 Good morning, everyone. It is February 3rd. This is a joint meeting with House Health Care and Senate Health and Welfare. Representative Lippert and I will be guiding the testimony this morning. Let me just say that this is an opportunity for us to look at extending or not some of the flexibilities and deadlines that we had put in place during the pandemic in our bills. I think it was Act 40 and Act 40 and Act 91. Thank you. And then a little bit of 159. I was looking for the other number. Thanks, Bill. So as we're going through the testimony, I have a pretty heavy morning of testimony until 930. It would be great if you, if you have a question of clarification to ask that question, but let's try to hold any discussion and dialogue until we're back in with our own committees or maybe if we have time at the end. Bill, are your thoughts on that as well? Well, representative Lippert, sorry. Yeah, yeah, no problem. So we in the House Health Care Committee have been taking actually considerable testimony on the audio only issue that we received report from and I think many of the many of the witnesses today are we're part of crafting recommendations of not a completely consensus recommendation, but their recommendation. Senator Lyons, I'm wondering. So there's really, it seems to me there's two broad categories of question for us to look at in terms of extending deadlines. There's the COVID emergency legislation that we all crafted and worked on and updated. Many of which, many of which have a March 31st deadline at this point, March 31st, 2021. And then there's the audio only portion, which I think has a number of number of related issues. And so I just want to distinguish the two because our committee is taking a great deal of testimony on the audio only piece. And I'm wondering if we could, if it might be helpful to, when we asked witnesses to comment, to focus initially on the extension of deadlines generally. Good. This is a very good suggestion. And thank you for that. Our committee. If I may just, just, excuse me. If I may. And I know that you have had some language crafted, but one of the questions as well as if those deadlines are extended, which I think many of us believe they should be, but should they be extended beyond what point? Should it be what, what's the marker for the extension? Is it a state emergency of declaration? Should they be extended beyond what point? Should it be, what, what's the marker for the extension? Is it a state emergency of declaration? Should they be extended beyond what point? And I think if we could come to closure on that, that would be very helpful because I think we, I think that's something we probably ask, could we ask the witnesses to focus on. Good. Thank you for that. Our, our committee did, has taken testimony on some draft legislation, which is posted on our webpage. And Nellie, I think that's something that we should be able to, I think that's something that we should be able to focus on. Which is posted on our webpage. And Nellie, if it, if it, it should be up for today. So I'm hoping it's there. And you're welcome. I sent it to representative Lippert. It really is an enumeration of the flexibilities that we had in place and extension of deadlines. The draft legislation includes a three month extension for the most part. So the question about, is it three months or six months? Or what is the timeframe? You know, it, it, it will have to listen to the folks who are testifying and get their input on this. I think that will be very helpful. And then as, as representative Lippert said, our committee has taken less testimony on the audio only. And I think given the work that the house has done on this, it's going to be. It's going to be a house proposal that, that we look at initially. So we'll work, we'll continue to work together. You know, whether, whether, whatever goes from, from Senate to house and back is, we'll at least we'll try to gain some consensus as we're working along. And the other, the other last thing I, the last thing I want to say is that. We also will be looking at. We'll be looking at, we'll be looking at, we'll be looking at, we'll be looking at, we'll be looking at, we'll be looking at. One or two. A couple of provisions. I'm not sure how many that deal more with human services side of things. And so we may have some of those in the bill as well. And I have communicated with the chair of house human services about that. And we'll. Make sure that that's all coordinated as well. So we'll try to get it all together in one bill. And perhaps just to say procedurally, I think our goal unspoken perhaps, but our goal is to move this because of the March 31st deadlines are in statute to move a bill through the Senate, through the house or the reversible. However we choose to do it, but to move it through both bodies probably prior to crossover even, or if not very soon after crossover. And I've had that conversation with the speaker of the house who understands and fully supports, understands that this is a, this is a COVID emergency piece of legislation that needs to move as a priority and not be encumbered or have any, have the crossover be any impediment. So that's part of why Senator Lines and I are doing this joint testimony today to try to expedite both our committees and working to move this forward. Okay. Good. So terrific. And thank you all for being here. Why don't we get started with our testimony with Jen. Carby is first, but Jen, I'm, I, I think unless you have something to help us as we're looking at the information, we'll move on to testimony. Did you want to say anything first? Thank you. Senator Lines. Jennifer Carby, legislative council. I think just to sort of frame, again, your discussion for today, the provisions of acts 91 and 140 have, have administrative and regulatory flexibility that they provided during the COVID-19 time period. Some of the provisions expire March 31st. Some of them expire June 30th. If you are already tied to some period of time after the end of the state of emergency. And so the question for you is whether you want to extend any of the provisions that are otherwise going to end on their own. And if so, for how long. Okay. Thank you. That's great. In a nutshell. All right. So let's, um, let's begin with, uh, Lauren Hibbert, office of professional regulation. And as I, we, we each, each committee has the table that Jen put together on the timelines, deadlines, flexibilities. And now we should each have a copy of the draft legislation. I'm thinking that looking at the table might be the most expeditious or the simplest thing to do. So if you have that on your iPads or in front of you, that would be helpful. Lauren, welcome. Good morning. Thank you very much, Senator Lyons. Uh, for the record, my name is Lauren Hibbert. I am the director of the office of professional regulation. And there's some new faces here. Um, people that I haven't spoken to directly before. So I'll just say a very thumbnail of what OPR is. We are the regulatory oversight umbrella for, we're now at 50 professions. Um, importantly for this conversation, we oversee, um, healthcare professionals. Everyone except for the people who are regulated under the medical practice board, which are, um, Allopathic physicians, podiatrists, a few other folks, but, um, the majority of the healthcare professionals. In Vermont are regulated by OPR. Um, I want to say thank you very much for this bill. Um, in its entirety, it's helped us through an incredibly stressful time. Um, OPR has been, um, triaging, trying to help wherever we can during COVID. Um, and the provisions of act one 40 have helped us tremendously. Um, on the deadline extension, um, I appreciate the state of emergency plus three months, but I do have a preference to have it set out to a set date. And the set date that I think makes sense is a year from the March date. And the reason is I understand that may seem like a long time. Um, but in terms of communicating these emergency provisions and start in terms of setting up the operations to house these emergency provisions, it took considerable time and effort, um, and messaging and a firm date would be helpful in terms of talking to mental health providers to people who are in facilities. I think it's important to remember, particularly for the older people, that we have folks who are in big hospitals, um, and in local practices, but we also have a lot of solo practitioners, a lot of mental health practitioners, um, who are trying to navigate what is a very complicated thing, um, providing healthcare during, um, a state of emergency. So being able to communicate clearly to them that, um, these provisions continue until this date. Um, and to have it be a date certain, um, is helpful. Um, the way that the emergency orders have been coming. And, um, I would never want to be in the place where I have to be the author of emergency orders. So I have a lot of deference to the process. Um, But they