 So before we begin, I would just like to acknowledge and welcome our new director of trauma and drug programs and resilience, Auburn Water Song. Welcome. We're going to bring you in here and have you sit here and talk with us at some point soon. But we're very happy you're here. Thank you, Senator. Yeah. That's great. OK. So we have online draft 3.1. So Katie McLean, Office of Legislative Council for the Record, we're looking at S7 this morning and you have a new draft of 3.1. Oh, sorry. Your new draft is 3.1. So I'll take you through the changes once you have it pulled up. Let's pull it back up. It's the end is near, so everybody is really close to the end. So in the first section, we have a report that's due on January 1, 2020. And it requires the Agency of Human Services in collaboration with the Green Mountain Care Board to submit to CMS, House Health Care, Human Services, and Senate Health and Welfare, a plan to coordinate the financing and delivery of Medicaid behavioral health services and Medicaid home and community-based services with the all-parent financial target services. And the plan is to describe a strategy for including Medicaid behavioral services and Medicaid home and community-based services in the state's delivery system reform efforts and for supporting the inclusion of these Medicaid services and the definition of all-parent financial target services in a subsequent agreement. And I have to confront this with Ina, but this is already a requirement under federal law. And the only addition here is that the report is being sent to relevant committees of the General Assembly. OK. I'm going to make some suggestions after we've been through the whole bill. Sure. OK. So the next section is also a report it has to do with contracts between the DAs, SSAs, and Accountable Care Organization. This says that by January 1 of 2020, the board is to submit a report to the two committees upstairs and to this committee detailing any actions the board has taken involving contracts executed between the DAs, SSAs, and the Accountable Care Organization. Next, section three, this is language that you passed last year that created the Director of Trauma Prevention and Resilience Development. In subsection B, you have the list of responsibilities that that person has. And on page three, at the very bottom of the page, you're adding a new item to the list, and that is to serve as a resource in ensuring new models used by community social service providers that are aligned with the state's goals for trauma, trauma prevention, and resilience. So this is a tough one to do because as I'm talking with people out in the community, there are a lot of people who are very interested in making things happen in their municipalities or communities. And some of them are not fully engaged in trauma-informed programs, and I don't know how to link them, everybody, with Auburn as the director. So this was my attempt to help her build a framework with community organizations and groups who are interested in reducing trauma. And it links in with substance misuse programs at the more global level. They're the best we could. OK, the next section, section four, has to do with the Dulce model of embedding somebody from the parent-child centers within pediatric practices for the purpose of connecting patients with their correct services. So this is a report that would be due on October 1 of this year. The director is to submit the report to the Health Reform Oversight Committee in consultation with stakeholders assessing the model in which social service providers employed by the parent-child center network is embedded within a pediatric primary care practice and the director's to make recommendations to further develop the expansion of the model in coordination with any proposals for reform resulting from the CHINS review that was requested in last year's budget. So I mean, this is fine. The question I have is we know that things are moving pretty fast out in the community. We don't want to stop the work that's going on. On the other hand, we want to make sure that we have resources to accomplish our goals. That was my question. We're talking about someone employed by the parent-child center being embedded in the pediatric office. It's the reverse from my perspective. It's someone from the pediatric office being embedded in the child service center? The parent-child center. So the dosing model is the dosing, huh? Who's paying for it? I think they just do it. They just shift where they offer their services. I'm having a hard time. So remember, maybe I haven't been in a pediatric office in a while. But there always was a doctor, a nurse, and a receptionist. Are we requiring that pediatric office is higher personnel? And so this is just a report on the model. So it's evaluating the model. And there are some parent-child centers who are already implementing the model. So the model is already doing it. And Scott Johnson was in. Right, yes. They have grants to do it. Yes. But now they're doing it in St. Albans and at the Lund Center. And the Janet Lund Family Center in Burlington is beginning to do it on their own. And their goal is to have a three-year pilot program and then affiliate with the ACO or others. OK. They're doing it. So we've got other places that are implementing the Dulce model or the Dulce program. Is there a fee to buy in to Dulce? No, I don't think so. OK. So they're implementing. It's really the model that they're looking at. Is this just a study of how that's going? Or is this a study of what it would take to have the Central Vermont Power Child Center do this? I'm going to reach out to Ina and Auburn. And it's because you did help inform us on this piece. So can you talk about that briefly? Do you want to come up here to do that? OK. Ina Beck is director of health care reform agency of human services. The intent would be to assess the pilots. The intent is not to evaluate them in a formal way, as an evaluator would, but to assess how the pilots are going, how they are being implemented, and to offer recommendations for implementing them more broadly, but also to ensure that those recommendations are aligned with other efforts to assess this model, which are already established or are already being discussed. So making sure that everyone who's looking at this model is looking at it in a live way. OK. Is anyone evaluating? There is a proposal for an evaluation of this model. The proposal is from the Children in Need of Services work group. That's in here. And that's in here, because before you probably should evaluate, I mean, it hasn't. Before you spread it? Before you spread it. And it should be evidence-informed, yes. And that should take, you know, you're talking about changing family behaviors. And that's not something you evaluate when you could do something, but it's got to carry on. Yeah. And the reality is that nobody wants to get in the way of progress. I mean, we don't want to, but at the same time, to ensure that any framework that's in place for these things is going to offer value. I guess I'm a little gun shy. I've been long enough to see enough programs that we have lashed on to, and then it's gone. And I'm still trying to find out what's going on with visiting nurse, on family visiting, that we're supposed to be getting a better set off one year. And how that, well, we can ask. They said, we can ask, but we can't ask. We can ask. We can ask. We can ask. I'm already right. You're right. I'm just giving them a mile. And the money in the budget adjustment is to do the training for the people of the Department of Health that's necessary in order to implement the New Zealand model. That I did find out. Which money? The in the budget adjustment. Well, how much is that? Did you want to? We think one minor recommendation would be to strike the language that says the social service provider employed by a parent child center. Because we think that there may be instances where there may be a social service provider embedded that's employed by another agency. With regard to that language, it might be nice to have some clarity. So I was under the impression that the Dulce model was somebody from the PCC and the pediatric practice. If there are links in the reverse that there's somebody from the pediatric office within the parent child center, we should have language about formal linkages. I don't think there is. In the existing pilots, I don't think there is a reverse. In Lamoille County, where Appletree pediatrics exists, it's embedded in the PCC. So it's not. PCC is embedded in the pediatric practice. But they meet at the PCC. OK, I'm with you. That's fine. It's fine. As long as they're together and as long as they're reaching out for issues together, it works. We don't want to misstate it. So how would it be a social service person hired by somebody else? I mean, if you have a behavioral health record, a social worker working for an agency for the parent child center, would you want that person to be there? Would that be the preferred way to go? I don't think there's a judgment on the preferred way to go. We just wondered if there was a, if something emerged that was that model that the person was employed by another provider. How does that work with parent child centers? So, Stephen Faulk was chilling on behalf of the parent child centers. So we can imagine a scenario where, for instance, the pediatric office was the actual employer, but they were coordinating with the care coordination team at the parent child center. So I think that is a scenario that matters what you guys are discussing. But primarily now, in these pilots, it is an employee of the parent child center within the pediatric office, though I should say this is not a pilot that's been adopted across the entire parent child center network, not all the parent child centers are engaged or are intending to engage in this pilot. So I just wanted to clarify that as well. So should we add some language to that? I think the way we get to that is the suggestion that we heard striking employed by a parent child center and just being silent on who's employing the service provider. All right. Thank you. So that brings us to section five, which is the effective date. And you'll notice there's language below the effective date, and that's renaming the bill after passage to be an act relating to social service integration for Montt's health care system. If you remember, the initial bill was very specific to ACOs, and the title reflects that. It was a placeholder in June, I think, or May or sometime. Go ahead. No, we'll focus on the places like Head Start, who may also be dealing with a lot of the same people. We have the parent child centers, but I think Head Start may be targeting more of the kids that we'd like to pick up. So at some point in this process, we should probably yield from them. It's probably too late to do a typical process. Yes, what I agree with you, that's a really good suggestion. I mean, the idea is to have a safety net without holes and to coordinate all, to make sure that everybody gets if they want, and they have to give permission. Somebody to come in with new children and provide the support and the access to services, et cetera, et cetera, no matter who provides it. But that somewhere, there is that service being provided. And Head Start is federal money. OK. That will be. Is there actually, is there anyone else in the room who'd like to make a comment? OK, so I have somebody back here. Hi. Susan Barron. Susan Barron. OK, if you want to state your name for the record. Yes, Susan Barron, Executive Director of Green Mountain Care Board. I just wanted to comment on which section it is here. Section 3, where the board is at section 2 about specifically the language on. The board shall submit a report to. No, not the reporting, yeah, report contracts with designated and specialized service agencies. Just clarification on detailing any actions the board has taken involving contracts executed between the designated and specialized service agencies and accountable care organization. I would be concerned of interference of contracts with those agencies. We are certainly made aware in our budget process of the work of the ACO. So, Nate, can I come back to you with an alternative language? Well, I mean, the goal is to really understand what those relationships are. So we don't want to know that there are five different contracts with one organization. We really want to know how they're put in place and what that means for access to support programs by people. So we are looking for that. It may be more. Yeah, could I offer some language for that? I think it's a perfectly acceptable ask. It's just a wording on it. What about detailing the components of any contracts executed