 Welcome back to the Vermont House Human Services Committee. This is sort of part two, and we are beginning, we're continuing our discussion and of an opioid use disorder response bill. And we have a third or fourth draft that we are looking at right now. And Legislative Council is going to, I guess I think what makes sense is because we haven't really seen it as a whole is for Legislative Council to go through the, I think it's a three-part bill, and we'll go through the whole bill and then we will take each section in terms of a general, in terms of making answering questions and whether or not have an informal poll, whether we agree to insert that section. And we'll see how far we can get by noon, and then we will be back by one o'clock. So have an hour for lunch. We're on 621s, you're at 3.1, right? No, it was 2.1. Okay, 3.1, 3, yeah, yeah. Okay, okay, go ahead, thank you. And then Office of Legislative Council and I think I've got 3.1. The changes are highlighted in yellow, so we can track them. The first section. Okay, Katie, I'm gonna suggest that you not just go through the changes because- Yep, got it. We've gotten, yes. I'll review the whole bill. So the first section is section one. And if you remember, we, there's been a change. So this section has to do with the operation of syringe service programs. I'm gonna skip us to subdivision eight two and then go back up. So just refresh your memory. There, the language that we reviewed last time we looked at this, it hasn't changed. But the idea is that the language that is being structured limits where this service can be provided and that by striking through the language and which is operated by an aid service organization, a substance abuse treatment provider or a licensed healthcare provider or facility that that expands the entities and locations where that program can be operated. And then I'll bring us back up to A1 now. I should have highlighted this, but the definition of drug paraphernalia does not include so, does not include needles, syringes in this language or other harm reduction supplies. I think that was a change that's been since the last draft and that's not highlighted. So I wanted to flag that for you. I will continue. So the next section has to do with the prior authorization for MAT. This looks different from the last time you've spent. The actual substance piece that we'll get to in section three is largely the same. It's not exactly the same. What's different is that this section two amends the definition of health insurance plan that is applicable to the MAT section to include Medicaid. And then just to give you the big picture and I'll go through each section. After this section two and three, there are sections form five that pretty much revert to the law as it is now without including this Medicaid language. And that takes effect July 1, 2025. So there's a three-year window where this language would be effective in applying to Medicaid. So to look at the actual language itself, first is section two and we're amending the definition section. And this is in the same chapter as the MAT language. Health insurance plan means any health insurance policy or health benefit plan offered by a health insurer as defined in section 9402, as well as Medicaid and any other public health care assistance program offered or administered by the state or any subdivision or instrumentality of the state. The term does not include policies or plans providing coverage for a specified disease or other limited benefit coverage. And then section three. That's the question. Yeah. So in other work across the hall on things impacting different plans, there are certain types of plans like self-insured plans that we're not able, as I'm learning, we're not able to dictate. And so does this exclude those plans? I would have to confirm that, that those are excluded. I believe they are, but I'm not gonna, but let me confirm and get back to you. All right. I believe that is being said. Can't, I mean. Right. I was just reading this to be more inclusive, but I don't know exactly what 9402 says. So the question is, does this language exclude self? Things we can't include. Self-administered plans. The things we can't include because of federal unemployment. Let me get you an answer when you come back for lunch. Okay. Section three, this is the language you have seen before on the prior authorization requirements. Subsection A has some new language in it, not new since the last time you've seen it, but new newly proposed language. A health insurance plan shall not require prior authorization for prescription drugs for a patient who is receiving MAT if the dosage prescribed is within the FDA's dosing recommendations, or during the first 60 days of MAT when the medication is prescribed for a patient for opioid or opioid withdrawal. And then we have a new subsection B. Health insurance plan shall cover the following medications without requiring prior authorizations. One medication within each therapeutic class of medication approved by the FDA for treatment of substance use disorders. And one medication that is a formulation of a buprenorphine mono product approved by the FDA for the treatment of substance use disorders. And then we're re-designating the existing subsection, B to be subsection C. Cool. The next two sections, the full is to revert back to what is now existing law on July 1, 2025. So if you see in the definition section, we're getting rid of the new