $8,500 per month per member that received the broad panel test. So that's significant savings. There's also savings indicated to Medicaid. There is a cost obviously associated with this, I know that will come up, and it's probably more concerned at the Pundits Committee, but on the low end, we have a peak fence per member per month, and on the high Massachusetts, which I would say a much different system than we would consider per month, but it's fifty months. But there are still potential costs associated with that. And I can actually email you the entire development report. It's several 100 pages. I didn't print it out. All the trees thanked me for that. But I'm happy to provide that, but I don't believe I've emailed that yet. This is truly access to this testing of the game changer of patients. And there's one sitting behind me that wants to talk about her experience. Unless there's questions, I'm happy to answer whatever you have, but I think you can hear real life experiences.

[Sen. Virginia "Ginny" Lyons, Chair]: Let's hear her, and then we can ask

[Kelsey Stabseath, Executive Director, Northeast Kingdom Human Services; Co-President, Vermont Care Partners]: I'm not going

[Sen. Virginia "Ginny" Lyons, Chair]: to with stat Lynch Council coming in. This is great. Appreciate you coming in. Of course, Ms. Newsome.

[Adrianne Breitre (on behalf of AdvaMed)]: Thank you for this opportunity. My name is Adrianne Breitre. I am here also on behalf of AVMEV. We are the largest device manufacturers in the country. We've got about six fifty members. We also have about 80 companies that specialize in diagnostic equipment. We are here in support of the bill. This bill, it's not only cancer that this bill impacts. It impacts arthritis, Alzheimer's. This is the huge spectrum of both. The story I wanted to share is mine. I underwent biomarker testing when I was looking at a cancer diagnosis as a graduate student in Boston. The test at the time was $2,500 a test. I was a graduate student. I was fortunate that I was in Massachusetts. I had access to Romney Care at the time. It was not a volunteer. I think we all have that now. But my parents were willing to spend the $2,500 a test to let me have these tests because we did, we talked about it, and it would make a huge difference in my treatment. I would have to There is a potential that I would have to go through a series of invasive tests. I would have to go through a bone marrow test. I would have to go through any number of tests that would have to be continuously repeated throughout my life. Because while I have a blood disorder, this is a blood disorder that's faced with me my entire life. The other thing that compounds this is that the treatment varies whether this has a genetic risk factor or if this just is a naturally occurring mutation. Those changes are a huge difference, because if I was on that treatment of drugs, that could actually impact me negatively. These bioharmon tests have allowed me not to undergo invasive care. I go to a hematologist once a year and we run a blood test. And I joke a lot about World War II history because I love World War II history and he is a buff of that. We talk about, Okay, I'll see you again in a year. Maybe we'll run another test. Those tests are now covered by my insurance because I have a private employer. Are they still $2,500 No, they have gone down in price. Okay. They have gone down in price. They are no longer $2,500 because this was 2,009. These tests were just coming out. They were just being marketed. I was actually being treated at an academic medical center. Now these tests are, at the time, I could be wrong about this, maybe Mike can on the others can correct me, but my understanding at the time was these were mostly used for cancers. Now we've realized through precision medicine, through not having to put people through step therapy, through sort of a trial and error phase of, if we can determine something right away, or we can determine it in a invasive way, it saves the system costs. People are not taking time out of work to have ill side effects after a treatment that may not work. This gives people a little bit of hope to say, I am getting the best care possible, because then you're not wondering, like, Well, what if this doesn't work? There's a little bit of hope that you're like, Okay, I've undergone this test. This is what is indicated for my treatment. I understand it may not work, but I also then know I'm not looking at six months or a year of getting poked and brought in, and, Oh, maybe we'll do a Let's scope something. Let's just see what happens if we stick

[Sen. Virginia "Ginny" Lyons, Chair]: a needle in you. It was

[Adrianne Breitre (on behalf of AdvaMed)]: a little bad at the time, not really understanding what's going on. The other thing is that patients don't often understand what these bottle locker tests are. They just say, Oh, we want to run a test, and this will help. I think also Mike and others have been doing a lot of education about what these biomarker tests are, and allowing these people to have this option is most wonderful thing for people to continue. And I'm sorry. I would've prepared testimony a little better, but I was here speak on behalf of Adam.

[Sen. Virginia "Ginny" Lyons, Chair]: It would be terrific if you could send some written testimony and Sure. And we'll have it.

[Adrianne Breitre (on behalf of AdvaMed)]: Yeah. I have Adam's written test I will send I posted a message that last night. That's the money on the behalf of ad event.

[Sen. Virginia "Ginny" Lyons, Chair]: But Thank you. And the cost of the test is important. Obviously, having it fully covered for the Yeah.

[Adrianne Breitre (on behalf of AdvaMed)]: For eternity might be a little difficult, but having The cost had gone down so much because it's one of the it's a volume thing. The more people that have access to it, the lower the cost comes. Of course. And the more that competition in the market also helps. That when you only have one company that's doing the tests,

[Sen. Virginia "Ginny" Lyons, Chair]: it represents now being companies that develop these tests. Everybody's that has information and cost Uh-huh. Should get it to Charlotte in the finance committee. We're gonna be really pressed getting these things out next week, so the more we have in advance of Right. Administration is probably gonna be a jam. One last question.

[Sen. John Morley III, Member]: Yes, that's not a question. I have in my notes from previous testimonies that the average cost is now being between $46 and $400 in $10

[Emily Brown, Green Mountain Care Board (GMCB) staff]: And that's the change in fifteen years, fifteen years. Right. So it's not overwhelming. But that also saves the system cost because then, like for me, had to go to chemotherapy. I didn't have

[Sen. Virginia "Ginny" Lyons, Chair]: to have all number of tests and I

[Emily Brown, Green Mountain Care Board (GMCB) staff]: was looking to the economy. Well, potentially surgery. Mean, it's a number of those.

[Sen. Virginia "Ginny" Lyons, Chair]: No. I'm when you have a biomarker test Mhmm. It's 4,500 or $46. Do they just go in and do one biomarker, or do they go in and do a 100 biomarkers?

