Vermont Legislature SmartTranscripts:

[Senator Phil Baruth (President Pro Tempore) [probable]]: Sorry. Get the big thumbnail.

[Senator Virginia "Ginny" Lyons (Chair)]: You're alive. Alright. Good morning. It's Thursday, March 19. This is Center Health and Welfare, and we're we always begin the day with something good. And today, that good is having some physical therapists join us. I'm glad that glad that you're here. So we're gonna introduce ourselves to you, and then you can introduce yourselves for us, and we'll listen to your presentations. So, great. Go ahead, John.

[Senator Phil Baruth (President Pro Tempore) [probable]]: John Morley from Morley's District. Nice to meet you. John Benson from the Orange District.

[Senator Virginia "Ginny" Lyons (Chair)]: Ginny Lyons, Chittenden Southeast. Martine Larocque Gulick, Chittenden Central in Cummings, Washington. So this is it for health and welfare, but we have think we've been pretty supportive of physical therapists, and we would like to continue doing that, but in order to do that, we need to hear from Katie. Thank you for being here.

[Heidi (President, APTA Vermont Chapter; PT from Middlebury)]: Yeah, thank you, Chair Lyons, for having us. Thank you, committee, for listening to us. I'm Heidi. I'm the physical therapist from Middlebury, and I am the president of the American Physical Therapy Vermont Chapter, and I cover Addison and Rutland County.

[Senator Virginia "Ginny" Lyons (Chair)]: I'm Elizabeth Sargent. I am also on the executive board of Vermont Chapter. I've been a physical therapist for over thirty years, most of those in Vermont, and I am in Franklin, Charlotte. My name is Estelle LeClair. I'm a private practice owner in Essex, Vermont, and Georgia.

[Estelle LeClair (Private Practice Physical Therapist, Essex/Georgia)]: We also do a home division on the new physical therapy, and I recently took the APTA role of the policy and payment chair.

[Heidi (President, APTA Vermont Chapter; PT from Middlebury)]: So thank you for having us come and speak. As the chapter of physical therapists in the state, we represent over 400 PTs, PT assistants, and students. We cover a lot of different sectors that sometimes I think people don't realize the whole lifespan that physical therapists can really help with. We're here to help, you know, educate everybody on the role of PT and how we can help increase quality of life and save our society money. I run a private practice down in Middlebury and I do home visits for babies. I'm a birth to five specialist. For the past twelve years, I've only taken Vermont Medicaid because I think that's where the most need is for early intervention,

[Senator Martine Larocque Gulick (Vice Chair)]: which is

[Heidi (President, APTA Vermont Chapter; PT from Middlebury)]: the birth to three program in the state. I do provide services in the home, and again, cover all of that and then some of Rutland County too. So to provide services in the home and in the kids' natural environment is pretty costly. It has been really hard for me to keep my business open, And unfortunately, right now, with the changes that are coming from Medicaid because of the federal changes of the evaluation code that we've been using for the last fifteen years, is gonna put such a significant cut in my business. I'm going to have to change my priorities, I'm no longer going to be able to take just Medicaid. I'm no longer going to be able to see just babies. I won't be able to do it at homes anymore because I'm going have to figure out how to keep my business open, which might include going to more cash pay, which I know is not great for equality and access, but I have to make sure I feed my kids. I think in early intervention and even pediatrics and neurology, if people have a neurological condition, the amount of services that it really takes for them to meet, you know, their proper outcomes is really tricky, and I think if we don't meet the kids' needs, it's gonna increase our school budgets. A lot of the school budgets are really high right now. A lot of it is because of healthcare and because of the special education services that are needed. If these babies don't get their therapies, PT, OT, and speech when they're little, those services and the needs are gonna go up tremendously. We have a lot of young families that are moving out of the state because they can't find services for their kids, and then a lot of people like me aren't staying in the state because we can't run our practice. PT is just really, really important.

[Senator Virginia "Ginny" Lyons (Chair)]: You work directly with special educators for kids with special needs, any patterning or what's

[Heidi (President, APTA Vermont Chapter; PT from Middlebury)]: going Yep, so usually that's not until they're three So on the educational I work with the early intervention program usually, but I'm also on the medical side. So like, a lot of people, maybe if an adult had a stroke, they would know that they would need a lot of rehabilitation, but a lot of people don't realize that babies have strokes, and it's not just high needs parents or parents that have used drugs, it's well educated working families who have issues. And unfortunately, you know, if they don't get the therapy that they need when they're younger, they may not be able to walk. We might have more kids end up in wheelchairs than we do now. And the families and kids can't get the equipment unless they have a PT involved. We're vital for getting them wheelchairs and walkers, but it's still really tricky for administrative burden how much work and how little I get paid for it, so it's really hard for me to keep it open. So I'm just here to help educate what we can do to help.

[Senator Virginia "Ginny" Lyons (Chair)]: Is there anything else? Because we're gonna have lots of questions, but we're Yeah, not here to get yeah, So I'll just be brief. I'm here also to help improve the understanding of a doctorate of physical therapy education. I'm a deputy educator and have been for the last ten years. I'm core faculty at the University of Vermont, and now I'm also faculty at a hybrid program in Eastern Kentucky, Appalachia. So I'm quite familiar with trying to meet needs of rural citizens. The DBT education, if you look at the curriculum, it is not, layperson wouldn't be able to differentiate it from an MD program or a DNP program.

[Emily Brown (Executive Director, Green Mountain Care Board)]: They are very

[Senator Virginia "Ginny" Lyons (Chair)]: similar. The reason I wanted to point that out is because I think if PT can be considered part of that primary care team, it reduces barriers to Vermonters, improves access, reduces cost. So, I was working in the primary care office with physicians at Memorial Health Partners, that improved access, improved outcomes, improved patient satisfaction, and the patients were able to get feed faster. The physicians and nurse practitioners were so grateful that I could help unburden them because they are burdensome. So the question that I have about that, I'm glad you brought this up because obviously we're pushing forward a bill S197 on primary care based on the blueprint model. Right. So do you work within a community health team? Do you participate in that blueprint process? So in effect you are primary care folks. Do you see US primary care? So it depends on the team. Was part of a federally qualified health center. There are some dealing challenges that are part of the Medicare Handbook, and that's not gonna be handled at the federal However, as part of that primary care team, thirty five percent of visits to primary care are most hospital models. So, physicians and the nurse practitioners are not trained to handle those cases, and they need to offload those to us. So, some of the challenges are payments, some are legislative, but not a scope of practice challenge. Yeah, some of them are just administrative stuff. So, I'm independent, so now. But then you're talking about code changes through the federal government. That sound that whole bill that's coming up for Medicaid is gonna get every part of Medicaid. Yeah,

[Heidi (President, APTA Vermont Chapter; PT from Middlebury)]: and so what we're hoping is maybe the state can come up with ways to pay us for the other things that we're doing, some of the administrative pieces or the collaboration pieces.

[Senator Virginia "Ginny" Lyons (Chair)]: You know, I don't get paid for team meetings, although for a high needs kid, they're asking to join monthly. For an hour meeting is a lot of non billable time for me. The travel is tricky too, especially in the rural state. This is an ongoing issue. You're all in an area that makes you eligible for the Rural Health Transformation Grant. And I don't know if your organization is looking at what RHT is doing and it does include primary care and it does include transportation. Have you looked at any of the opportunity there? And I'm thinking it's difficult for you in your practices to do this. You can't do it, but the organization itself might be able to put something.

[Heidi (President, APTA Vermont Chapter; PT from Middlebury)]: I haven't, only because a lot of the things that I've seen are going towards nonprofit agencies. So I'm not familiar about that without my fees. Oh, I bet I

[Senator Virginia "Ginny" Lyons (Chair)]: could go rook down. Yeah. Yeah.

