 When we turn to that first, I'm going to turn it over to President Donahue first to walk us through some issues around some language that has to do with mental health and commissioner work. And then we'll transition without a break to some further conversation. We had some briefing last night, or yesterday, briefly, about health care affordability issues. And if we need a break in there to do anything else, we'll do that. Then we will have a break in those trip gears to different topics. Hey, great. We talked about, I mean, there are three specific areas, pieces of language. The one we're starting with, I don't think anybody actually has seen actual language, although we've talked about the concept. When DMH presented on the 10-year vision plan, the commissioner said there was one legislative ask in terms of a follow-up, not that there isn't a lot of follow-up from the departments doing, but in terms of legislation. And that was the recognition that DMH and the vision can say all sorts of things. But if the whole health system isn't involved in buying in, then we're not going to achieve integration. Because it's integration in with a lot of other stuff. So this is the language that would establish that council, which has a lot of membership, because it's really about getting all those other parts of the system on board. So we can walk through the language. I would actually suggest that we first go to the purposes of what the group does, because that will help make it more clear why there's all of the representation that there is. And I know there was one person who reacted, one of the members of the Council, who said, well, our only reaction is it's too heavily on the medical system people and not enough mental health representatives. And I said, well, actually that's the whole point of this. The mental health folks came up with a plan, and now this is about carrying it forth by engaging the rest of the mental health system. So you're in the scroller, or David? We're already scrolled up. I pulled up to that section. Great, thank you. You're welcome. All right, so if folks look at where it begins after the list, powers and duties. And this is really the core. This is why this Council is being established. So it's addressing integration. At the very beginning, it talked about our statutory requirement for integration and the vision plan. But these are the very specific things that would be the Council's responsibility. First, identifying obstacles. I'm sorry, and I have no idea where we are. Oh, I'm sorry, because I'm looking here. So it's on the one that says on the top. Oh, powers and duties. Okay, I got it. Is it what's up here? I can't tell you that part. So powers and duties. The Council shall address the integration of mental health and the health care system, including. And then there's one, two, three, four, five, six. Six duties. So the first one is to identify obstacles. In other words, in all of the parts of the system that each of these people represent, where are their obstacles to achieving the goals that have been set out, both in legislation previously and through the vision plan. Second, helping to ensure implementation of those existing laws that require integration within the members' expertise in the Council. So different groups representing different parts of the system. To scroll up a little, we can see three. And establishing commitments from all of those non-state entities to adopt the practices and implementation tools for integration. Again, that's referencing back to the beginning where we talked about the vision plan and the legislative mandate. Fourth, the Council can propose legislation if our current statute is inadequate to achieve it or creates barriers. And then fifth, the routine language on any other duties it deems necessary. It will then report back in 2023. So that's, we're giving, this is a two-year Council to work on this. Report back with recommendations, including whether there's any recommended legislative actions and whether they need to be extended. The assumption is it's two years, it's not an ongoing forever group, but it's two years to identify and put together how we're going to achieve this. So now if we go back to the start and we can look through the membership, I have sent out contact to everyone who's been asked to be a member, basically saying if you don't think you belong on this Council, speak up. Nobody has said they think they don't belong. I've gotten a number of people saying yes, you know, but nobody has said, oh no, take me off, I don't want to be involved in that. But we can look through, A through F are all commissioners within the state system, beginning mostly with AHS, but you'll see each of those departments in AHS have relevance to integration towards our goal of an integrated system. Corrections has a division in how it delivers healthcare systems and so forth, and the F, then the Commissioner of Financial Regulation, is pretty self-evident why they're important to be a part. We then have both the Green Mountain Care Board and the Secretary of Education, and after that it begins more the community-wide stakeholders, which includes the Medical Society, the Hospitals Association, Vermont Care Partners, which are the designated agencies, the Vermont Association of Mental Health and Addiction Recovery. That's somebody we haven't actually, I don't know if some of the new members are Peter Espen Jay, who is the Executive Director of that group. The by-state primary care, important aspect of primary care delivery, representative from the University of Vermont Medical School, and that's really important. This was some of what the task, not task force, but think tank, made recommendations about when we're talking about sort of the unconscious bias of the system, if you will, that right in medical school that needs to begin to be addressed, and we need that commitment from the medical school. One care, the healthcare advocate, the mental healthcare advocate, representation from the insurance industry, and just to clarify, the council is getting three large. Often we, you know, there isn't a group that represents all of the private insurers. They each speak for themselves. But it didn't really seem rational in terms of expanding the council to have both Blue Cross Blue Shield and MVP representative. I spoke with them about that issue, and MVP said they were completely okay and understood that only the largest insurer, which for Vermont is Blue Cross Blue Shield, represent that perspective. So you can be sure that's not going to create a problem, that it's just one which, in the language of art or whatever, what that's saying is Blue Cross Blue Shield. And then in terms of direct stakeholders to keep that voice at the table, two people who have received services, one of them being somebody who delivers peer services. So that's the peer workforce representation. And then family members, there are two also there because one is family of people who receive services, but the other is a family member who has a child who receives services. So that's the list. I think there's been some cross discussions around trying to make it inclusive. And that's really the core of the bill. There is language at the end that is the routine, you know, the Department of Mental Health chairs, the Department of Health co-chairs, I mentioned the reports. There are directives around meetings, and that is meeting at least bi-monthly, ceases to exist. July 30th, 2023. We routinely have councils exist beyond when their final report is because we may need them to come in and tell us what's in the report and so forth. And reimbursement is under our statute, which basically means people who are not getting paid by their job position for their activities are eligible for a stipend. So if we could now have our witness comment and maybe answer questions. Yes, of course. Well, thank you. Good morning. For the records, Sarah Squirrel, Commissioner of the Department of Mental Health. I want to thank Vice Chair Donahue for her leadership on this in terms of thinking about the council. From my perspective, as this committee is aware, the Department of Mental Health really leaned into our charge in terms of articulating a 10-year plan for a future of integration of mental health within the broader health care system that I think will benefit generations of our monitors to come. One of our very specific asks of the legislature was to form this council. We have several other action areas that we are able to implement within our existing authority and resources that we, of course, are working on. But when we think about, as I said before, the 10-year plan wasn't the end, it was just the beginning. And we really want to create conditions for change. I really feel that what we have articulated as a state system, as systems partners, really has the opportunity to be transformational. When we think about implementation as someone who's been steeped in implementation science, we really need a council, a table that is set with high-level leaders across mental health and our health care system if we really want to move things forward and actually operationalize some of the incredible opportunities that we have around integration. So the Department of Mental Health fully supports the representation that's been articulated here. I think from a facilitation standpoint, we're always trying to manage inclusivity and representation with a body that is manageable and that we can really move forward in a reasonable way. I feel very confident that given the scope of the council as it's currently been presented, that we can be very effective. It is proposed to be chaired by the Commissioner of Mental Health working in collaboration with the Department of Health. I think that's the right way to approach it because really we can really continue our leadership on the 10-year plan and our vision for integration. I think that the council itself can hold the vision of integration under the tent of the council, which is, I think, significant as we look to move this forward. It also creates an accountability structure that we need. It provides structures so that we can create decision-making. As the Vice Chair noted, we have some significant areas that are actually already statutorily in-law, but maybe not being fully implemented. So we need the folks around the table to help us do that. A good example of that is payment parity in terms of equal rates of payment for the same services when provided by mental health professionals as compared to physical health professionals to ensure that folks can access those services equitably. I also think there is an opportunity, as we look to implement the 10-year plan, that the council creates an accountability infrastructure to oversee that implementation as we move forward. So those are my high-level comments. Again, the department supports what's been presented, and we're looking forward to this as the next step to advance our statewide worker migration. If we could just scroll back to your beginning, because one question that had already come back is, are we starting over on trying to identify what does it mean to integrate? And I think the introductory language helps make it clear that this is about ensuring that everybody participates in the principles that are already in statute and as envisioned by the plan that's been developed. This is not to start green-working a plan, this is to involve everyone else in making it happen. That's a great point. We have put a lot of time and energy over the past year in terms of