[Emily Brown, Green Mountain Care Board (GMCB) staff]: Just depends on the tests. What I just have

[Sen. Virginia "Ginny" Lyons, Chair]: you So that's not the total cost. It's per Per biomarker.

[Emily Brown, Green Mountain Care Board (GMCB) staff]: It's per test. And so some of the tests are multiple are multi or Multi test. Multi test or a large panel. Mine were very specific because I have a very rare blood disorder. Was less than 100,000. I think it's less than one hundred thousand people, technically. It's weird. But Dana Parker studied it, so Oh, was good. Oh, the Dana study? Yeah. Was not sick enough, I did not disqualify, but

[Sen. Virginia "Ginny" Lyons, Chair]: Daughter worked there in a work study when she was in college. Oh, testing anthrax. It made her mother go, oh, wow. Oh, wow. So Yes. No kidding. She said it's all in. Oh, I'm gonna put it Thank you. And we'll look forward to looking at the testimony. We will go back to the bill tomorrow.

[Jenny Morgan]: Madam Chair, so sorry. Jenny Morgan with the Allstate Kick Association. I know you guys were so gracious if you had the opportunity to speak before, but we actually have an advocate here as well that can speak to personal experience.

[Sen. Virginia "Ginny" Lyons, Chair]: I know time is so short, but We are short. Okay. We will what we'll do, if you could stick around either here or in the hallway and then as we go through our other bills we may get back to this one. Okay, perfect. That's a real pressing issue. Absolutely. And I appreciate your coming in very much. Thank you. I appreciate that. And anything you have, you can also send. Absolutely. Appreciate it. I'll see you. Thank you. Alright. So, Jen is here and we're moving on with Markup. I don't know about what you did last night. In addition to reading about what was going on in my district, I I read through all the witness testimony for all the

[Emily Brown, Green Mountain Care Board (GMCB) staff]: bills that we're looking at today.

[Sen. Virginia "Ginny" Lyons, Chair]: Read and made some comments. I went through and identified my own decision points. One ninety. So draft, the new draft that you just put up is draft number 2.1. Okay, good. We have it. So we went through sections one through three yesterday. That's 197. Oh, was 197. 190, we went through reference based pricing, and we were having a conversation regarding how continue the implementation of RVP. And I think I'd like to start there if I could. Alright, good morning, Jen Harvey, Office of Legislative And, actually, and Calista, if you have a chance, can you get me or copies of all of them that I sent them? Just the three I sent you. Yeah. We can work anyway, but it'll be helpful for me and Martine. So, I made changes based on your conversation yesterday. So, this is, just to orient us, S-one 190, currently entitled an act relating to Green Dot Care Board reference based pricing and hospital outsourcing of clinical care. See you at the end. So section one is on reference based pricing, but I actually took out the parts we were talking about because I moved them based on your conversation yesterday. So here's what I did. I kept the new section in title 33 around targeting reductions to the qualified health plans, qualified health benefit plans. So that language is now not highlighted. Wait, don't go too fast. What page are you on before you zip along? Yep, so this is page four.

[Emily Brown, Green Mountain Care Board (GMCB) staff]: It's in that section. I know if ever got it.

[Sen. Virginia "Ginny" Lyons, Chair]: And it is limitations on hospital reimbursements. So, is the 250% cap on registered carriers prices for hospital services, for enrollees in the qualified health benefit plans, and the language that goes along with that, but I added to the purpose section, hospitals shall not increase the amount they charge other commercial plans or private payers for various items unless the board authorizes the increase pursuant to a new section that we're gonna look at next. Wait until the new section. And then I've also added language saying, in its review of premium rates in accordance with the rate review statute, the board shall ensure that the limitations on reimbursements established in this section are appropriately reflected in the premium rates for qualified health benefit plans. That was something that had come up yesterday about making sure those limits flow through to the QHBs. So that's what that language says. Then I added a new section in the hospital budgets and budget review, what I now call hospital budgets and budget review, because it allows us to do some more stuff in this chapter. I added a new definition, the same definition of Medicare adjusted base rate, which I recognize is still under

[Emily Brown, Green Mountain Care Board (GMCB) staff]: scrutiny

[Sen. Virginia "Ginny" Lyons, Chair]: discussion, but the concept being to have a definition that would go in this chapter, or sub chapter in title 18, and then adding a new section on targeted commercial reimbursement reductions, and directing a hospital to implement, and I may have terminology wrong, so I'm happy to be corrected by the board or the hospitals, but shall implement any commercial reimbursement rate reduction ordered by the board under a hospital budget order through the limitations on its commercial reimbursement rates for qualified health benefit plans in accordance with that section we just looked at that sets the 250% cash To the extent that a hospital is required by the board's budget order to reduce its commercial reimbursement rates by amounts greater than the reductions achieved under the QHP breaks EQ. The hospital shall reduce its commercial reimbursement rates that exceed 500% in the Medicare adjusted base rate, or if the hospital doesn't have any of those, then by reducing its commercial reimbursement rates that are the highest in relation to the Medicare adjusted base rate. This is based on a conversation yesterday saying, start with QHPs. So the language we looked at yesterday said, reduce anything over 500% of the Medicare rate and 250% cap for qualified health care. This instead, based on the conversation yesterday, says first do the QHP, focus on the QHP limits, and then if the hospital still needs to further reduce its commercial reimbursement rates, then you look to the 500% or they don't have any of those the highest in relation to the base case. I have a question here. So obviously people have been contacting us. So the question is, is the two fifty that is here going to be implemented immediately on top of everything that has happened last year. I think the timing in here is yes. Yes, Emily

[Emily Brown, Green Mountain Care Board (GMCB) staff]: Brown, my answer is yes.