language that was added in section two and we're going back to the definition as it is now. In section five, right? I mean, we do that in section five too. I just went over section four. And so the impact of this or the import of this is that this gives a three-year window to evaluate the impact of the policy change. Yes, so in essence, the change that you're making in two and three are sunset. They go away. I have a drafting question. Why don't we just put a sunset in? I was thinking about how to do that, but you're not getting rid of the whole... I had thought about this a lot last night. You're not getting rid of the sections. You're reverting back. And I was thinking it would be harder to track if there is a piece in session law versus and the way this would look in the green books is you'd have the paragraph and you'd have a header that says this is an effect until July 1, 2025. And then underneath it, you'd have a paragraph that says this takes effect July 1, 2025. So it really is for tracking on some level. Yeah, I think it would be easier to track and also easier for somebody who's looking in the green books to understand the law, to see this is what it is now, but it is set to change, if that makes sense. Okay, and then if three years down the road, we find out that the earth hasn't shattered and we wanna continue this. Then we would amend this bill and we would repeal sections four and five and we'd amend the effective date section that makes them take effect on July 1, 2025. Excellent. Okay, so the second piece of this is the section five. And again, the idea is to revert back to the language that's in place now. So you'll see that section five undoes the work that section three does. And then on page six, there is a new section six that the committee hasn't seen yet and this is a reporting section. The honor before February 1st, 2023, 2024 and 2025, Eva is to report to the committees of jurisdiction regarding prior authorization processes for medication assisted treatment and Vermont's Medicaid program during the previous calendar year, including, first, which medications required prior authorization, second, how many prior authorization requests the department received and of these, how many were approved and denied and third, the average and longest length of time the department took to process a prior authorization request. And we move out of MAT and the next section has seen, although there's some changes, this is the overdose prevention site working group. So first in some section A, we're creating the working group and recognition of the rapid increase in overdose deaths across the state with a record number of opioid related deaths, 2021. There's created this working group to identify the feasibility and liability of implementing overdose prevention sites in Vermont. And then we have the membership of the group and there have been several changes here. So we have the commissioner of health or designee, the commissioner of public safety or designee, a representative appointed by the state's attorney's offices, two representatives appointed by the league of cities and towns from different regions of the state, two individuals with lived experience of opioid use disorder, including at least one of whom is in recovery, one member appointed by the Howard Center's safe recovery program and one member appointed by the Vermont Association of Mental Health and Addiction Recovery. And that's the same language you drew from H711. In subdivision six, the program director from the consortium on substance use, the program director from the Howard Center's safe recovery program, a primary care prescriber with experience providing medication assisted treatment within the hub and spoke model appointed by the clinical director of ADAP or its successor, an emergency department physician appointed by the Vermont Medical Society and a representative appointed by legal aid. And then we have the powers and duties of the working groups. First, to conduct an inventory of overdose prevention sites nationally. Second, identify the feasibility and liability of both publicly funded and privately funded overdose prevention sites. Third, make recommendations on municipal and local actions necessary to implement overdose prevention sites. And lastly, make recommendations on executive and legislative actions necessary to implement overdose prevention, if any. Can I just ask a question? Conduct an inventory of overdose prevention sites nationally. It just seems like a big project when we're really looking for some examples, right? There aren't that many. There aren't, okay. You're like four, but okay. Just when you say inventory, you get this sense of big. If we did internationally, then it would be a big job. But really looking at how other states have been able to do it, seeing if there's anything that could transfer over to Vermont. Okay. And just a question on number four, line eight. Is it intentional that it's necessary to implement overdose prevention and not overdose prevention sites? Okay, I got a mess out there. That's a nice sign mistake. That should be overdose prevention sites. Thank God. Tapper, you have your hand up. Yes, Madam Chair. I'm just wondering, I bring this up often. Are there any other agencies that can do the things that the Howard Center does? I bring this up often. I think Chittenden County has too much to say about what happens in the state. And we continue doing it. And I would like to see what