articulating what our end state is, what those short-term, mid-term, and long-term strategies are. The council is a vehicle to advance that work, not to start over. Sure. So any questions? You have a lot of commissioners here, and then I see, or Designee, do you expect all your commissioners to participate in the membership of this board? Or do you expect it perhaps will be passed off to somebody at a lower grade? I think it will depend. I think there are commissioners, some we share, having talked to some of the other commissioners that really want to see at the table. For some commissioners that I think oversee large departments. Sometimes it's actually beneficial to delegate to someone whose particular purview might be a little closer to the provision of mental health services and integrating that broader in the healthcare system. Department for Children and Families is an example of that. It's so big, it could be more beneficial to have someone who is more directly overseeing that specific area. I think another good example is the Department of Corrections. Yes. They have a medical director. That person probably would be better suited than the corrections commissioner. If I could say, just as a general observation, this is the type of language that is almost always used when trying to involve, this is not unique to this council, whenever trying to involve a department or an agency, it says it names the commissioner or secretary or Designee so that they have the authority then to find the right person to represent them. This is not unique language. This is kind of boilerplate language to facilitate the right person being at the table. That's correct. Right? Could you scroll back up the top? Sure. I was reading the first paragraph. It says, the purpose of it, helping to ensure that all sectors of the healthcare system actively participate in the state's principle. Are you saying there are people that don't participate that should right now? I am saying that we are moving towards articulating a vision for integration. In order to achieve that, I think there is a lot of commitment to the vision as it currently stands. The next step is to make that more actionable. I think our healthcare partners, which was clearly operationalized and I think Tang really came to the table. And now we need to take it that one step further. How long has this been a concern? 30 years. Or longer. Or longer. I think what I credit Representative Donahue and this committee and the speaker in saying in moving responsibility for mental health from the human services committee to this committee, the healthcare committee, as a structural statement that mental health is a part of healthcare. Historically, mental health has often been siloed off to the side both because of sometimes issues of stigma and sometimes issues of disparate funding, different kinds of funding like when we have healthcare here and maybe we'll do something with mental health. And I think there's a recognition that mental health is an essential component of health and healthcare. And so I think in many ways this is a reflection of an historic reintegration of the acknowledgement of mental health as an essential element of health care. And this is a recognition that we're not there yet. There's more work to be done. So if you could scroll down to the bottom there's a date somewhere there that I saw January 15, 2023. And you probably will still be here. Would you make sure that there's a follow-up on this? I'm sure it will. So that it can be proven that that group amounted to something. If I'm not still a member of a legislature, I will be here as an alphabetic. Maybe speak from the governor's office if you want. Thank you. Yes, thank you. I have a question. It's admirable that it is so inclusive. It's very inclusive. Is it too big though and unwieldy? It's a great question. And as I mentioned in my opening remarks, we're always trying to balance inclusion and representation with actually facilitating a working group. I think that actually our facilitation of the think tank was a good demonstration of our capacity to take a large group such as 25 or more key stakeholders to really have good solid facilitation. I think the Department of Mental Health has a deep bench of talent when it comes to facilitating large groups and we will be the primary kind of administrative support. So I think my answer is, is the group big yes? Can we manage it and be a productive entity? Absolutely. I have a couple things. I guess to Brian's point, it's something I think I've been thinking about a lot as far as creating groups and asking for reports. And I think, I guess just a proposal to the committee that I think it might be a good idea if we hold ourselves to the standard that anytime we ask for a report or create a group, at least one member of the committee verbally commits whether they're reelected or here or not to follow through to the very end. And this is something I've been thinking about where I would not ask for another report or group unless I personally was committed that I would stick with it through the end and make something come of it and it's just a thought to flip to the committee. And then my other piece, could you go to the duties? Yeah, I really appreciated the intro part about making sure that it's, you know, the idea is not to come up with a new plan. The idea is to implement the plan that extreme work has gone into coming up with and the only one here I wonder about is number one, if identifying obstacles to the full integration of mental health, it seems like a lot of what the vision group was doing was identifying those obstacles. So I wonder if there would be a way to word that something more close to identifying obstacles to the full integration of and then specifically list the statute and specifically list the 10-year vision. So it's clear that the idea is not to start at square one with a new discussion of what do we need in our mental health care system but talk with these stakeholders about we know what we need and what are the obstacles to all of us getting there. I don't know just to float that out. Yeah, I mean that could work. I think because of the overarching purpose at the beginning, I think that that's assumed here. But it also, if it was limited to kind of only identifying obstacles to achieving the vision plan, it might close off some really important pieces of not changing what the vision is but what the obstacles to achieving it might be. There might be ones that the think tank didn't because it didn't have this broad conclusion might not have thought about or been aware of. So it's about achieving the plan and the statutory obligations which were only put in statute I think about four years ago in terms of those principles. Identifying obstacles probably wants to stay broad enough for obstacles to achieving those things that might not have been enlisted in the think tank plan. What about putting both like full integration of mental health into a holistic health care system as outlined by an enlisted statute where it says, you know, where it talks about as outlined by the statute and the tenure vision? I think that'd be fine. I think that's duplicative of the purpose part because this is sort of just filling out the details of what was already stated as the purpose of the council at the beginning. Yeah, the only thing I might add to that is that we did very strategically use appreciative inquiry as a strategy to move this work forward when we look at systems change. Not only do we want to identify obstacles and barriers, we also want to be lifting up the current assets that we have and build on those that actually creates motivation for the kind of transformational change that we're looking for. So my only other thought reflectively on this was to capture that somehow that we do have existing assets in the system that we can also build upon in addition to identifying, you know, the barriers as well. So can we talk for a minute about the process of moving this into moving this forward? There is discussion about having in our miscellaneous health care bill which we're talking about moving, which we will move by tomorrow. Because it talks about per diems, initially one thought was that perhaps that would pull it into the health, pull the whole bill into the appropriations committee at the same time it was per diems. Something has to go to appropriations and then they have to vote the bill out. It doesn't go directly to the floor. I didn't know that the, and I'm not sure that this gets around it, but that the per diems are actually coming out with mental health budgets so they're not additional per diems that have to be authorized by the appropriations committee. And in noting that it seemed to me that maybe it wouldn't be pulled into appropriations. But I think I would like to take a strong hold on the general construct or the language and then be able to consult with appropriations. Because frankly, I don't want the whole miscellaneous health care bill to linger in appropriations if in fact this becomes a part of, then we might find another vehicle or even have it be freestanding. So that if it was required to go to appropriations this will want to go there rather than all over our other elements. So rather than a bill number to vote or, yeah, how it, where it fits in. And then we'll talk, I'll discuss that further with the committee in terms of the actual vehicle for moving this forward. Because I think there's some strategic issues that we should think about in terms of the, what it might mean to have it going to appropriations as part of a larger bill that otherwise would not be going there. Does that seem to be able to vote? So with that, then... Just take a straw poll. So I think our people prepared to just, in general, take a straw poll on the... Is it interpreted, should it be interpreted as a straw poll on generally we like the direction or a straw poll on formally? Exactly. I'm talking at this point we need to be moving. So where we talk, was there interest in expanding it to talk about the asset? I mean, is now the time to have the final, final language? Yes. So should we talk about if there should be a piece about in the identifying challenges also identifying the... Anything that you wish to talk about? This is the time because... So you're making a suggestion. Yeah. What is that? I mean, it sounded like the commissioner just suggested... Do you want to say anything? I don't think she was suggesting language. I think she was just talking about... Well, let's ask her. I think that... I don't know that it requires a language change. I think that it can be inherent, kind of linking back to Vision 2030, which was referenced in the beginning. We have a lot of information about appreciative inquiry in our approach in order to engage the council towards change. We will be facilitating looking at obstacles and assets. So I don't think it's necessarily needing to be included in the language. Satisfactory? Yes. Okay, other questions? We're not talking about a lot of money for this bill. There's only a maximum of four people who would actually be eligible to ask for a stipend. Are you already working under a salary position? Do you have any live vocations with that on issue? Well, they probably wouldn't alter it, but technically, anytime there are per diems, it has to go there, and they don't deal with this until they've completed the budget, because they have to look at the entirety of the budget. They set aside a pot of money for per diems, and if it exceeds a request for study committees, that