[Sen. Virginia "Ginny" Lyons, Chair]: So what does that mean in terms of hospitals,

[Emily Brown, Green Mountain Care Board (GMCB) staff]: period. So, we have our hospital budget guidance right now. It's a draft issue on our website, which calls for hospitals, most hospitals to reduce their commercial reimbursement rate by negative 1%. So, we are asking hospitals to cut. What this legislation does is requires that reduction to be satisfied through the QHP costs, right? The costs, or like healthcare costs for the QHP plan. So, those savings are to individuals and small groups who are enrolled in

[Sen. Virginia "Ginny" Lyons, Chair]: the QHP plan. So it's actually consistent with the budget guidance. I think So it's how that budget guidance is achieved. Correct. That's what we're putting in here.

[Emily Brown, Green Mountain Care Board (GMCB) staff]: Correct. And just to clarify too, it doesn't mean that every hospital by implementing this legislation, every hospital will be exactly at negative 1%. But if they, if for instance, a hospital implements the 250% of QHP and let's say it ends up based on the population of QHP patients they have at the hospital, it ends up being, it could end up being slightly more than the negative 1%. It can also end up being slightly less than the 1%. I think that's why here we have that language about applying then any further reductions are needed to those high dollar services, high cost services.

[Sen. Virginia "Ginny" Lyons, Chair]: And then I just wanna also note, so the piece we didn't get to yet is the kind of hardship language. If a hospital demonstrates to the board that the limitations on hospitals' reimbursement rates for QHPs in Title 33, or this section are having a negative impact on, and I use the same triggers as in the Act 55 outpatient prescription drug, don't know if those are the right ones, so just noting that that is literally where these came from, but there may be different criteria that people wanna suggest or that the committee is interested in. But if a hospital demonstrates the limitations are having a negative impact on access to care, quality of care, or the sustainability of rural healthcare services, or a combination, hospital may propose to increase commercial reimbursement rates for one or more of its service lines, such as primary care, and the board would consider both the demonstrated impact and proposed increase to reimbursement rates. Okay.

[Sen. John Morley III, Member]: We'll have to get a comment from

[Sen. Virginia "Ginny" Lyons, Chair]: People are all just saying this language now. Understood. And we worked on this yesterday. So we talked about this yesterday, I drafted it the evening, and people are saying the first time. I'm glad somebody else were talking. All right, then the hospital outsourcing, so when the last draft we looked at struck through a bunch of language and put in the budget guidance and the reporting, so that is, it's just I've changed the section number, but otherwise the text is unchanged. Same thing for excluding reference based pricing from the scope of healthcare professional bargaining. Changed the section number, but otherwise just incorporated that piece that we looked at that was remaining after everything else was struck through. Just the change of the section number on appeals agreement care board orders. After direction from the chair, it's post striking the hospital audit section that allows the chair of agreement and care board to conduct investigations and examinations, including audits. So now we have no section change and incorporated the changes on the health system performance tool that were proposed in the last draft, and implementation contingency, and then we have the study committee, so I incorporated everything in the last draft in here with a few changes that are highlighted. So the first is pretty ambitious timeline in the language you looked at yesterday. This group were providing its report on all of these topics by December 15, so after consulting with the chair, with a new proposed date of February 15, so an additional two months, and moving out the expiration date of the study committee by two months as well, and then, again, after consulting with the chair, this would take out language draft per diems and instead specify that members would not receive per diem compensation and reimbursement for participating, which is the only one we used in some of the groups last year in Act 68, and it would appropriate $200,000 from the general fund to the Treasurer's Office in fiscal year twenty twenty seven, and that would be specifically to pay for the services of consultants or firms who are authorized to work with the committee and facilitate meetings. Right, the reporting. And then I proposed after section 10, which still has the Act taking effect on passage, that the title would be an act relating to the agreement care board, reference based pricing, and studying the creation of a public employee health benefit employee. Since there's significantly less on outsourcing, so it didn't seem like So the language relating to, no, go back. Language identifying VHI and VSEA for inclusion and RVP, we don't have that. We just, we have the study. Right, you have the study. Well, I'm open to conversation at the I think it might be helpful if folks know that we're actually looking at reducing some of the costs associated with, especially school based healthcare services. So just having it in there for future consideration in some way. But based on the analysis that's come back, I don't know. We don't know that this study is gonna go through. It has to go down the hall. We have to find money. So that's where my thinking is. If we leave out the VHI and the VSEA and the initial

[Sen. John Morley III, Member]: part of the bill nowhere. That whole study could be dropped down the hall.

[Sen. Virginia "Ginny" Lyons, Chair]: So you can see, I would encourage something, some mention of it in the future, a future consideration by the board. I'm looking at the board.

[Emily Brown, Green Mountain Care Board (GMCB) staff]: We'd be happy to, I mean, we are planning, we did the study very much, and we did, it saved a lot of money.

[Sen. Virginia "Ginny" Lyons, Chair]: Correct. But it also, if we put it on top of everything that's going on right now, we might kill the hospital, so we don't wanna do that. Right. So putting it in the future makes some sense

[Emily Brown, Green Mountain Care Board (GMCB) staff]: for me. Yes, and if you want

[Sen. Virginia "Ginny" Lyons, Chair]: to put something in, just need to understand what you're wanting to put in for the future. So right now we're looking at QHPs.

[Sen. John Morley III, Member]: That would go back up into

[Sen. Virginia "Ginny" Lyons, Chair]: section one, it's at the top, targeted commercial reimbursement rates. We could add just a sentence that would have the board review its analysis and look at how to include reference based pricing for those cohorts, ensuring that our hospitals are not negatively affected, just something like that. So, would this be just a stand alone session law provision directing that Yeah. To the Doesn't seem like it goes in that statute that kind of talks about. I mean, all I hear about when I go home is, I'll tell you my property taxes are so high. It's all because of the full home care costs. And whether that's true or false, it's something to be considered. It's a big concern. And so it would be directing, I mean, you want them to report back to you or just to be considering how to do it? Either do it or don't do it. I mean, put it into the process for consideration as reference based pricing or as pricing goes farther than possible. I don't know how else to say.