come in, you know, they come and therefore two months or three months. And then we don't know when the next one is going to come. So there's not a lot of surety, um, that of how long the state of emergency is going to be. And then I'm concerned that three months may not be enough time to communicate clearly to people and to get people appropriately licensed if they need a license here. And I'm happy to go, um, section by section. If the committee is interested in, um, how we've used the section, um, of this bill or whether I still think they're necessary. I am prepared to do that if you're interested, or I could prepare that in writing, send their lines and, um, representative Lippert, if you'd prefer. Um, I, you know, I think it would be helpful for us to hear two things. A thumbnail of whether or not these extensions were helpful. Um, maybe a short comment about, um, and then secondly, um, just a comment about how many of these that you would might be recommending that do not go forward. And then I think in writing would be, um, would be a good way to go. I'm happy to provide it in writing as well. So, um, very, um, fortunately the, the first two sections that we no longer need, um, if it's okay, I'll take your two questions in reverse order. Um, the two sections that, um, OPR does not see that, see a continued need for our section 10, which begins on page seven of your draft legislation and section 11, which begins on page eight of your draft legislation. These are both pharmacy, um, sections that are part of, um, we put them in, um, I'll never forget our time in the middle of March in, uh, representative Lippert's community committee, you know, long days altogether, but we put these two sections in. They were concepts at that point that were contained in the OPR bill, um, section 10 is, um, it's short. It's basically, um, being able to fulfill a prescription without an order. If it's a standing prescription, um, we don't need that anymore because the OPR bill did pass and that, um, pharmacists now have authority to issue short term extensions. These are five day extensions with notification, to a prescriber and that a new authority is under, um, 26 BSA, um, section 20, 23 B six, a, um, so section 10 is no longer needed. And similarly section 11, which is therapeutic substitution is no longer needed because that authority is now in the law as well with the OPR bill, um, which was S two, 20 effective, um, October 1st. Um, so that section is 2023 B four. So I do recommend striking those two sections. Um, and I understand that that's then going to screw up all the section numbers. So I apologize. Um, we have used section 17, um, and 18 quite a bit section 17 is the deemed licensed if you're, um, and that means that you're qualified to practice in this state. If you hold a valid license in another state, um, if you're working in a Vermont facility, you must be registered, but I don't know if you're working in a Vermont facility, um, if you're working in a Vermont facility, you must be registered, but I will say that the majority of the folks under this section have been doing telehealth. Um, telehealth, um, has been, um, really widely used. We have many guidance documents on our website about telehealth at this point and people call us. We still are receiving so many questions about telehealth. Um, but it's obviously, um, it's a very necessary thing right now and section 18 is similar. That's for retired people. Um, if you're retired for under three years, then you can do telehealth unless you're working in a Vermont facility where you have to be registered. And if you're retired for more than three years, but under 10 years, then you can seek out, um, a temporary license and on numbers. These have been very well used. Um, we, my data is two days old. So we might have a couple more, but right now, um, we have 536 emergency licenses and 2,441 people on the registry. And we know that there are more people that are, um, providing telehealth, but don't have to check in. And I guess for the folks who haven't heard me talk about professional regulation before, I just want to reemphasize that. Um, OPR exists to protect the public. That is our first and primary function. Um, that's why we were created. I would not be recommending a year long extension if we had seen problems with these provisions. And I went through all of our complaint data. Since, um, COVID began and we have not seen any indication, um, that we would be able to do that. Um, we would be able to do emergency profession provisions in improper ways. Um, and so that's what is guiding me and feeling comfortable saying, um, that I believe that an extension for a year out. Would work. Um, if the committees are, um, committed to the emergency order plus three months concept. Um, or the emergency order plus something. I would just ask the committee to explore, you know, some of the, um, some of the, um, Um, Um, it has been a large educational ramp. Um, and. Again, I just want to emphasize the lot of our, um, licensees do not work in big institutions. Many of them do, but, um, I would say probably a third of them are in small practices or solo practices aren't part of the larger network. And that's where, um, communication has fallen down, I would say. Um, Um, I would ask that this be continued. I will say, um, this section was used, um, quite a bit in the beginning of COVID. Um, this is where I as the director can stand in, um, on behalf of a board. If we have an inability to provide a quorum. Um, We have not, we've been able to provide a quorum since probably July. Um, but I, Um, I would say, um, Um, this is, it doesn't hurt anything and we don't necessarily know what's coming. Um, I used this authority, um, Between March and July as we were developing our emergency rules for remote hearings, um, to sign decisions on summary, um, suspension orders of nurses diverting narcotics. Um, and I will say, um, that was very helpful. Um, I would ask that this be continued. Um, that section, um, I used, I don't want to say quite frequently, but I did use it, um, with, and I haven't used it in the last three months, but, um, We did have some practices that were, um, Dangerous to the health, self safety or welfare of the public. Um, some notable ones, um, that did make the news. So maybe you've heard of it was some MMA fighting, um, with, um, unlicensed people holding MMA fights, um, and having children wrestling. So, um, that was very alarming. And we were able to stop that activity. Um, thanks to this provision. Again, very forward thinking that one. Like it was two or three days in March, very forward thinking, um, and deeply appreciated. And then section 14, which, um, I forget which page it's on. It's on the very bottom. Um, I've lost the page. I apologize. Jen, maybe you can. I'm sorry. What, what, what section is it, Lauren? It's section 14. It's at the very bottom of the draft bill. It's about, um, the ability to, um, issue emergency licenses to people who cannot take their exam. That's team page 16. Yeah. Page 16. Yeah. So that section is not necessary because we did add that, um, authority to the permanent, um, statutes. And that's now housed in three VSA. Section 129. A 10. A. Two. Um, and we have, um, um, allowed people, particularly, um, nursing, um, students who were unable to take their exams due to COVID, um, practice while they're waiting for their exams. There was a period where all of the exams shut down. Um, now there are exams happening. The national exams are happening. Um, they're just, they're taking a lot longer. And, um, and, um, they, you know, people are waiting nine months for an example, they are taking them. And I will say that this provision is not specific to healthcare, which I do appreciate as well because, um, the pandemic, um, affected everybody. Um, and, um, there were many people graduating from engineering programs, architect programs. You name it. Um, accountancy programs who could not take the national exam and could not start working until that he was unlocked. So that was a very good, um, policy. And, um, it's now in permanent law and we don't no longer need that section. So can I just, can I just jump in here and say it's, so you earlier said that we no longer needed section 10 and 11, but you're also including section 14 as no longer needed. Is that correct? That's correct. I apologize. I'd forgotten about section 14. That's fine. I just want to make sure that we have. And our alleged council is following. Uh, that so we can revise any statutory proposal we put together. Yes. Thank you. Thank you. Okay. Um, that was pretty clear. And thank you. Uh, for that. The, the extension to a date certain, um, we'll, we'll have to ask others what their thoughts are, but certainly from your perspective is, is helpful to the folks who you, um, regulate and are within your jurisdiction. And, and might I say that it's, it's actually on behalf of. Our committee and you're both our committees. It's