between the DA's, SSA's, and accountable care organization? So that would talk about the contracts and the type of contents the contracts. But the specifics that could be private, I would think. Yeah, OK. We're getting a conversation going. So we'll see what you want to say. Maybe if you could clarify exactly what you're looking for for one care. Maybe we can offer a letter instead of going to the Green Outant Care Board. Right. Well, I think it's a Green Outant Care Board has that responsibility of looking at this stuff anyway. So I think the goal is to really understand the extent of services that are being offered and how those contracts are put in place, what they mean. And going to the board rather than the ACO, I think it's the right thing to do. We have the ACO submitted to us. Well, you're already getting that information. And you can do it cooperatively with the ACO. We're not asking to have all those contracts laid out in black and white. But we do want to know what exists and what services are being offered. Because we're trying to move this whole thing forward. We do not want to get in the way of that. But we do want to know what's going on. So if we get caught between a rock and a hard place. So if you want to offer something and if you want to get together and make some suggestions, go ahead. That would be great. OK, thank you. Because just to clarify, at least my perspective is that the ACO is together as an organization is doing really good work. And it is an independent, private organization. But there are elements of it that include state dollars. And so we want to know that we are benefiting from our investment. That's all. Yeah, I think that makes sense. OK, OK. Thank you. That's a tricky place. Look at USTURA. Right in the contrast. Oh, look at them. Jill. Hi. Jill Olson, Executive Director of the BNAS in Vermont. I had two comments. One, I think picks up on something, Senator Cummings, that you were saying, which is in the report on the Dulce program. We've also got a program that is federally funded for nurse home visits to prenatally and then 18 months postpartum. That was the program we had a lot of talk about, right, about this time last year. That's the New Zealand model that you talked about. Australia. Australia. We have like oceans. We have different accent. Yeah, right. So it's not the one we had that we ditched that now. That's correct. We ditched the nurse family partnership. And now we're using a different model. And but that program is federally funded. And the caseloads that we are serving are entirely dictated by the number of dollars that we're getting. And so there has not been, to my knowledge, an evaluation of whether we have waiting lists or whether there's a need that's not being met. And so it seems to me that as long as you're looking at this issue, that it may be too early. And I would want to, we could chat about that. But I don't want the Home Health Agency nurse home visiting program to get left out of an examination of how those programs are going. Because they play a really critical role. That to me is important. So we should get an update on that. Yeah, I think an update on that one. Yeah, we're not looking for the mile-long report. No, I don't want the right one. We can. I'd like a bullet. Yeah, I'd like a bullet, too. And then I had another comment. And I may just be misunderstanding the language. But in section one, where you talk about describing, supporting the very last line, supporting the inclusion of these Medicaid services, meaning home and community-based services, and the definition of the all-payer financial target services and subsequent agreement. So if that means that we take risk, I don't want that. Because I'm very concerned about very underfunded home and community-based services moving to a risk-based model. Nobody's talking about that right now. And that's how it reads to me. That we would potentially be asked to continue to shrink when, in fact, under this model, we should be growing and suggest that we would be taking risk. And we are very far away from being ready for that. Because our margins are so small. And there's not a lot of room, really, in our capacity for that. So I'm not sure what's intended there. But when I read those words, that's what I read. I just like that. It's a plan. And it's a plan to strategize how to include the delivery system efforts so that in including home-based services. Right. But you said it says all-payer financial target services. That's where I see that we're going to be in the financial target. I see risk in reducing our budgets, not growing our budgets. We're trying to reduce the hospital expenditure and increase the community expenditure. Let's give Nina a chance to respond to that. We are required by our all-payer model agreement with the federal government to submit a plan that addresses how Vermont would propose in a subsequent agreement to coordinate the delivery of these services with all-payer financial target services, the total cost of care. That plan is something that doesn't have to. The plan is a process that we have to undertake. And Vermont's plan does not have to. Our plan may be that the plan that we propose to see MMI is going to be based on the readiness of our system and not necessarily incorporating everything that they are asking here. The readiness of our system, including our financial capacity to accomplish those goals. So in that sense, it might actually help home health. If the federal government were to learn that we need more money, I don't. Because no, I don't. No, they're going to say in the overall that they want us to cut money. It's in the individual that she wants. She doesn't want to get caught up as the individual. Could I suggest that by removing the last sentence, doesn't change the meaning of what you're trying to get from the Agency of Human Services? So the last sentence is just. But just one who knows that the agency will be putting that into their proposal to the other report. And that's already a place we are going to expect to be. Yes. So we are required to work through this process and where we arrive based on that. Yes. All right. So if we look at our base Medicaid funding. Well, we're going to do that when we're getting into the budget. That's one of the things we actually must do. Can I ask a question? Yes. Just before you go off of this. So it sounded like the committee was in favor of adding language about the home visiting. Is this mesh? Yes, it's not. We don't call it that. I can talk to you offline. I have a strong family. It's from Australia. I don't know. I was not that happy to see. OK. This is a mesh. There's a mesh in here. Yeah, I can talk to Ian and I would just suggest some language. Which maybe that would be great. OK. Yeah. So. Good. Good. OK. Oh, I'm sorry. Yes. Follow Shelly on behalf of the Parent and Child Centers. Just looking at this current draft, we would request that the Parent and Child Centers be under Section 2 with a report about statewide contracts. Similar language in the original introduced draft included the Parent and Child Centers. And you heard from Claire Kendall earlier about the fact that contracts right now are not statewide and integrated with the entire network. So I think that would be a good opportunity to hear about how the integration is happening. OK. Right now, most of those contracts are through the Dulce Project, which doesn't cover the entire network. How did that language get taken out? You said it would have been added in earlier? What was it for in the original bill? In the original bill, which is slightly different. No, I agree with that. I think that should be in there. I do. And I know that there are those who disagree with that. But our whole goal has been to utilize the services that exist in the state, and especially the Parent and Child Centers. So am I adding the original language from the bill as introduced back in that maybe we want to narrow it down given the scope? Including, I think, where's my section? So the language in the bill is introduced so that there would be a record from the Green Mountain Care Board evaluating the manner and degree to which social services, including services provided by the Parent Child Center network, DAs, SSAs, Home Health and Hospice, are integrated into certified ACOs. And then the evaluation shall address the number of providers receiving payments through one or more ACOs, the extent to which any existing relationships between social service providers and ACOs address trauma and resilience, recommendations to enhance integration between social service providers and ACOs appropriate. Well, maybe then, if your workplace would take the effective heritage note. Yes, put this back in. I know that we're going to have a disagreement around this. And then do we still want the existing section 2? I guess I'm asking, do out both sets of language, or does this from the bill as introduced replace what's in draft 3.1 section 2? Let's look at them together, and then we'll make a decision. I know we only have one more day, but we do have a little bit of time to look at those together. So I'll include them both in the next draft. Just to speak for my afternoon. Yeah, it's hard to. I can't answer that question. I'll see you in a break. In the section 1, on the presence of financing, should we say that the report should go to professions, too? Oh, yeah, put the report to a provisional. OK, well, yeah, because I think it's coming in during. In section 1, section 2, you don't need the section 1 specifically in English, so by the end of the season. Stop it. And what about the language, and the bill is introduced, the integration, the ACOs? We'll hold off until we see it together. OK, yeah. Anybody else want changes or suggestions? So here's what I think we should do. There are people in the room who need to talk with one another and help us as we formulate this. So I'm going to suggest that you do that and get your information to Katie within the next few minutes. I can't see it. We're going to have to do it this morning sometime. We're going to have to get the information. And then we'll see where we are if we can look at a draft later this morning or we'll sink tomorrow. Sure, I have to be at another committee at 10. OK. So I have 25 minutes of social distancing. So I think it sounds like there are a lot of hallway conversations going on, and that would be helpful to us. Thank you all. I appreciate your time. And I know that we're going to hear comments from people about the draft, so maybe just take a look at it. The difficulty of doing what's in the bill as introduced is that it's difficult. Cancel. That we went around and around. It's really complicated. And so if you tell the insurance company to go ahead and do the simple bill, then they're doing it. If you tell the hospital to go ahead and do the simple bill, they're doing it. And tell the patient to do that, they're doing it. So there is no simple. So we need to pass this off. I know what a way to do it now. I think it's a way of doing it. Yeah, we are way of doing it. So we can't share that. Why are we doing any? Because people are concerned that they are getting bills laid or that they're inaccurate. So let's see if there's a way to smooth that over. The other thing is that the federal government has asked for hospital transparency, and the hospitals are already in the process of trying to post that. So we'll look at that when it comes back. Blue Cross and Blue Shield already has billing information, the charges for their patients. You can figure out what you owe. Yeah. So is it the patient's responsibility? But once the hospital posts this stuff, then the patient looks at what their premium offers them. So it gets to be. More complicated than that. I've said this before, but the things I get about this, when you get to have Medicare, and you have a supplemental, and then the supplemental company is out of state, I don't know how we do anything about it. Correct me if I'm wrong. I'm looking at Susan and Sarah. We don't have the out of network problem in this state. So we've correct. That's all done. Right. The big problem's solved. That's the big problem. That's the big problem that was in the New York area. Maybe we should put that down in the bill and say, hallelujah, we don't have any problem. We are a model for the nation. Yeah, so. Yes, are you sure? But we did hear from some people in groups that are very concerned about this. So I don't think we can ignore it. I don't think we can ignore it, but I'm not sure there's anything we can do about it without making it worse. That would be unusual for us. I don't, we never make anything worse. It's like, it is a very complicated system. We have multiple insurers. We have federally