 Good morning and welcome to the Vermont House Human Services Committee today is Wednesday, November, March, March, and the first part of our morning we're going to be having a discussion about impact of age 728 and act relating to opioid overdose response services. The impact on our Medicaid program, one of the pieces in the bill that we passed that's sitting in appropriations relates to prior authorization as it relates to Medicaid. So that is our just that is our focus today and we have with us to help educate us is Ms James who is the, actually Dr James sorry your PhD. Who's the health care director from the Department of Vermont Health Access and the Commissioner of Diva. Andrea do love. Very, very excellent, excellent try Madam chair, thank you very much. And how do you I apologize how do you pronounce your name. It's delivery air, but no worries. It's lovely three name. It's actually three words, all of the almost all the letters of the alphabet practically but it's a pleasure to be here and I really appreciate the opportunity to talk with you today. Commissioner for the record Andrea delivery air commissioner for the Department of Vermont Health Access. We were anticipating Nancy Hogue our director of pharmacy joining us as well I want to make sure she's on here. She may be having trouble connecting. She is also one of our subject matter experts that we're anticipating having joined today. We're here today to talk about the fiscal implications. But first I really want to take a moment and appreciate the work that you're doing with this particular bill this. These topics are near and dear to my heart. As I have not personal experience with the issues but certainly someone I was very close to has been impacted by these issues so definitely appreciate the work you're doing. It's a very thoughtful insightful work that has happened over this the course of, I can see the many drafts here that that you're really taking the time to try to address the crisis that we're in so thank you. I wanted to start there. But as we dive into the fiscal implications specifically for Vermont Medicaid you'll see there would be a significant impact with the proposed changes. And if we don't have Nancy yet I'm wondering if missa we you and I may want to walk through this together. I think that probably makes sense. I want to ask a naive question and perhaps. After the words said it, what we were going for was not to totally remove prior authorization and are are very clear reading of your memo. We wondered if, if those words weren't clear, and if in fact what you were responding to was a remote total removal of prior authorization. Great question and I really, I really do appreciate that I think for us. The, the change to include Medicaid in the bill I think was probably our biggest challenge. Simply because the, our responsibilities to manage the whole class of drugs is the fiscal responsibilities to manage the class of drugs would be impacted by the change by us being added to the bill. And that said there the legislative report that we have provided in the past has been a solution to this and I know I've been doing some research on the history here and I know that this very similar conversation happened I believe in 2019, if I have that right. 2019. It happened. It was a bill started in the Senate. Yeah, and I think it was because of what was perceived as the fiscal implications that's a compromise was to not include Medicaid but have a report. And when we look at the report and the numbers, what we see in the report, and this is, we may not understand all of the, how things work. But when we see the numbers in the report, and we do analysis based on that, we don't quite come to the same huge impact that you presented us with. I understood. Okay, that's very helpful. Thank you for the background on that, and this will be today's presentation will be a comprehensive and more holistic look as to what you were seeing the report, versus what you've seen that report. And I hope that this provides some clarity, but just to circle back just a moment, we are more than happy to continue providing a report to you, if that is acceptable versus having Medicaid named in the bill, if that's the direction you determined to go in. What I'd like to do today what I'd like to do is now that Nancy has joined us. I'd like to hand off to Nancy to walk through the fiscal impacts here to further explain how we arrived at the numbers that we have. And, as you know, this is managing access. We want people to have access to the medications they need, while also being fiscally responsible. So, with that I'll hand off to Nancy, if you wouldn't mind, Nancy, she has the information and she'll walk you through. Good morning. Good morning. Good morning. I'm Nancy Hogan I'm the director of pharmacy services for diva. I've been in the state for 12 years. And I'm certain I've been in front of this committee before so it's nice to see everybody. So let me just walk through how we arrived at that fiscal impact it really was composed of three separate impacts. Significant impacts is since we since the bill prohibits us from really managing the MIT class as we do currently. We will not be able to collect the supplemental rebates that we receive on these products today so we we. Yes, you probably know Medicaid receives a federal rebate on all medications that that are dispensed for Medicaid members. In addition to the federal rebates which are statutory and are always available to us. We negotiate additional rebates through a consortium sovereign states drug consortium. Vermont was a founding member of that consortium back in 2003. And through that consortium we're able to negotiate additional rebates that we call supplemental rebates. So these rebates are negotiated directly with manufacturers and of course they're willing to give us these additional rebates when we can help drive