other parts of the state could recommend, other agencies. That's just a personal feeling that I've had for a long while. I think there are other people and other agencies that can help us just as much. Not, and I'm not trying to run down to Howard Center, they do great work. I just think that we should, as we go forward, look for other agencies that can do the same thing to help us. I absolutely hear you, Tapper, on this one. And just for reasoning why we have the program directors of the Consortium on Substance Use and Howard Center's State Recovery, is that these are the two organizations who have done pretty extensive work so far on what implementation of an overdose prevention site would look like in the Burlington area, as well as the Brattle borough area. So we kind of have a north and south. I was hoping for someone centrally as well, but we do not have interested parties or organizations there yet. So it's kind of top and bottom, but I hear you on getting more perspectives than just Chittenden County. And that is where potentially a private primary care prescriber or emergency room department on a physician or a representative from the Vermont League of Cities and I mean, so those kinds of things. Other parts of the state. In terms of other parts of the state, Tapper, and I, as a representative small was outlining and thinking about who might be here, based on my experience testifying in front, no, I wasn't testifying. I was listening to the Appropriations Committee talking about prior bills that we have presented to them this year. They don't like working groups and they want the numbers as small as possible. So every time Taylor said another name, I said, no. No, but I said this, you have to cut it down. And to that point, I meant to be removing the representative from Vermont Legal Aid and I think that's what you're saying. You say you have cut that one out. Yes, it's still in this drop, but all right, okay. Didn't we have a one-time almost 10 people from around the state? What did you buy? Oh, well, that was from 7-Eleven. This one, I had three representatives, but we marked it down to representatives to reduce the number. Mm-hmm, that was good. I'm learning from James. Okay. May that change, let's see, we had just gone through powers and duties. So we were at subsection D on page eight and this hasn't changed, that the group is to have the support of the Department of Health. As far as a report by November 15th of 2023, the group is to submit a written report to the committees of jurisdiction with its findings and recommendations for legislative action. Meetings, subdivision one, the commissioner of health or designee is to call the first meeting to occur by September 15th of 2022. The committee is to select a chair from among its members at the first meeting. A majority, the membership constitutes a quorum and the group ceases to exist on November 15th, 2023, when its report is due. Then we have the standard language for compensation and reimbursement. Let's see, so it's eight meetings. The first paragraph deals with the legislative members. Although, I think you removed the legislative members. We did, I see. You did, okay. Thank you for making that, suggesting it gets smaller. There we go, so let me update that. They'll never, they haven't gotten to the pilot programs part. Okay, so I removed paragraph G1 and now paragraph G2 is just G and instead of other members, it says members of the working group. So standard language, eight meetings and the payments come out of the health department's budget. And then we have a definition of overdose prevention site. That is it for the working group section. Pilot programs go around, such a name. I thought we talked about H. About H. We did acquired instead of purchase. Oh, I'm sorry, yep. And I didn't highlight it. We previously acquired regulated drugs. Very true. Online 1680 program is good. Yes. Instead of an O. Thank you. Okay, so typo corrected, page eight, the middle page nine, line eight. Okay, so the next three sections are the pilot program sections. Section eight has to do with the mobile medication assisted treatment. So in fiscal year twenty three, four hundred and fifty thousand is appropriated from the general fund to ADAPT for the purpose of awarding one or more grants for mobile M.A.T. services and accordance with federal laws. Award the grants based on applicant's ability to provide M.A.T. including methadone to currently underserved areas of the state. We want ADAPT and a success. So we went back and forth and I thought we had decided and said no because it's national but I just am remembering that in the previous section, section seven and one of the appointments, we do say the successor. So we should at least be consistent with them. I'm trying to take out you want to take it out. OK, I'll just write in a section seven successor. So what did what did you just say? So you know what? In section seven, where we have an appointment that's being made by ADAPT, it's on page seven line 17. We're removing the phrase or its successor. OK, so that brings us to section nine on page nine. And fiscal year twenty three hundred and fifty thousand is appropriated from the general fund to ADAPT to award one or more grants to an organization or organizations providing substance use treatment counseling or substance use recovery support or both for individuals within and transitioning out of the criminal justice system. The division shall award grants