regulated insurers. And state regulated insurers. And we have hospitals. And inside the hospitals we have, and we have offices. And when we have some place, some poor individual, that decides on a code or makes a typo. Yeah, and somebody's bills get messed up. And yeah, that's a problem. It's a problem for everyone. But I'm not sure you can fix it. Humans aren't perfect. And I just don't want to make it worse. Yeah, no, I don't either. And so, yeah, big systems out there. Now we were working, at one point, going to a common code. Common codes, which Colorado has done. And Mark, we will. We were working on that. That's a true system. And so I don't know if we have all payers claim database. They didn't ever get there. So that's what the first section was about. Okay, so we're gonna leave that for now. Sorry. We'll come back to it. We're scheduled to come back to it after at 1030. So I think we have to end here early. So do you mind coming up? I just want to talk about what we heard yesterday and to get some clarification on the Prop 5 proposal that we have. Whoops, I forgot to put it on the folder. So, Bryn, thank you for all your help on this. I have a couple of questions. So if you all have your Prop 5, well, we have an alarm. I have one that's marked up a little bit. If we were to go through the Constitution and look at the articles of Constitution that are in there, would there be some that have lead-in sentences the way our article does? So, I mean, one of the concerns we heard from one person yesterday and I'll clarify that concern. One of the concerns we heard was about the first sentence in the article, the article being entitled Personal Reproductive Liberty, but then the first concern was that that first sentence might stand alone and give offer sort of controversy or allow for a lawyer to argue something different from what our intent is. So for the record, Bryn Hare from the Legislative Council, I think that you may have heard from the Attorney General on this point yesterday. I wasn't in the room for the entire hearing, but I would just point out that a court or a judge isn't going to take one sentence out of the Constitution just like they wouldn't take one sentence out of the statute and interpret it out of context without looking at the whole article. So I would just point out that the article has a title that indicates what the article is about and the remainder of the article makes it clear that the article is there to protect personal reproductive liberty. And again, I think we talked about this the first time I was here to talk about the proposal five, the way courts interpret constitutional provisions is to look at the provision in its entirety and the court will look to a legislative intent from the record, including the purpose section in interpreting what the legislature meant by that. I guess. Okay, go ahead. No, this is our opportunity. I've heard, I think you were there for the discussion. Well, I was going to ask the same question, but go ahead, Seth. Yeah, that one lawyer said, I was a lawyer, I find that a lawyer's dream, you know, to determine your own life's course and I could take that sentence and apply it to almost anything out of context that they could, my example was the 14 year old who wants to get rid of his parents who won't let him do whatever or the 16 year old. I mean, I should be free to because the constitution says I had guaranteed the right to determine my own life's course and wasn't sure that it was necessary to the proposal. Did I get that correct? That was the argument. Well, or how was it necessary? How was it necessary? Wasn't it, but how was it necessary? I think the explanation for how it's necessary can be readily put forth, but then the question would be, would you take, would it be, what would happen if you took that sentence and you said the right to personal, right to personal, to terminating, to reproductive autonomy, including to somehow to say, determining one's own life's course. To add it into the sentence. Yeah, to add it into the sentence is central to what does that do? Makes sense. This is a bad question that's not only coming from the testimony, but we've also talked with other senators who have expressed a similar concern. Some of those senators happen to be lawyers, so we will listen to that. I think if we want, what we want to say is reproductive autonomy is a right under the Vermont Constitution. We don't need the first sentence at all. Go to the right to personal. Let's debate that. But the other thing is, I gotta say, man, I raised this yesterday and I don't wanna keep beating the same drum, but I'm not entirely satisfied that we're sort of resorting to originalism. The argument that the court would understand the context in which the language exists and they go to, and again, I wanna say, I think the Brigham decision and the Baker decision were both correctly decided and I think they were wonderful improvements in the laws and the quality of life in Vermont. And I was proud to do the legislation that they required, but they were certainly not respectful of the original intent. The original intent of the Common Benefits Clause was to calm down the political enemies of Iran. I mean, we know this, there was a lot of people in Vermont thought this whole convention when Zerder righted new, the Constitution was applauded by the Alans to rip their neighbors off and get richer. Okay, Senator, I want to know. The issue here is whether or not how that first sentence improves our understanding of this piece. And I will say that some of the testimony yesterday was very compelling in that area. For example, when one has family planning and decides whether or not to have a child, that for a woman can mean the difference between continuing the professional career or not. That it can or earning money sufficient to support her family. That is an extremely important part of determining one's life course. For me, that is really, really important. So, I know that there are those who would say that this sentence on its own could be taken to have different meaning and be interpreted, but I have to listen to Bryn again. So, would it be, is it possible for a savvy lawyer to pull that out and make an argument for another cause? I think, without commenting on whether an attorney could do it, commenting on would the court take that as a legitimate argument based on the context in which the sentence can be found, including the fact that the article is titled Personal Reproductive Liberty and the remainder of the article is about a specific rate. So, I think it would be a tricky argument to pull off. A very tricky argument to pull off. That's a good, that's a quote I can make for you. Well, let me turn it over. No, this is very helpful to us. So, but it has become kind of been elevated to a concern that we've heard. Constitutional language tends to be very terse. Okay? Our, under the U.S. Constitution, our rights to free speech are a very short subordinate clause. That's all. It's after the freedom of religion is common, nor abridged by speech. Common. And then it goes on to other things. It says, the Constitution works best, I think, when it says what it means and nothing else. The Second Amendment is unusual in the U.S. Constitution in that it does explain itself. Not only shall the right to bear arms not be infringed, the reason is because of the necessity of a well-regulated militia. And that is, that's an endless debate as to what that means and how that applies. I think we do best when we just say what we mean and leave the rest to them. I think we do mean that a woman gets to choose her own life, of course, and that reproductive autonomy is directly aligned with that ability. Because otherwise it's a very sort of clinical medical procedure. But what we're really saying is that we want women to have the choice about when and where they, you know, what time during their lives they have children, whether or not they have children at all. And so I do think it's actually a larger right that we're trying to assert. But in planning it gets to the use of contraception. And seriously it does. And it does goes not just to the woman, but remember also to the woman. Again, I agree with your reasoning as to why this right should exist. But you don't necessarily need to write the entire argument into the constitution. James Madison wrote voluminously on separation of church and state. He wrote voluminously, but all the First Amendment Congress should make no long regarding the reception of religion or limiting the free exercise there. That's it. The argument for it exists outside the constitution. Okay, so looking at this article, would it be helpful to talk a little bit about the genesis of the language? Yes, it would. Thank you. So in crafting the article originally we talked about rooting it in some of the United States and court jurisprudence finding the right to abortion and specifically the nature of the regulations on that rate. So the court in Casey and reaffirming Rovers' way describe the centrality of the decision of whether or not to bear a child to a woman's dignity and autonomy, her personhood and her destiny and her life's course and her conception of her place in society. And then there was some additional language. I think that the attorney general mentioned yesterday that came from the Justice Ginsburg's dissent and the Gonzales versus Cargher case in which she concluded the legal challenges to undo restrictions on abortion procedures. Don't seek to vindicate some generalized notion of privacy. Rather, they center on a woman's autonomy to determine her own life's course and thus to enjoy equal citizenship, et cetera. So I think that the idea was really to play some context on the nature of those regulations that would seek to restrict the rate. So basically what you're saying is that this was lifted in large part right out of that broken way decision in the language that was laid. It's actually the Casey Courts interpretation of Rovers' business. Have we got that? Yes, today. Yes. Again, I mean, I'm not disputing any of that language. That makes good sense. My question is, doesn't belong in the Constitution. The Constitution is not a discussion. It's a tower of constitutions. Simply debates. I don't see this as a discussion, Senator, so we're going to have to disagree on that, but I want to listen to my friend have to say, it's not a discussion. I mean, one's life course is pretty clear that if you choose reproductive liberty and you choose to have an abortion or you choose contraception or family planning, that is your life's course from that point on. No, as I said, I agree with that. So when we argue for the constitutional amendment, that belongs in the argument. The question is whether it belongs in the Constitution. Well, a life course belongs in here. That's one more short sentence. I'm sorry. We were working on that seven, and I had to stop, so I missed something important. No, we all stopped. No, I make my argument again. So, I mean, the question for us and for people who are around the room who have worked very hard on this proposal is how to deal with that. And that's a political question at this point because it's not people who have taken testimony. It's people who are looking at it differently from the way we are. So is there a way to incorporate that sentence into the article without losing meaning? I'm asking you. If there's a way to incorporate the sentence into the article without losing meaning. But fighting to make it one whole sentence. And whether that works or not, you know, it very well could work. Yeah, I think that could be... I have a suggestion. If you don't want... Before you have a suggestion. Okay, go ahead. Go ahead, make your suggestion. Sorry if I'm annoying you. No, you're not. I was going to follow up on... Actually, what my job is, I think this is what we do here. Senator, I was following my question of friend. But you can interrupt me and I'm happy to have you make a comment. I didn't think I was interrupting you or I was answering your question. I think we could do away with the period and put in a comma and change between the first and second. Hold on. I'm just... I had the text in front of me. Good God. Does anyone else have the text? Yeah. Thank you. Yeah. Okay. The people being guaranteed the liberal indignity to determine their own life's course, comma, the right to personal reproductive incentive. Ooh. That's good. I'll have to ask our word master. I think that... I think we could do that. I was also thinking the right to personal reproductive autonomy is guaranteed and the liberty and dignity to determine one's own life course and central to the liberty protected by this constitution. Oh. That I worked to. That's the second