helpful to know that there was. That there was really impact from, uh, The work that we, like, as you acknowledge, we all did very, uh, Under enormous pressure, but with trying to be as thorough as possible and as forward looking as possible. And so hearing, hearing that it would have an impact. Uh, is helpful to us in thinking about how we, uh, How we did our work and how we do things going forward. And so, uh, I'm really grateful for that time and for this work. And it was, um, has proved to be, um, Very helpful. And I'll say that it's, It's, it's, it's, It's, it's, it's, it's, it's, it's helpful to us in thinking about how we, uh, How we did our work and how we do things going forward. Yes. I just like to say representative liver with true calendar. There hasn't been anything that I think we missed. Um, I've really, um, I think it's, it's, it's, it's, it's, it's very helpful. And I'll say that, um, you know, I speak with other sister, uh, Relatory authorities like myself and, um, many of them wish that they had legislation like we have, um, at this point. And that became particularly painful when the legislatures, um, were not functional because of COVID or, um, Had gone home, had done a special session, but didn't get some work done in other states. Um, and Vermont is seen, um, as very forward thinking in how they've approached this that I'm speaking about that too. And CSL on the middle of, um, March, how Vermont handled this. So thank you. It was a team effort. Yeah, absolutely. Absolutely. Thank you for that comment. Uh, Senator Hooker has her hand up and, um, we're, I think questions of clarification. Um, so go ahead, Senator. Thank you. Thank you. Uh, and thank you, Lauren. This is really helpful. I do have just a curiosity about section 18 and those people who are doing telehealth, but don't have to register. Um, and do you have ideas that, you know, how many people are doing that and why, why not, you know, keep a list or have them at least weigh in somehow. Um, so, um, Well, I, I don't know how many, I don't think it's as many as, um, people might assume, um, based on call volume, because there are so many questions about, um, telehealth. I would assume that we would hear more from out of state folks asking questions. Um, if there was a large, large group. Um, I will say most of our telehealth questions are coming from Vermont professionals who had to switch. Um, why it's happening. Um, a big driver was mental health. Um, honestly, um, we had a lot of college students come home in, um, March and April who had been receiving mental health treatment in another, um, state at their, at their college, their institution, and all of those, um, therapists wanted to continue counseling services for their students. So that has been the largest source of, um, questions and answers that we've provided. Um, I do think that, you know, obviously we are a small state. We, we, um, have many Vermont, um, Patients who, um, receive care in New York and New Hampshire, um, some in Massachusetts, but more in New York and New Hampshire. Um, and that is, was totally fine when the patient crossed the river in their car. But once that patient stopped crossing the river or the lake in their car, um, the regulatory rules prohibited that conduct. So, um, I know that that has been, um, A source of use of telehealth, um, and flexibility. I hope that's responsive to your question. I'm sorry. I don't know the exact number. And in terms of, oh, I, I remembered a little piece, um, in terms of requiring them to register, um, I suppose we could, um, I don't think the registry is a huge barrier. It's, it's the messaging at this point. I don't know who, um, these folks are. And they're looking at our website and I could put, you know, some glaring things on our website, um, to get registered. Um, but at this point, I just, I'm concerned about shifting our approach from my perspective. The approach has worked very well. I don't think it, many of the items are not long-term solutions to healthcare in the state of Vermont clearly, but some of them are, um, and telehealth for out of state licensees, um, doesn't make me comfortable in a long-term fashion forever. Um, but I do feel comfortable right now, um, based on the data that I'm seeing. Thank you. And, and given no complaints, it seems, uh, things are working. Uh, representative Peterson has his hand up. Yes. Thank you, Senator Lyons. Um, I wanted to get just. Clarification on section 21. And what it gives you the authority to do. Uh, it sounds like, and I'll, I'll give you my take as, as in reading it. Um, that you have the authority to stop a licensed entity from doing something that's unsafe. Is that, is that fair to say? That is correct. Yes. I can issue an emergency order, um, that acts, um, sort of like a cease and desist order. Okay. But only for licensed, uh, entities. That's right. Only for licensed entities or a licensed activity. So, um, you could be holding a license or you could be, um, doing engaging in a practice that would require a license. Okay. If I. Want to have a big bonfire and bite all my neighbors over. Um, and no one has a mask on. You can't intervene in that. I'm not the same as I would. I'm just giving it. Just trying to understand where your authority is. That's all. I may have private internal thoughts, but I cannot act on behalf of the state. Okay. That, that's all I care about. Thank you. Thank you. Okay. Thank you. I'll get the bonfire going. I mean, we'll be there. As long as we stay six feet apart. And masks. And masked, then I can do nothing and I would come. I would have to have, I would have to have a mask on. I would have to have a mask on. Preferably double masks. Okay. Any other questions of clarification? Thank you. Lauren. Thank you very much. See you again and have the. Hear the report. The update. I'm happy to come back anytime. Thank you. Terrific. And so next on the list is Jesse Barnard. Representing the Vermont medical society. Good morning. Thank you very much. Hopefully I'm up on your screen now. I'm a Jessa Barnard with the Vermont medical society. And I will say I am also, I have the pleasure and I'm very proud to be representing not just my own organization today, but to be speaking on behalf of a informal coalition of healthcare provider associations who have been meeting regularly during the pandemic. So again, just to introduce my organization for those who I haven't met yet. And the medical society represents physicians and physician assistants and all various specialties and locations around the state. But more importantly, this, this coalition of healthcare provider associations, we don't have an official name. There were some, some ideas about the last session kind of in jest. But we've been working really closely together. I did submit a little outline of our comments. And on the back of the second page, there's all the organizations that are part of this. It ranges from hospitals to long-term care, the FQHCs, Vermont care partners, the dental society, the naturopathic physicians, independent physicians, the VNAs. So we really cover the healthcare spectrum during the height of the pandemic in the spring. We were talking three times a week. I think now we're meeting twice a week and coordinating on all sorts of efforts from at this point vaccine administration, but earlier on it was access to PPE and testing supplies or any number of questions and how our organizations can implement them. So some of our work is on the advocacy side. What do we need in a regulatory or advocacy environment to help us serve the patients of Vermont? But some of it's really the implementation. How can our organizations either work together or learn from each other to help the patients of Vermont? So this testimony is on behalf of the coalition. And you will see there is a long list of folks to testify today. I'm actually kind of coordinating that effort. So I have certain subject matter expertise, but I've asked some friends to be on here with me in case there are areas you have questions on some of the sections. I am not the expert, but I could tap those other people, but we are not all planning to testify. In fact, I'm the only one on your list. Let's see if I have your list up here, at least on the provider side who had prepared comments. So I'm going to go down through Devon Green. Again, they're all on in case there are questions, but they're not, you know, planning to speak or present unless we need them. So thank you for giving us that flexibility and letting them be on Zoom with us if things come up that I can't address. Our basic goals as a coalition are in terms of the deadlines, consistency, clarity, and some sort of off-ramp. So we'd really prefer that any sections being extended to the same point in time just because it's been very challenging. I'm sure not only for the legislature, but for us and our members to, you know, every certain couple of months be back revisiting this bill