per diems exceeds that, then they will bear it back. I'm going to slow something down from moving through our process. Right. Is your concern the money coming out of mental health appropriations or health appropriations? Is that the concern? No. Then I'm missing what this provote is going to be about. Okay, I'm sorry. Let me try to clarify. I was trying to just move us forward and explain that we were initially talking about maybe having this be part of a larger miscellaneous health care bill or alternatively having it stand alone. We could make the decision right now to just have it stand alone as a bill. We could take it to the floor as a bill, and then that would, if it goes through appropriations, so be it. If it doesn't, then our miscellaneous health care bill won't have this as part of it. If it's a standalone bill, it's not a lot of money involved in it, is there? No. It doesn't seem to be. Very small amount. Maybe that makes sense just to take one thing off your agenda of people you need to talk to. We could just go ahead and say. So then the process would be asking Jen to craft this as a committee bill. It's not in that form right now, but we would ask her to put it in the form of a committee bill from the House Health Care Committee, which we can do it, and have this be a standalone bill. Does that seem like, maybe that's the most straight bill that you are on? At which point then, I would suggest this, that we ask her to bring that back to us as a committee bill, and we will vote on that sometime later today, rather than take any more time now. And that way we'll have it in the form of a bill, that we will then have a formal vote. Sure. Okay. Is that the best way? There's no, if we do that, this is not going to fail. Is that correct? Well, I still will communicate with the preparations, but it avoids the possibility of complicating the House Health Care Committee, the Miscellaneous Committee. To respond, would it be fair to say that it doesn't in any way increase the likelihood that this fails relative to including it? I think that was not your question. No. It actually increases the likelihood of not getting a comfort in helping the appropriations for a period of time. Okay. Well, let's leave that there then. Okay. Be prepared to, be prepared for us to put that into a committee vote later today. Assuming Chen gets a chance to craft it into a committee vote. Okay. So this next piece is not new language. You haven't seen it, except that it's pearly that. Because in talking with the appropriations committee, this is the part which is a little technical. In fact, in many ways, although it's based on key philosophy about integration, the same topic, it's a technical change in the budget process, which is at its core saying, we should not be siloing our budgets and splitting up where in the budget mental health shows up, beginning the first step being about inpatient health care. If you recall when the budgets were introduced to us earlier this year, even in budget adjustment saying, well, we have this increase in rate for the retreat because of their financial situation, part of that showed up in the diva budget, part of it showed up in the DMH budget. So this is really just about having them be in the diva budget together. The original language we looked through had this long piece about why this was important. It was language that was important to me. But we got unofficial feedback from the appropriations committee. But we got unofficial feedback from the appropriations committee that they did not have an interest in lengthy language about all the whys and the values and so forth. And they just wanted to get to the bottom line. So that's really the fundamental change from the language from before. If you... It does retain the core purpose language, which is A, there, pointing out that the budgets an essential structural component about integrated care and that separating budgets is an obstacle to that reform principle of ensuring equal access. This time we have the actual quote, so that's the section that was referred to on the integration council just before. This is a principle that we've adopted already, ensuring equal access to appropriate mental health care in a manner equivalent to other aspects of health care. So that's A. B is just the directive. It shall integrate the public funding, in other words, Medicaid, for inpatient mental health care with the funding for other health care services within the DEVA budget. Oversight and utilization review and how the care is managed is the more policy end. That's the Department of Mental Health's role. So it's noting that that will maintain according to which department it is legally overseeing that. On the request of those departments, the date for it actually to occur will be basically to be achieved in fiscal year 2023, which means proposed for the 2022 budget. In other words, not this year, but the year after. And based on that, this is the new section, Section B, which says, because we're giving you an extra year next year, you do have to come back with that kind of layout showing us exactly where the money is in each budget so that it makes it clearer for that next step the year after to actually do it. And it outlines the existing categories of where this money gets currently split up in inpatient care. So as we scroll down, you see one, two, three, four. Those are the different categories of inpatient psychiatric care and the different categories of which some are in Diva's budget and some are in DMH and folks who are in the CRT, Community Rehabilitation and Treatment Programs, as that line right before the one, two, three, four points out, they can be in any one of those four subcategories, therefore determining whether they're in the DMH or the Diva budget. So we're saying, fill us in next year on where all those pieces are following and then subsequent year they will all be moved into Diva. This has absolutely no impact. This language and this directive has absolutely no impact on the budget itself or the amount of money that's subject to the normal budget process. What it does is move it in terms of which budget it appears in to put it in the budget with the rest of our healthcare budget. So that's the overview of the now much-briefer language and if the commissioner would like to testify. And my understanding is that the commissioner Diva has spoken with you and you are representing both departments testimony on the record about this. Yes, the agency of human services as a whole has reviewed this and we are aligned with the recommendations as proposed in the bill language. And just to echo the vice-chair's points that this really does provide the structural components of creating conditions that will support the integration of mental health in the broader healthcare system. Many other states have actually transitioned to finance integrated financing models where managed care plans manage all the physical and mental health programs for Medicaid and release. So this is aligned with I think national practices and where other states are moving. Again, a goal of this is to enhance shared data, incentives, tools to deliver integrated services. The area that I think we just want to be careful about and thoughtful about is that the, I guess the potential of this integration of the fiscal part of it is really hinged on our ability to ensure that clinical integration is also happening when we think about care coordination. So it's important that for those with complex health and social needs that the outcome of this is that their care is better coordinated and we have better outcomes. So I just don't want to lose sight of that is the ultimate goal of what we're trying to achieve. So broadly, the Agency of Human Services supports this as it's currently written. The timeline feels appropriate from our perspective. I just want to note a few other points related to the custodial and legal role of the Department of Mental Health. So there are some differences between the Department of Mental Health and DIVA. It's important that we recognize that DMH is not an administrator of health insurance like DIVA. We are responsible for prioritizing managing the care of specific populations. As a custodial commissioner, I feel an enormous responsibility to the individuals who are under the care and custody of the Commissioner of Mental Health. So we want to make sure that as we move toward integrated financing, and this is I think reflected in this bill, that for those who are under the care and custody of the commissioner, particularly for those who are level one, my care management team manages the care coordination of those individuals from the time that they are in the emergency department admitted to inpatient and then transitioning to lower levels of care. So when we think about that integration of the fiscal components and the clinical and programming components, I just really want to ensure that the Department of Mental Health is still overseeing that care coordination. That feels essential from my perspective. When we look at the current budgets between DMH and DIVA, as the Vice Chair noted, that what currently sits in the DMH budget that is separate from or carved out from the DIVA budget is level one. So that level one is inclusive of the Vermont Psychiatric Care Hospital, our level one contracts with the Bratland Regional Medical Center and the Bratilor Retreat. So you'll know at the very end of this there is noted language related to that our budget presentation that the Vice Chair was noting shall also include any implementation recommendations to achieve that integrated funding. I do think there are some pieces that will have to work out behind the scenes because there's current statutory language of the Department of Mental Health related to level one and reasonable actual costs. So if those funds shift over to DIVA then would those contracts for level one need to be facilitated by DIVA versus the Department of Mental Health and there are some pieces that we will have to coordinate around there. Not insurmountable, but certainly some things that we want to think about because those level one contracts are essential to us actually creating some accountability so that those Bratland and the Bratilor Retreat actually accept those individuals. So that's a little bit of an accountability and a leverage point with the Department of Mental Health. That I should reflect when the commissioner pointed those pieces to me and that was where in helping to craft this I agreed that providing that extra year instead of saying this shall happen for next year's budget made sense. The other thing that I would note is that VPCH is also currently all within the Department of Mental Health's budget. The pediatric care hospital is run by the Department of Mental Health. They're by my people, they're the staff so if that entire budget moves to DIVA that will just be another point that we'll have to navigate in terms of the budget for the hospital will actually sit in a different department than the department that's running the hospital itself. So again that's why I requested the additional time because we need to respectively figure out how that will work and how we operationalize that and maintain the great outcomes and quality that we're currently achieving from our psychiatric care hospital. So those I think that's the summary of my points for the committee related to this proposed language. On the surface I mean this is the integration seems simple it's a short bill but is this going to behind the scenes