thing. Yeah. It puts reproductive autonomy first, which doesn't make sense. So what do you think about that? Actually, I like the broader thing first, setting the constitution. Okay. So we have two choices. The people being guaranteed the liberty and dignity to determine their own life's course, comma, the right to personal reproductive autonomy is central to what they go on. Yes. And could you give yours? Can we look at both of those? That would be nice to see. Yeah. That would be helpful. If we do anything, it has to be a formal amendment, right? Yes. We cannot miss out words, Smith. We can strike all. We can do it in the... We can strike all. Once it's... And so there will be a... The people will see... We can strike all. Okay. We can't strike all if someone brings us an amendment. Right. They have to... They have a certain period of time to come back. Right. So we also have another... Is it okay to bring up another... You know, that we got testimony from two different sources to actually insert the word abortion in the purpose? Right. Okay. Hold that thought and remind me where that is. That's important. So let's help Bryn then. Senator McCormick's suggestion was to put the sentence first with a comma. And then, Bryn, you had something after autonomy. Yep. So I can bring those in. Right. That would be really helpful. I'm going to be back. We need to see it. Okay. That would be good. And then we need to have others comment on it. Would you like that this morning? Are you planning on possible? Okay. Yeah. If we can get it this morning, it would be good. My plan is not to pass this out right away. The plan is to have us go through our discussion based on the testimony that we've heard. And then let it sit. We do not have to meet crossover. But we do have the information in our heads now. So we want to work on it. If we just replace the period with a comma, is that grammatically correct? That the people are guaranteed? I think not. I think we'd have to do a slight more change as well. The people being guaranteed. Yep. And if I understand the concern, that that first sentence could broaden the scope of the article in a way that you do not intend. Right. And this confines it. This makes it a subordinate clause to the right to reproductive autonomy. So instead of just standing on its own, it's sort of like the well-regulated militia. This is explaining why this following clause is there. And that has never been debated. Sorry. I'm sorry. Over that. Okay. All right. So then we'll get that. And then Senator Ingram, you had something else here. Yes. We heard from both the attorney general and... I think it was the ACLU. ACLU, yes. Thank you. The word abortion actually added to the... I think it was in the... Yeah. The right to reproductive liberty, including the right to abortion, is central to the exercise of personal autonomy. Yeah. I would agree with that addition if it makes sense to include that specifically. Can I ask a question? I think we all heard that. Oh. And I think we had talked about that earlier. I was missing. Yeah. Oh, you were out of the room, Senator. We heard from the ACLU. So you both had an opportunity to listen to the... Yeah. I will read the text to you. As long as we could go with that. She was only up to a little bit. Absolutely. She missed the attorney general. Okay, so we're in the other question that sort of arose from the conversation with Senator Bloomer was about the purpose of the purpose and whether the purpose is included when it goes on the ballot. No, it is not. It is not. But what purpose does it serve then? So as he mentioned, it is a relatively recent addition to constitutional amendments that are under consideration. And my understanding is that the purposes of the purpose section is first for the senators and they're putting the article in context and their consideration of whether or not to pass it. And also as for a court to refer to to glean some legislative intent on the addition of the article. So a court will look to the purpose section and interpreting the article. And also the people who are considering the amendment to pass the amendment will also use it in their consideration. So where does it go? I mean, if it's not in the Constitution itself and it's not... where is it that the courts can access it? Would that then be in the journal? So it's a part of the legislative record? So just like they can access the record of this committee and its consideration of the amendment, they can access the original proposal of the amendment. Okay, so it's in... Whenever we do a bill in here, they have our findings even though the findings aren't in it. Because it's a part of... And they can access any spoken word if they so desire. Just like the findings are part of the final act that is passed, it's the same for constitutional proposals. That's important to clarify and that it does not go to the voters. So the only thing that goes to the voters is the article itself. And there's some statutory lead-in language that will also be a part of that. Who sends it to the voters? I know that the governor makes a proclamation that it's coming, but then who puts it? Is it the Secretary of State who puts it on the ballot? Yes. Let me just check. I think that it's in one of the handouts. My understanding is that the General Assembly has to issue a resolution to send it to the voters and then it's the Secretary of State who puts it on the ballot. That happens in the next by any rate if this passes and that ensues. And then the other... I'm sorry, one other thing is that the Secretary of State has to publish about the amendment in two, I believe, widely circulated newspapers for at least three weeks prior to the general election. This is such a thing as a wide circle. You took the words right. I apologize. It's actually a general circulation not a wide circulation. General circulation? At some point we're going to have to... We're going to give it a shot. Let's give that one to GovOps. Okay. That would require a constitutional amendment. Isn't that the Constitution that says... No, it says... They didn't have generally circulated newspapers. They had Paul Rear. They had Paul Rear. Well, it says newspaper. Yeah, they had newspaper. Okay. More partisan than Fox. Crazy bonus. The reason I ask these questions is I get questions about that. And even though it might be two or three years away if and when this would go forward I feel... I don't know. It's nice to have some inkling of what we should be doing. Yeah. Okay. Is there anything else from the testimony that we heard yesterday that was important for us to sort of read? I think that just... The wording. Just a wording piece to be... Out for clarity. So let's look at that. And we are the committee that's always ahead. So if you have time... I do. I have a little bit of time so I can go and do that right now and bring it back to the committee. That would be helpful. Excellent. And then while you're gone you can leave now. I don't know if you're... While Bren is gone Katie has miraculously brought together a new edition of S7. So switch gears briefly if she's available. Can you see if she can come down until... So Katie has a new draft with the choices in it for us. We're back to... We do need her here when we talk about... And she wanted to be here. Yes. If she can get here but let's go through it. Let's look at it. Because I want to get ahead of people who might want to be involved in the other bills that we have. Is that draft 3.1? Okay. It's draft 4.1. Okay. Refresh. Katie, I'm drawing here. Refresh. I've got it right in front of me. This is 3.1. 4.1. And it's all highlighted. You're getting a copy. You got it. Oh, you have it. So the section 2 is the base section of that or that. So let's just go through that. So honor before September 1, the Green Mountain Care Board shall submit a report evaluating the manner and degree to which social services including services provided by the Parent Child Network. So this is the language from the underlying bill provided by the Parent Child Network. And the evaluation shall include the number of providers receiving payments, the extent to any existing relationships to address childhood trauma resilience, and then recommendations to enhance that integration. Okay. That's good. We're looking to move forward. That's the old one. That's the old one. No, the old one is the first one. That's the old one. To the new one which was the Green Mountain Care Board shall submit a report and to the Senate, the services offered by contracts executed between okay, so the first one is broader. I like your first one. It's very detailed. Yeah. I like the first one. There's too much wiggle room in the second one. Okay. So we'll go through it again with Katie because we want to trust our lawyer. Are there any other changes? Folks around the room happy with it. They might want to make a comment. Are there any other shaded things? Yes. Section four. Section four. The service provider. Okay. Okay, 1130K, you'll be down. So let's just look at what's here and then we'll see if you can finish it. Nice to see you too. Looking at it, I mean. Strong families from long years. Care partnership. The Director of Travel Residents and the Director of Maternal and Child Health shall submit a report to the health reform oversight. So this is in October. This is between sessions. The model in which a social service provider is embedded within pediatric care practice including recommendations for further development and expansion of the model and then including the CHINES report and the strong families for non-nursional business programs. Okay. We'll have to talk about that with Katie. So I don't read the words. I read the words but I helped write the words so I think it's okay. So we'll come back to this at 1130 when Katie is here. And we can't go anything else until Jen is here. We're going to look at the bill that Katie redrafted at 1130 but it's online and so look at it and then shake your hand, yes? Thank you, Senator. Okay, let's take a little break. We'll need a little break. We'll be back here at 10. Okay, Jen. Oh, Brent. We can't have one, we'll have the other. Do you have something for us? I have some copies just enough for the committee. Yeah, good. So let's do this. Why don't we hand them out and look at them and then we will come back to them but not probably not today. We need to sort of deliberate a little bit on what's here. So for the record and legislative council I just put three options together. The last one I think is representative of Senator McCormick's language and the first two are some other options that incorporate that first sentence and have effect. Okay, so there are three different proposals here and why don't we just think about the one that's different so the middle one doesn't have life's course in it, right? That's right. So the first one sort of tries to incorporate almost the entirety of the first sentence into the second sentence and the second option there instead of using liberty and dignity to determine their own life's course changes that to the right to personal reproductive autonomy essential to the liberty and dignity of self-determination that is protected by this constitution. Okay, either the first two because they don't the first one says that you're guaranteed the right to determine your own life's course and that's what was getting us into issues to taking the light off of that and making it important. Okay. Either the first two I think work. Okay, so let's do this. Thank you very much for putting this together. So let's keep our minds thinking about it and we can come back to this probably not until next week. We'll schedule it in for another discussion. Give us time for reflection and then we can deliberate further. Yeah, this is great. I would ask as courtesy of nothing else that my suggestion also be added to this. It is. No, it's not. Well, not exactly. The third one is closed yet it's not exactly closed yet. The end therefore. Yeah, and therefore sounds very constitutional. So I was endeavoring to make it grammatically correct and did not I didn't know you're exacting this. If you would like to tell me exactly what you want I can include it. Okay, do that. We should put that down. Is Jen Carby out in the hall? If he feels like it. It's not his job. Right. I can do it. We know where she is. We have to have a conversation about this. You know, I've tried it for years. You know, we've got all morning meeting in the morning and I get in the afternoon and here it's even worse. You know, I've got all morning meeting in the morning and here it's even worse. Okay, Brandon, do you have Senator McCormick's? I do. And so can we get, before we post it let's get all of the suggestions and we'll put them up. But in the