[Heidi (President, APTA Vermont Chapter; PT from Middlebury)]: So that might be something for the rural things. We know that there's lots of fees. And there's lots of other bills that we know, like, PT can be part of. I mean, we can really help the workforce, you know, if people are out on workman's comp, I know Stella's gonna speak to that a little bit, but I think there's a lot of areas, you know, that we can really help with. I think one of

[Senator Virginia "Ginny" Lyons (Chair)]: the things that we should look into is how the code is written in terms of who is considered a provider. Sometimes those are defined as NVNPPA, and if PT is a designated provider, it would remove enormous number of barriers in terms of being eligible for grants like the ones you're prescribing. And so, all of everything you just said about, well, designated provider, that's something we can dive into. But some of the code changes and which codes need to be supported differently, what administration needs to be supported differently, need definitely specific recommendations. Right. I do have

[Heidi (President, APTA Vermont Chapter; PT from Middlebury)]: to say Medicaid has been really, really good, and I wanna thank them and you guys also for supporting that. So they have decreased our administrative burden at times. Been working on that. Yeah, that is definitely, so thank you. So now we just have to figure out how to not let the federal changes kind of squash us.

[Senator Virginia "Ginny" Lyons (Chair)]: I know, just when we get started on doing good things. Estelle, did you wanna talk about? I love the idea that you start the day with something good. I wish I could follow that. In private practice, see the biggest challenges, there's tenfold, but the biggest challenges for us in private practice is having practitioners. Right now in Chittenden County, there's a huge wait, four to eight weeks at any given time, for people to get into physical therapy. That's a problem in our state. The challenge for me as a business to provide insurance for my employees with the subsidies going away on the healthcare connect. Getting insurance for a small business is costing me 3.5% more of my revenue than it did a year ago. So on January 1, my costs had gone up 3.5% of my revenue. That is not sustainable in Vermont. Unfortunate, some practices that are small are calling me to say, Can you buy my practice? Can I just, I'm ready to fold? I'm ready to go back to work at UVM. The hospital, I should just close my practice. It would be easier for them. So, that is not, I don't believe that that is what we want to see in Vermont. I think small practices and small businesses in Vermont are an important part of our state's picture. And we know that private practices save money for the health care system. So, between keeping staff here, affordability in Vermont in general is enormous challenge. Just yesterday, I received a resignation from one of my clinicians. Third one, moving out of Vermont. That is not what we want to hear this morning, or in general, as a business. So, with that said, what do we do, whether it's pelvic floor PT, keeping people out of nursing home care, that's the number one reason women go into nursing homes. Incontinence issues. That becomes a problem in healthcare. UTIs, that lands you in the ER, which is far more costly to the system. ER visits, physical therapists, with Elizabeth speaking to the doctorate level of education, we can treat acute vertigo. If you've never had vertigo, good for you. That's a happy moment. Yeah, but it's

[Jennifer Carbee (Office of Legislative Counsel)]: not a good thing. If you have it,

[Senator Virginia "Ginny" Lyons (Chair)]: you know that you think you might be having a stroke and you need to go to the ER. You don't need to go to the ER. You can go to first line care at physical therapy first. That saves money to the system. Low back pain, same thing. Those are acute areas where we do function as primary care providers. They fleet a lot of people know each other and they say, Oh, if you've got vertigo, we saw a therapist over at that clinic. And they know that they can come to us first. So whether it's pelvic floor, whether it's workers' comp, as Heidi mentioned, getting people back into the workforce, those are the places where we hold a huge part of the healthcare system and just community members in our state. And I'm glad that we're doing a lot to

[Heidi (President, APTA Vermont Chapter; PT from Middlebury)]: try to keep students that might be graduating. We're trying to work more on keeping them in our state because a lot of students leave. We have a very small percentage. We only have one GPT program, the doctor of physical therapy program. But I think it's good to, you know, be working on student loans and stuff and keeping them in the state, but we also have to figure out how we can support the providers that

[Senator Virginia "Ginny" Lyons (Chair)]: are already here. So I'm gonna have to look at our time, but Yeah. I'm You've got more information. This is great. I really appreciate what you've brought to us. We wanna help you. We wanna help you. But we need all the help we Yeah, can we'll need to. So, you have your written testimony, all the things that you've talked about? We have.

[Heidi (President, APTA Vermont Chapter; PT from Middlebury)]: Yeah, we have sent the other things, and

[Senator Virginia "Ginny" Lyons (Chair)]: this is just like a

[Heidi (President, APTA Vermont Chapter; PT from Middlebury)]: better summary for it. I

[Senator Virginia "Ginny" Lyons (Chair)]: don't know that mine made it. No, didn't. If you have something further, just send it in and we'll look at it because honestly, every time we hear something like this, I think, oh, we should have put that in that bill. And then so going forward, as we look at what's coming to us from the House, we may be able to put some provisions in or in the budget. This So is called This is one code. I heard it, is one code, but for her business, it is capsizing. The vote goes over. She can't stay in business. One code with Medicaid. So just one code, you look at it collectively, you think, oh, no big deal. We all need to go to the federal government and get them done. I'm going to Oregon. Yeah, let us

[Heidi (President, APTA Vermont Chapter; PT from Middlebury)]: know if you guys want more information. We've got lots of

[Senator Virginia "Ginny" Lyons (Chair)]: I do. That's just helpful. Discreet recommendations are really great. I will send you additional information. Please do. And I like numbers. Numbers.

[Heidi (President, APTA Vermont Chapter; PT from Middlebury)]: We'll try

[Senator Martine Larocque Gulick (Vice Chair)]: not to come on healing since I

[Heidi (President, APTA Vermont Chapter; PT from Middlebury)]: don't have the data. Right, thank you. Thank you.

[Senator Virginia "Ginny" Lyons (Chair)]: Thank you. You for your work. Thank you. And the World Health Transformation Grant, you need to get in touch. I'll give Calista some information to connect with you so that you can get on that as a organization, because there's really a place for you. Great. Thank you for that lead. Right. Senator Baumgartz, thank you for being here. We've got a five page amendment.

[Senator Phil Baruth (President Pro Tempore) [probable]]: Oh my goodness. It's not.

[Senator Virginia "Ginny" Lyons (Chair)]: So, is Amy coming in on this one or not? Here's what we're gonna do with this. First, we'll have you explain what you have here for the amendment, and that's what we have time for. Then at some point our committee will dive in for a discussion and consider how we might support or not support on the floor neutrality, I know that you're very interested in this, so why don't you go right ahead.

[Senator Phil Baruth (President Pro Tempore) [probable]]: So what the bill does is Register Bill of Acting. Oh, yes, as I always say to everybody, yes. So Senator Septalom breaks the Benson Senate District. And what this bill does is allows somebody to open a home childcare center with a level one certification or license and then gives them a total of six years through the extensions to gain their level two. So my fear is that we have those regulatory requirements of level two before somebody can open a home center, there's gonna be no home centers because it's too big a lift out of the box with a particular deposit for people to get started and then give them, with a minimum, with a level one license, and then give them the six years to get the rest done that we'll get to the place we're trying to get at. We'll have more home childcare centers in rural Vermont where they're privately invested in people. And I also just added a couple of things to the study on page four of this. Looks like there's a lot to do with Ersson, and it's to number five on slide 12, page four, and number six. I see it. Changes in the number of registered and licensed family since the United of Club, and then recommendations to encourage the alternate additional family caregivers. And that's it. That's what the bill does, those two things. Makes it possible to open while you obtain your next level of certification or advice and advice about the study.

[Senator Martine Larocque Gulick (Vice Chair)]: Thanks. Senator Gulick, everybody. Thank you, Senator Baumgartz. Is this for, like, is in perpetuity they'll be able to open a home center with a loved one?

[Senator Phil Baruth (President Pro Tempore) [probable]]: Yeah.