add more bureaucracy or to coordinate or you know you're talking about we'll work these things out behind the scenes but in the end is there going to be another layer that we're not seeing sort of like the unintended consequences of bureaucracy? I think that there are certainly going to be some coordination pieces that we will have to work out behind the scenes. They do not feel insurmountable from my perspective the bigger gain that we're going to make in terms of the fiscal integration of the funding outweighs some of the inconvenience of having to work out some of these things behind the scenes. I think managing the BPCH budget is probably my bigger concern and what that means from an operational standpoint. We already have an MOU with Diva in terms of their kind of delegating Medicaid authority related to level one CRT that we oversee who work very closely together and have a lot of collaboration so I'm confident that we'll be able to move that forward and then if we have some time to work with our fiscal offices about the details of the BPCH budget I don't think that we're going to get overly bottomed down in bureaucracy if those are clear and I think the language actually supports that because there's clarity of roles that's already articulated in the language. Well I was going to say I didn't understand this yesterday and I think I have a clear picture now of what we're talking about and what you just said makes me feel a little bit better that you're comfortable that the benefits of making this switch will outweigh whatever additional work there is. Was there any discussion of like making the switch except for the BPCH and keeping that in DMH for logistical use? That is not currently the recommendation and I think if we truly want to get a picture of inpatient services without BPCH as part of that integration we miss a big part of it so there will have been no discussions as of right now in terms of carving out BPCH from the intent of this language. So the ultimate goal is about having the big picture of this services all in one place from a budget perspective and that doesn't work between the two. Like it doesn't work to have that big picture when it's split between the two departments. It makes it more challenging to have that big picture and it's not aligned with our vision of integration. Delicate questions and I don't mean to criticize you or your department but I read somewhere where there was an incident with your department and I guess the corrections department in which an ill patient whether that patient should go to a hospital emergency room setting versus going to a prison corrections department and I think your department took the stand that that individual should go to a prison setting and then the corrections department had an issue they felt that there was a budgetary issue and that's why that individual was being sent to the corrections department a prison. Would this bill correct that situation and do you know what I'm referring to? We have a lot of situations where the bright line between criminal justice system, criminogenic behavior and mental health is blurred and it's confusing and this is I think one of the opportunities we have right now and we think about a true forensic system of care that we're grappling with so I don't think that this in particular addresses that particular issue. What I can assure you is that the department of mental health as a healthcare provider is managing individuals who might be involved in the criminal justice system to meet their acute mental health needs within an acute care system that is all Medicaid funded if we are able to treat an individual and their mental illness it is the requirement that we have to transition them to lower levels of care that is how that's philosophically and fundamentally what Vermont a fundamental value of Vermont federally that's what we have to do to meet those mandates. Those decisions are not made for budgetary decisions those are clinical decisions that are made to ensure that people are receiving the right care at the right time in the right place and for some individuals they might also have criminogenic behaviors and public safety risk that we also have to manage and so we have to work responsibly with our criminal justice partners. The other piece I would just add is that sometimes because we are a healthcare provider we have to abide by protective health information. So what you hear publicly or in the media might not actually reflect kind of the true state of the situation and that's just something the Department of Mental Health has to manage on a daily basis. Thank you. Any more? And I was going to say just to finish this piece there is a bill coming over from the senate that will be asking the house to look a little bit more into that issue of criminal justice, forensic mental health. Which is separate from this issue of when there is mental health hospitalization does it go into the DIVA or the DMH budget. So the Department of Corrections aspect is not in this bill. That issue is going to be coming to us. Thank you. And then one other question if we already have an MOU why do we need a bill? Because the MOU allows us it's really just delegating Medicaid authority so it doesn't address the integration of the funding within the DIVA budget which is what we're trying to accomplish. Other questions? So this is language that we only need to vote not as a bill but on sending it to ask appropriations to include it in the budget bill because this is a budget alignment issue not a obviously it has policy behind it but it's not an independent bill. Again just to explain that the budget always includes both numbers and appropriations but there's also budget language that reflects about how to move things around or in this case integrate differently. And the budget, the appropriations committee has asked all committees if we have language for the budget to have that prepared for that by tomorrow. They are anticipating the possibility of this as well. Yes, the person who started that actually I had told them it's on our agenda Thursday. She said good I want it Thursday. So are people are your questions answered? Are you prepared to do it? I would do it as a strong pull really to the budget language Henry. I do have at the end when they say including any subdivision between the person served by the community we have in treatment program they list those. There's no really report I know we hate reports but report back on yeah we have these problems there's unintended consequences or we need more time or is there someone that's going to write on this and bring it back to the committee? So the language B that you see here departments this 2022 budget presentation which will be our way of articulating the integrated budgets even though we're not there yet operationally also includes implementation recommendations so part of our budget report back to this committee will also include implementation recommendations related to some of the areas that the Department of Mental Health said some coordination concerns that we need to work out so that's what that language is intended to do. Okay. Any other questions? Then I would suggest that we take this language I take a strong pull on recommending that this language be moved into be given to the appropriations committee as budget language although it's a favorite show. Let the record show that all members present and Brian are you on the line still do you wish to join us in this? I am on the line Can you hear me? Yes. I am here. I think at this point we have a clear all members present and we will that's sufficient to move the language to the appropriations committee and we will we will do that and we will have you can weigh in as you wish along the way because it will be in the final budget as well. Okay. Thank you. One last piece which we discussed before so I'm hoping this is sort of we're already there on it but this last piece is the technical language to achieve the Brattabourg retreats budget being under the Green Mountain Care Board in the same way all other hospital budgets are. This had been proposed last year the retreat had concerns about being fully included so we sort of created a special language review light if you will in light of some of the budget issues that came up this year some folks like me thought maybe we need to have it fully under the Green Mountain Care Boards review process so what this language does is it strikes the special carve out language that we created last year and then the line after that is just a the definitional the existing definitional talks about hospitals meaning a general hospital and general hospital excludes psychiatric hospitals so by striking the word general it means any licensed hospital but clearly the one budget that doesn't come under the Green Mountain Care Board is the state run hospital VPCH their budget is controlled by the legislature wouldn't be controlled by the Green Mountain Care Board so it requires adding the language that we're not including hospitals that are run by the state so this is the way that achieves the the purpose of saying the Breidelberg retreats budget does come under the Green Mountain Care Board and we did have on the record previously testimony from the chair of the Green Mountain Care Board and the director saying they're fine with this this does not add a burden on them that requires additional staff requests sometimes we ask them to do things resources so sometimes we ask them to do things and they say look you're asking us to do something more we would need more resources to be able to do it and they told us on the record that's not the case with this they can handle this with their existing resources questions are we going to hear from the Breidelberg retreat we have, they tested earlier on the record to support this when they were here and when Lewis you yes I forgot that when Lewis when he was here talking about the yeah specifically when he was here about the retreat early on in the session we raised this issue and said it was likely we would be wanting to do this sort of recommendation he educated no problem I I think maybe I'll go back on the record and look at it it just strikes me as interesting because last year when we brought it up there seem to be lots of problems from the retreats perspective I'm no I know it's just I'm curious as to how what has been done to resolve the problems of the retreat had last year with it and I think the issues were not more difficult I think the issues were one of transparency and last year what we agreed to was that the secretary of human services would have access to Breidelberg retreats records sufficiently to know that they were confident in giving the kinds of support increases and rate increases and at the time the secretary of the and he we agreed to back off from asking to have it go through the Breidelberg care board as a hospital budget review and then I think in light of the frankly the emergent situation which we were addressing in the very first days of the session where the Breidelberg retreat was here with Mike Smith from the Hidges and Human Services it was in that context before they had resolved to resolve that we also raised the question of having the Breidelberg retreat be given a significant amount of their budget which is in fact state funds now be part of the hospital budget review that he indicated that was not an issue at this time. Other questions? Again this is not a free standing bill this is a recommendation that approaches already anticipating that Well let me