meantime we have a lot of thinking to do. As usual. And we aren't starting S-31 until Jen is here and Katie is coming back at S-30. So we are scheduled. A new draft of S-31? Yes, we are. It's not a draft. But there's some language. Language. Yeah, that's right. Yeah, I'm going to do it. Somebody's got to do it. We should have a recommendation. I am going to see if I am slightly looking at this and once we really need to give them any more work we're getting to a point there. Could be coming up personal research library. No, when you get down and you say we want common codes and we want it published and we want to know exactly what everything, well the fence have already said that. I know, the fence have their language. We could say go do what the fence said. Okay, good. Thank you very much. We don't have to do that. No. I'm sorry. I just went through and said not doing, not doing, not doing. It is important and it is very frustrating for people when they either don't get a bill, they get a bill late and they get that surprise. It's already and the fence is not having a fence are actually doing something. I'm not sure we can fix it. And I think we're blocked to fix it. And if we're blocked to fix it we pile so much on the green on the trip. Or should we buy more? They want to do this. They can do it. They don't need us to tell them. So let's at least we'll pull up the line which I've done like that. Just telling them to do what we figured out and can't do it. Well, in the meantime, read it. It's dated 31319 and it is 1.1 and it is simplified. That's 31. So the other two bills that Jen is going to be talking about 53 and 128 53 is a bill that we've been through before and it is fairly straightforward. So we'll look at that and we may have to come back to it tomorrow. And then 128 is a new bill that just came in. If we get to that today just to go through it once that would be helpful. It is a bill I think that we could take up and pass but I'm not sure that can happen before crossover. It's a change in the licensure requirement for PAs. Is there a household coming over on that? I don't think so. I think it's going to be up to, you know, I don't know what's it. There's a lot of finance in it. I can't do licensing but I can. So we can talk about that bill when it gets here. Good morning. Hi. How are you? It's crossover. This is a popular person. So, Jim, we know that S31 is like one of the most complicated tough things that's to crack but we don't want to leave alone. We would like to see some simple things. You might want to use the issue that is so critical. How do you resolve it? That's the question. You brought us a new language to look at. Why don't you walk us through and we can talk about it. And then people in the room will be able to chip in here and there. We'll get to that. Jennifer, let's set a council. So did you have my post the language? This is some potential language based on a conversation with the chair. And this would direct the Green Mountain Care Board in consultation with interested stakeholders to determine whether how and what cost at what cost claims information from vCures, our all pair of claims database could be used to determine the actual amount paid for hospital services delivered in Vermont. And how that information could be made readily available to consumers of health care services in the state to help inform their health care decision making. So remind us what the vCures is the Vermont patient all pair of claims database. But not included in that are self-insured. Some are still including are choosing to be included. Some are not. So as a result of a Supreme Court decision from a couple years ago now the state cannot require administrators of self-insured business employer plans to report their claims data so we get some of it but we don't get some of it through voluntary participation and then you have it from all other payers including that. So now in states like Colorado or Massachusetts made in New Hampshire is an all pair claims database that has the hospital data explicit and you can show which one is more cost more than the other or charges more than the other. But that's actually which one costs more at the end of all the claims. It doesn't really tell you the individual assurance coverage. So I'm not familiar with all of them. I looked at New Hampshire's in New Hampshire and I don't know how they populate the information whether it's from their all pair claims database or a different source. But they do have it so that you can go on as any member of the public and look at the cost or the prices for different procedures at different hospitals in the state for five or six different insurance companies that may not be the same as an individual's actual experience depending on their own plan design where they are and they're deductible for the year. So it provides two different things. What the hospital charges or what they charge if I have paid right. I think it's based on the amount actually paid or the amount through the negotiated rate with the insurer but it doesn't necessarily indicate for somebody for different people. I don't know how it works with different plan designs in that state for example. What we were being asked to do to start with was to develop one simple bill so I know what Medicare is going to pay but then I got the Medicare supplemental that's somewhere else. So subsection B is getting potentially at that issue I want to look at that. We're clear that what's there. Subsection B of this proposed language would have again the Green Mountain Care Board in consultation with interested stakeholders develop simplified financial procedures for healthcare services that will coordinate processes between hospitals and payers without involving the requiring the patient's involvement and will provide patients to receive hospital services with a single comprehensive bill with a higher actual financial application. As we heard more and more about this right now some hospitals are have the financial services section and billing where they work with patients to determine what they're... They work with the insurance company but we're still getting surprises and we're still getting complicated bills so okay and then the final part and this is just a placeholder date I was trying to keep in mind your bill introduction deadline in the senate for the second year of the biennium so this would require on or before November 15th the Green Mountain Care Board to provide the findings and recommendations on both of those items to the committees of jurisdiction including this committee and the biennium. Okay, questions from the committee of Jen for any of the sections so the first section all payer claims database second section on structuring the billing and will November 15th sufficient time for you if a recommendation comes out? Probably I was trying to give them enough time to do their work and report back to you. I haven't calculated your actual bill How many things have we requested them to do this year along with things that they're already doing? Should we? Well we're going to have first report should be on report on reports We have to I know that So wait until Friday No, I don't So we'll go around the room and we'll get comment on this including that Senator the S31 we have talked about as a committee a couple of times and we understand the complexity within that billing procedure but if we don't do anything then nothing changes if we if we start to move forward on this maybe we can identify some things that will help people That's our goal So Alright So do you want to ask your question Susan Barrett in the city right behind you? Let's just all stay right in the room and then we can get comments because I know that everyone there are a lot of people in here are interested in making comments on this Again here So what if Susan Barrett Executive Director of the Green Mountain Board Would you like me to just comment on the bill? So the first section we actually did a report speaking of reports in 2015 section 21 I can send it off to your assistant and it looked it did a really in-depth analysis of other states and what they're doing using doing price transparency some of them do use their all-pair planes databases some of them do not the conclusion in this bill and this report was that the Cures was not the best resource when it came to price transparency and that there would be additional resources funding needed to stand up a system So I can send that over to No to utilize to create a price transparency system in the state and I don't want to misquote the number I have in the back of my mind three million dollars which was a lot but New Hampshire Maine Massachusetts Colorado Colorado has but they don't all use their all-pair planes databases some do some do not as Jim referenced I went out to look at some of them Colorado is furthest ahead in terms of having codes all analyzed and is there any benefit to following up and looking further at what they've done is there anything transferable there We are we're open to looking at what other states are doing and reporting back to you on that I just I don't want to commit to something that I'm not sure B-Cures can do So in terms of the language that's here using our database isn't adequate but is it possible that we could or you could the Green Mountain Care could build the board could build on the 2015 data and bring back some recommendations that might help us improve the billing system that we currently have I could look at the report and see if we could update it from 2015 I don't know if in this first section we can actually get you exactly what you want and I'm concerned about that but the question was would it be possible for the Green Mountain Care Board to bring us some recommendations for how to improve this whole complex issue? Are you talking more about the section B as well? Oh both of them, yeah I would feel more comfortable looking at at the information and providing recommendations instead of coming to a conclusion on exactly how you want to develop financial procedures as it stated in section B So how would you how would you change so how would you change section B to be more? I would suggest shall we study and recommend we want recommendations recommendations procedures or study and recommend options for health care services so instead of having that specific number because I don't I think we have to start at what we can get from D Cures because we don't have all of the data as Jen referenced Okay so we'll hold that thought but it's not impossible to get some information from you either based on the 2015 work that you did to build on that what other states are doing and then to provide some recommendations more specifically on the billing piece you could get something I could agree with that If I'm okay with that Alright I would ask you must be tracking the proposals that are out there around the legislature for us to because we spent the earlier part of this morning talking about other things for you to do and given the present workload of the Green Mountain Care Board and what we're adding could you and maybe you're not in a position to right now but some assessment of where the breaking point for the Green Mountain Care Board is Sure Good Because we can ask all of you Yes We don't want to break it I know Okay The more we do though in terms of reform and clarifying the issues that are out there the more we are going to have to come upon the regulatory body so it is difficult we understand and it's always the timing piece that becomes important And I'll just say we are willing to do the work I just want to be realistic about what we can what we have in our data source and what we can actually provide and I'd like to know what's realistic staff Okay Is there anyone else in the room who would like to speak to the proposal that we have for us? Don't have it in front of you but I'd like to just say something Go ahead It's online so and we're paperless but It's kind of hard to use a laptop if you're standing up Go ahead I don't have it on my phone Here she's got a copy Thank you Is there someone who has a copy we'll let Ginny take a minute to read it I'll just Okay What I want to say is just Fed ours is a capitalist society as much as I would love to see the same repair system that was well organized and set up that worked for everybody but particularly for citizens In this society I can get information to make all kinds of purchases and know what I'm getting into and there are plenty of people trying to get in the way of that I would love it if somehow we could figure out a way given the messed up system we have if I'm going to get a home monoscopy and that may be one I can get information on I don't know I can make a new forward decision