section by section and figuring out which we need or don't need. So our ask would be that they're all extended and extended to the same point in time, or at least all the ones we agree need to be extended. And then the point about the off-ramp, I think Lauren Hibbert brought this up in a nice way, is that we need, for some of these, or really for most of them, some kind of transition period. We need to know, okay, if licensure is being reinstated for telehealth, for example, folks need time to go through the full licensure process and be aware of it and get licensed and that sort of thing. So with all that said, I want to thank very much the chair for putting in this draft. We draft, what is it, draft request 21-0729. And I think actually the, you know, initially over the, in the past month or two, when our organizations were talking about it, we supported this idea of the state of emergency, plus three months. But in talking to Lauren Hibbert and OPR and amongst our organizations, we actually really strongly support Lauren and OPR suggestion of March 2022, that again gives us a clear date to have in mind. It gives us enough time, we think. And the other benefit is it's when the legislature is back in session. So in case the state of emergency ended in June, July, August, and there was a problem with transition from one of these sections, there'd be really no way to address that until you're back in January where March, like how we picked March this time around, it gives some time for you to come back into session to hear some testimony and take action if needed. So that did, when Lauren suggested that, that made a lot of sense to us. And so we would support that. I will say, you know, as a, as a coalition, we had not had a chance to talk about the pieces that Lauren mentioned around the couple pieces. She did not think needed to be extended because they're in the OPR bill, but we really defer to her on those pieces. So I don't think we would have any concern with those sections. Again, in our testimony, we submitted it listed those sections for extension. But if OPR thinks they have that in their underlying statute, then we're really comfortable with that. Other than those sections, she mentioned, we do support extending all of the ones that are in the draft that we saw from Senate health and welfare yesterday. I will, I will speak to a couple of them. Again, my expertise are more in the licensing areas and the telehealth areas. But if you have questions about some of the other pieces, like for example, you know, provider tax or some of the inpatient pieces or long-term care pieces, we can call on others who are on the, on zoom, but off camera at the moment. I just want to echo what Lauren said about sections 17 and 18 about out of state and retired health care professionals, you know, representing physicians and physician assistants. We do know these have both been used and very helpful. As Lauren said, we share a lot of patients with New Hampshire and Massachusetts and New York. And it's just as a reminder for those on the committee, I'm not sure this is really explicitly come up yet. I don't know, maybe Jen walked through this, but to offer telehealth, the current sort of state of the state in almost every state of the country is you have to be licensed in the state the patient is located. So if Vermont changes this requirement, it's really for those out of state clinicians to be able to provide care into Vermont for Vermont clinicians. Vermont has also Vermont clinicians have had to be aware of what has changed under the state of emergency in those states surrounding us. If they want to follow their patients who say, oh, what happened to the state of emergency, I know that you have to be aware of the state of emergency in terms of the state of emergency. I'm not going to come back to the New Hampshire, but get their, you know, traditionally have been seen in Vermont. I did submit one of the handouts I attached is a sort of a cheat sheet chart that VMS and the hospital association put together back in March, because it is complicated. It's kind of a matrix. Where are you located? What type of facility are you in? And what has sort of what applies without the pandemic question about why not change to registering for telehealth. I think honestly at this point it's really a simplicity piece. We support what Lauren said about that where just you know it's already there's the sands have been shifting you know daily, weekly, monthly in terms of the regulatory environment for COVID in all sorts of areas and so this would be an area where we would just prefer the simplicity of continuing what's in place for now. Certainly I actually noted Senator Hardy's question from yesterday which I think was a really great one about which pieces do we want to look at carrying forward more permanently or what have we learned from this state and I think there's been a lot of questions a lot of conversations at least on the provider community side about licensure for telehealth long-term and do we is it still is it still kind of the right policy decision that you have to have a full license in every state where you practice you know it's been an issue as you know you have a patient on vacation for a week in South Carolina that Vermont provider technically is not supposed to call in a prescription talk to you on the phone and give you advice unless they are licensed in South Carolina and we know that already you know that happens and I don't think any of us really like the solution of just kind of turning a blind eye to it so you know it may be an issue where some of us are back with your committees in the future to talk about you know what could something look like in the telehealth licensure world but for now we would support continuing the status quo for the next year. Let me just see I think I noted some other oh on section 26 on telehealth the HIPAA and consent waivers I know Senator Lyons asked some questions about that yesterday we do see many providers already switching to HIPAA compliant telehealth platforms we have encouraged our members I know other associations we work with like the hospital association and by state primary care have encouraged clinicians to be implementing consent so I think again it's one of these off-ramp or transition pieces you know telehealth went from very very little use to explosion of use in March and we're now kind of getting to more of a status quo place and so just some more time to work on that transition I know people have mentioned Zoom actually Zoom has a HIPAA compliant platform so if you're talking to your provider on Zoom they may already be HIPAA compliant but the real reason that this happened not only in Vermont but actually the federal level they allowed non-HIPAA compliant platforms are things like FaceTime or something like that where maybe there's a way to connect with a video but but the patient or provider hasn't yet had time to set up a platform so I think we will see this changing over time but again that year time just gives a little bit of a gives notice and opportunity for all of those clinicians to transfer over to to being HIPAA compliant and making sure they have consent implemented. I know I heard Chair Lippert mention you don't want to spend a lot of time on audio only and I respect that I know your committee is taking a lot of obviously a lot of testimony on that so I won't go into detail I will simply say our our thought on on this section 8c about extending the deadline on DFR's ability to have rules until January 2024 is again for a period of transition. The report that DFR wrote on audio only coverage that the Health Care Committee has taken some look at suggests that that there should be a transition period to paying with value-based payments and then the interim fee for service payments would be needed and allowing DFR to do rulemaking around that is one route to accomplishing that it would allow DFR to lay out the requirements for what services and or reimbursement rates would be covered in the interim period obviously another approach is for the legislature to craft that in legislation so it was it's sort of a two-path option of how to accomplish the what was asked for in that report one is statutory change one would be allowing DFR to do it through rulemaking so wanting to support having that option of DFR putting in rule what that coverage would look like during that transition period to a value-based payment. Our committee is also going to be taking testimony about this because we do want to include it in the bill and as you're talking there's some there's some sense to be made of the DFR rulemaking there's also some sense to be made of having whatever rules are put forward to come back to the legislature for some oversight. Sure so again those are the pieces that I had prepared comments on or heard questions about yesterday but if you if there are other sections as well that you'd like to hear from the