[Senator Virginia "Ginny" Lyons (Chair)]: So right now the period of time is what, nine years for the beginning of this to take place, and you're suggesting that in order after that 2031, guess it was, after the time period that we have in the bill. 20 you're 20 right. After that, there would be a two year period, you could open your home, you could then go to get your credentialing to move forward. And if someone else came in in 2034 and they want to do similarly, they could open a home and then they'd have a two year period within which to meet the conditions for continuing. Okay.

[Senator Phil Baruth (President Pro Tempore) [probable]]: This

[Senator Martine Larocque Gulick (Vice Chair)]: is a comment rather than a question, but as I look at the requirements for ECE-one, it's strictly field experience and no actual learning. And that concerns me just because we talked a lot yesterday about you've done a lot. Neurodevelopment and professionalizing, but also just understanding trauma and poor practices and what you don't necessarily get in just field work. So I guess I'm a little concerned about that, that it's just going in perpetuity. So, leave that there.

[Senator Virginia "Ginny" Lyons (Chair)]: So, in a period of time, you know, I understand that at this point, and going along, there might be people who get the great idea that we've got experience here taking care of children and would like to open a home center. I can understand that happening. I think the concern you're raising, and correct me if I'm wrong, is that this would just go on forever rather than have a limitation of playing 40. It's day out. That's all. Okay. But, so we're gonna we'll we'll talk about this. So, I think first we wanna understand. So, questions about understanding. Right. I'm not what you're saying. Someone with a level one, which is experiential. I have three kids. I I would like to open a whole center and take care of couple more kids. I have

[Senator Phil Baruth (President Pro Tempore) [probable]]: two years. Yes. With with extensions. With extend but Yeah.

[Senator Virginia "Ginny" Lyons (Chair)]: I I have a time frame in which I need to get some educational credits.

[Senator Phil Baruth (President Pro Tempore) [probable]]: Yes. It's a number of years.

[Senator Virginia "Ginny" Lyons (Chair)]: I think we need to remember, we're sitting in Chittenden County right here in the megalopolis of the state capital. I bring out what bill we were looking at. May have been licensing. Adequacy. There was childcare on the West Coast, and there was childcare on the East Coast of the state, and there was a huge swath in the middle where you have you don't have enough kids to open a center. I mean, the population is such that probably for the foreseeable future, the only practical way is to have a halt centered. And people that live up in Island Pond are not traveling out to get a degree to I understand the need to professionalize this, but honest to God, I'm a history major and I've raised more successful kids. And they all read and they all are law abiding, and I didn't know anything about brain development. Women have been raising kids for years, and I am proud to see women's work being recognized for the importance that it is. But I wanna make sure that in trying to do a good thing, we don't like to do Okay. Senator, I'm gonna ask for questions of senator Vanguard regarding the proposal.

[Senator Martine Larocque Gulick (Vice Chair)]: Oh, because I sorry. I haven't had to read this. This is I'm just seeing

[Senator Virginia "Ginny" Lyons (Chair)]: it for the first time. Yeah. That's alright. I'm gonna read and

[Senator Martine Larocque Gulick (Vice Chair)]: pay you. Yeah. And I I just wanna make sure that I understand. So you could open a home based facility with with just an ECE one, but you do eventually have to move to an ECE two. Okay. Thank you. That's helpful.

[Senator Virginia "Ginny" Lyons (Chair)]: So they're definitely getting no. They they don't they they can't just keep going at at the level one. They have to go ahead and achieve.

[Senator Martine Larocque Gulick (Vice Chair)]: Our wife didn't get that at first. Now, I guess, it's helpful. And they can and then they can stay at ECE too. They don't have to continue to three to. Okay. And they have two years to move from. You can

[Senator Phil Baruth (President Pro Tempore) [probable]]: get extended. You can. Okay. Yeah. So yeah. Understood. So I I appreciate everything I do, and I do I I can't think of the notion of the Yeah. Guidance that comes with. I don't and it's just that in some areas of the state's choice, if you'll have some areas of state can have this, and then my fear would be some areas of state will have that and get get into here in those areas where that's what's required to provide to have done this homework and have a decent list of things you know, what I'm trying to get at. Understood. So recognizing the realities on the ground.

[Senator Martine Larocque Gulick (Vice Chair)]: Yeah.

[Senator Phil Baruth (President Pro Tempore) [probable]]: Yeah. So Okay. Rural areas. Yeah. Okay.

[Senator Virginia "Ginny" Lyons (Chair)]: I I don't think we're gonna see a 100 of these things happening overnight. No. Okay. Some but as you said, someone might decide about this experience. I wanna expand. I've been taking care of kids from two families, six kids for six years, and now I wanna open up and do something different. It's a hard job. They still have to register with OPR and apply for a license, a level one license, and they still have to then commit to

[Senator Phil Baruth (President Pro Tempore) [probable]]: education. Getting to the options, yes.

[Senator Virginia "Ginny" Lyons (Chair)]: I think we finally understood the standard. Good. That's Oh, Justin. I I'm next We're gonna we're gonna replace you

[Senator Phil Baruth (President Pro Tempore) [probable]]: Thank you.

[Senator Virginia "Ginny" Lyons (Chair)]: With the

[Senator Phil Baruth (President Pro Tempore) [probable]]: I agree with it. With

[Senator Virginia "Ginny" Lyons (Chair)]: you for bringing this in. Yeah, it's very cute. You.

[Senator Phil Baruth (President Pro Tempore) [probable]]: Actually, if somebody could let me know, because I have to get it up to Will do. Yes, time to courier over. Yeah. Thanks. Well, I'll begin. Just send this.

[Senator Martine Larocque Gulick (Vice Chair)]: Go ahead, Emily, can I ask you a question, please? Yes. The 60 college credits that the DCD2 needs. I hear Senator Cummings is reluctant because of choreography and schools and all of that, but I would assume there's some great online college credits that you can get from even if you're wherever, any part of the state, Vermont or I don't know, I'll small paths. Could name them all, but do you know what I'm saying? It is available. Yes.

[Emily (Let's Grow Kids Action Network - early childhood advocate)]: I'm only trying to go on record because Action Network yes. Certainly, don't speak about where and how accessible they are, but certainly there's a ton of online options. I think what you want to look at when you're looking at EC1 and putting someone in an on ramp, There could be a sole provider providing for six kids at that point. So I worry about the drop off and the ability to actually get to that EC two once they've actually opened that center. That's one thing to think about. Whereas that I don't want

[Senator Virginia "Ginny" Lyons (Chair)]: to get into full testimony

[Emily (Let's Grow Kids Action Network - early childhood advocate)]: on this because we've had testimony,

[Senator Virginia "Ginny" Lyons (Chair)]: but the question about education was fine.

[Emily (Let's Grow Kids Action Network - early childhood advocate)]: Yeah, it's all about diversity. There's ways to access in all areas of

[Senator Virginia "Ginny" Lyons (Chair)]: the state to get Understood. Thank you.

[Devin Green (Vermont Association of Hospitals and Health Systems)]: Yep, sorry, thank you.

[Senator Virginia "Ginny" Lyons (Chair)]: Okay, so Katie, we're looking at Senator Brongard's proposed amendment on two zero six right now, then we'll move to the 193. Okay. Good morning. Let's see, I didn't realize this is where we were starting, so let me just pull the document out. Things happened rapidly.