even if my insurance is going to cover it as to where the best place for me is to get that When I go to the doctor's office for a shot I'd like to know if I'm going to get built for it or not and my testimony that I submitted earlier addressed that kind of issue if we're going to bring down healthcare costs somehow we need to know what things are going to cost and putting hospitals and insurance companies together it is the nature of things that hospitals are trying to bring in as much revenue as they can they need to insurance companies are trying to spend as little as they can so with that kind of arrangement I just wonder who's looking out for my interests and that there are a lot of other people older car monitors who don't have the ability to make those decisions for themselves because they have I understand that I'm hearing your testimony again I appreciate it I think it is very frustrating to all of us not to be able to go and have a magic of the silver bullet and what we've learned and all the testimony that we've taken is that what you are asking for is extremely complex and we would like to do that so we're taking a first step so if this isn't the right first step then we need to hear from you so I'm just asking that you review the language that's here and give us some positive feedback or negative feedback or suggestions I'm going to defer today and I know in our statutes 18VSA 9413 or something like that the hospitals have to post information we know that we know that the federal government has a transparency requirement now and then if we're also going to go to every single physician's office and have that posted that's another interesting complex process okay so anyway I'd be interested to know what the government here would come up with for suggestions as to what's available and whether I don't know that whether there's some way that you folks can look at other states and how they're doing it that's what we want because it's greatly frustrating if we could take Colorado and put it right here in this state we'd be done and we tried to do that a few years ago we looked at all of the codes we tried to get the codes in line we said let's do it but then we found out how much it was going to take away from our healthcare dollars and we said well let's look at what Colorado does so I'm hoping that with the report and recommendations that we get back from the Green Mountain Care Board there's something in there that helps us so David David Mickenburg on behalf of Cove and ARP I'll echo Jan's frustrations about consumer price transparency in the healthcare market but I won't talk about them specifically on this I don't necessarily have a problem with the language here or an update to the 2015 report we support the establishment of a statewide database and if you go on to Hampshire or Maine's databases it's really incredibly useful even if it doesn't say what your deductible is and how much just getting a sense that you can have a colonoscopy for $4,000 or for $400 depending on where you go is really helpful for consumers there are a few pieces of S31 which do not in my mind the underlying bill proposed amendment that they may be sent to collection seems like a pretty basic concept and I thought the testimony that we heard that one third of the members of the AFT union have gone in collections letters which is the union that so this is very helpful and remember this is only part of the this is only part of the bill so we'll go through the rest of the bill and identify those things that we feel are doable that's mostly what I just wanted to say there are going to be a few of those items which are far less complex for instance being told that you will be charged a facility fee just being told that you'll be charged a facility fee it prepares people for understanding the complexity of what the billing is going to be I need to understand something because I agree that's important but when we talk about a facilities fee how far does that definition go for a private physician's office for example a private physician's office has overhead for the facility within which the staff work so is that included in that so you want to break out how much I'm worth and how much my secretary's worth and how much my business manager how much my nurse's worth and then how much I have to pay in taxes or utilities for my office it gets complicated when we try to fix that what we're trying to do I don't understand it's a separate fee I know it's the Medicare my question is I paid it when I went in for my physical I paid $200 or my insurance or somebody did $200 facility fee because I get access to everything that UVM Medical Center has when they refer me to a dermatologist am I paying that fee again and no one has ever told me that and mine is just there's a slip on the receptionist desk when you check in that says you will be charged a facility fee it's not really bold print fine print it's not mouse print but it's you need glasses yeah I couldn't see it without my glasses I couldn't see bold print I can't see a stop sign I think the facility fees are specific to hospitals or a surgical center so we should have that a one time facility fee for your at least an annual facility if you return me to somebody else that's working in your system I don't think I should have I don't know if I do but no one generally told me they're very good about telling me what shots I will my insurance does or does not cover or they're in process of deciding if they're going to cover the pneumonia shots so and I had to sign and say if they did not pay for it but that one was new we want to know and I want to know do the hospitals or somebody else when the facility fees are imposed and when they're not and I'm not prepared to speak to it but I think there may be some more discrete standards at least that Devin or someone else can help you understand for when there is a facility fee maybe that's what we could spell out yes I think it needs to be transcribed whether or not it's five times or six times or one time then it needs to be stated that you're really sick and it's every time you're in trouble is it every time that Medicare is billed or is it every time it's billed once for that visit but if I'm in the hospital and I get readmitted three times in a year am I paying $600 for the privilege I think it's high procedures right so if you go for a colonoscopy you get charged a professional fee and a facility fee the next day you go get an MRI you get charged a professional fee and a facility fee and if the next day you go get a CAT scan you again get charged a facility fee and a professional fee that means a little excessive so can I jump in I'm sorry Devin Green from the Vermont Association of Hospitals and Health Systems the facility fee is a Medicare based billing mechanism and it is not done through Medicaid it is not done with our commercial insurance it is Medicare it's not something we can change and so I'm not sure what the hospital would charge it every time as David was saying every time a patient goes in for procedure so if you go in three days in a row if you stay in the hospital are you paying a facility fee every day I mean does it Medicare no it's procedure based and it's required by Medicare to be charged that way the federal government has taken steps to reduce that facility fee I believe it's being reduced by 40% by next year so that it's more in line with independent providers okay so that's the good news in the bad news for hospitals yeah no because the patients are not paying yeah Medicare is paying we're requiring it and Medicare is paying it yeah then why do we need to do that that's maybe that's why we're going are they dividing out the cost for the hospital and then the cost of professional service but has the professional service bill been lowered I mean it used to be you got one bill and it included your overhead now you're getting two bills something tells me the cost of professional service well so it would be important to have those posted because if you see an increase in professional services then the other one is going down that's curious yeah I'm not going anywhere but I just got a bill from the hospital and one was a professional bill and the other one says very much on the title facilities bill but that's lower head that's what you would get from that's what you would get from can you get a hospital bill and a physician bill and this is targeting hospitals this is just based on hospitals okay so we will look at is there another section of the bill that you felt was the ones and like I said if that one is too complicated for people to figure out then we can do the ones that are easier and less intrusive but certainly the codifying the two things, the two insurance pieces that are in rule seem to make sense since they're already in rule unless it's like so many pages they are in rule but they're sort of I think they're spread throughout the rule in a way that will make it so that I would have to codify the unfortunate of the rule and I'm not sure what the gain is there okay we could talk about that and if and how to do that I would like to hear another look just briefly to go to a report also that the board had submitted I think it was 2015 or 2016 and it actually lasted a couple of years where the board led by board member Holmes did a ton of work on provider reimbursements and bringing in this site neutrality issue just I think it lasted about two years and it did culminate in a report to the legislature and as Vaz has said the federal government is actually doing quite a bit of work on site neutrality so that there are less of those facility fees charged so I just wanted to add that as well are we getting into this did work two years ago and I know before that I was financed with the professional charges went up and then the practice got bought out and the insurance payments went up for the same doctor in the same building but that was over and above any facilities cost right? I can see where there's a facility if I'm using the facility and I can see where some insurance companies want to break out what the overhead is even for private practice and where you might pay a benefit because you have all these specialists you can easily access but this isn't getting into that just basic cost fee difference of what you pay an independent primary care doctor as opposed to one that works for a large research we work very hard on that for not sure how much progress right I don't think it actually has to be added onto a bill that went to that house and did not I wonder if we could look at that one I don't know if we have time there was important studies and you know it was H20 it was Colorado I mean I was part of that discussion very complicated and controversial I think from a consumer perspective focusing on the pieces that provide the greatest level of transparency maybe there's just one or two plus this language I think would be ideal just to as you say start to move I agree and I know it's very painful for a number of people but it's painful to people without it so I think we need to so okay so in terms of the language that we have for this section one area we're okay with that and Susan you're going to make some yeah I would I would work with Jen okay maybe looking at other states as we talked about and then reporting back to you in Colorado yeah I would just for clarification the Colorado work that was done a few years ago was not on this transparency piece it was on uniform billing code it moves in a great direction well I mean look at all the states I mean so so this is for MPP MPP can support what you folks are talking about is this proposed language with the ends that are we suggest if I agree with that we're good with that alright okay so let's try and move beyond the languages right in front of us and now go back to the bill in the sections that David had identified okay where's the bill I'm requesting it okay we'll hold off until she gets it hold off I did that you know just while we're waiting today is Einstein's birthday it's also Pi Day right Pi was referring to the number or the three number and it's my son-in-law's birthday my son-in-law's birthday was yesterday my other daughter my other daughter my grandson my grandson so we have three children born in the city is that what you said a grandson and a son there's a movie too we're having a live movie yeah you can do it okay I'm pulling it up okay okay we have it as introduced there was an amendment that was proposed but it's got to be fresh so let's go to introduce and then we'll go back to his okay I'm going to wait because it's not coming up yeah I have a question but if you search under on my bill yeah I hope it's got a bill go back I did I've got it and what's the number of