based on applicants ability to accomplish the following. First, provide justice involved individuals with direct substance use support services while incarcerated, such as through alcohol and drug abuse counselors. I left out the word abuse on the last draft, so that's been changed or certified recovery coaches or both subdivision to support justice involved individuals in their transition out of incarceration, such as through referrals to existing statewide resources for substance use treatment or recovery. Or provide long term support for justice involved individuals, such as coordinating peer support services or ongoing counseling post incarceration. And then the last of the three pilot programs is section ten and fiscal year twenty three one hundred and eighty thousand is appropriated from the general fund to ADAPT to award for grants to organizations to provide or facilitate connection to substance use treatment, recovery and harm reduction services at the time of emergency response over emergency response to overdose. And the division is to award grants based on the applicants ability to support individuals at risk of fatal overdose by facilitating warm handoffs to treatment recovery and harm reduction services through coordination between public safety, emergency medical services, substance use treatment and health care providers and substance use recovery services. And then the effective date section, the bill takes effect July one twenty twenty two and then this language highlighted reflects that we're removing those section or the sections four and five don't take effect until July one twenty twenty five. And as you remember, that's back to the existing language. What was that last comment I'm sorry. So the in the effective date section, the highlighted language, those sections four and five don't take effect until July one twenty twenty five. And if you remember the purpose of those two sections is to revert back to the existing law as it is now. It basically sunsets that change in sections two and three. I have a question. Yeah. So the the language we have under the pilot program, particularly with regard to warm handoffs to treatment recovery and harm reduction. I'm just wondering why we're not using that warm handoff language on the incarcerated section prior in section nine. I guess my thought is that I think that people need more than, you know, a referral. And I think that our recent experience with overdose deaths during the pandemic after release from incarceration is proof of that. So would it work to say such as through referrals and warm handoffs to existing statewide resources? I would put I would put warm handoffs instead of referrals. Instead of OK, I mean, that's just me. I'm just putting that out there as a suggestion. Well, we have any others, right? That's that's what we do. That's what we do out there. And the systems like those like that was the actual intent. Yeah. Cool. Thanks. It was a great. So I would like to bring something to the committee's attention. And that's not easy to see within this version as presented, which our prior draft included language around peer delivered syringe exchange and we received feedback. Well, that's not included in this, right? And you can't see the strikeout because it was just taken from the draft. And so basically some of the feedback that we received from the department was that that was really sort of the first point that they had reservations about. And we started to discuss, you know, can we have them report back on the feasibility of it? But I also sort of learned through their testimony and some of the testimony from Vermont cares that this is happening to an extent within their existing flexibility of guidelines. But I understand this is a pretty significant change. So I wanted to open it up to discussion. I actually had that as a question. And I I think the removal of the limitation language will give the opportunity to expand and without needing to to say expand at some level. I mean, a different group might be able to come and meet the requirements. What you might want to do, because I've got a copy of it as well, is share with the committee, the the Department of Health has a six page not quite sure bulletin or something around what are the qualifications, what are the steps for something like this for syringe exchange programs. And so you can see that it's it's not something that I can go. Oh, this is a really good idea. I want to do this. I want to do this. And they go, OK, you want to do this, but you have to be able to give reports and you have to meet certain criteria. And that they have developed internally. They have it's not since they have not updated it in the past eight years, not 10 years, 10 years. So, you know, hopefully they will update it. That's good. I agree. So so I'm fine with taking out the language and, you know, having it be as it is. So the one thing that I guess I just want to bring up as a a point, not only with regard to substance use services, but the impact of having peer support services really in any realm. But and I I have a bias that I don't feel like state government adequately recognizes the value of peer support and peer provided services. And so I appreciate it's later on in the bill, you know, that we just talked about. And I appreciate the fact that, you know, the Department of Health has, you know, this six pages long list of criteria you have to pass. And probably, although I don't know this