[Katie (Office of Legislative Counsel)]: I, yes, I'm I very well think this was when I was sitting here last night around 06:00. Oh my. It has been a week. You're still in committee. I know. Yeah. Took the job working. Well, this is good timing. Our document management system isn't letting me open the document. I I see. Yeah. And you don't have a draft with it, for instance? Who owes it? The amendment? Yeah. Have a You do have a copy. I have a copy, but I just can't We can go through it physically. With a neighbor. Okay. Great. Okay, Mithenden, Office of Legislative Counsel. This is instances of amendment, as you can see, that's a new type of variant specific to family child, sorry, family, childcare providers. And we have some varied effective dates, which is why this section appears a couple times. Unlike the other variances that are time limited, this one is permanent. So let's just walk through it. So in section, we're striking out the repeal of the variances because that section is being retained with one variance, and instead we're putting in a new section four and four A, both of those sections amend the same underlying section of law, which is 62.55. So, when the bill is enacted, it will have a variance in subsection a and subsection b of this section. Mhmm. And then at a later date, check my effective dates, 01/01/2029, this subsection C is added, and that is after the date by which somebody has to have a family child care provider license to get the family child care provider license type. And after that 01/01/2029, somebody operating a family childcare home would come in as an EC one, two, or three. Do you recall that conversation, how that license type goes away? So, that date is when this new variance is established. This language says that the board is to issue an ECE two license to a provider operating a family childcare home who does not meet the educational experiential licensure requirements of the ECE, I should say one. I've wondered about that. Oh no, who does not meet the requirements of an ECE two, that's correct, sorry. But does meet the requirements of ECE one. So basically what this is saying is a person who's operating a family childcare home will be treated as an ECE two, even if they only have the educational experiential requirements of an ECE one. And then there's language to say that a transitional license under the subsection is valid for a two year period and renewable for two additional two year periods. So that's up to six years for that variation where somebody who only has the ECE one credentials would be treated as an ECE two for the purpose of operating a family child care home. What are the educational requirements, going back to Senator Gulick's question regarding educational requirements that would have to go through for that six year period? Because it becomes a six year period. Yep. So ECE one, the person has the wrong section. So for VCE one, the person has received a certificate from an approved credential program in early childhood education requiring a minimum of one hundred and twenty hours of training and instruction. Two, ECE two, this person has received an associate's degree in either early childhood education or related field requiring a minimum of 60 college credits, or any unrelated field and a minimum of 21 approved college credits in the core childhood education competency areas. So, those are the differences between the two license types. And this would, I'm sorry. Go ahead. Sorry. This would give a permanent variance that somebody who wants to come into the field as a family childcare home provider would have six years to attain the educational difference between one, ECU one and two.

[Senator Martine Larocque Gulick (Vice Chair)]: Six years.

[Katie (Office of Legislative Counsel)]: Well, the variance is two years and it says up to two additional, two year variance. So, I'm thinking if it were one additional variance, that might be more appropriate. So, four years? Yeah. Rather than six. Six is a long time.

[Senator Martine Larocque Gulick (Vice Chair)]: Yeah, six is a

[Katie (Office of Legislative Counsel)]: long time. And because, look, they're running a center without the credentials that everyone else is needing. So I can be a little bit understanding, but six years is a long time. It is and it isn't. You're running business probably from seven in the morning till five, six at night. You live up in the middle of nowhere. You may or may not have access to the Internet. And to get college credits, you're going to have to and you have children of your own and perhaps no partner. And you are going to have to get in your car and go somewhere to get college credits. I would agree. I understand that hypothetical situation. I understand that that is extremely possible. However, we're passing a bill right now in 2026 law of release. And if someone wants to open a home center, they're gonna know what the requirements are and that there's also experiential learning validation, there's online learning. I know we're and let me tell you, I know that the expansion of Wi Fi is going. It's going to be there. It's going to be an island pond. I know we've heard that appropriations. It's to happen sooner. Everything. But if you go out to 2034, by that time things ought to be pretty well understood. Six years seems a long time to move from the certificate to the associate's degree. That's all I'm saying. The beauty

[Senator Martine Larocque Gulick (Vice Chair)]: of the original bill was that folks would have already done that work. They opened up their centers. So if there wouldn't have been this competing, I'm trying to work while I'm doing my coursework, coursework

[Senator Phil Baruth (President Pro Tempore) [probable]]: would have been done.

[Senator Martine Larocque Gulick (Vice Chair)]: So that's what I really like about that original one. I don't know, I think, you know, the ECE one, I can imagine a world, a landscape where you have a lot of sort of apprentices who are apprenticing with the folks running their home childcare centers, and then they decide they love it, they want to keep going, and they can be working on that degree while they're practicing as BCE1, but that was all in the original bill.

[Katie (Office of Legislative Counsel)]: We're just they're one of the couple. The reality is women, and they're generally single women, need to feed themselves. Mhmm. Generally, the practices don't get paid or don't get paid a living wage. We're having trouble. Part of this bill is to pay the providers a living wage. Maybe it's that I've spent a fair amount of my life working with very low income. I'm out of the And I understand the difficulties Oh, yeah. That they face that people with more means they don't have a car that's reliable. They So I'm gonna just flag that two year and I'm gonna suggest we reduce it to one and I think we should continue going through the proposals. Okay. So then we have a new section 4A. Again, we're amending the same section we just looked at. In your bill, the first two variances A and B are set to sunset 07/01/2036. And this achieves the same thing, but it retains the new variant that's being created in this Yeah. So whereas we could have done it just in one sentence in your bill because the whole section was going away, now we have to show this straight through because we're regaining some of the language. So that's what the difference is. So the variance for the home center with the two plus two continues. It does, indefinitely. Page three, the bottom of page three is the second instance of amendment. This is your reporting requirement. New language here, I'll point out where that is. First, initially this report was being done by OPR solely, now it says OPR in consultation with the Department for Children and Families Child Development Division. The reason for that is that there are new reporting requirements in Subdivision 5 And 6, And I think some

[Heidi (President, APTA Vermont Chapter; PT from Middlebury)]: of that data would require CDD to be able

[Katie (Office of Legislative Counsel)]: to answer that question. So that's why CDD's added. So those new reporting requirements include any changes in the number of registered and licensed family childcare homes since the enactment of this licensure act. And, and six, recommendations to encourage the opening of additional family childcare homes to be part of that report. That report is a 2031 report. Okay. Next. And then we have effective dates changing to reflect the fact that we have new sections and new tiering. And also the, now that we know that the Appropriations Committee report was accepted, an effective date for that section that was added about the contingency of funding. So sort of irrelevant to the proposal, necessary to the function of the bill. Page five, line two, six a, contingency of funding. Takes effect July. That's appropriate. Yeah. Okay. There we Okay. So now Let's take a couple minutes to do the best test, and then we'll dive into one ninety three with 80. First first, here's what I like. Got a couple questions.

[Senator Martine Larocque Gulick (Vice Chair)]: Well, it is a question.

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

[Senator Martine Larocque Gulick (Vice Chair)]: ahead. I'm not for anyone necessarily around the stable. To Senator Cummings' point because I have a lot of I mean, obviously, Burlington is actually a high poverty area. People don't realize that, but it is. It's hugely high property. Yeah. Williamsky is as well. So we I understand the restraints and issues around poverty. I'm wondering if we could find out or if we can get a sense of what kind of scholarships and grants were included in Ag sixty '7. Because Ag sixty seven had a

[Senator Virginia "Ginny" Lyons (Chair)]: lot of,

[Senator Martine Larocque Gulick (Vice Chair)]: you know, developmental Yeah, exactly. Is that something I don't know.

[Senator Virginia "Ginny" Lyons (Chair)]: Again Well, I think there there will be some changes to it. I mean, so part of the part of what we'll see is during the budget process or some of the workforce bills. And I can't answer that question. I don't know where they are right now. Go ahead.

[Senator Phil Baruth (President Pro Tempore) [probable]]: I guess I don't have a problem with six years because I can see somebody starting the business, not knowing if this is what they really wanna do. And that first year basically is completely lost. And they don't really start on Exactly. Entering into the higher degree of education for a while, but they know this is what they really want to do and want to basically retain the service.