that maybe it's easier to be a paper committee it's definitely easier to take notes okay does everybody have it no just go back to the way you get it says Thursday document we and hit Thursday again I have it wow if you can't get through there's really no okay a section two I do request okay let's look at that so we just need a bill what are the two sections David that you had identified and we'll go through the whole thing the one was the so the possibility of the center collections yeah just be sure talking about the person I think you said as introduced yes yeah it's on page two the bottom one on page two and to know if the dispute is we'll be sent to a court page two the patient has a right to receive an itemized detail and to know if the dispute bill will be sent to a collection agency yeah okay I think that's the first part of that it's great they're resisting law and that's easily posted can I just go ahead Devin Green from so the first part is already done the dispute of billing part I just wonder the language I wonder what the purpose of putting that on there would be when we want people to come and negotiate their bill and make a payment plan so is the language the dispute of bill that is a problematic what should it be late payments I don't know how to say it but I think that something about how collection will be handled would make sense but I think the thing is if we focus on the negative aspect you know the very worst thing that could happen up front and you know the hospitals work with people they set up payment plans when we were having the message being not to scare people after death that it's going to be sent to a collection agency that to say you know either say nothing or say we'll work with you if there are any disputes or questions that's always been my experience you get disputed bills and you call up and say so why did I get that no I didn't do that at some I can dispute a bill for a long time as a method to avoid paying it well some people do that I mean these things but I can and there are people who will on the other hand if you tell me up front your disputed bill is going to be sent to a collection agency I guess if I've disputed this for two years just because I don't want to pay it I can see then you can say alright we're going to send this to a collection agency and you need to tell me if you tell me up front you're disputing this bill and oh by the way we're going to send this to the a collection agency if we can't resolve it that to me is threatening I don't think that's helpful I don't think that's helpful at all and I'm trying to think it's just well there well everybody knows that anyway I don't think they know it at all so one possibility would be to add some language either instead of or in addition to in this provision to identify the patient whatever the assistance center whoever it is that will do the work with the patients so to say something like right to receive this bill to be informed of the availability of the patient assistance services and to know that a disputed bill may be sent to a collection agency if you want to include them all in there at least that way I think that's better besides the person who disputes the bill as a delaying tactic it seems to me there probably are some people who dispute a bill because they think they honestly believe they don't know it and that bill being sent to a collection agency strikes the case well how it's very unfair but they only do that as a last resort they'll work with people they would rather get paid than send it to a collection agency so they wouldn't be able to negotiate the work with people to help them pay the bill would fail but there are people who think they don't own the bill shouldn't that be settled before the collection agency well I think at some point it's going to be settled so if I understand that part of the hospital association's concern is that not every they don't send every bill to a collection agency they don't want to say every disputed bill will go to a collection agency they want to say we will work with you and if it ends up that we can't resolve this we'll send it to a collection agency and suspect in this at least in my small hospital most of the time they kind of and most of them so how am I what are we talking about for a whole field that they would send based upon that anyways and not get the collection you know is this a real case or is this from the New Yorker this from the New Yorker whoa did you ask him any New Yorker testing only from the nurses union of one third of the members had gotten collections notice so well they testified we as consumers we have discussions with consumers all the time who have repeatedly received collections the hospital association do you collect any information about how much really ends up in the collections versus what you do work with people you do send and bring association hospitals and health systems I would have to check on that we collect information on what is written off you know what is considered uncompensated care I'm not sure if we have information on how much goes to collection but I can certainly try to get I suspect each hospital has the individual information that some shifts a couple of possibilities I'll also just say that the IRS requires hospitals to have their filling in collections procedure on the website that has information about their financial assistance policy so if they don't have a filling in collections procedure already so my suggestion is here to go back to Jen's recommendation a little bit and to look at that and then end up with the May piece or at least that the process will be provided to the patient at the front if it's possible that it goes to collection agency that may I think somehow that has to be shared I think you want to share that the important thing is to let people know that there is a place to go to getting information you're getting home it's a last resort I had the constituent that called me that I know she went to the Green Mountain Care Board and the president of the hospital was there and they took care of her issue but she had gotten a bill and it was one of those things where she was her parents had had surgery and was going to the physical therapist on her own thinking it was $90 a visit which is what it had been and then whatever visits was $450 well, her physical therapist joined the hospital there was the fee she called the hospital and found out she wasn't financially eligible for assistance but the minute the president of the hospital heard her story she said come on, we'll work on this and got it fixed but apparently she did not know because the first thing I said to her is I'm still paying off my surgery it's so much a month this is what you can pay you just pay it every month and they will work a deal and that's what people need to know that it's not financial support you're not it is you can work out a payment structure that works for you that it isn't I pay it or I can't pay it and it goes to collection that to me is the important thing that people know is that talk to them and they will okay so we want to try and get wrapped so let's put that in and then on number 21 which is a facilities fee we heard there's an interest in having that in I do not know how to word that and it is Medicare but it's also a facilities fee that people get on the bill to help pay for the facility how that is sorted out with patients who are not Medicare patients but I think we're also hearing that oh everybody pays and I don't know if your insurance covers it if you're on a health savings account if you if you've got a high deductible do you pay that $200 fee if I go in for colonoscopy and a mammogram at an ultrasound am I paying $600 worth of facilities fees because I go in on 300 or three different days and if I did them all on one day would I just pay the one I don't think it's a daily rate I think it's per procedure I'm remembering from when we've talked about this in past years I think Medicare is the only one that currently breaks it out yes so the facility fees are included in the single rate paid by insurance it's under Medicare that they're broken out into separate fees so the same amount but a facility fee is still being paid on insurance it's just all in one comprehensive view but I am paying that under my deductible yes I mean that so when I logo when you pay your if you're still working toward making your deductible then that full comprehensive bill at the insurer's negotiated rate comes out of your power toward your deductible if I'm looking up and pricing colonoscopies and just going where my doctor happens to practice but decide for x amount of dollars I'm going to go to some stranger who only charges $400 does that that $400 include a facility's fee do some other hospitals only charge $100 am I going to think I'm getting a $400 bill and be really upset when I get a $600 bill for the colonoscopy so I think that the insurer billing is comprehensive is inclusive of the facility fee but the facility fee may not be the same from hospital to hospital mainly the difference that we talked about a couple years ago I think is the difference between the academic medical center and other hospitals yeah hospital charge for their open rate let me ask this question if we were to put something in here about breaking out facility fees facility fees that would be a whole new for private for non-medicare services offered that would be a whole new listing on the part of hospitals question I don't know what's going on now yeah isn't it not easy so can I ask the interested parties to work together and maybe there's something we can put in here that would be helpful so that we can get a breakout of facility fees I can't think of anything else to do with that at this point Senator Lange I'm the Vermont Association of Hospitals and Health Systems I just want to say again that it sounds like what you're looking for is a breakout of overhead from the hospitals and it seems a bit unfair to just target the hospitals with this that was my point earlier about physician offices they get paid because they have an office so hospitals so I don't know if we're going to resolve it but maybe you and David can have a conversation and we'll see if we can get anything out of this sure that would be good sorry to do that to you I'm not sorry just of course I will if we're trying to make a health care building more like buying a soccer ball or whatever you don't break down a facility I know your store has got overhead too this is how much the range costs this is the wholesale cost and making people do all that work to break that out I don't know how that helps consumers okay it just makes the worse if I understood you correctly David you're saying that it's Medicare that makes the hospitals that's right it's just Medicare so unfair or not yeah we're not judging that but they're talking about expanding it to every professional so I think the question that I'm hearing you've come down to is is there anything useful in breaking out the professional fee and the facility fee does that help consumers make any different health care decisions I think a couple years ago when we talked about this there was more interest in one comprehensive fee that didn't break out facility fees because consumers found that confusing and the idea was that the cost for the service should be sort of a holistic cost for the whole service that would include the overhead regardless of whether it was an independent practice or hospital based practice so I'm trying to figure out what gain you're looking to get I think that the one price is what I'd like I think the new thing is I've been going through the same medical office for years and I have been paying and I assume I have been paying their overhead they are attached to the hospital building but they joined UBM the last summer when I went in for a physical there's a note on the counter that says I will be charged a $200 facility fee that is something that came in new over and above the cost because I didn't notice the rest of the bills going down and saying in that that's exactly that's the point and I think you did pass language two years ago to provide notice to patients that their providers office was being affiliated with the hospital and that there may be some additional charges as a result and I have one quick comment we need to talk with Katie about S7 is there I know that there are people in the room who have come especially for S128 and if you would just like to I'll just forward to just say I'm a hot PA I live in Williston and practice a nice extension and thank you for considering the bill it's so important for healthcare for volunteers to have PA's be able to practice and to essentially update the legislation so that they're