provider community on please let us know and some one of us will be hopefully be able to answer the questions. Can I just go ahead but go ahead I have a question when you're done. Yeah I'm more comment that I think you referenced a question raised by Senator Hardy in your testimony yesterday about what what can we learn to look for to take forward I think it's an important question and one to be quite honest that it seems to me that we can set to the side for the moment as we continue to try to extend emergency procedures while we're still in this state of emergency but I absolutely support that we circle back and learn from what we have experienced as I think we have learned there are there definitely areas that we we've learned and that we should consider whether to change our regulations or statutes going forward but I'd really like to try to bookmark that for a future future focus of testimony. So and to to let you know that Senate Health and Welfare last session in the spring put together a draft proposal on that and realized that this isn't something you can put together in the middle of a pandemic. I think we need to wait till we're out yeah so but then we have taken it up again as a committee and we will have a committee bill that begins the process so I look forward to to working on that and including not just not just health care committees but others who have worked so hard during the pandemic so we will we will be working on that but Anne Donoghue representative Donoghue has her hand up. Thank you Senator Lyons. Yes I have a question on section 26 which is the extension of the regarding telehealth but trying to flip back to the document here specifically the the third clause which is about patients informed consent and you talked about the the HIPAA compliance and I understand the challenges in sort of getting up to speed and what that might require but there are other pieces of of informed consent and in fact there's a question about informed consent simply telling the patient you know we don't have the HIPAA compliant platform right now you know just so you know and I'm wondering because the it was you know the initially and continues to the extent that it's not practicable for informed consent do you know how often that has been being used where there's no discussion with the patient about some of the other provisions of the informed consent or about the fact that it's it's not HIPAA compliant. That's a good question I don't have any data on it I will say again it's an association we are and the associations I've been working with making it clear to our members I get that piece about practicable I would think in most circumstances these days it now is practicable it's you know less of an emergency these are getting more routine providers and practices can have their workflows down now and can have that conversation with the patient either at the time of the appointment or when making the appointment so we I would expect that it wouldn't be very frequent but I don't have any data on that for you. Thank you I mean I just expressed my concern about that continuing for a long time separate from the technology in terms of HIPAA but just simply you know providing informed consent to a patient in terms of the other parts of that. And I'll say we actually worked with by state primary care the health care advocate and some others to come up with a really patient friendly consent form over the I'm losing track of time now summer and fall because I think there were a lot of there have been a lot of organizations that you know there's consent and there's consent and there's you know a one page short document that's written in 10-point font and filled with words that you may not really you may agree to it but not really know what you're signing and then there's really understanding what you're what you're doing what services there are I'd be happy to share that with the committee you know would be really interested for your your feedback because I think we we do share that in most cases the patient should know this is what we're doing today this is what happens if we get disconnected this is what your charge will be you know we've heard on telehealth in particular patients there have been instances of patients being you know frustrated with with copays so we do think to the extent possible that should be discussed with the patient ahead of time you know this might be the same copay as an in-person visit so we we should certainly share the goal of information being given to the patient at an appointment and I think in certainly in most cases of routine care now you know chronic care management mental health visits that there should be the opportunity for this discussion it may be more the some of the inpatient circumstances urgent or emergency care circumstances where you know it's not as easy to to implement this thank you I'd appreciate seeing that you're saying that that is being used uniformly well I it's it's a volant you know it's a sample out there for practices or facilities or whoever's interested to use it it's nothing you know required but we did design it to meet both the state's consent stat you know statutory requirements divas requirements medicare has some requirements so it is actually a tricky thing you know that's I think been one of the barriers for practices is that there you know there's sort of these layers of who requires which consent and which patient is this so we designed this to be sort of a universal it should meet all of the requirements that we're aware of and also be understandable to the patient but it is you know it's voluntary for for practices that like it you know maybe they've already had a form that their lawyers reviewed and they want to use their form which is you know is fine but certainly I'd be happy to share that with the committee but that would be helpful um and you know there are other we had a short discussion about a bit of this in committee yesterday and it will be interesting we'll continue our discussion around the use of federal dollars to build HIPAA compliant technologies that would aviate the need for some of this so okay I think are there any comments that others in your group would like to make relative to any of the questions that you have heard or to clarify any of the sections for us and I I know that the I know that Laura Pelosi is here for the Vermont Healthcare Association, Julie Tesler for Vermont Care Partners, Helen Laban for Bi-State Primary Care, Devin Green for the VAAS Vermont Hospital and Health Systems Association so any would any of you folks who are here on zoom with us like to comment at this point wow we just saved your committee a lot of time yes you did no and we let me just say that the work that this group has done throughout the pandemic has been extremely helpful to both of our committees and and we really appreciate it and now that we're getting we're now that we're feeling like the vaccine is around we're asking more discrete questions and I think Representative Donahue's is a good example of that so we'll we'll continue to work together and we appreciate your time well thank you and feel free to reach out to any one of us at any time we all know how to reach each other very easily so we're happy to field questions to the right group of people we just walked down the hall that's all right thank you well thank you for your time thanks for hearing from us this morning let me let me second second what Senator Lyons just said too we could not have we could not have accomplished what we did without the absolute immediate and in-depth cooperation and recommendations from the coalition which we the the coalition which has no name it's the star wars alliance well whatever whatever it is called but it has been one of the most effective efforts that I've seen in in in many many a year and so I the way that people cross professional areas to just chime in and work collaboratively with us as legislators was profoundly important and thank you thank you I mean there are some sections that were in the acts that we passed earlier that are not in here so and those also I'm I'm thinking that you have that you've decided that those are no longer appropriate at this time and you know the one that comes to the top of my head is the provider tax well we walked we looked at what you know the chart from from Jen and the draft and it looked like those all the some there are some sections that our group cares about but they were most of those were already pegged to the state of emergency or coven diagnosis or some kind of more ongoing point in time so we were comfortable with that approach okay Jen did you want to comment on that I well I think just as exactly right those were things like the provider tax are already tied to six months after the end of the state of emergency and the other provisions that are not in here that were in your other x were things that were codified and statute so they