just say out loud it doesn't seem like that has seemed satisfactory. I can tell when there's consensus in the room when there is so that's not satisfactory. I want to hear what we need to do to There seems some uncertainty on faces. Do the committee wish to hear from the Breidelberg retreat directly about this in which case try our best to arrange that I remember them saying instead of being very I just wanted to check because I know this is not an issue I think it was one of the questions I had when they were here My responses quite frankly it really doesn't matter to me if they are in favor of it that we have a situation in our hands and we need to they need to be part of the process so I'm I just feel like there's clearly dynamics that I'm missing especially I guess that's where I feel is I maybe need to understand more of the dynamics and said earlier that we could have a conversation so I guess in my mind it just kind of feels like maybe that needs to happen before I would I will say it on the record it's not very distant from what Lori is saying. I think last year they felt in a they felt able to argue that they didn't they were a private hospital and that I mean their fundamental argument which I believe to really be an issue of not wanting to be as fully transparent as is required of other hospitals that's my opinion their argument was because they're so significantly funded by Medicaid and the Green Mountain Care Board review the bottom line of the review is the Green Mountain Care Board has the authority to say you can't increase your you know your rates it's a by more than X percent and the other hospitals are able to do cost shifting inside their budgets that allow for if they're required to reduce private payment they their amount of Medicaid is less in terms of all of that functional pieces of the budget and so the retreat was saying last year well we don't think we should be part of that because they can't you know we have so much of our budget that state controls because of Medicaid and I think this year the retreat recognized that quite frankly you know from a political perspective recognize that they weren't in a position to say we're not comfortable with being required to be evaluated as closely as other hospitals budgets are and so they were not objecting anymore and the Green Mountain Care Board clearly will have to look at their budget understanding the percent that's Medicaid in terms of how it reviews it do we have a sense of how much it will cost the retreat to undergo the budget review process no I mean we have asked that they did last year based on the new language have to start providing a good deal of information that is required of hospitals to budget review but it just seems like an interesting time to be asking them to do something that's going to put more costs on them when we already know that well I would take the position that it's also a very interesting time and it's an interesting time when they in fact are turning to the state for an additional million and a half dollars when we're already giving them millions of dollars when their entire budget is practically state funded that it's the time when they should be given some additional cost they should be fully transparent and they should be not treated differently just again it's interesting in terms of what we were talking about earlier the integration of mental health and the healthcare system they are a siloed mental health inpatient facility are not going to be well they do others but they're not strictly inpatient I don't think that we should be making them an exception but based on the fact that their primary exclusive work is around mental health and substance use disorders I think they should be treating the same as other hospitals just to answer that a little bit at least in my experience at Gifford actually the work that goes into presenting the Green Mountain Care Board is sort of presenting the financials you already have the format that they want oh say the bigger issue might be if the Green Mountain Care Board comes back it says what we want a sustainability plan like they're trying to put on other hospitals now which might involve a little more cost but they would do it for a reason and they only do it when the hospitals are financially struggling and we want to see how that's exactly why they should spend whatever time it takes I'm sure Secretary Smith would agree with this and I would give it some so I'm going to ask that we put a straw boat to move it to the language in the budget as well by show of hands is abstaining a possibility of straw boat? oh on the straw boat? yes that's fine this is a straw boat on an actual roll for clothing so those in favor of moving it to the budget by show of hands those opposed those abstaining okay so we'll move it to the budget thank you so I'm now going to we're things are shifting as we're sitting and talking yes Sarah we'll let you shift we'll let you shift okay great thank you so much really appreciate it while we were working I was also being communicated with by the speaker's office and there is a chairs meeting that's being called for 10.30 and I'm being asked the chairs are being asked to meet the speaker in 10.30 one of the issues that we are being asked to talk about so I'm going to ask us that we're going to ask this committee to help me weigh in on the question and then we'll figure out how to get back to portability which is on our agenda which is actually a question I think the line that's been debated is please come prepared to share your top two or three ideas for emergency support for remote and it's a evolving crisis and I think that's an appropriate answer and rather than just putting my brain to work I thought even though we only have 15 minutes I would like to engage the committee in helping to figure out as to what recommendations I might take to the chairs meeting in 10.30 just so you can do maybe the line I miss sure and I I misread it when I first because there's also been a request a different kind of request but this is a request for please come prepared to share top two or three ideas for emergency support for our monitors in this evolving crisis I would ask that we part where the healthcare committee that might help kind of frame what we're thinking about but I would like to open it up for a general discussion and that will help me just bring some thoughts forward to the speakers on this so what I'm going to suggest is that we each get a turn to be heard and if someone doesn't wish to speak that's fine but I'd like to make sure each of us gets a chance to kind of share what things come to mind initially is this the idea of financial assistance it could be it could be financial assistance it's basically what are the things that we need to be thinking about as a legislature or as a because we hold unique responsibilities in terms of what actions might we need to take to support for monitors in the COVID-19 evolving situation yes Brian I've been thinking a lot about this since I'm self quarantining right now can I say something sure and I'm just going to suggest since I'm supposed to be there at 10 30 I realize this is a short notice but that's what I've been to be honest I've been a little antsy trying to move us along this morning so apologies for that but I'd like to hear from you make sure we have time here for everyone else to go yeah I'm not going to say a lot what I'm going to say is that I'm going to send to the committee a few documents for us to review and think about one is I don't know who it came from I think it's the ACLU but it's a long list of things that suggestions about government should be doing right now to take care of people and another thing is going to be a list of demands from the Burlington tenants union which is like an organization of tenants who are concerned about how it can affect them these are mostly people living paycheck to paycheck I'm not going to read all of it because it will take up too much space right now but I'm going to share it with the group and perhaps we can talk about these things a little bit more in detail later but it is it covers everything you can think of from health care supplies, financial assistance, how are people going to eat you know etc okay is that a document you can forward Brian? okay great is there anything else you wanted to add at this point? I don't take up too much space in the conversation I just wanted to throw that out there as a starter I think other people will probably say a lot of the details of what I'm referring to okay thank you Brian Smari financial concerns is what I am hearing about most and people being able to quarantine and not you know they not have to worry about mortgages and whether that means finding a way to encourage lean holders to allow mortgage holidays for a month I paid sick leave paid family medical leave it would have been great if we had a strong program that's a kind of a moot point but if there's anything done on the short term to help people with their incomes while they're quarantining let's just keep going around just to follow up on that as an employer what I'm hearing from employees is will you pay us if we are sick if we're sick and I'm sure there's also will you pay us if you tell us not to work if we're so quarantined and we can't work and that larger businesses are making that commitment but larger national businesses are making that commitment they have the resources the smaller business might not what can the state do to help if you've got this COVID-19 viruses obviously quite relevant if someone's going to be home sick there should I think there should be some sort of compensation for someone that has COVID-19 not someone that's sick and trying to cash in on it people get sick every year and they stay home they lose a little bit of income but if this virus is involved and the doctor said you have COVID-19 I think there should be some sort of compensation for that if they have to stay home because of this virus yeah I think pretty much echoing what's been said is my top concern I just want to add to the conversation I know I've raised as like a younger member that your law kind of the biases that this position puts us in as far as recognizing that people come to this position from all financial backgrounds but that we as a legislature likely are biased towards people who could afford to pay for two weeks of ourselves needed and I think it concerns me a lot because I talk to my constituents and I hope that we stay in touch with the fact that we as a legislature may not be representative of our constituents as far as what it would mean to take I mean I just talked to a constituent yesterday who runs a child care center in my town and she said like I should close I think like the responsible thing to do would be to close and I like cannot make it two more weeks if I close so I'm staying open I think the whole idea of large gatherings is something that people talk about basketball players basketball games and all this stuff but then you have legislature which doesn't seem to be following the large groups you know they were keeping outsiders out and that's a step but still when you look at the demographics of the people when you're sitting on the floor those are the ones that are checking all the boxes like over 60 pre-existing conditions and I think we are not leading by example however I also realize that money is going to be a big deal going forward on budgets and keeping government running it and I don't have an answer to that but I think that's something that needs to go into