[Emily Brown, Green Mountain Care Board (GMCB) staff]: Yeah, that's fine. I just also, so we don't regulate VHI or the VSEA. So I think it would be important to make sure, like I'm thinking about what this analysis would entail. I imagine it would be, you want more of an in-depth look at implications of reference based pricing. Know we did a study which was not based on using Beehive's claims directly, but you would need to update the study. Correct. Commensurate with the methodology that we're implementing for the multi state. And so, just want to flag that I think it would benefit Degree Mountain Care Board if we could in some way, if it was applied in this language that we would be able to work either with DFR or BIHI on Or both. Or both, right, on getting information to make sure that it's not ambiguous that we actually would have authority to do that. I think that would be important since they are a private self insured entity. I think that would be appropriate. We can't do without their support. And you also mentioned the state employee plan. I think it would be the same. Yeah, I would like there to be just a specific authority for the Going Mountain Care Board to access data related to those plans. And

[Sen. Virginia "Ginny" Lyons, Chair]: that's going out. That's not coming out. Right.

[Emily Brown, Green Mountain Care Board (GMCB) staff]: You can't do it that fast. Correct. Right, but

[Sen. Virginia "Ginny" Lyons, Chair]: it sounds like you're wanting them to kind of update with more actual claims experience data, the analysis of the impacts of reference based pricing on if it was targeted to those plans, the state employees and teachers plans. And then report back on, I'd like them to know how to implement, how to do it. You know, I think if they can report back, but also how to

[Emily Brown, Green Mountain Care Board (GMCB) staff]: impact.

[Sen. John Morley III, Member]: Senator Graham. Bring some clarification, in your study, I assume you're also looking at how that would impact certainly on rural hospitals. Correct. Exactly. Oh, yes.

[Sen. Virginia "Ginny" Lyons, Chair]: You need to have that in there. Yeah. Yeah. That made me to believe Right. That was impacting. Yeah. How how did we

[Sen. John Morley III, Member]: come up with those five hundred and ten fifty? The board and the hospitals.

[Emily Brown, Green Mountain Care Board (GMCB) staff]: Missed the question. Was there

[Sen. Virginia "Ginny" Lyons, Chair]: I come up with two fifty and five hundred.

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

[Emily Brown, Green Mountain Care Board (GMCB) staff]: two fifty came from Oregon, came from the other states. It's equivalent. Using our methodology, it's equivalent to the other state of them.

[Sen. John Morley III, Member]: Okay. I'm still concerned about the critical care costs and Yep. Who will that? Right. But we built an off ramp into the current team. Yeah, mean, it's basically, they're gonna go under that

[Sen. Virginia "Ginny" Lyons, Chair]: We don't let them go under.

[Sen. John Morley III, Member]: No, right. Pre month care board would be able to now adjust upwards. Adjust upwards. If they have to.

[Sen. Virginia "Ginny" Lyons, Chair]: Has her canvass? Oh, you can't see it. Oh, can't Senator see Gulick? Oh, because she doesn't have her video. Are you there? I am

[Sen. Martine Larocque Gulick, Vice Chair]: here. I just wanted, I'm sorry, I'm not getting better as quickly as I had hoped.

[Sen. Virginia "Ginny" Lyons, Chair]: Well, then you just stay home. Happy to have you on Zoom to getting better.

[Sen. Martine Larocque Gulick, Vice Chair]: I just wanted to chime in that I guess I'm disappointed that we're not able to act. I understand that we need to protect the hospitals, but Senator Lyons, to your point, all I hear in my district is about the cost of healthcare. And I just wanna make sure that this study is as specific and as strong as possible and that maybe we add intent language that really makes it explicit what our plan is and what our hope is to come out of this. I don't know if anyone agrees with me, but I'm feeling a little disappointed right now that we're not able to take bolder action at this time.

[Sen. Virginia "Ginny" Lyons, Chair]: So yeah, I'm in agreement with you that we need to act. It's not something that can happen right away for a couple of reasons. One, the board needs to identify, do the work, do the analytic work, and looking at the board, they're gonna come in. And then the other part of this is right now the hospitals are already under a budget order and to pile something else on top right now might be the straw that breaks the camel's back and that's what we're trying to prevent.

[Emily Brown, Green Mountain Care Board (GMCB) staff]: You don't have Emily

[Sen. Virginia "Ginny" Lyons, Chair]: Brown. Emily

[Emily Brown, Green Mountain Care Board (GMCB) staff]: Brown, pretty much your board. So I'm also, I hear the frustration. I think there are other aspects too of the VHI plan that is also important to point out, like the benefit design, which again, the QHP benefit design is largely set at the federal and state level. It's predictable. We have control over it. There's other aspects of the Beehive Plan that I think it would be important to look at. If you're going to look at the underlying costs, it's not only the underlying costs. There's other aspects of the plan that I think if you wanted to take that kind of If you're wanting to tackle the price of healthcare for teachers, it's not only about the underlying costs, it's about looking at the structure itself. You could look at several aspects of the plan design. You could look at I know there was a study done, I think it was in 2018, there was a committee style group, but I think it's important to not just, okay, thank you.

[Sen. Virginia "Ginny" Lyons, Chair]: Yeah, we get it, we understand. Thank you. Quick comments because we're gonna move along. I'll let VI talk and then, I think the hospital's at the end of first. Do wanna go first or second? VI. Alright, go ahead.

[Sen. John Morley III, Member]: To be clear, Colorado State of Vermont and VA, speak on behalf of Vermont

[Emily Brown, Green Mountain Care Board (GMCB) staff]: and VA, not VI.