[Senator Virginia "Ginny" Lyons (Chair)]: So let me respond to that. I mean if they're going to apply for the license to be a home center, they're going to have to meet requirements through OPR. And they're going to have to, there'll probably be some rule making around this that says they'll have to have a timeline for achieving goals. And six years is a long time.

[Senator Phil Baruth (President Pro Tempore) [probable]]: It is, but it goes past.

[Senator Martine Larocque Gulick (Vice Chair)]: Probably four cohorts of kids, three or four cohorts

[Senator Virginia "Ginny" Lyons (Chair)]: of kids. Yeah, is. A bunch of kids. For me that's the sticking point in this one for me. I don't mind having a variance if we can really encourage more workforce and more opportunity in parts of the state that don't have it. I'm okay with that. I am very concerned about the time that is embedded in here.

[Senator Martine Larocque Gulick (Vice Chair)]: Speaking of OKR, have they weighed in on this amendment at all for me to hear from you?

[Senator Virginia "Ginny" Lyons (Chair)]: No. No? It's my decision, check. So, mean, don't even vote, we don't even have to vote on this, you understand that. Yeah. We can do a straw poll. We can make a recommendation about any of the language, and that's what I was raising. Don't know whether the proposer, Senator Bronkhardt would welcome that or not, but that would be something that we could consider. Okay. OTR will be in

[Senator Martine Larocque Gulick (Vice Chair)]: a position to be supporting these folks. Yeah. They'll have to work for that.

[Senator Virginia "Ginny" Lyons (Chair)]: I mean, remember, the next step is the house. We also have other opportunity there to look at it. If this passes, I mean, honestly, it may not even pass the full senate. So remember, it's an amendment being proposed by one person to move it along. Senator Bond, do

[Senator Phil Baruth (President Pro Tempore) [probable]]: I have a question for you? Oh, you do. I've seen people work on school. That

[Senator Virginia "Ginny" Lyons (Chair)]: indicates that you didn't really want to leave. Yes. We're glad that you're back. But question: So within here you have a renewal of the transitional license. There would be a total of six years, so they're in two years, renewal in two years, renewal. My concern is that six years is a long time. What would happen if it were renewal once? So four years. Four years.

[Senator Phil Baruth (President Pro Tempore) [probable]]: On one level, you know, me making that decision, me making it as a little bit of arbitrary. The number is always arbitrary in some degree, so you might have a better sense of that than I do. Okay. I just wanted to make sure that it wasn't too much, too fast, and that people just have to be able to do it.

[Senator Virginia "Ginny" Lyons (Chair)]: Yeah, and what we're talking about in here are cohorts of kids who are going through a facility that doesn't yet have a fully licensed provider. So that's working the balance. Fine.

[Senator Phil Baruth (President Pro Tempore) [probable]]: Thank you. Let me know where you end up. Oh, we will. Gotta get it to John. He'll let you know. Yeah. But thank you. Okay. Yeah. Don't have the, you know, I, would I prefer a six? Yeah. I'd be fine. I'd rather go for a six. Yes. Okay. I just wanna make sure they have enough time. Thank you. Okay. Thank you.

[Senator Virginia "Ginny" Lyons (Chair)]: Thank you. Okay, I do like about this amendment.

[Senator Martine Larocque Gulick (Vice Chair)]: I'll try to keep positive. What's nice is if you're working for an associate's degree and you're only lacking your last three credits, can open up center and you can get those three credits over four years or whatever we decide and then it's done. So, I guess I will speak to the positivity of the incremental impact.

[Senator Virginia "Ginny" Lyons (Chair)]: So if we recommended to Senator Boggars that we put in the took out that last two years, just said four years, then I would would that be okay? I mean, he seems okay with it, and I think it makes sense, and then based on what Senator Gulick has just added, which is, Nathan?

[Senator Phil Baruth (President Pro Tempore) [probable]]: I'm just thinking of my district, my folks at home, and the situations there, and the education requirements, and the stress that they're under and providing them

[Devin Green (Vermont Association of Hospitals and Health Systems)]: more

[Senator Phil Baruth (President Pro Tempore) [probable]]: opportunity isn't necessarily a bad thing. So I don't see that harm. I haven't seen the harm ever. No one's convinced me that there's harm keeping it at six. I just don't see that, me personally. So I have no problem supporting the Senator's amendment unless I hear something different.

[Senator Virginia "Ginny" Lyons (Chair)]: Okay, can I let them struggle how many of you would like to, I'm gonna ask this backwards, gonna ask it my favorite? How many of you would support it as it is rather than the four years? Okay, how many of you, if it were four years, would support four years?

[Senator Martine Larocque Gulick (Vice Chair)]: Can I speak to it real quick? Is just that this is all pretty arbitrary. The work that was done in the Sunrise Review was based at a lot of research. Yeah, so I'm kind of loath to support it, I will. I'll support the workers.

[Senator Virginia "Ginny" Lyons (Chair)]: That's what we need to do to

[Senator Phil Baruth (President Pro Tempore) [probable]]: So,

[Senator Virginia "Ginny" Lyons (Chair)]: So, now I'll go back and ask the question again. Would you support the change? And Senator Boggart was open to that. Would you support the change to make it a four year period? Six years is a long time to accomplish this. And I know you think it's not, but it's huge, and it will have a devastating effect on kids. I am concerned that we do have childcare deserts in your state. We don't have enough kids to open a center. It's just not financially viable if there's poor kids in a 10 mile radius. And the reality of trying to run a business, we heard the very well educated physical therapist talking about how difficult it is to keep a business open. Plus, you may very well have your own family and your own kids. That's fantastic. So to keep people it's good that we wanna have great childcare. It's it's like insurance, but if we make it too difficult, we won't have any. Okay, so the proposal that came to us from OPR has been done with extensive research. What we're doing is we're opening it up to a variance that was not in the original post, and the variance could allow a four year period. This one says six. Four years to get, finish your associate's degree, long time ago. Anyway, so I want to finish this right next. So, how many of you I'd

[Senator Phil Baruth (President Pro Tempore) [probable]]: like to

[Senator Virginia "Ginny" Lyons (Chair)]: start a poll. So, you see I'm going push my position. How many of you would support the four year period? Because this will be important on the Senate floor, have to understand that. How many of you would support the four year period? Okay. How many of you will support the amendment as brought to us by the center of office? Okay, that's it. We're done. And I'll let them know. But I'm gonna say I think it's a huge amount of time. So it's a that's it. Thank you. Thank you all. And Katie, 193, we have it. We looked at it yesterday, but I didn't think we've had the 20 fourseven in there. Let's make sure we're looking at the right version. And then we're gonna go to one ninety. We should get Jen down. Okay.

[Katie (Office of Legislative Counsel)]: So this is S193. Yep. It sound this is draft four 0.1. Oh, I see what's happening. So my my that's why I couldn't open documents. Word is frozen on my computer, which is Well, that doesn't help. Phenomenal. So let me grab my hard copy, and it sounds like you all have copies. So you're in bed. Actually, you know what? I'm gonna I'm gonna make an exception. Would you mind putting can you put that up now? Because we have Almost three. Is that 93. I I I don't usually do this, but I think Yeah. It's important. Four point. Right.

[Senator Phil Baruth (President Pro Tempore) [probable]]: You know? We're at three point.

[Katie (Office of Legislative Counsel)]: We have 41. No. 41 is online.

[Senator Martine Larocque Gulick (Vice Chair)]: 4801. Have

[Senator Phil Baruth (President Pro Tempore) [probable]]: 31 is what we have.

[Katie (Office of Legislative Counsel)]: Okay. I probably have it in an email, which means I can forward it to close that. Sure. Yeah. Also, I was looking at 31 last night, and I thought we had gone backwards with new language. So now

[Senator Phil Baruth (President Pro Tempore) [probable]]: Yeah. Right.