the conversation and I'm sure it is but we don't know anything about it that's it and the other thing is that we are carriers we are leaving a central point going to all points of the state and then coming back again so it's something let's do that I don't know the nature of the meeting but I can tell you that that is seriously being thought about and contemplated what it means for us to be here and balancing the need for government to function and that we in fact have a role in how we need that and one last thing paid family leave I don't know how we can constitute that for another vote that wasn't going to be in effect that meeting you can't just roll that yes can't do that well I mean I don't want to speak for a while yeah and I agree with some of the suspense that I think the one thing that I've been thinking about getting obligated my ear from my home representative who's on the board of capstone is just food and making sure that I mean we have a lot of people that especially kids that get lunch at school and that's really the best meal they're getting and whether we need to consider some sort of centralized food production school or a community center or something that could be distributed out to people that are quarantined I mean anytime you're moving things around you're exposing people but and especially like meals on wheels and some of those things need to think about I just wonder what's the Fed's doing to help our state are they going to provide the state's money to help individuals home when they're sick with this virus you know it's the difficult time economically and this could be a very difficult time for our state economically as well as the nation economically we're seeing it in the stock market but it has other rules throughout our state and local commas and I just worry yeah I my top of my mind has been the issue of employment and quarantine and I think framing it in terms of health care I can't imagine people not thinking I don't even want to be tested because if I'm told I have to self quarantine I can't feed my family and I think even of my you know my hairdresser who has the hair salon in her home and if she says oh I have to self quarantine for some reason she can't have any customers coming in maybe she shouldn't be but then she has zero income no customers will be coming in or no customers will be coming in and I the issue becomes of course the money I don't know if the workers comp system is a tool that I don't know what the tools are but that's I think my health care free can I actually know one other thing besides the economic issue the medical issue do we have the equipment to treat you know a major pandemic particularly when it comes to respirators how many respirators does the average hospital have I'm sure UVM has a great number of them but I mean that concerns me I'm just gonna add I agree with all of it particularly concerned about food not just for children but seniors and those in need and also I think the state needs to be helping municipalities and coming up with plans to physically check in years and those in need a little bit to get to Ann's point of are there people in their home who are sick who are not coming to be tested because they're scared of what the cost is going to be and just making sure they're okay do we get the test are there enough tests it's like there are there aren't there you know I think we don't know I want to just mention a couple things one is that medications access to essential medications for people who in fact if they're being asked to self-quarantine or if in fact there's social distancing to the degree that the different things have happened in different settings as this is advanced and in the barriers to I mean I was approached by someone who said my child needs insulin my family member needs insulin I can't afford to put out for a month's supply of what's being required to get an advanced supply of medications even though I'm being told try to get an advanced supply so that you're not you don't have to worry about that but we literally don't have the funds to do that and what we're talking about tonight I don't know if the answer to this is but quite honestly I think the mental health pressures are going to be there are going to be elevated for the entire population and for people for everyone there's a high significant level of anxiety at fear you can name it just cascade through the issues and I think we need to at least recognize that and recognize that the pressures on all of our formal systems but our informal systems are going to be highly pressured as well can I just add on to the point I know healthcare workers I mean that's my biggest concern is if this does take off we have a limited supply and how are we going to protect them keep them safe keep them working to help people that are playing please Dan and Green from Vermont Association of Housing I just want to do a quick public service announcement along those lines of protecting hospital resources is call your primary care provider get advice from your primary care provider do not physically go to the emergency room unless you're short of breath don't go to the emergency room if you've had, you know I'm glad you're doing it because you are the leaders in your community so so we're taking a break come back at quarter of see if our chairs bad you will hold on eleven o'clock eleven o'clock yes Brad come back at eleven thank you hello alright so I want to dispute some report back from the meeting I was just a part of we met the speaker's office it was an emergency meeting of the chairs and the intent was as we did some go around what were some of the ideas to how to respond for monitors in this emergency situation we did that in many of the I recorded back from most of the ideas that we talked about here and then as did others not every committee have taken time to look at it as a committee but the speaker then to take to take some specific responsibility over the next several days and I want to share with within the framework of trying to see if there were immediate policy changes or financial changes that should be put on the agenda literally on the agenda on the floor of the house today or tomorrow and immediate short term changes and we were specifically to look at the issues of the impact on home health and healthcare workers who are going into settings to sustain folks to look at the issues of mental health whether there are any financial policy or financial changes that need to be facilitated to allow what needs to happen over the next media period of time and I also raised the issue of pharmacy and I think issues of access to essential medications or supplies that are sufficient and and I think quite hard on that but in addition is hospital situation hospital preparedness but I so I'm going to end that we need to balance trying to find a way to try to engage the key stakeholders on those issues with our committees that this is as a speaker this is no time to form a task force to figure this out this is a time to see if there are immediate actions that people are putting on the table that then we can in turn have drafted the speaker's office will take charge of what the vehicle is if there's a decision that something needs to happen so I think I need to step back and look at what we have left on our agenda because every committee also is facing crossover there's some suggestion that maybe crossover will be moved but in the meantime crossover is nothing and we're trying to find balance between looking at prioritizing what it is we're trying to move forward with looking at these issues now I'm just trying to think out loud right now about how best to proceed I think what we might do is I think we have a specific proposal in front of us that I think is prepared to that is a longer term piece but I think one which we might be able to go through quickly and so why don't we do that in the meantime I would like looking around the room but also thinking some of the key players both around home health issues mental health issues and pharmacy issues in terms of carriers and obviously pharmacy so what I'm going to ask is that if you're in the room and you are engaged in that specific in any of those three specific areas or in hospital preparedness that you be thinking about are there immediate policy changes that you believe should happen and could happen in the near I mean in the immediate term and or financial changes that would be necessary in order to support for monitors that the legislature has the ability to take steps in the next 48 hours I'm asking you to be thinking about that and for us to be reaching out to other stakeholders who are similarly situated but I think in the meantime we'll find the time either later today or certainly tomorrow to come back and see what those proposals are so I know that some folks who are engaged in these issues are in the room and some are not but that's to the degree you who are can communicate with your stakeholder colleagues who are who would be a key stakeholder on that if you would ask them this is a request from the house health community to help us think about those immediate policy changes or financial changes financial issues that could be addressed by the legislature in the 48 hours that would be essential in anticipating the needs of the monitors because I know that doesn't answer a lot of questions but I think that's the framework that I'm asking us to think I would assess this committee members to be thinking in those terms but I also want to reach out and engage the stakeholder community as well but I think we have something in front of us which I think we could take a look at which is a longer term because we also have a longer term responsibility so we're going to try to balance all these issues so I think we have brought some people together around at least one of the proposals longer term and it is definitely longer term but nevertheless could potentially have to be quite important around prescription drug issues and are you prepared to help us walk through this would you mind coming up? yes so we talked about this and then there was a small group that kind of met separately and talked about how we could make this happen so we have some language that I will walk through or Christine if you want to walk through it whatever you prefer and then we'll answer questions and then Jeff's here to respond so Christina I can't take full credit for drafting it but it was a group effort at the board so in front of you is some and it is posted online this people's language for the board to develop a prescription drug technical advisory group to do exactly what it says and have some transparency around prescription drugs so just to read through it the remand care board shall establish prescription drug technical advisory group pursuant to 18 BSA section 9374 D2 to provide input and recommendations for the topics described in subsection E to the board to January 15, 2022 the board shall appoint interested stakeholders with applicable supplementary activities as appropriate and provide recommendations to the board on one or more of the following topics one, models that enhance the board's ability to analyze, monitor, or report the pricing of prescription drug products or the relationship between prescription drug pricing and consumer prescription drug costs the effectiveness of prescription drug initiatives on prescription drug costs or three other mechanisms for increasing prescription drug price transparency at one or more levels of prescription drug supply chain the remand care