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

[Sen. John Morley III, Member]: couple of quick points. Definitely appreciate the acknowledgment of the issue that has been shared. Obviously, yesterday, we spoke to the value and the importance of doing this with urgency and also understand, look forward to seeing the draft language that legislative council comes up with. I do wanna clarify a couple points. One is this committee has received testimony from BIHI about the fact that the two biggest cost drivers, the BHI costs are the same as all others. So, I think plan design is not the fundamental cost driver

[Emily Brown, Green Mountain Care Board (GMCB) staff]: of So

[Sen. Virginia "Ginny" Lyons, Chair]: we're not gonna get into that debate? Yeah. And I understand your concern here because we're not getting into the plan. And The benefits. And so the benefits, you know, are there.

[Sen. John Morley III, Member]: Under understood. Just wanted to

[Mike Rollo, American Cancer Society Cancer Action Network (ACS CAN)]: correct the

[Sen. John Morley III, Member]: record. And also just Lehigh is going through the process of plan reassign right now.

[Sen. Virginia "Ginny" Lyons, Chair]: Oh, good. Oh, so that's good to know. So that's good to know for everyone in the room. Yes.

[Emily Brown, Green Mountain Care Board (GMCB) staff]: Jennifer. Dan Green from Buzz. I'm to the 250% for the exchange plans. I appreciate the Green Mountain Care Board's efforts to strike a balance, but to be moving quickly and not closing any hospitals. So, thank you for that.

[Devon Green, Vermont Association of Hospitals and Health Systems (VAHHS)]: I, again, I support the work of going for those high prices for all Vermonters first, but having it more across the lines. I know Blue Cross Blue Shield and hospitals are starting work now. We had them at our board meeting. They are sending out negotiation letters. Having this 250% piece sort of undermines that ability to try to work that out with Blue Cross Blue Shield to bring down those high prices. So, we do have a concern there. And then we also have a concern on the definition of the Medicare base rates, especially if hospitals are going to be doing these calculations. We think it should be what is paid to hospitals, which is what we know, and that's what other states base theirs off of as presented by Baylor Health. And so we want to be compared fairly to other states. We want to know, we know when we're paid, and at the same time, it could There are a lot of policy determinations that go into that amount that hospitals are paid. You look at the rurality of the hospital, you look at what type of hospital, you look at the patient mix, and so the federal government has made a determination that these policy considerations are important, and so we think that that should be the base as opposed to something else that's not necessarily what the hospital is actually getting paid by Medicare.

[Sen. Virginia "Ginny" Lyons, Chair]: Are we talking about loaded rates? Yes. So that's something that is the board, should we be mentioning loaded rates in here because there should be a comparative analysis with similar hospital We can

[Emily Brown, Green Mountain Care Board (GMCB) staff]: certainly do the analysis in that part of the work that we've started and anticipate continuing. We explore the fully loaded amount with all those policy considerations. It includes performance on quality, it includes academic teaching, it includes technology, it includes all of these Medicare investments that may not translate directly to this program. So I think what we were really going through was apples to apples, and then adjustments, discrete adjustments that we can identify. It doesn't say that here.

[Sen. Virginia "Ginny" Lyons, Chair]: It doesn't say that in the bill. And you're asking us to put some very discrete information in the bill. That we're not, now you're not asking us to put in the, it says Medicare adjusted face rate. So is there any reason why we can't reference, at least are you going to be writing rules regarding So is it possible that we could reference this, the information that you have just shared with us in the rule making process so that offers reassurance that consideration will be given to different hospital types and based on what other states are doing. But if it's just carte blanche, there's a lot of trust in this room. I just wanna say, from my perspective, there's a huge amount of trust. But when you don't have something in statute and you go ahead a few years, interpretations can be made. So if there's a way that we could put that in, that would be helpful. And so I'm thinking about something around rule making, around Medicare adjusted face rates or loaded rates or including the criteria that you had just indicated?

[Emily Brown, Green Mountain Care Board (GMCB) staff]: Yeah, think it's alluded to in the existing Act 48 language, Act 68 language, sorry. We don't reference Act forty eight? Sixty eight, yes.

[Sen. Virginia "Ginny" Lyons, Chair]: Or 68. And let's consider

[Emily Brown, Green Mountain Care Board (GMCB) staff]: different roles of hospitals and community needs. Yes, we need That's exactly what we are going to do with the rulemaking process. So this is the starting point. It is not the ending point of the policy.

[Sen. Virginia "Ginny" Lyons, Chair]: Okay, well then that's important. I'll show you the let's put up the existing language. So where I'm in, I'm in ATVSA 09/1976, and it says, in establishing reference to make crises for a hospital, under this subsection, the board shall consider the composition of the communities served, including health of population demographic characteristics, acuity, payer mix, labor costs, social risk factors, and other factors that may affect the cost of providing care in the hospital service area, as well as the hospital's role in Vermont's healthcare system.

[Sen. John Morley III, Member]: Is that

[Emily Brown, Green Mountain Care Board (GMCB) staff]: what you're talking about? Absolutely. So that's the work we have ahead of us over the next year, which is how do we do that in a way that makes sense for Vermont, right? We don't want to assume the Medicare policy, especially right now when that could be changing. We want to have flexibility to adapt our program as the environment evolves and make sure it makes sense for our

[Sen. Virginia "Ginny" Lyons, Chair]: hospitals. What section of law is that to be read by? It's in the, 100 what is it in, is it in here? It's not in the three, I don't see 18. It's not in, so section one of the bill is amending ATVSA 9,076 E. That is, and in that N 90 three-76E is subdivision 2B, which we're not amending, so it doesn't show in the bill, but it does exist. So the bill picks up right here at 3A, and in existing law, it's here in 2B. Got it. Do we need to say anything about any of the more contemporary work that's going

[Sen. John Morley III, Member]: on with hospitals,

[Sen. Virginia "Ginny" Lyons, Chair]: rate setting, motor rates, should we say that? I think

[Emily Brown, Green Mountain Care Board (GMCB) staff]: we definitely want a way to compare to other states and I think that will be important. So, we're happy to, and as I mentioned, that's already included in our analysis. I think other states are actually looking and excited for this new definition. But where it gets very important to do that analysis. So, we're sticking with that because the other thing that has been thrown in here is that the hospitals are reporting out their prices as a percentage of Medicare and we can't do this base rate calculation. We know what we get paid but we don't know how to convert to the base rate. So, I feel uncomfortable having this in statute without further discussion with the Green Medical Care Board and clarifying So, what

[Sen. Virginia "Ginny" Lyons, Chair]: let me put up the language where I think Devon was talking about, so that would be whether there should be some additional clarification there. This section would no longer have a definition of Medicare adjusted base rates in it, because they're going in different pieces, but I think you're talking about when making a couple of the charges. Each hospital shown food in its machine readable files, pricing information shown as a percentage of Medicare rates, dollars thousand and 3¢. And so I think the question that you're hearing is, is that intended to be Medicare dose base rates, in which case the hospitals don't know how to calculate that, or is that intended to be the Medicare rates that the hospitals receive, in which case they do know what that is, but it won't be the same as

[Sen. John Morley III, Member]: what's happening in other places.