[Katie (Office of Legislative Counsel)]: We're good. You and you were looking at an institution. So you

[Senator Phil Baruth (President Pro Tempore) [probable]]: we had was three point one. Got it. So that was the problem. Katie was not available.

[Katie (Office of Legislative Counsel)]: Okay. So I have it in email. So I'm just gonna forward this email to you, Colette. Good. Thank you. And then I have the PDF in it. Okay. I might just restart my computer because that's where we are right now. Okay. Alright. Just. Did you receive a question? It's okay to have a little pause, actually.

[Senator Martine Larocque Gulick (Vice Chair)]: I kinda like it. Just take breath

[Katie (Office of Legislative Counsel)]: and Okay. No. This is good. Laura, maybe I could share from this PDF. See what happens with my dress up.

[Heidi (President, APTA Vermont Chapter; PT from Middlebury)]: I mean, honestly, you know, we should

[Senator Martine Larocque Gulick (Vice Chair)]: all do it in these moments and stretch. Well, just stand up and say just standing is good for your is good for your health. Standing and then sitting back down again. Thanks, John. I

[Senator Phil Baruth (President Pro Tempore) [probable]]: do feel better.

[Senator Martine Larocque Gulick (Vice Chair)]: Right? The spinning is I used to save my Sorry. It's like spinning is the new smoke.

[Katie (Office of Legislative Counsel)]: It's just Steading is bad for you. It's so bad. So And we do a lot of it. We do a lot of

[Senator Phil Baruth (President Pro Tempore) [probable]]: it. Okay.

[Katie (Office of Legislative Counsel)]: So I have a PDF. So I think we're good, Costa. Apologies.

[Senator Phil Baruth (President Pro Tempore) [probable]]: Oh, I love that.

[Katie (Office of Legislative Counsel)]: I'm so dangerous. What's your name? So, Jeff four point one of s one ninety three. We have yellow highlighting that's older new language. The highlighting in green I'm not sure if you looked at a version with green highlighting yesterday, but green is what I think I haven't walked through this committee. I haven't walked you through the green language yet. So that's where we are. I learned while I was testifying in Senate institutions that this committee does not have custody of S one ninety three. So previous version had this as a committee report, but it is not a committee report. So this is now being presented as in the individual senators' names. So I put it in Senator Lyons' names with the ability to add any other names. So that is that change. Trying to remember what our changes were here. So we have our first instance of amendment. This is in the section about the forensic facility. It has definitions. We went through draft 3.1 yesterday. So you can walk us through pretty high level. Go right ahead. I want to bring you to all the green language, but just to set up where this is, this is in the section of S 193 where it has the definitions of forensic facility, has definitions of a qualifying condition, and then we have this language that's not highlighted. That means it's language that came from Senate judiciary. Yellow language is language that you added, and this is requirements of a forensic facility. So being added here is that the forensic facility shall ensure that a registered nurse licensed pursuant to Chapter 28 or physician licensed pursuant to Chapters twenty three and thirty three of Title 26 provides care to transfer persons twenty four hours a day, seven days a week. So that is requiring that there's somebody with clinical expertise always available. Not just available, but present. And then seven, there's a request from DMH to have this language an initial person specific treatment plan, so that is that addition. That brings us to the second instance of amendment, and this is adding an annual report at a later date. DMH requested that the Department of Health be one of the entities that DOC is consulting with in preparing this report, health department is added. And then we have the reporting requirements, and like the language up above, during the previous calendar year, that was added in subdivision two. That brings us to the third instance of amendment rulemaking. Similarly to the previous section where DOC consults with various departments, health department has been added to this list. And then in terms of creating the rules or the contents of the rules, we now have language that the rules will address any other provisions necessary to ensure safe, effective, and clinically appropriate implementation of the forensic facility sections of this act, including potentially requiring the provision of forensic facility services in a unit that is separate from other correctional populations. Section seven is an interim report. Again, you're adding Department of Health to the list of individuals or individuals, departments to consult with. Interim report shall address, that brings us down to subdivision two, forensic facility planning, including the specific proposed location of the forensic facility, space considerations and design elements necessary to support the provision of therapeutic services, and security at the proposed location and the timeline for any necessary fit up of the forensic facility. And then we have our effective dates. So, section meaning effective dates. Section two, which doesn't pertain to the forensic facility, the rulemaking and the interim report all take effect on July 1 that you just looked at with the secondary report coming in at a later date is 07/01/2028, and then the sections about the forensic facility themselves and operationalizing the forensic facility processes is 01/01/2028.

[Senator Phil Baruth (President Pro Tempore) [probable]]: Questions?

[Senator Martine Larocque Gulick (Vice Chair)]: Go ahead. Thank you, Chair. Madam Chair, the part about the registered nurse, does that nurse have to be physically on campus or in facility or can they be online or?

[Senator Virginia "Ginny" Lyons (Chair)]: Let's see. They've survived care. I guess we could tighten that up if you So the intention, I think, behind it was to have somebody physically present. Provides care, I guess there would be an argument that I'm providing care via Or could say available to provide care. Yes. I think that is different than what the original intent was. Maybe something like her physician, she'll be physically present to provide care twenty four hours a day. Senator Benson, and now I'm gonna turn to department I sorta had a question

[Senator Phil Baruth (President Pro Tempore) [probable]]: along that same lines, and so that says that these folks have to be there twenty four hours a day, seven days a week, and I was just wondering, should it be tied more towards what their clinical program is? Every one of them has to have an actual plan and that the physician and the nurse or whatever should have to fulfill whatever that requirement is. Some may require twenty four hour a day, some may not.

[Senator Virginia "Ginny" Lyons (Chair)]: That's the language on clinically appropriate care in number five. So I think Karen Barber is up, and Claire, do you want me to go to you or to Care? I have to go to Karen. Karen, welcome. Good morning, for the record.

[Karen Barber (General Counsel, Department of Mental Health)]: Karen Barber, General Counsel of DMH. I apologize I couldn't be there in person today. We would ask that the language be changed to is available to provide care. There's a couple reasons for that. One, this isn't a hospital, and this is out of line with a residential level of care to have 20 fourseven care provided. The facilities are staffed 20 fourseven with the nurses, so they would be available, but no one is getting care 20 fourseven. So again, we would ask that it would just say be available. And that way, if they actually needed it, it would be available, but it wouldn't be a requirement that they'd be on-site, which isn't really feasible for the facility, nor is it in line with residential level of care. If someone actually needed that high level of care, they would, you know, we would be looking at hospitalization.

[Senator Virginia "Ginny" Lyons (Chair)]: Thank you. That does make more sense, honestly. But we can continue to use green in that area. It's available to provide care for our kids. Yeah. And Karen, anything else you'd like to okay. So we're good with the rest of that. That's good. It's just taking some time to get here. So so we don't have the bill? No, we don't have the bill. I forgot where it is now. It's approach. It's an Yes. We're looking at it.

[Senator Phil Baruth (President Pro Tempore) [probable]]: Okay, so if it does come here?

[Senator Virginia "Ginny" Lyons (Chair)]: We won't get it. If it comes here, it will die because it will not obtain crossover. Because of jurisdiction. Right, so it's in appropriations. Appropriations will look at any money issues there. What we have here will be a floor amendment, and I can present it on the floor, institutions can speak to it. Okay, thank you. So all I need to know from you folks, and you can give that to me or Katie, or copy us both, about whether you'd like does anyone know that they'd like to sign on to this at the?

[Senator Phil Baruth (President Pro Tempore) [probable]]: I can support it if there is.