board shall also provide a report to the general assembly on or before January 15, 2022 based on the recommendations from this advisory group and we suggested that the effective date is kept upon passage so I have a question, why the 2022 dates? so at the board and working with Jeff, we kind of Jeff Hockberg, we agreed that either we ask for money so we can contract out some of this work or we not ask for money and have a little more time to work on this and we felt that no money was a safer bet any questions? I don't see we're analyzing I don't see where we're actually taking any action to decrease the cost of pharmaceuticals in Vermont so that is somewhat of the intent of this it is to bring in all these experts and others to develop a model or options for the board to review and analyze prescription drug costs and see what the best mode of action is I think with this Friday deadline and just with this is pretty broad language and we wanted it to be broad so that we had some more power to develop but again, I just don't see the action in this at all other than monitoring so I guess if I were to be completely honest if we were to take action the path would have maybe a lot of resistance so I know there is this struggle to want to have action and maybe Jeff can speak more of this as well because he is in this way I want to see prescription drugs at a lower cost I want to see insulin products at a lower cost and I just don't see that this bill upset me can I chime in from my friend Christina because I know you know this but you probably don't have it at the top of your mind you did bear it executive director from the mental care board we and also this committee has worked closely with National Academy of State Health Policy they are a non-partisan group that brings together states to work on issues such as they have a task force on prescription drug price transparency and reduction in prices of cost control for prescription drugs and I was an initial member of that task group so task force they are working right now on some additional programs that are not ready for prime time and so we can't share the specifics with you that we believe we would like to work on with them and could fit into this language and does exactly the intent of the work that they're doing is going exactly where you're going in terms of getting to the root of the matter so I don't know if there's language we could add to work with Nashville on additional I don't know what else I can say we will work with Nashville either way we are and we have been and the time is just off I believe Trish Riley said that within the next month or two it will be up and posed and as long as everything goes well again we just can't it cannot be shared at this time and if I could just add one thing we worked with them on the drug importation for those who work here at the time so there is a working relationship that's established with them which is that I know you're not good but you can ask me I guess I would just also say if we had something that we could be able to take direct action on at this point in time we would put it on the table I don't think we have that I know the senate has looked at issues around insulin and capping insulin copays or some element of that that will be coming over from the senate that's why we did not take that specific issue up in this committee but there are I don't think we're prepared at this point there was a bill in front of us that would tax the green map care board with actually setting caps on prices and controls on prescription drug prices I don't think we have the ability to move that that would not move anywhere at this point in time we would simply grind into endless testimony but I think the intent is to try to give the green map care board some additional ability to dig into prescription drug pricing issues in particular and position them to work with us with more specific targeted proposals that hopefully will emerge in the medium term if not the near term I would just say if I have your assurances that that you're going to do something that we're going to have some sort of action with that I think it's a frustration that we don't have some and the issues are complex about what we can do at the state level and what can be done at the federal level we're kind of caught in the midst of a lot of this Ashley likes to continuously remind us that a lot of these proposals that they have is met with resistance and that takes time and money sometimes so we were trying to I think everyone agrees that we need to do more it's just we need to find out what's the best path to do more David and Lucy I've been listening to this advisory groups suggestion groups we're going to look into this we're going to think about it we're going to talk about it and we're going to discuss it by January 15, 2022 that's sitting in a room peddling a bicycle and peddling and peddling and peddling getting absolutely nowhere in a year or two years from now you're still sitting in the same living room peddling a bicycle and right now agreement care board has had plenty of time to do something about this about prescription drugs and nothing's been done and that's all we do in here is talk about it and listen to people talk about it why doesn't somebody actually do something so our regulatory role is given to us by the legislature so what we work on is in statute and with our limited staff that's what we can do and there were there were various bills proposed that would have given us that more authority but chair Lippert just mentioned there and I would say I mean I've only been in this committee for a couple years but every year we have tried to take steps and it is frustrating and it is slow and it's frustrating and it's slow and in some regards we have our hands tied between as Bill said what we can do versus what the feds have to do I hear your frustration I'm there too I mean prescription drugs is one of the reasons we have high healthcare costs so I think this is a good step in the right direction I wish it was more too but I think it's what we can do I could remind this committee that there are other reports about the state I mean the board has a report relating to prescription drug costs there are many transparency reports that are for transparency so this is really to see what action we can take and just kind of evaluate just like everyone has mentioned what the state's power can be can I be blunt and just say that if we had a proposal on the table here why would the Green Mountain Care Board why should they be taking specific actions why should we allow them to take action so I mean I'm not directing that at either of you but just generally this is the dilemma we are in the midst of and this is trying to give them some additional ability to work with the appropriate people to develop the capacity for us then to identify and debate frankly specific actions if we were talking about having the Green Mountain Care Board actually put price controls on prescription drugs which is embedded in one of the bills we would be needing to take some very extensive testimony and if we come to that if we ever come to that that would be a significant step beyond which we have not given them any type of authority so it's just a frustration at a time when we know that prescription drugs can now just say that for myself we have passed the first bill on price transparency in the country around prescription drugs we were the first state to pass a bill around importation allowing to work with the federal government about the potential of Canadian importate drugs from Canada and my point of view is we need to keep just taking step after step and not stop but we are not going to but there's not a single thing that is available to us to do at the moment that I'm aware of this is part of that I agree and I think frankly to be quite honest and I'll just be really blunt about it for us to make noise on a bipartisan, tripartisan basis and that's what we have done successfully up to this point when we have moved the bills on price transparency in the face of objections from the pharma and the pharmaceutical industry when we did Canadian drug importation this committee collectively on a tripartisan at the time basis said we need to make noise and we need to make it clear that there's action that needs to be taken and so I'm hoping that we can continue to do that even in the face of knowing that this is not sufficient I would like to see more follow up rather than wait until 2022 and I know Tony Derby is still waiting for the Y2K Generators that's 20 years ago the state promised a ton of Derby Generators when we're going to turn into Y2K still waiting for them I hope we don't have to wait that long for something like this to happen that might be a little bit of an over exaggeration can we add a line about giving Derby their generators I think so I think we should do that and there are the Derby Generators yes I can add we're happy to check in with this committee on our progress towards this, I think Christina did an excellent job describing the conundrum we're in that we have other duties we're performing and we are very to your point about the task force and the technical advisory group we have a very successful advisory group, the primary care advisory group that actually I believe brought to light a lot of the workforce issues that you're dealing with now so I think that this is a promising avenue and I don't know if you want to put in a check in we're happy to do that next year as a progress on our I mean a check in on our progress that's easy enough I think that would be absolutely appropriate that's what our expectation is that this is not something we want to sit back and wait until 2022 if we are being honest to this this has no cost attached but it will take a lot of staff time and after the session ends we are quite busy so we are happy to do a January check in if that's what January check in January 2021 check in is that the appropriate that helps explain us too as much as Lucy said before we ask for stuff and then we run out of time and we're a very transparent board so we will most likely have a committee page on this we will post meeting information we will make this as transparent as possible okay, given the context in which we're doing all of this I'm going to suggest that thank you for the less early specific questions for Christina did you also do go ahead I was just wondering what in this is outside of the board's current powers what new authority does this grant the board so this actually we came to this realizing we can use our existing authority to create a technical advisory group since there were all these other bills that were this bigger ask we took into consideration all the other bills and came up with this that we felt we can't make everyone happy but we felt with working with Jeff Hockford and internally that this is what we can do with our current staff our current timeline so this isn't giving us anything new per se but this is to put in language that we will come back and report in 2021 and 2022 we're all sick I have two questions and they may not be best directed at you so you can say so if you want I'm not clear on what in number two what a prescription drug initiative would mean so the effectiveness of prescription drug initiatives I guess when we propose recommendations as to how to control prescription drug costs or be more transparent or whatever it may be how effective those initiatives may be if everyone understands that that's what that means the language just in the little bay