not failure readers and it's so PA's are part of the practice team with physicians and we definitely need to continue that and access is an issue across the state and we want to be there so I want to have the minutes that's it you did a fine job we will get full testability at a later date and we'll take the bill out we'll have to be after crossover but we do want to take that up do you want to have anything to do with that do you want to go over the the four points we'll look at the four points there's four short sentences good thank you both for being here there's probably other times do you want to add anything no thank you for being here we're crunched for time but we're going to take this up don't worry alright so Katie thank you Jim it's been a fun day careful careful thank you for coming here can you that's our Katie thank you I'm just hearing from Katie okay that's on it is it also works back on S7 and I've already gotten some more questions changes but there's so we're looking at our four point one and I've highlighted the changes left in the draft to help you follow along I'm ready to get ready okay so the first section is the language we looked at earlier today this is the having the Green Mountain Care Boards a bit of plan we've added house appropriations and senate appropriations on the list of recipients of the plan and you remove the last sentence of this section that had specific directions about the plan there's a little bit of disagreement about that language and it wasn't necessary so I chose to remove it section two there are actually two section twos in the bill because I wasn't sure if you wanted both or we were choosing one or the other so the first one is the language of the bill as introduced so this is a report the evaluation of social service integration with accountable care organizations this is language you have not looked at this morning so by September 1st of 2019 the board is to submit a report to healthcare human services senate health and welfare evaluating the manner and degree to which social services including services provided by the parent child center network DA's SSAs and home health and hospice agencies are integrated into ACOs certified ACOs and the evaluation is to specifically address the number of social service providers receiving payment through the ACOs and for which services the extent to which any existing relationships between social service providers and ACOs address childhood trauma and resilience building and recommendations to enhance integration between social service providers and ACOs appropriate so that was from the bills introduced and you'll see in line 12 of it and or I wasn't sure which direction you were going but we had looked at language earlier this morning that by 2020 the Green Mountain Care Board shall submit a report to this committee and health care and human services detailing and the changes services offered by contracts executed between the DA's SSAs and accountable care organization what would be wrong with putting that in section 2 as well um the department of redundancy so it sounded like when you sent folks outside to make a decision that there was a preference for one over the other so I kept them separate instead of combining them what does the committee think about it's choice this week I like one we all like one okay sorry there we go and you know before I keep moving I should go back so I mentioned when I started that I've already received a bit of feedback from folks looking for small changes so in section 1 there was a requested change to the date that this plan was due so my understanding is that AHS has to submit the plan to CMS by the end of December 2020 so is that right 2020 so this has them submitting it a whole year earlier so the request I think was to change it to December 1st I think January 1st November 1st okay November 1st okay so okay you just get started earlier so sorry that was the request to change to section 1 so that brings us to section 3 this was the director of trauma prevention and resilience the change here was on page 4 just adding the new responsibility and we did not make any changes to that when we last met. So that, I've left alone. Section four, this is- I was looking for the highlight, but it's- Yep, there's no highlight, that was intentional. Section four, this is the Dulce Conversation. Earlier we had, oops, there's some funny formatting. We can change that and send it to the editors. We had specifically referenced the parent child centers in the heading of this section because we've struck language talking about who is a social service provider employed by the PCCs. I've made a corresponding change in the heading to be social service provider. You'll see that that language about the employment has been struck from section four. And now there's language that on or before October 1st, the Director of Trauma Prevention and Resilience Development and the Director of Maternal and Child Health is to submit a report to health reform oversight and consultation with stakeholders and we've split it into two responsibilities. So the first is what we've already discussed, the model in which the social service provider is embedded within a primary care practice, including recommendations for the development expansion of the model in coordination with any proposals for a form resulting from the Chin's review. Jay, why the ointment? There's been some discussion about health reform oversight committee and there's a possibility it won't exist. Won't exist. Oh. That's so. In our committee. We might want to put this v since we're in there. Okay. And the other one that would. I don't know what's gonna happen this year but I know last year it was the subject of some discussion. Okay. So I could just say the committee is like we normally do or I could say the chair is because you're not meeting them, what is your preference? Oh, well, we want the whole committee to know about it. Okay, so we'll just put the whole committee. So every time the chair gets something then the chair has to distribute it. So we want to put everybody, I gotta share the reading. And the next piece, so the leading language was that you're requiring an assessment and in the new subdivision two, the Strong Families Vermont Nurse Home Visiting Program and the requested change there is to be Strong Families Sustained Home Visiting Programs. Say that again in the small family. The Strong Families Sustained Home Visiting Programs. Can I ask a question? So I know that in the budget adjustment there's a pilot program. How does that relate to this? No, it isn't a pilot. They told me it was the money to train. Okay. The healthcare piece. You're right. Got it. At least that's what I was told when I asked yesterday. Yeah, thank you. Good. Okay, so with those changes, so we pick number one from the first part on that. Was there anything else? Changes that you just made? Yeah. So you added, you changed in section one, when the report is due from January, 2020 to November, 2020. You've chosen the second of the two section twos. I'm fixing up format. No, the first one. The first of the two section twos. But yeah. You said the second one. I'm sorry. The first two sections. The first two sections. Yes, the first of the two section twos. In section four, we're correcting formatting. We're striking health reform oversight committee and putting healthcare, human services and health and welfare. And then page five, correcting the name to strong family sustained nurse home visiting programs. No. Strong family sustained home visiting. Strong family sustained home visiting. Yeah, no worries. Take the word nurse now. Thank you. But we're keeping Vermont. So let me check this. So this family sustained home visiting programs. So this family is just naming it correct. Just naming it. I'm not making it clear. Strong family sustained home visiting programs. So the email is accurate, okay. They're important to our lives. Because you've got it. It's accurate, yeah. Okay, great. Thank you. Thank you. In section one, we already need to submit the plan to CMS. And so I don't think it's necessary to require us to submit it to CMS on November 1st. The requirement from CMS is the end of performance year three, which is actually not November 1st. Yeah, I think CMS should take care of themselves. We shouldn't put them in our statements like you might. They might not be here by now. I know. That VBA, they'll be out. We don't need those anymore. We need some money. Well, there's that, but we're losing it. When you're good, you lose it. We should be Alabama and Louisiana. Now what, what you need to do is vote red. Is there anything else? Is this okay? I'm not gonna ask that question. Is this okay with the people around the table? Yeah. We're good. Okay, thank you. So the intent of S7 is not really to meddle, we don't wanna get in the way, but we do wanna keep pushing things forward. We wanna keep it on the front burner. That's what this is, and we need to keep doing that. And we really appreciate your time. So tomorrow morning at nine, we'll have this and we'll go through it and hopefully we'll be able to vote it out. And then 141, we'll look at this. That's a bill that we looked at last year, and I think we passed it. Can you bring us the language that we passed? Yes. So we can read that. And then we'll go through with Jen. I will try to finish S31, and we definitely will be looking at S53. So I ask you to read through S53 and any new language that shows up on our webpage. Should that happen? Okay. And this is the committee that's early. So what I'm gonna do is I might ask Jessica Barnard to come up and talk a little bit. Or do you wanna do that on S53? No? Sure, no, I'd be happy to. Okay, well at least do that because I know I was gonna ask you a comment when Jen was here and we didn't have time. So why don't we do that? So this is on S53 so we can pull that out. Thank you, Jessica Barnard with the Vermont Medical Society. Thank you for your interest in S53. So I just wanna say one thing to Auburn. You'll be very happy when there's a Director of Prevention so that they can be directed to do things. That would be great. Thank you. Thank you, no thank you. So as introduced, this is the bill about increasing the proportion of healthcare spending directed to primary care. And when we saw the bill introduced and George Joe Mejares who buys state primary care reached out to a number of us before when the bill was even still a concept so we've been talking about it since the late fall. And a number of us, of organizations and I don't wanna speak for anyone else around the room but a number of them are VOS and UVM, by state, one care, sort of chatted about how the bill was introduced, what direction we as organizations would be interested in seeing it go and we did share with Senator Lyons some feedback from that group sort of consensus we came to which was we absolutely want to build on the work degree mountain care boards already started and presented to this committee a couple weeks ago, looking at how much spending the different payers are directing to primary care. And we, at least our organizations would have concern at this point about building a specific target into that language. But let's really look at where we are and where that is compared to other benchmarks. So where are other states, where are other, if there are comparable nations, because we don't even, I think at this point, know what that number should look like and what that number determines. So we want us to really get that baseline. And then a piece that I'm, at least from my perspective, really interested in is what, having any analysis, look at the pros and cons of different levers of increasing primary care spending, because I think we wanna be careful about unintended consequences. We don't necessarily want, are we not necessarily able to cut spending on tertiary or specialty care, but how can, and if we do it through fee for service, what are the pros and cons of that versus can we do it through the way we're going with more bundled payments or capitated payments. So I think we really, as our organization wanna look at where we are compared to baselines and what might be ways about, we could go about increasing primary care spending and what's already underway, for example, through the ACO, trying to target more of that funding to primary care. So very interested in the approach. We had some suggestions and language in terms of the focus of the initial analysis of what we're looking at. So, unless it's overly complicated, we'll look at that tomorrow with Jen and make a determination if we can get something started and so that the other body, other body in the house can look at it Great, thank you very much. All right, thank you.