for a fact, you know, a peer support organization might have more difficulty in meeting those requirements. But part not the end. One of the things that we talked about yesterday is the sort of inclusion of peer support, you know, perhaps within an existing provider. And I just putting out there that I feel like it's important for us to recognize the value of peer support. And services in our formal human services systems. And I just sort of question whether we recognize that sufficiently as well. But it doesn't go I was going to say, this is just nowhere addresses necessarily your comment. But the last line says such programs shall be operated. And if we put such programs, comma, including peer support, peer, including peer programs, comma, shall be operated in it. In other words, just to highlight those. I mean, I know it doesn't address what you're talking about, but it puts the concept of peer support. Yeah, that's talking about hazardous waste management. But it's the only place where they, yeah. I'd offer something up. I've been thinking about it since we just received this morning, the guidelines, the six pages for Syringe Exchange, I had the chance to read through them. And there is no mention of any kind of say training for peers to become staff, to be oriented into this organization. And perhaps there is value in specifics around that. I would say that judging by the fact that the guidelines are 10 years old, maybe we could ask to say, hey, can you take a look at them and report us back on what your potential updates might be to reflect current practice? Including the potential of peers. And I did notice that number two on the guidelines is just a reiteration of the law that we just are proposing to change, which is I think number two says they shall be aid service organizations, substance abuse. So they're going to have to modify those. They're going to have to update. So to put that in there. So I think at lunch, I'll send out maybe a draft paragraph about that. You don't have to send it out in advance. It can be in the next iteration. Thank you for listening to that concern. I appreciate it. And I think it really just grows on. I mean, we heard really wonderful testimony yesterday as to the impact of peer supports and that right now, when it comes to those peer supports, it's untrained. It's folks who are in community care a whole lot and are able to do this, but I think there's such a value in offering both that professional development as well as making sure that they're able to do those warm handoffs that we're bringing up so often throughout the bill. Right. Well, and we have seen through, you know, multiple occasions in this committee, testimony from recovery centers, and those are largely peer operated or at least staffed services. And they, those, that testimony over the course of the years has really impacted me in terms of thinking about how peers can assist other individuals. And so, you know, expanding that into other areas. I think. Before we ask Katie to do that. In part of this, whether it's definition or something, I'd like a show of hands as to in this particular area of the bill, which I want to say, which expands the potential definition of who can be a representative of the department. And I think that's a range provider if there is a majority of the committee who supports, at least concluding that one piece in the bill. Well, that's the one issue that the department is concerned about. Right. So what we're, can I frame that just a little bit? Yeah, please. I mean, I think what, what represent Whitman is proposing is that we. You know, we need to, you know, revise and update those guidelines with a focus to include peer support. Right. So it doesn't necessarily. Change what we're doing exactly right here, but it asks the department to consider. Here supported services in that update. So it doesn't authorize, but. I have some considered. Well, if they, if they don't, if they don't provide those services, then it would, but we don't have to say that in here is what I guess. It doesn't require them. It does not require it. It makes it a possibility. Right. I think that's what. Yes. And our language. And previous drafts was actually really targeted. So it was peer-delivered syringe services. Right. So this is broadening it to peer supports and how we include those services. Right. Well, and I think the prior draft was almost a. Requirement. It was. And so this is not, this is. Opening the door, but not requiring. Right. That's what I just want to make sure Carl understands that. Right. So, so it's not requiring it. Carl. It's just asking them to. Yeah. Yeah. Okay. I just don't want to do something that. Has the department. That tremendous odds with us. I understand. Yeah. To implement this. I think it's important to implement. Yeah. You know, I want them to be at odds. Yeah. It's great. I think it's sort of a way of threading the needle of asking them to sort of consider something that. Beneficial. Yes. Okay. Don't mind. Somebody. It's going to draft. Something that. That says that is that what we're saying now. Right. Topper before we were asked before we asked. Katie to do that. I wanted to get a. A, a, a, a sort of show of hands of people who are. At this point interested in going forward with that one piece. It's not prescriptive. Okay. Okay. To be clear, this is sort of like a report asking them to address. Yeah. What's changing in the new guidelines and how to maintain. Yeah. Yeah. I