prescription drug initiative but it's clear to the board then and then I'm also not clear myself on in number one difference between pricing and costs we're using both of those terms to mean not the same thing so I I guess pricing is pricing which can mean various things but cost to say the consumers the ultimate cost to the consumer so when we say the relationship and the end of part one relationship between prescription drug pricing and consumer prescription drug costs that's retail or list pricing is that what we mean by the first list pricing but then the cost there's so many there's quite a few different costs and Jeff could probably take a minute and walk through it when he comes up that happened through the supply chain and then what does the customer and the patient end up paying there's a lot of his very complete wholesale acquisition costs some other costs we'll let Jeff comment to that so hold that for a second okay anything else for me yeah I have one more question I don't know whether whether this bill should cover this whether it's an issue that you would look at but it has to do with the coronavirus I don't know what type of pharmaceuticals or meds that will be required to attack this virus but will the Green Mountain Care Board also be looking at say price gouging that I'm sure will probably come up eventually yeah I'm sure and that's why we kept this language pretty broad we can look at everything and anything so this would be covered that would be reported yeah this is an important point in this kind of emergency situation we would particularly need to be aware of protecting our monitors from being exploited thank you Christian Jeff would you like to comment absolutely Jeff Hawkeberg from what we tell Druggist and Pharmacy Illinois State first I think I need a tissue to cry because I think the comments about wanting to do more to tackle this it's been my almost career endeavor here for the last 10 years of advocating to this community and others about the need for transparency the need to make change and when I come to learn you know maybe apart from Susan and maybe Mike probably been at this a little bit longer than I have the point I'd like to make is that you know I can come here and I can give you a bill I could give you incoils recommended language for reforming PBM that's going to have downward effect on patient co-pays today to then turn around a year from now it may have lasting impacts on premiums and I can say that I'm being underpaid on these drugs I'm being overpaid on these drugs the hospitals are having you know access issues these meds B pricing there's so many factors that go into this that the one thing that I've learned over the years is that what we need more than anything is true reliable data to move forward effectively and that's what this bill does and that's why we fully support this bill and it is I think it's a milestone to really put it in statute to actively drive a cost containment data acquisition acquisition program that is going to perpetuate throughout our lifetimes and that's what's key because we could institute something today we may not see any savings tomorrow and we want to be able to make sound decisions going forward because we've tried things in advance and they just haven't paned out but why? and we hear from different stakeholders if you hear from me that this is what's going on in pharmacy if you hear from insurers this is what's going on in insurance role so there's a lot to it and I'm very thankful that this committee is concerned and wants to act today but I think this is going to be the next appropriate step to move forward effectively and given the time crunch to move forward this year to have something that actually goes across and without drawing in just everyone so that said we fully support this bill and I'd like to thank the agreement on care board for coming up with this and I'm always available to come here and testify more to the companies and goings of pharmacy matters and I'll just start by saying to you that one I don't have any hand sanitizer available for you so I can't sell anymore it's not available to me I have my own stock file I don't thank you though but to the board or to the committee's chairman your comments earlier about what some of the things we can think about now in the immediate I have actually done a lot of this we've been in active discussion both within our store group with other stores I've been in conversation recently with the national national committees there's a lot of discussion going on about and there are going to be access issues there already are access issues I think one thing that I would like to stress to this committee that I would thinking outside of the box and things that I would like to see are maybe an emergency access request you already asked the question about what are the treatments for coronavirus viruses there are a heck of a lot of treatment unless you have a drug that's developed specific to target a specific virus there's little you can do other than really protect against treat symptoms and you can treat secondary infections what we're seeing and what we're being told at the pharmaceutical now is to try to gain access to inhalers to steroids to antibiotics and all of those are already under allocation from all the wholesale so the wholesalers are already limiting how much is available to the local pharmacies and to the hospital entities so the drug supply chain has been disrupted and a lot of it has to do with China because 80% of the raw ingredients used to manufacture all drugs in the United States come from India and China so there will be a slowdown that will be perpetuated beyond this quarter it will continue on to the least recorded two before we see a true reform of it also the drugs that are going to be that are being investigated by big manufacturers by Gilead, by ATV you see these in the headlines these drugs are all very expensive drugs they're usually limited distribution drugs and they're usually restricted network drugs what I would I think one thing that I think would be helpful is that maybe an emergency measure to make to require that these drugs be available to every access point possible within our system the retail community pharmacies should be able to access these products as appropriate and go through so that we can distribute to the general public as quickly as possible so let me ask you specifically about that because we are looking for immediate recommendations but that sounds to me like that's probably a federal recommendation rather than a state recommendation would that be fair to say or am I not no because a lot of it is dictated by insurance market dictated by the insurance market so where certain drugs are acquired by patients is dictated to a level within the insurance market and that would need to be uplifted in addition to any federal stoppages that may exist in the pipeline but there is without question a hard insurance market narrow marketing of certain drug processes you're talking about prior authorization and prior authorizations certain medications which they like to call specialty medications have limited restricted networks they may not be limited distribution drugs I have full access to some of these drugs but yet I can't dispense them to patients because I'm not in the network to dispense them so something like that maybe of consideration increasing access I you know one thing I hear constantly in the news about is this massive move which we're seeing today about the evasion and move to capitalization for individuals and companies so perhaps maybe a moratorium on deductibles so that constituents are only paying co-pays or even bottom tier co-pays in the interim here so that their own financial resources are not depleted unless any potential that may come so that they can prepare effectively they can buy other consumables as necessary water whatever it is toilet paper which is hard to get to and I think the third thing that I would suggest for consideration would be something to protect the healthcare industry pharmacies hospitals positions offices in order for those to work all require significant infrastructure of staff in the event of a massive outbreak if our staff goes down we cannot continue to service our population what I think would be and this is just an idea that popped into my head is some assistance with small businesses to furlough positions so that we could self-isolate staff members to keep rotating in and certainly so that they can be compensated for this lack of actual work hours but we could rotate people in in the event that people there is an outbreak they're somewhat segregated and can effectively manage with staff so that we can continue to service throughout the outbreak I think it will kind of explain that correctly I don't know it's just an idea that popped into my head I'm not sure let me try this again I just suggest that I'm not going to try to open up but I'm going to ask you to think about it and try to articulate something further for us at a later time so those are I'm good Mark about the bill so I'm concerned that the language about the interested stakeholders the board should appoint interested stakeholders in the subject matter expertise is appropriate do you think that's clear enough and strong enough to make sure that it's not the stakeholders are not lopsided it's not one-sided I think that's efficient enough I think one of the things you're running to is if it gets I think the board I have full confidence I'm not concerned about that right we have a better day January 15, 2022 um just your opinion my opinion would be the more information that comes it may not be the full report I think an updated report I do not think that a solid report that's going to give answers, meaningful answers for strong comprehensive action is going to be ready before 2022 it's just unrealistic quite a few years I've spent too long trying to review people about how Pharmacy Unit works I'm still doing Pharmacy 101 I think I'm trying Murphy and I think Susan Kalski are still doing Pharmacy 101 discussions here with various committees it's a very complicated industry so I think it's reasonable for a full report to be issued by 2022 with some kind of progress periodically thank you so I'm going to ask that we we're going to come back to this once we have we ask further to be in addition of checking with the committee in 2021 and we'll come back to that in terms of having the language in front of the group so um we're going to I'm going to need to step back and think about how to touch base with all of you how best to proceed we have some new challenges on our plate as well as our ongoing work and so I'm just going to ask you to be flexible and stay connected to the stay connected with them with our emails that will give you an alert we may choose to be back in here this afternoon and in the meantime we're going to be reaching out to the appropriate members to get further input to get input in terms of immediate steps that we can take to support for monitors around issues upon health, mental health, pharmacy, etc and while at the same time trying to move some of our agenda forward yeah I was just going to request members because we couldn't get to the affordability piece this morning that to the extent you can get the time to read the language and ask questions offline in anticipation of us being able to discuss it at some point to the extent that can expedite everybody's understanding and you're able to do that I think in the interest of everyone's well-being stop for lunch