don't require an extension so I think everything that had an expiration date of some sort is included in the legislation and you may decide to take some out after testimony but I think they were consistent in their approach okay and if the six months post emergency becomes an issue we should know about that to put the date certain in but thinking that some of as you were indicating earlier transition time becomes important can I can I just suggest Jen that could you flag and I think it's in the chart but could you flag those which don't have an extension beyond the kinds of extension that we've just been talking about which would I think there's maybe a I'm not going to overstate this but OPR has suggested a date certain of March 2022 and I think Jessa on behalf of the coalition has said they in further reflection would support that date certain as well so if that emerges as a proposal in the legislation if should we adopt that would you flag the other provisions which have other extension points such as six months past emergency declaration etc so that we can review those to see if any of those should be brought into conformance with a single extension point in time which might and whether we should consider does that add clarity or does that add confusion because there's there's something to be said for having a single point of extension that so that we all know what what what has been extended into when but I'm not going to I'm making no prejudgment about that at this point but I think we should we should be aware of that and consider the whether or not to have that single point of extension for those as well yes I I agree with that that's a good comment and so that would serve both committees our committee is going to continue this work later in the week so it'll be helpful to begin looking at that okay all right any other questions of clarification Jen did you want to add anything Jen did you want to add anything good okay this is Devin Green from Vaz I just wanted to quickly add that we we at least from the hospital side we did look at those provisions some of them affect hospitals and we did not think that they needed to be brought into the single point things like extending the green mountain care board flexibilities to six months out after the emergency and that sort of thing and that's mainly just because they really are tied to the emergency and we also don't have the same communication issues as OPR may have you know we have a discrete amount of hospitals we can communicate pretty easily with them and so we're not as concerned about those provisions that are not included in the current legislation okay thank you then it would be helpful to get maybe a a short written testimony that we can have on our webpage for if you don't mind that'd be helpful okay I'll do that and and any of the other folks who are here within the coalition who can also do that or the coalition as a whole that would be very very helpful to both committees okay all right well then thank you jessa thank you we'll we'll move on to our insurance representatives who are here I keep looking for my agenda I've got so much open on my iPad there it is so yes I know Sarah teach out is here are you here Sarah I am here okay why don't you um you've heard the discussion and you know what the issues are and I think your most particular interest is telephone only and we're happy to hear your testimony yes um I was going to talk more broadly about the provisions extending beyond the the the emergency period for three months the way that you have drafted I did spend quite a bit of time with the house health care committee talking about our concerns about audio only care and I'd love the opportunity to do that specific for the senate health and welfare committee but I'd rather not repeat the testimony for everyone so we can do that we'll have we may even have time later this week to do that so I thank you I would appreciate that so just to lay the background all of our state health care policies are an attempt to balance consumer protections access to care cost and safety and during the height of the covid lockdown we chose to emphasize access to care over some of these other considerations which everyone strongly supported um as we progress through the pandemic from full lockdown which was what we were originally responding to to this partial reopening phase which is you know a little bit strange and hopefully into the newer vaccination phase and then maybe someday it'll be done um some of these measures may be out of balance and I hope that the committee will consider that this is a continuum and not a single point in time and I just had one example I wanted to talk about and that's the early prescription refill policies that we really did at the height of the lockdown to prevent to allow people access to their Medicaid when they were afraid to leave their homes unable to see their providers and really needed their medications the reason that we have refill limits in place is to prevent excess amounts of prescription drugs in people's medicine cabinets to prevent these medicines from being wasted if they fill a prescription and then for some reason have to switch to something else and also because they can be potentially dangerous for individuals or family members in the house so just I'm not saying that we um don't support extending these throughout the full phase of the emergency but just really do consider the balance of the consumer protections we try and put in place um and the cost protections um with the access to these medications in that particular instance um well so are you talking about so the some of the prescription I don't have your chart okay well the draft legislation has it but when Lauren Hibbert was talking she and Jen you're going to have to help me with this she suggested that page eight section 11 was no longer needed right this I think Sarah's talking about a different provision the one she's talking about is section nine okay this is the one that requires health insurance plans and Medicaid to allow members to refill prescriptions for their chronic maintenance medications early so they can have a third-day refill at home I think or maybe it was the is that is the flexibility piece I I believe is already now in statute or in regulation that's right now it's in statute you're right right and to be honest that one's been super helpful we believe dealing with those types of issues when the person is in the pharmacy filling their prescription is preferential to honestly sending them home and spending a lot of time um on the telephone figuring out what they need so that that truly has been a really helpful provision um a couple other things I wanted to say just more broadly about extending these um I believe for us a date certain would be helpful um we have a lot of technical changes to make notifications to do and so certainly a date certain would be I think more helpful for for our members um and then the last thing I would want to bring up is that um largely our self-funded employers have complied with every one of these emergency regulations once we get into a post-emergency period um I think each of them will be reassessing to the to their own company priorities what their value is here whether this is something that is valuable for their employees or if it's too costly for the employer and making a decision there so I just wanted to say that the way that these have been implemented have been fairly smooth for providers um because everyone has complied I think we may be entering as we go into this gray area a phase where there is more differentiation between how these are being treated um and I just wanted to make that very clear so when we get into the post-emergency phase that's where where it may be more difficult um for everyone and then the last thing I I I will talk you know I think everyone knows um our position on audio only care um just extending it to 2024 without some patient protections and some other changes um we find troubling um and we would like to propose um some some some changes for the transition period I think some consumer protections as well as some ways to get additional data for quality analysis so I won't go into it any longer because I know others have heard from me already on that but we do have some recommendations there okay I uh so questions of clarification and I see uh Senator Hardy's hand is up thank you madam chair um Sarah thank you for that testimony I I do have a clarification question on the issue you brought up with self-insured employers um and are you specifically talking about their compliance with the prescription pieces or are there other things that in this bill that are optional for the self-insured employers right um I'm mostly focused on the prescription drug pieces and the audio only care the telehealth moving forward I think those are the two costly more costly provisions that self-funded employers may not choose to