utilization to the preferred products. That $4.2 million is related to the loss of the supplemental rebates, not the federal on the Suboxone products on on I'm sorry on the buprenorphine products. Are there any questions about that before I move on. We do have a question. Wonderful. Thank you so much Nancy question on the supplemental rebates are the supplemental rebates dependent on prior authorizations. Yes, they are the manufacturers always require that their product be listed as preferred, and that any competitor products be listed as non preferred. And there are different, I guess I would say tears for those agreements. So it depends on the product and the offer, but sometimes they do not want any other products preferred only their product. And there's a certain amount of rebate associated with that kind of structure. And then other times were allowed to have two preferred products. And then the rest have to be non preferred. And then, you know, it just depends on how the agreement is structured. So, but yes they always require that non preferred products require a PA. Yeah. Yeah, I was just, I want to follow up on represent smalls question. Because not quite sure that the answer got at what she was trying to get at I'm going to try a different way. With the preferred product that you're able to get the rebates on. Is there another way to communicate that to prescribers. So that they understand that if it's clinically appropriate that they actually prescribe that drug, as opposed to a non preferred drug. So essentially accomplishing the same thing without having to do the current process. It's highly unlikely that manufacturers would accept that structure. You know, prior authorization is very effective at moving utilization. And that's why they typically are looking for that. So I don't think that would be very effective one and number two, I don't think that manufacturers would accept that as a strategy. Follow up question on that then. So I'm hearing that the agreement that you have with the manufacturers is that there has to be a prior authorization on non preferred products. Am I understanding that correctly. Yes, that's correct. And so are there prior authorizations for preferred products. No, there's no prior authorization on two formulations of buprenorphine that are preferred on our preferred drug list. And one of those is Suboxone film. There is no PA unless the dose exceeds 16 milligrams in obats, office based practices, and there is no PA either buprenorphine naloxone tablets, which again, only if it's over 16 milligrams. If I could follow up. Thank you madam chair so the report that we received that outlined in 2021 there is some, you know, I think it was over 1000 prior authorizations for Suboxone, where those all due to quantity being over 16 milligrams. That's correct. One of my questions is that they're understanding the sort of fiscal impact that you've outlined. We're wondering to what extent, like a sort of scaling back of different components, you know we outlined maybe four different things in this one was dosage limits. One was the first 60 days, and the other were designated medications. Say if we were to align it with the statute or non Medicaid insurance, and to make it just about no prior authorizations, if it's within the dosage limit without have a significant change on this fiscal impact. So if, in other words, if we were still able to apply the PA to the non preferred products, but if we open if we raised the if we allowed providers to use up to 24 milligrams in the office based practices, is that what you're saying. Yeah, that's one configuration of it or another. So I'm interested in your response on that. So that would not have a significant a fiscal impact because then the fiscal impact would be limited to the number of PAs that were denied for over 16 milligrams, which, you know, we'd have to look at the, I think Lisa, it may be testified to that last week, but the number of those that are denied for over 16. So the fiscal impact would be that number of PA denials, and that that is pretty close to what we estimated for the second fiscal that we estimated that was just under $700,000 was prior authorizations that were previously denied that would now not be subject to PA so therefore all those would be approved essentially, and we estimated $688,000 point five for that. So what I what I'm hearing is that the at least the component about one designated medication, not receiving prior authorization, maybe one of the smaller ticket items on this list, but then to be clear about the the mono formula of buprenorphine. What are your thoughts on on that as far as how it contributes to this amount. Well that certainly would be part of the contractual negotiation with the manufacturer. And, you know, there isn't as much of, there isn't really a fiscal impact in that case, the issue there is more clinical. But we would have to make sure that that was, you know, not going to affect our contracts. And at this point, it is in non preferred position. So I. And but so also just to be clear, the kind of first thing on our list of potential exemptions for for prior authorization was any medication under within the FDA dosage limit. So that's not where you see the majority of this fiscal impact coming from when people can essentially pick and choose between preferred and non preferred as long as it's within the dosage limit. The, the fiscal impact is if we change any of the preferred or non preferred product status. So we currently have two preferred products that's allowed. That does not that allows us to collect those supplemental rebates if, if any of that changes, if we either move a non preferred to a preferred, or remove a PA on any of the non preferred that's what would affect those contracts. Yeah. I just wanted to add a clarification for Rob Whitman. One of the, one of the questions I think that