mean, I think. Maybe less of a report in that they will have an update. Yeah. I mean, I think. I think we. Okay. They will have an update because they will update their. Review and update as necessary. Whatever that document was, it's a forward. Yes. I have. I have one. Little concerned. Absolutely. Back on page seven. And unless I misunderstood. What happened there. Did number eight. Get taken out all together. No. Number eight stays. We just removed the language or its successor to be consistent throughout the belt. What it would read now is a primary care prescriber with experience providing medication assisted treatment with the, within the hub and spoke model. Appointed by the clinical director of alcohol and drug abuse programs. Yes. So you. All right. Success. Okay. Okay. Thank you. You're welcome. Dan, could you explain. The sunset. Or so I would say why the sunset and why not just. Put it in place. And if people don't like it, they'll change it in future years. Absolutely. I think it was mostly just wanted to put the proposal forward based off of some of the suggestions from representative would. Yesterday. It pairs up with three more years. Reporting based on what are we seeing any changes within prior authorization. And then we're going to have another window of time. In which we can. Evaluate. See what the changes are. And then. Come back and make the decision either to even expand it further. If we're seeing that it's not having. Enough of an impact or. Bring it back or anything like that. I also felt it was a way to. Work with. Both Diva and the department of health who were reluctant about that. And when I. Asked if they would consider something, you know, that had a trial period, if you will. They said they would consider it. So. Sometimes when we. Have a change of policy that people don't really know what the impact is going to be. Yeah. And that would be us. You know, I think it's important that we do something. That can be. You know, people that were asking to implement this. It sometimes. Is helpful to have a. A period of time where that can be evaluated. That's pretty much what that is. I think it also encourages that. That we do something now. Right. As well, like whether it's most important that we do something. Immediately. I mean, I think it's important that we do something. I think it also encourages that we can do some further evaluation. It really is good policy. To be, to go back and look to be, it helps us to be more accountable as. Government. Sorry. I know I'm always touting this, but I really do believe that that it gives a, it sort of forces us to look at those reports and say, oh yeah, that's what we're doing. That's what we're doing. That's what we're doing. That's what we're doing. That's what we're doing. That's what we're doing. What can we do different. So I'm super supportive of. Doing this. This way. Any other discussion? Are there other right now questions? I just have one quick point. That was an edit reference. Recommended by the department. On section 10 page 11. It's just simply. Changing the word and. To or. So the idea is that this would just provide flexibility and the ability of the department to award grants to. Any of these organizations. But you'll see below that on number nine that we still continue to have. And because we're awarding them based on the merit of their ability to coordinate with all organizations. So. What I'd like us to. Do is. I think this is a good place to stop. And it gives. We'll be returning at one. And. We will continue. I think we have sort of brought, but we have sort of a, a, a straw poll on the first section. So. So. So. I'm sorry. I'm sorry. I was. At two of. 12. Are you able to come back? Today's early. Special day for school at one. Oh, okay. So. In 30 seconds. Would you come to the. Table. The first time. In a long time. And hi. And I'm sorry, committee. I know I said. I'm sorry. I'm sorry. I'm sorry. I'm sorry. I was. Be quick. Rebecca copans. Blue cross. Blue shield of Vermont. I just wanted to come and say, you know, we are here to support you in, in this bill. We do not. Have any PA on. On MIT. And we're. Sorry. On the, on the medicated. You don't have any. Prior authorization. And so we support what you're doing. We think it's, it's great. We do use. We do use quantity limits. And that catches it's like a, it's a double check to catches, you know, to catch pharmacies if they make mistakes. We've never had a prior authorization request. To go over a quantity limit, but if they did come, we'd be happy to consider them. We. And we just follow the FDA dosing limit. For quantity limits. That's it. That's it. That's it. That's it. That's it. That's it. That's it. That was easy. This is the easiest. That conversation. Dane has had. Either in person or. A bunch of us have, you were part of that too. There was a, a call with your boss. I was there too. Yeah. Yeah. On what. Happen in the context of the committee. And so. I wanted the whole committee to, to hear that. Yes, we had been communicating. With blue cross blue shield. And. Thank you. Thank you. All right. Thank you. Thank you. Okay. Committee. So we'll come back at one. And we will sort of go through the other parts in terms of. Do we have. You know, sort of. Agreement, you know, do we have at least a, you know, majority agreement. Put other pieces in and then we'll go through the. One by line. Okay. See you at one. Thank you. Thank you. Thank you. Thank you.