[Emily Brown, Green Mountain Care Board (GMCB) staff]: Right, and the same for Section one, about our provider contracts entered into and began expressing it as the Medicare. Other piece of this is the critical access hospitals cannot do the PPS, the conversion to They're not PPS hospitals. They're not PPS hospitals. Because I can't do it. We don't know how to convert what we're paid to the PPS They're critical access hospital.

[Sen. Virginia "Ginny" Lyons, Chair]: So, the question would you kind of treated with?

[Emily Brown, Green Mountain Care Board (GMCB) staff]: I mean, I think we can, we need to get there.

[Sen. Virginia "Ginny" Lyons, Chair]: Yeah, we're in a strange place right now. Yeah, is it something about putting a goal in here? I can't answer this question. This is not a question that we can answer. We're listening to what you two are saying. Right, I think the issue is if you don't specify which Medicare rate you're talking about for these provisions starting 10/01/2026 and hospitals showing the information that they're required under federal law. It's all over the place. Which, right. You're hearing from the hospitals that they, there's one way in which they can provide that information that is not necessarily the way the board is wanting that information to be presented. And if you don't decide which way it goes, you may not be happy with the results. Well, I'm leaning toward the board right now for this one. I think you need to have something that they can work with. I'm very sympathetic to the hospitals on this. I think we put language in that we'll go going forward on what to say at this point, so let's leave it for now. So what are the hospitals, oh, skip. What will the hospitals report? Again, think what you're hearing is, the hospitals who report the information that they know, which is not the Medicare adjusted base rate, but they're, what you were calling, Medicare, the fully loaded Medicare rate. That's different from the limitations on hospital reimbursement language.

[Emily Brown, Green Mountain Care Board (GMCB) staff]: We may report the fully loaded rate until we establish the rule, in which case, and that gives us more time. Would

[Sen. Virginia "Ginny" Lyons, Chair]: you Thank love you. That would be great. Let's do it. Thank you. I was hoping something. Oh, wow. Alka Seltzer. Thank you. Good work. Okay. We've been working on this thing since January. Okay. Alright.

[Emily Brown, Green Mountain Care Board (GMCB) staff]: Devin, again, there's also the critical access to PPS conversion

[Sen. Virginia "Ginny" Lyons, Chair]: with ACE. That would be a little bit.

[Emily Brown, Green Mountain Care Board (GMCB) staff]: I I think, again, for now, I think that's fine. I think part of the analysis that we'll do can back that out, but I think it would be good to have the language such that when the rule's in place and we all have a clear methodology that reporting will align with that.

[Sen. Virginia "Ginny" Lyons, Chair]: Cool. So we'll put something in saying that for C and E, the hospitals will use the amounts they receive from Medicare as the, in calculating percentage of Medicare until the board has, until the, I guess we'll talk a little bit around if it needs to be that applicability date, or an expector date, or something earlier than that. Because they didn't die. But, okay. Great. What else do you wanna discuss? I don't wanna talk about anything more. I think we've been through the bill. We've been through the whole bill committee. Do you have specific questions about sections of the bill at this time? No,

[Sen. John Morley III, Member]: I think it addressed my concerns, which was an off ramp of a two fifty Yeah. Which we have in here. And I was also concerned about the heating audit, which that's been taken out.

[Sen. Virginia "Ginny" Lyons, Chair]: I feel a lot better about it, yes. Yeah, I knew that was a concern that was in the committee, and I had Ginny to take it out. And I think I understand that there are those who would like a back answer, but I think at this point, this is not something we would discuss, pick

[Sen. John Morley III, Member]: it up if they would.

[Sen. Virginia "Ginny" Lyons, Chair]: Okay, so I think for tomorrow, I will be back with a brand new provisions, incorporating everything that's been done so far, and with some new provisions around the Medicare rates to use in the provider contracting and public reporting, and around creating a new section directing the board in collaboration with DFR, BIHI, and DHR to analyze and report back on reference based pricing or implementation of reference based pricing for school employees and state employees, and the impact, projected impact on hospitals. Require the board to get access to data. You need data on claims experience. Is Is that what you need to be able to do the updated reference based pricing for school employees and state employees? Yeah, so you need all their claims, yeah. To claims, but the same claims data. And then have the board report back on implementation, timing, whatever else you want. Is that what you're thinking about? That sounds good, thank you.