[Senator Virginia "Ginny" Lyons (Chair)]: Okay. So we got a big, big, right? Big. Yes. Ready to enter. Yeah, so we got everybody here would like Okay. To sign on That's good news. Then I know that Senator Harrison wants to sign on, and her committee will be looking at it this afternoon. Okay, so I will make those changes. I'll send a clean copy to Gulick, all the names on it, and I will also send it to Senator Harrison to present so Senate institutions can look at it this afternoon. Thank you. Okay. Perfect. It's just been a bit of work, but it's really important work. It's in a difficult area, so appreciate your time. Yeah. Okay, so now we need to move to s one ninety and proposal of amendments. Jen has. We don't have it here. I have it on my page. Oh, and so if you, yes. If you have given

[Jennifer Carbee (Office of Legislative Counsel)]: Do you have her pulled a post or not?

[Senator Virginia "Ginny" Lyons (Chair)]: Yes, keep her posted. This is, After we finished our work on S-one 190, I had thought that we were finished with it. And then the hospitals raised an issue that we have looked at in here. And then we've been through some iterations outside in the ethernet and communicated with the PreMountain Chair Board as well as Vaas on a proposal. So now there's another proposal and I haven't heard back from because this is all moving quickly. There's not a whole lot of time on this one.

[Jennifer Carbee (Office of Legislative Counsel)]: Good morning, Jen Carvey from the Office of Legislative Counsel. This is at least right now.

[Senator Virginia "Ginny" Lyons (Chair)]: And just to say, we're gonna look at this proposal amendment, then I'm gonna reach out both to the board and to VOS to get their perspective,

[Senator Phil Baruth (President Pro Tempore) [probable]]: and then we'll try to end this.

[Jennifer Carbee (Office of Legislative Counsel)]: So I'm presuming that S-one 190 will be amended by corporations. They talked yesterday about taking out the language or the money for the study, and so in the sequence of events, expect it will be this committee's report, the Appropriations Committee report, and then an individual amendment. So that's why it has Senator Lyons amending this committee's report as amended by the Appropriations Committee report by striking out section two. So the context of this S-one 190, as you may recall, is the bill on reference based pricing and Green Mountain Care Board and a little bit now on outsourcing. Section two is the limit on reimbursements for qualified health plans. Would make, there's a takeout section two that's in the bill as you've passed it out of here, put in a new section two, still entitled limitations on hospital reimbursements, but getting rid of that definition of Medicare adjusted base rate that the hospitals the type of not being able to calculate on a sort of standardized basis until there's some development of that from the Green Medicare Board. And so this would create a new definition of, at least for now, called it actual hospital specific Medicare reimbursement rate, so there's no confusion about what we're talking about and what terms can be used in the future, like Medicare reimbursement rate. So that means the actual reimbursement amount that hospital receives from Medicare for items provided and services delivered to Medicare beneficiaries. And I'm doing this in markup so you can see the changes from what you passed, but it would be clean in the Senate. So then it would still have registered carrier, meaning an insurer offering plans on the exchange, qualified health plans, shall not reimburse or agree to reimburse a hospital more than, and then this proposal would change the 250% to 225% of the hospital's actual hospital specific Medicare reimbursement rate for any item provided or service delivered in Vermont to an enrollee in a qualified health benefit plan, and then I put this in here just to be clear. I think somebody had questions about qualified health plans from other states, which we can't regulate, but I clarified that this is a plan issued pursuant to this Vermont sub chapter on qualified health plans. And then, still has that, if the carrier reimburses a hospital for something on a capitated or other non fee for service basis, the carrier would ensure its reimbursement method is adjusted to account for that account. And then changing a little bit the timing of how long this lasts, this reimbursement limit under the version you passed out would apply until the applicability date specified in the Green Mountain Care Rule establishing the reference based pricing methodology for all items provided and services delivered in Vermont hospitals, sort of coming up with that Medicare benchmark rate is. This would instead change it to be more like the camp on outpatient prescription drugs enacted last year, and say the reimbursement limit would remain in effect unless and until the board establishes a different reference based price pursuant to a reference pricing authority. And then it keeps the language prohibiting balance billing and requiring the board to ensure in its premium rate review that the caps in this section are appropriately reflected in the premiums for qualified health plans. Okay. So again, to hit the high points, this would change the Medicare reimbursement rate that the hospitals and insurers would be using in applying the cap and changing the amount of the cap from 250% to 225% based

[Senator Virginia "Ginny" Lyons (Chair)]: on that different calculations. So, questions of clarification? Go ahead.

[Senator Phil Baruth (President Pro Tempore) [probable]]: How did we get from February down to $2.25?

[Senator Virginia "Ginny" Lyons (Chair)]: Okay, well, good question. We'll get there. That's my question. Okay, that's my question.

[Senator Martine Larocque Gulick (Vice Chair)]: Yeah, I have a protein.

[Jennifer Carbee (Office of Legislative Counsel)]: You wanna hear from Okay, before you have a problem, let's listen to,

[Senator Virginia "Ginny" Lyons (Chair)]: I have a problem. Also, I mean, the hospitals came in and wanted to change everything that we had done with regard to QH and we were not completely, I understand. We wanted a different Medicare base rate for hospitals. I'm gonna go to Degree Med Care Board and Emily Brown, and because one of the recommendations that the board made when we suggested a change was to go to a lower rate. And so, Emily, do you mind talking, please, explaining from your perspective what this proposed amendment will do to the work that we've been doing? Sure.

[Emily Brown (Executive Director, Green Mountain Care Board)]: Thank you. Emily Brown, Executive Director at the Greenmont Care Board. So the definition that was originally in there was the Medicare base rate. And so this was a rate that would have been uniform throughout the system, and then is also a rate that's usually lower than what the hospitals are actually reimbursed, which if you look at the language in this amendment, it refers to Sorry, I'm just going to pull up the language. Jen, if you could help me. What the hospital is actually

[Senator Virginia "Ginny" Lyons (Chair)]: The actual hospital specific care reimbursement rate. So

[Emily Brown (Executive Director, Green Mountain Care Board)]: that would be a higher number. And originally our estimates on the cost savings were based on the base rate in the 250%. So because this definition would then allow for a Medicare reimbursement rate, we felt it appropriate to lower than the percentage because then you're accounting. And we haven't had time. This has been moving quickly. We haven't had time to do and generate an estimate of what the lower amount would be that would kind of match where we had been. But it would definitely be lower than the 250%. And then just going back, the reason why we had originally suggested the Medicare adjusted base rate was because that's what we are planning to implement when we move to reference based pricing. So, if we go with this actual hospital specific Medicare reimbursement rate, it would be a deviation from what the direction of the Green Mountain Care Board is now for reference based pricing. And again, I hear the hospital's concern about being able to calculate it. I think I've talked to my policy director, and I think there is an option here where the board would be able to publish the Medicare adjusted base rate, again, going back to that prior language, because I think there was concern about the hospitals being able to calculate that and relying on the insurers. So, we're willing to try to work with VOS to figure out how we can make sure that there's a uniform understanding of what the Medicare adjusted base rate is. But that's kind of, I think, where we are right now. And again, trying to respond in real time to these changes.

[Senator Virginia "Ginny" Lyons (Chair)]: Okay, so what I'm hearing you say is that are willing to work with VOS to change the language so that there's less responsibility given to the hospitals to determine that Medicare base rate.

[Emily Brown (Executive Director, Green Mountain Care Board)]: Correct, yeah.

[Senator Virginia "Ginny" Lyons (Chair)]: And so, we can hear from Vas at this point, but that is a preferable solution to the problem from my perspective than trying to go through and reevaluate the numbers and then look at another step in getting to our reference based pricing. So I'll leave it there, but do you want to comment, Devin?