he's driving at is in each seven 28 under section three, the definition of health insurance plan is changed to include Vermont Medicaid. As a result of that section for subsection a where a health insurance plan shall not require prior authorization for prescription drugs for a patient who is receiving medication assisted treatment. If the dosage is prescribed within the US FDA dosing recommendations would now apply to Vermont Medicaid. I believe the question he was asking was, would that provision alone result in the fiscal impact that diva has provided for the committee's consideration, because of the removal of prior authorizations across those therapy that therapeutic class. In consideration of the language in that section. Yeah, yes, it would affect the supplemental rebates. So I think that, thank you, thank you for that response, but I'm also hearing that the concept of having the one designated medication, perhaps exempt that you could essentially designate as your preferred option because again you have over 1000 prior authorizations for group or northing because it's above the quantity limit. You're ultimately approving many of those prior authorizations. Right. I mean there's only so few that you'll ultimately deny so you're triggering prior authorization for say suboxone, which I'm assuming it's, which I believe is your preferred medication. You're going through all those prior authorizations, you're approving the vast majority of them. And so this, what I'm hearing is that that's a larger fiscal impact and I'll defer to others as far as I'm happy to hear that you're willing to continue this work I know that within the house we are under time constraints as far as how much more we're anchoring and tweaking we can do with this I think will probably and and the amount of sort of time to get back information quickly. Maybe one of our constraints say that we can delay action. In other words, if the appropriations is not going to vote out a bill with the with the this section in it. Without given your, given your fiscal note, but if you all can work with representative Whitman and others, if there is something we heard testimony that there is there are some barriers. And we are there are some barriers for folks who whose insurance is paid for through Medicaid. And if there is a smaller step or a more targeted step that will not have such an immense negative impact on the rebates and things like that. So if, or if I'm fantasizing but if I'm not fantasizing if you all would be able to continue the conversation. We can always propose an amendment on the, we can delay action on the bill until next Friday. And so a week from Friday, or something like that. I'll just jump in. Yeah. If I, if I'm fantasizing. No, I think you're, I really appreciate you taking the time. And these are, I think we're willing to, I think we're willing to definitely collaborate and try to work toward a solution that meets everyone's needs I am curious though. Who you're hearing from regarding barriers because that is, that's a concern. I also have done some research of my own with our hub providers, and they are not experiencing the barriers, or at least that's what they're sharing with me. I absolutely recommend you speak with some of them. That's who we go to for expert advice because they see such, you know, hub and spoke providers are are, I think one of the valuable contributions in, you know, in our landscape here in Vermont. My only, I, yes, I think that makes sense and whether we do it, when I say informally, ie a small group. Absolutely makes those connections. So is there anyone specific with access to the hubs have on some level more to do with where are they, and the hours they're open, some of those kinds of structural issues. Some of what, and I'm going to look to representative Whitman and small. Some of what we are talking about are the spokes. And the spokes that that you know that that's all. Okay. The spokes but I, I hear you and we will, we will do that and if you could actually provide us with, you know, either some names of some folks that we could connect with and then we can connect with our own. Absolutely. Absolutely. I think it benefits all of us to have more information so I will follow up with a couple of names for you, and that would be great and in the meantime. Is it appropriate for for Nancy to review the rest of the items on the fiscal impact at this point. I'm absolutely you did the work and that will be educational for us, whose, whose focus is policy and we'll figure out how to pay for it later. Okay, great so then I'll hand it back to Nancy and then we'll have some follow up discussions after this. Thank you, Andrea. Yep, there was just one other so we talked about the supplemental rebates and then we we also talked about the previous, the PAs that were beat that are being denied today what the fiscal impact of those no longer being denied would be so it was 4.2 million for the 688,000 point $500 for the previously denied PAs and then the the significant there is a significant impact for not being able to prior authorize a drug called sublacade because sublacate as you probably know is a long acting buprenorphine depot injection. It's a new drug and it has no competition in the market at this time. There is a competitor product that has been trying to get FDA approval but they've been struggling to get their product on the market so we don't expect any competition in that class until at least perhaps the end of the year, or even into 23. So, it as with many new drugs, it's very expensive, and it is anywhere between 10 and 15 times the cost of the oral medications. So we had to estimate an impact of removing a PA on that product, even if the utilization of the product is is minimal. So we estimated a sort of bottom impact that of all the people in our fiend that we dispense, if only 10% of that was shifted. I'm sorry