[Sen. John Morley III, Member]: And

[Sen. Virginia "Ginny" Lyons, Chair]: then when we look at it tomorrow, I understand that there might be everybody willing to comment. We're gonna sit here at the table and we're gonna decide both models and for us. I will look at it. I have a question. Next bill. Yes, which bill? I probably do 197. I wanna go to 64, and then 189 is there, but we've finished that pretty much. You should know, you should, I mean, should still look at it. I'd like to have a new draft. Okay, we can take a quick look at that. Do 197. The 197, okay. So for I can't tell you how much fun I had last night reading all of this information, all these bills. It is really great to do that. So, 197. 21. There we go. 21. Working out today. So, we went through the sections one through three. We went through the sections one through three, and I think I made a couple of very minor changes, almost that should be true, Having editors look at it. Yeah, so I made a couple of just technical cleanup changes, having learned from the different folks that the NCQA score is now just the NCQA Patient Centered Medical Home Score, and that doesn't include the language about physician practice connections, so I took that out from two places, and the language around the amounts from health insurers beginning in 2027 being in amounts at least equal to Medicaid, and the editor suggested maybe they'll just say Medicaid payments, which I don't think is that. So I added that language. And then, this is a piece that BMS has proposed that I think is still up in the air with AHS. I had not weighed in on yet. And so this is in making recommendations, further recommendations on modifications to payment amounts that the director of the blueprint would not only strive to achieve or maintain parity across payers and payment methodologies, but also to adjust payment methodologies annually as needed to adequately support practices in maintaining CTQA, PCMH status as the updated term, or meeting other requirements for participation in different programs. Can I ask Nolan a question? Will this have any negative effect on our Medicaid process at all? I don't know the answer.

[Sen. John Morley III, Member]: For the record, Nolan, I won't get this goal. It will if this results in increased participation of Medicaid. Right. But if Medicaid were flat and insurers were going down, it wouldn't impact the state's budget. Understood.

[Nolan Langweil, Joint Fiscal Office (JFO) analyst]: But the piece I'm not clear on is, is this requiring Medicaid to increase their pay and again, and I don't know, I'm not clear on. Okay.

[Sen. Virginia "Ginny" Lyons, Chair]: And just so folks know, I did reach out to AHS and asked for how much would we have to put in our budget to increase reimbursement rates for primary care? Because I don't know the answer to that. And then as this shifts down the hallway, if we know how much, I got one number back that was exceedingly low, I said, well, we can raise it by 20%, no. So we'll wait for some accurate numbers, and we'll either do it in here or maybe it'll get carried. And just a comment, Jessa, did you wanna comment?

[Jessa Barnard, Vermont Medical Society]: Jessa Barnabas with the Medical Society. I just wanted to comment briefly about the impact, potential impact on Medicaid budgets that we were trying to be very careful to propose language that just says this is in recommendations that, and to strive to maintain parity or make adjustments so that it's nothing requiring, if there are budgetary impact, there's nothing requiring those. These would just be stated in recommendations that the legislature would then consider. Okay.

[Sen. Virginia "Ginny" Lyons, Chair]: Thank you. That was good. That was helpful. Okay, so those are the only changes I made in those sections that replaced sections one through three. I did not give you existing sections one through three struck through. I just put these in instead of one through three, and then because this is now one through five, everything else gets renumbered. Okay. Total number of sections is now five. Of the one to three, And then there's the rest of the So, group three is until one. One through five. Yeah, one through three becomes one through five, but we're gonna take out a section. I think we almost catch up. Okay. Section numbers. Let's go right to six. So six is the Clinician Landscape and Site Mutual Reimbursement Reports. I didn't make any changes in the content, just section numbers. Did

[Emily Brown, Green Mountain Care Board (GMCB) staff]: we,

[Sen. Virginia "Ginny" Lyons, Chair]: there was a mention about having the primary care advisory committee included in some of the work that's coming up here. I think that was maybe in the context of creating a separate committee. It's in section seven. So, they're already included in section seven, But what I added in section seven was that the agency shall incorporate the recommendations. The section seven has AHS in consultation with various groups reporting to this committee and Health Care with recommendations on ways to accelerate appropriate transition of patients from hospital care to care delivery in a community setting. It talks about the recommendations including opportunities to use community health teams to the Blueprint, And then I add that the agency shall incorporate the recommendations into the healthcare delivery strategic plan as appropriate. That's good. That's can do. That's what we've been discussed yesterday. I struck the section relating to VQHC. Yeah. Committee discussion yesterday. Just changed section eight, the treasurer's office exploring regional universal primary care. I've just changed the section number. Section nine is removing the sunset on the medical student incentive scholarship program for primary care, and as we briefly discussed yesterday, there is money remaining from prior appropriations, and this language has been proposed with the budget. I don't know if it's actually going in the budget, but wouldn't cost any new money unless there was an additional new appropriation, but it would allow this to extend into future years based on the money that's available. Section 10 is based on the request from committee yesterday around, I'm I had mentioned about notice when a drug is gonna not be covered by insurance anymore. So, I added an existing provision of the health insurance statutes that require health insurers to notify individuals on a periodic basis, but at least once per calendar year of any changes in pharmaceutical coverage and provide access to the preferred drug list, added a new provision saying not less than, and I put 60, but you can pick whatever you sixty days prior to removing a prescription drug from its formulary or from the formulary maintained by a pharmacy benefit manager on its behalf, A health insurer shall notify all individuals covered under its health insurance plan who filled a prescription for that prescription drug within the previous twelve month period. The coverage for the drug will be discontinued and at the date on which the coverage will end. Seems like transparency. That's really interesting. Could just turn around and ask Emily with her old hat on. That sounds strange. Thank you. Thank you for that. And then I proposed changing the name. It still doesn't quite cover everything, but it has been an act relating to establishing a primary care payment reform program, and that is no longer what the bill does, so I just did an act relating to payment reform for primary care, which doesn't reflect everything, but is still most of what's in the bill. Okay. That's it. So why don't we do this with this one? It seems like unless there are some burning additions or subtractions that need to be made, I think we've been through the bill, What we'll do is, I'm happy to hold the vote off until tomorrow, but let's just put it aside for now, and if we want to come back to it later today we can do that. If not, we'll work at it tomorrow. Which one is the next? You wanna do 64 next? How how much does $1.89 I think 64 might take more, but Yes. I think 64 will take So that's why I'm thinking most of our time at 64, go to 8189. 180 Everyone is here. Alright.

[Emily Brown, Green Mountain Care Board (GMCB) staff]: You're well. That's that's fine. That's 31.