[Devin Green (Vermont Association of Hospitals and Health Systems)]: Sure, thank you. Devin Green, Vermont Association of Hospitals and Health Systems, and appreciate this committee trying to address the concerns of the hospitals on the definition of Medicare in this space. My concern was the two fifty going to 225% is that the Green Medicare Board originally testified that this would impact hospitals by $50,000,000 When we did this calculation on the tool that they've put out around reference based pricing that has that base rate, you know, their definition, that comes to $72,700,000 which is not the $50,000,000 that was originally proposed. I have asked the Green Mountain Care Board about this calculation. They have not gotten back to me. And so we are trying to figure out, I assumed the $2.50 was $2.50 of our definition, 250% of our definition, is how they got to the 50,000,000 as opposed to this 72,000,000, which changes things significantly for us.

[Senator Virginia "Ginny" Lyons (Chair)]: Okay, so here we are. Place at where we need to finish this thing off, literally. What I'm gonna suggest is that the board and boss get together, and I'm leaning very much toward the language of having the board support the hospitals in their work to look at what that Medicare reimbursement or adjusted base rate is, what the reimbursement rate is for hospitals. There is language in the bill that offers forgiveness to hospitals. One of the reason we started all of this stuff in the first place was to make sure that hospitals remain sustainable. And so I'm not I'm not thinking that the board is going to allow for some catastrophic financial result for hospitals. And this is a tough place for us all right now because we know things are getting harder to do. And so all of which to say, I'm gonna just say we have a couple of proposals before us. The board would have said 200%. I said that seems very low, let's put 02/25 in. I asked Jen to do that. But the board may have some other recommendations. They've got the data. And so I'm gonna suggest that we leave this for now and allow for the board and the hospital to come together. This bill is in appropriations. It's being sent out today to be on notice tomorrow, and I need to have some resolution in this committee before that because appropriations isn't looking at this. This is not their jurisdiction. So I'm just saying that's my thinking and I hope, I think, I just have to say, Chittenden, I think this is the best we can do at this point. Hospitals are gonna be petrified. I get it. It's not easy to look at savings of this type, but it's something that's important for folks who are seeing escalating premiums and we know we've been through all of that. So we get it. We all get it. Anyway, so can the board and vise have a conversation, please?

[Senator Martine Larocque Gulick (Vice Chair)]: Emily? Yes, we'd be happy to do that.

[Senator Virginia "Ginny" Lyons (Chair)]: And Devin? Yes. And Laura? Who against one? We'll be good. And I know there's a concern about having insurers dictating pricing. That can't happen. This has to be something that is a process between board and regulated entities. DFR will be looking at insurance, but I know it's a three way problem, but the regulatory process between board and hospital is going to be critical. I want to put that out there because I know that's a problem. So,

[Senator Phil Baruth (President Pro Tempore) [probable]]: does the Care Board and the hospitals going to work on the definition of Medicare?

[Senator Virginia "Ginny" Lyons (Chair)]: The Green Mountain Care Board and hospitals are gonna work out a solution to the hospital's concern that they would get more money back with a hospital definition than they would get back with what's currently in the bill. The reality is that we're moving toward what is in the bill, which is a Medicare adjusted base rate. And so we're trying to do it with a process that doesn't cause misalignment or hurt problems for hospitals. It's an itchy place to be. So what's in the bill allows for the board to offer some help to hospitals when it looks like they're

[Senator Phil Baruth (President Pro Tempore) [probable]]: So getting you know, Madam Chair, I will be consulting with my hospitals at home, of course, and also

[Senator Virginia "Ginny" Lyons (Chair)]: They don't want to do this, so Well I don't know what

[Senator Phil Baruth (President Pro Tempore) [probable]]: the two twenty five came from. I think anyone's answered that question.

[Senator Virginia "Ginny" Lyons (Chair)]: Ask the Board.

[Senator Phil Baruth (President Pro Tempore) [probable]]: That was a big over contention and custom over here as I recall. Two fifty.

[Senator Virginia "Ginny" Lyons (Chair)]: Two fifty is good if you have the definition that we have.

[Heidi (President, APTA Vermont Chapter; PT from Middlebury)]: Right.

[Senator Virginia "Ginny" Lyons (Chair)]: If you put two fifty on top of the increased amount hospitals are getting, that does

[Senator Phil Baruth (President Pro Tempore) [probable]]: lower

[Senator Virginia "Ginny" Lyons (Chair)]: the amount going in. And And so, I'm going let you guys work this out outside because I can see head shaking in both directions. Do you want to comment?

[Emily Brown (Executive Director, Green Mountain Care Board)]: Yeah, I mean, again, my point was when I was, again, when we were communicating on this yesterday and this morning, was that if you're going to change the definition to allow greater reimbursement, then you would have to go lower than $2.50. I didn't suggest the $2.25. I think that was the middle ground between the 200 and the two fifty and what was put in there. But again, we haven't done analysis on anything aside from the two fifty, which was the basis of our original proposal. So, I think changing the definition creates a lot of variability. It creates variability between hospitals because each hospital is paid differently by Medicare. So, with the original definition, it creates uniformity.

[Senator Virginia "Ginny" Lyons (Chair)]: We call it alignment.

[Emily Brown (Executive Director, Green Mountain Care Board)]: Alignment. Okay, sorry. Alignment. So again, I think the board would prefer the original definition with help facilitating the hospitals on the calculation.

[Senator Phil Baruth (President Pro Tempore) [probable]]: Yeah.

[Senator Virginia "Ginny" Lyons (Chair)]: So here's my ask of the board and the hospitals. The hospitals are afraid that they're gonna lose more than the $50,000,000 predicted. So the prediction is $50,000,000 They don't wanna lose that other 20,000,000. We'll get that. So there's language in here that would kind of ameliorate that concern. The board will help to ensure hospitals don't lose too much. So maybe there's an improvement on that language in some way that offers reassurance. Yeah. And going back to our I'm sorry. I'm just gonna say I have to put this in your hands. Otherwise, we're gonna wordsmith it. It won't be lovely.

[Senator Phil Baruth (President Pro Tempore) [probable]]: And I don't wanna vote for a bill that they had other than voting against.

[Senator Virginia "Ginny" Lyons (Chair)]: Yes. No, no, no, no. Look, there's a legitimate concern from the hospitals. They're stepping into new waters. They want to be able to swim. So, we need to put the life jacket in here. So, can you please do that for us and communicate with Jen as you come to some understanding? I'm going to leave it at that. Thank you. Thank you. Good luck. Now we look for this because we'll be back on it tomorrow morning to catch that right away. Okay, thank you. We're trying to understand, we do understand, we don't wanna leave people high and dry. At the same time, goal is some alignment of payment reform that has been so critical right from the beginning. Okay, that was fun. Thank you both. I mean, look at Laura and Devon and Emily for both organizations. Thank you for giving them. Okay. So we'll, because we're gonna, now we need to inhale a little. Take a break. Now we'll move on to cannabis.

[Senator Martine Larocque Gulick (Vice Chair)]: But I mean, I actually have to. I

[Senator Phil Baruth (President Pro Tempore) [probable]]: was quite close.

[Senator Virginia "Ginny" Lyons (Chair)]: I promise. We're good. I think we're good. My message was to you what I was saying. It's really good. Down by the chest.

[Senator Phil Baruth (President Pro Tempore) [probable]]: See you again.

[Senator Virginia "Ginny" Lyons (Chair)]: Nice to see you.

[Senator Phil Baruth (President Pro Tempore) [probable]]: Nice How

[Senator Virginia "Ginny" Lyons (Chair)]: are you? Good. Good. Good. I'm learning more about cancer. I know. That's the same.

[Senator Phil Baruth (President Pro Tempore) [probable]]: When you come down, are you ever even started? Oh, I I got twenty three farm. I got Hamburger. Yeah. Campari. Yeah. Yeah. We talk to us. Yeah.

[Senator Virginia "Ginny" Lyons (Chair)]: Alright. Go play.

[Senator Phil Baruth (President Pro Tempore) [probable]]: You can be