if only 8% of that was shifted to the depot injection that that would have an impact of $12 million. So it, because this product or these collection of buprenorphine products. This is our number one drug spend. It is also our number one drug by volume, and it's been that way for close to 10 years. So, that's why the physical impact is so big because we use so much MIT in the Medicaid program, and because this particular is such a high price point. It's about, you know, it's in excess of 20. Let's see, I'm going to do the math in my head here. It's an excess of $20,000 per patient growth. So it adds up very quickly. So if 10 if if we shifted another 8% to that product that would be 12 million. And then we just set sort of, you know, if things really escalated and we saw as much as 25% of the utilization shifting then that would be a $30 million impact. So we tried to give sort of the low worst case scenario, if you will. So that's where those numbers are primarily derived. Representative Small. Thank you. And so looking at these projection numbers is, is this increase and anticipated increase which is why the department's including it and its fiscal impact. Or am I understanding that you chose the most expensive product to show fiscal impact. This is an anticipated impact. We took every single drug available in in the class and determined what the fiscal impact would be. So, so that's why, you know, for example, we included the 688,000 because that was an incremental impact to no CPA. So we looked at every drug, figured out the cost, and it's supplicate surfaces to the top just because it is the most expensive drug in the class. And we do control utilization of that drug with a prior authorization today. So that's why that has such a big impact. I really appreciate the, and we appreciate the, the explanation. And I will again repeat that we are policy committee. And what keeps coming into my mind is, how do we ensure that Vermonters, who are struggling with opioid use disorder, get their medication, when they need it, how they need it. And so as you I have to admit, because I'm not a money person, which is why they keep me far away from there as possible. When you personally, I have a hard time with the worst case scenario, because I'm looking at it in terms of both the immediate for the individual or the individuals and then the potential cost avoided. And those individuals are then able to work, able to go to school, able to more able to raise the family, but that's what I really appreciate. Commissioner, you're speaking on behalf of diva your willingness to and it may go nowhere, and I get that. But your willingness to in the next. Next week to continue the conversation that I know you've been having with representative Whitman and sometimes with representative small, in terms of, is there something that we can do, or is there something in the report that we would be more helpful as we move forward. Or something as simple as you come back with a way to, but all of that I mean, because I as much as I wanted to try to find holes in your analysis. I'm having trouble finding holes. I really am not disappointed to hear that. And, and I think the joint fiscal offices is breathing a sigh of relief as well. Representative McFawn. Thank you, Madam Chair. Madam Chair, just to clarify something with me a week planning to have somebody from the hubs and spoke program to come in here, because it appears on one side we're talking about Senator McFawn, you have a good question. Are we planning on connecting with whether the we is a committee, or whether the we is the continuation of the small group that worked on this is at this point up in the air, because we have basically until we basically have a week to do this. And so it may be a piece of this and Senator McFawn has said that she will provide us with a few names of spoke people. And I would also recommend hub, if that's okay with you. Okay. Now I'm chair. I never got to my question. Oh, sorry. The question is, on one side, with the small group, we're hearing that people aren't being served as well as they could be. And on the other side, we're hearing that there is no doesn't appear to be any problem in the hub and spoke program. So I want that settled. That's what we're trying to do. That's what which means hearing from other people and talking to other people and you know, it's not going to be a perfect system. I mean, you know, the goal is improvement, right? The goal is that we improve and make it accessible while also being fiscally responsible and balancing that scale as much as we can. So I appreciate the opportunity and we are absolutely committed to work with with all of you and others. Thank you. Thank you very much for responding so quickly this morning and coming to have this conversation. I really appreciate that. Okay. Oh, wait. I have a question on chair. Yes. No one could do we can't hear you. I just have a quick question. Representative small Whitman and myself are scheduled for appropriations day at one would you like me to ask them to postpone. No, like just to still go and present. No, I mean, I think that it is Wednesday. I think that will make them very nervous. My suggestion would be to say that we, we understand the appropriations is going to do something to that, you know, that we prefer they not, but we understand they're going to do something that we may be coming with an amendment. When the bill is when the bill is put on the floor, we will be asking for it to be delayed to the last possible date, which is I think Thursday, I mean, you know, or Friday to see if there is a step that is fiscally responsible that we can take. And with that, this ends, we're going to take a pause or we're going to take a pause or move directly are people waiting people are waiting so thank you. Everyone from diva really appreciate it again. Thank you so much. Thank you very much.