[Mike Rollo, American Cancer Society Cancer Action Network (ACS CAN)]: Alright,

[Sen. Virginia "Ginny" Lyons, Chair]: 189, so that's 31. So, again, this is an aggravating to an approval process, although this may change as well for reducing or eliminating hospital services. So this modifies the scope we talked about a little bit yesterday. We talked about kind of the intentionality. So this would now say, a hospital that proposed to intentionally reduce or eliminate any service. I get seventy two minutes and then looking at it. I appreciate. Yes. But to be fair, this is a legal standard for their attention. Yeah. So a hospital that promotes us to intentionally reduce or eliminate any service, and then it goes into the notice process. So, after your conversation yesterday about sort of wanting have this process start before the statewide healthcare delivery strategic plan is established, I went back to just having it start. The agency of human services shall analyze each proposed service reduction or elimination For consistency with the strategic plans, that's why it's highlighted but not bold, put it back in. Consistency with the statewide healthcare delivery strategic plan once established and the community health needs assessment. Consider the community's response and the impact on access and then provide non binding recommendations on the proposed reduction or elimination to the hospital, board, and the public. Then it requires, if a hospital decides to go ahead, that they then by business days notify the agency of human services to inform the agency's transformation efforts and future versions of the strategic plan and the board to enable the board to review the impact on hospitals budget and then it strikes the process added in Act 68 last year, and instead has language directing the board once it's been notified that hospital can reduce or eliminate. After completing the process, review the impact on the board's proposed approved budget and allowing the board to adjust the budget as necessary to reflect elimination or reduction, which may include targeted reduction of savings. And then keeping the language requiring the board and DFAR to monitor implementation of any authorized reduction of elimination should take effect on passage, and then it would become an act relating to establishing the process for reducing or eliminating possible surgeries.

[Sen. John Morley III, Member]: Not any verbal, though. Questions? So

[Sen. Virginia "Ginny" Lyons, Chair]: hopefully that was what you were looking for based on yesterday's conversation.

[Emily Brown, Green Mountain Care Board (GMCB) staff]: Go ahead. I just have a Emily Brown from Fremont here. What I have a clarifying question is the with the budget review, is it implied that that would happen during the annual budget review process or would this be a separate budget review process?

[Sen. Virginia "Ginny" Lyons, Chair]: I think the timing may depend. I think if the notification happens in November, then it may not make sense to wait until the following September. There's discretion. I think there's no discretion. Okay. Because you're reviewing the impact on the budget. Okay. I think, you know, depending on that's how I read it, it's not

[Sen. John Morley III, Member]: specific in the year.

[Sen. Virginia "Ginny" Lyons, Chair]: Right. And depending where you are in the year, it may depend on the the significance of the impact on the budget. Okay. That's helpful, thank you. So it does offer flex payments. Right, mean it says upon receipt of notification, the board would review. But what the board chooses to do as a result, it allows the board to adjust the hospital's budget, which I think suggests you have the authority mid year in addition to whatever authority you have at budget setting.

[Emily Brown, Green Mountain Care Board (GMCB) staff]: Go ahead, Deb. Is Ben Green from Bob. I just had a question about the return. What page? The I don't know. It was

[Sen. Virginia "Ginny" Lyons, Chair]: a lot. Part where

[Emily Brown, Green Mountain Care Board (GMCB) staff]: it says Yep. You're expensive. The payers and Vermonter.

[Sen. Virginia "Ginny" Lyons, Chair]: Savings related to the- Yeah, just like- Which has been in- For what? Yeah, it's not changed, but-

[Emily Brown, Green Mountain Care Board (GMCB) staff]: It has been, is there? I was just thinking like, I really wanted to go to Vermont or- But I guess maybe it's up to the discretion.

[Sen. Virginia "Ginny" Lyons, Chair]: Right. Mean, I think some of the return to payers is to put it to be Yeah. Reflected in

[Emily Brown, Green Mountain Care Board (GMCB) staff]: we say something like to be reflected in premiums or is that taking down?

[Sen. Virginia "Ginny" Lyons, Chair]: I can't hear you.

[Emily Brown, Green Mountain Care Board (GMCB) staff]: Can we say something like to be reflected in premiums or is that to That's what

[Sen. John Morley III, Member]: I was thinking. Yeah.

[Sen. Virginia "Ginny" Lyons, Chair]: Yeah. Sure. We can do that. What's that? I think that

[Emily Brown, Green Mountain Care Board (GMCB) staff]: has been I think that works. Yep. Yeah. I think that yeah.

[Sen. Virginia "Ginny" Lyons, Chair]: Otherwise, it can go anywhere. Well, exactly. Right. Well, I'm here. We don't know. Think the assumption was that that would be tracked and reviewed as part of Yeah. Premiums, but

[Sen. John Morley III, Member]: It's reflected differently.

[Sen. Virginia "Ginny" Lyons, Chair]: Yeah. I'm just trying I'm struggling with Reflected and creaminess. I'm not struggling with that part. Struggling with how to get the vermantras in there. Vermantirs. Well, I don't didn't know if it was vermantirs outside of the premium amount. That's what I wanted to So

[Sen. John Morley III, Member]: maybe I'll just flip it. What about individuals?

[Emily Brown, Green Mountain Care Board (GMCB) staff]: Pardon me? These providers that are affected?

[Sen. Virginia "Ginny" Lyons, Chair]: It it may depend. I mean, it could be so but I'll I'll just flip them, and so it'll say, I'll return to promoters and to payers for appears to be reflected. So, I guess we'll save reminders to address affordability concerns. Payers, we reflect any premiums for our community.

[Emily Brown, Green Mountain Care Board (GMCB) staff]: Alright.

[Sen. Virginia "Ginny" Lyons, Chair]: Okay. Great. That one, though, for you? That one, when that one's complete I mean, before it's complete, at the end of this morning, we might think about voting on that one because we've been forward A2. Okay. Well, if you've had a lot of conversation on something else, let me try to update the document. Now we're So, I'm gonna take a five minute break. I know that we need it. I'm four minute break. As quarter of, we're starting on S64, period.