continue okay and I haven't heard your testimony on audio only yet so I'll wait to get your take on that but but I just want to clarify that your point is that moving forward as things change they may decide they're not going to go along with this because they're not required to because they're federally regulated is that correct and they decide that it's too costly for their bottom line of ensuring their employees is that an accurate summary of what okay I just wanted to leave some okay thank you can uh can I just follow up on that just because this becomes a point of understanding for uh members uh new to the committee and ongoing uh and so Jen I just I'm gonna see if I can so Sarah just to clarify that self-funded plans were not in fact required to follow the emergency uh changes that we put into statute because in fact they're not required to follow our statutes in the first place is that fair to say I mean what you're saying is that most of them did but but that but that was a voluntary choice of compliance correct and there are some nuance because some of the things that we did in state mirrored federal regulations that apply to a RISA plan so just just to be clear yeah okay but but broadly broadly when we again when we made emergency changes to legislation uh it was really to modify ongoing legislation and self-funded plans are not regulated by the state of Vermont under our statutes because of the RISA exception broadly I don't know if that's the fair accurate way to describe it but I think that's what we all understand it to be okay is that consistent with what your understanding is Jen yes we the state is preempted under federal law from regulating the self-funded plans so to Sarah's point there are certain pieces that the when the federal government did some emergency provisions uh around access to to COVID testing and things like that that they specifically applied to those self-funded plans but nothing Vermont could do was going to reach those plans yeah all right okay thank you thank you okay um representative uh Goldman has her hand up thank you madam chair um I'm just wondering if one could make any generalizations of the types of patients or populations covered by self-funded plans as opposed to other segments of the population in terms of you know access to care or you know those kinds of things access to resources um that other populations might not have and you may not be able to but I was just curious about that so so listen I think that is an awesome question and it's a it's a question that deserves a discussion during your committee time so I'm going to I'm going to defer that question over to both our committees uh because I think it's a good one and it helps us to understand insurance programs generally and what we can and cannot regulate more specifically so excellent question let's let's let's let's bring that back to committee yeah and and I'm gonna I'm gonna assign uh senator hardy with that question and bring it back to committee okay um any other questions for uh Sarah uh Sarah thank you so much um and we'll we'll look forward to having you in back in committee and I know the house will also so thank you thank you okay um we also have um Chuck staro who is uh representing MVP healthcare uh and he's going to talk about audio only I think Chuck are you here I am uh madam chair good morning committees uh Chuck staro leonine public affairs on behalf of MVP I was planning on speaking to uh only the audio only issue but um I did speak to the house healthcare committee on that issue last Friday and I think I heard you say madam chair that um we would be coming back to senate health and welfare you know at a later date to speak on that issue so I'm happy to speak about it now but I don't want to bore the members of the house committee uh by repeating what I told them last week and I'm happy to wait until a different date for to speak to your committee uh specifically on this issue however you would like to go I'm happy to go forward right now too what I think would be helpful is rather than get full bore into your testimony would be to give a quick oversight of of what it is that you're going to be you have represented in house healthcare and what you will be representing just kind of the um the intro if you don't mind certainly um you know the the essence of the MVP's business is the issue of audio owner uh a coverage mandate for audio only health care services is that there should be uh a coverage mandate or that it's okay that there is a coverage mandate I shouldn't say should be but we're okay with that um but that there not be a requirement as is the case currently under dfr's rules that reimbursement be at parity with the level of reimbursement that would be the case if it was say in person uh provision of health care services that there are features of audio only health care services that may or should dictate that reimbursement be at a different level um you know mainly less um it may be appropriate in some cases that it be at it at parity but that there's no one size one uh you know uh size fits all kind of solution to that and that the issue not be spoken to in either legislation the issue being reimbursement rates and either legislation or in rules but that it be left to uh the insurers and the providers to uh work out okay thank you for that um that that helps us uh that that's a good refresher course for the house folks and it's a good uh startup for us so we'll and we will be uh asking you to come in with some testimony thank you thank you madam chair yes very good and i know margaret lagus is here also and we we have we have some time so margaret um thank you for being here and why don't you introduce yourself and then give give us um i think you're also talking only about audio is that right correct so for the record my name is margaret lagus and i represent america's health insurance plans which is a national association of health insurance providers um and all of the ancillary businesses that go along with that whether it's pharmacy benefit managers mental health managers etc um and i am going to comment about audio only because i have not spoken to the house uh health care committee yet so it'll be new for both of you um during the pandemic uh all care whether in person audio visual or audio only was reimbursed in vermont and as was recently stated even the self-funded iris of plans followed that guidance in vermont moving forward there should be a separation and recognition of the differing levels of care offered by these three options we support as jesse barnard just said as well we support a value-based payment pricing decisions should be data driven if we have learned anything during this pandemic it is that policies should be based on well-defined data pricing should be a decision between the providers and insurers and as you have already heard at least the house committee did um the office visit payment that providers receive includes what is assumed to be work that may be required outside of the actual office visit and it also includes uh costs associated with actually having an office the bricks and mortar and the employees required to just have an office these payments also include things like reading and interpreting test results extra phone calls consults if necessary setting up additional appointments with other providers so some of these audio only appointments would already be covered under this in person patient payment some patients may avoid coming in for in person vision visits if they want to avoid some difficult conversations that may happen due to routine intake evaluations like weight blood pressure and possibly blood tests around diabetes so we want to be sure that in person is the gold standard however the state could incidentally discourage the growth of telehealth by making short-term policy decisions that have long-term unintended negative impacts on individuals who need affordable healthcare if policy makers require employers individuals and taxpayers to subsidize providers for bricks and mortar infrastructure as part of virtual visits the cost savings potential that telehealth can promise will be jeopardized two recent sources of information show that the average telemedicine visit costs less compared to an in person visit teledoc health data shows that average telemedicine visits cost $45 compared to 141 for in person and according to health affairs the average telehealth visit costs $79 compared to 146 in office so their data is a little bit different but both show that there is a fairly striking difference in the cost to provide these services a mandate requiring that healthcare purchasers pay the same for telehealth visit as the in person visit will likely impact affordability for telehealth to realize its potential government should not be burdening it with the same cost structure as bricks and mortar healthcare settings additionally telehealth visits do not always require the same level of intensity the same amount of time or the same equipment as in person visits and are not a replacement for in person visits creating a one size fits all policy measure for care that should and must be patient centered and individually based is not only the wrong direction but could increase costs American healthcare consumers pay whenever we require payment for new services or parity for differing care we raise the overall cost of care as Vermont moves toward capitated payments through the aco this kind of thinking actually moves us in the wrong direction and as you already heard iris of plans happen to have complied with all of the measures that dfr instituted for the pandemic but they are unlikely to do so going forward because they're not required to follow and I do have sources and I will submit this testimony in writing to the committee so that you can see the sources for both teledoc and telehealth thank you I that was my question if you would please submit it and I do have a question as we're looking at teledoc and telehealth is the is the pricing that you're talking about pricing that is based on kind of the value based payment determination so based on the patient needs and patient then patient care or is it based on negotiated contracts between health providers and health insurers so this particular cost differentiation was based only on the actual cost to the provider to provide that care it didn't differentiate between the quality of care you know it didn't say because you were audio only because this was considering telehealth in the broader sense both audio visual and audio only as you can imagine audio only you can't see the pallor of your patient you know you can't there are a lot of things that you can't see about your patient your patients demeanor how they're walking you whether you feel like there's been a decline in their mobility or their mental health status a lot of that those are visual clues that you just don't get in in audio only visit but these numbers are strictly the cost to the provider to provide the services to the patient okay thank you and and you'll send us along the information that you have terrific questions of clarification for Margaret yeah I'd like to just ask Margaret thank you we had not had a chance to hear from you and appreciate your coming forward can you can you just clarify for members though which are the which are the insurance companies that offer services or offer insurance in Vermont that you represent currently SIGNA and MVP are the two larger ones and then many companies that happen to have a few individuals or are in the large group plans are also members of a blue cross blue shield is not a number currently right okay I think just just useful for people to understand the scope of representation because that's a good that's a great the trade name doesn't really capture that for us right it doesn't I mean when you when you send along your info maybe add add a little bit about that that be sure I will do that um representative goldman and then representative black that's the point of clarification for me when we're talking about parody are we talking about parody with in-person visits or parody with just audio visual visits so can there be a distinction between in face to face and then not face to face there there should be a value-based payment set up between providers and insurers or through a structure that dfr sets up that recognizes the difference in the value of care that is delivered it's not saying whether audio visual would be equal to inpatient or equal to audio only it would be that you would look at the data and make those decisions based on on the actual data that you can show on healthcare outcomes from the varying different types of visits okay can I can I just also jump in and say that I think the use of our the use of the term value based payments may be confusing in this context because that's a term that we use we're using broadly in terms of payment reform and I think what you're talking I believe if I'm correct what you're talking about is the value of the the service to the patient correct yeah what so just there's there's a cross-section of terminology which is the same word and language but different different entirely yeah so yeah I mean oh you're not you're not recommending at first it sounds like you're recommending that this be done through a value-based payment reform that's not what you're talking about no but a recognition of the differing values that these different patient visits give to a patient yeah so that's why I just feel like thank you clinical condition yes okay now that's a good point to be made it would be neat if all of our payments were value-based that is a whole another discussion that's a much bigger my perspective anyway representative black thank you simple question is united health care part of your organization as well or no yes they are okay okay and united health care does a lot of the supplemental plans is that right for medicare yeah okay um any other questions for our witnesses wow so I just like to say thank you to both committees and to everyone who has testified today representative leopard and I are back to the drawing board I guess yeah it does seem like represent our senator lions it does seem that the testimony that we've heard today uh least in my mind leads us in the direction of a fixed point in time uh has been there seems to be now it'd be fair to say some movement in that direction toward a consensus rather than a point past a declaration of emergency and uh and I think that that this is helpful that that that seems to be what most of our witnesses have been moving toward uh as a result of the testimony we heard this morning is that I agree and then uh the this the other areas that are not included in the bill that we we have felt were sort of had a transition time that we've asked folks to go back and review those so we'll make a determination as to whether they should also have a point in time but that'll be something we can also look at and then finally I think the one area of um concern that we may have to work a little more on maybe have more than a the paragraph that's there uh is on audio only yeah and we'll and we will we will be crafting a separate proposal based on our testimony that will either when you I think we would let me is it fair to say senator lions that we've you and I have talked about using your uh commit your committee is likely to move forward a bill that we will then receive in the house and again we're needing to do this within the time frame to move it uh before the so that we can get past all the deadlines before March 31st yes I think we'd like to do that as quickly as possible and so uh we'll our committee will get up to speeds on the audio only and then maybe there's a way of integrating language so that we're all on the same page as we move the bill forward okay uh and and I think the other area that there seems to be common agreement that there are certain sections that were articulated by OPR that can be deleted from extension right if we uh if we hear differently from you or um uh an outcry from constituents will take that into consideration I guess good okay thank you thank you uh in and just just like to let the house committee know that the senate committee has a reputation we have our own little reputation for finishing early and now we have so we're on we're on target well we're going to take a break as the house health care committee because we have a reputation for making sure that our health and welfare of our members is thought about as I'm sure you do as well we always work on that I'm sure you're doing as well but we are so we we're going to leave this zoom and you you guys can stick stick around uh our committee is going to take a break um and let me let me just look uh find my agenda again um we're due back at 1045 so we'll take a break until then so um we can leave this zoom and we'll come back to the zoom that Nellie uh has sent out to us thank you thanks thanks representative Lippert yes thank you senator lines I think this was a good choice to do collaboratively once again take care thank you so committee members and for members or witnesses who may be in the wings or the waiting room I think we do need to take a break and I'm going to suggest that we also take a break till 1045 that will give us an hour I think that should be sufficient hopefully to hear from the witnesses we have lined up and then we will also our goal will be to finish up at 1145 so let's let's come back take a break again reminder put yourself on mute and off video and Colleen will put up a notice saying that we're on a break but we're coming back it'd be great Colleen if there's some way to learn if there's a way for us to signal when we're coming back uh with a time on that if that you could check with it for the future but uh let's go on a break we'll see you back at 1045 we'll start promptly then thank you