 Okay, good afternoon is this is the afternoon media of the house appropriations Wednesday, March 16th. And we are joined here by representatives of the human services committee to hear of age 7 to 8, which is an act relating to opiate or dose response services. And and and Wittman and small, if you would like to join us down at the table, please do. And we are also joined by. Oh, and line well with and we have a fistful now. So, let's hear the bill first and then we'll hear from Mr. mine well and have a conversation about the bill. Uh, we could take a half an hour, no more than a half an hour. We're managing our time as everybody is doing and so you can give us the high, the high level overview and then bring us down to the money and the reason that you're here with us today. So, thank you for joining us and we'll turn it over to you. Hey, great. Thank you all for the record representative gain Whitman I serve on human services. Thank you again for having us here today to talk about age 728. So yeah, to put this bill into context. Looking for a response essentially to the sort of second epidemic that we're experiencing as we've described it, which is sadly continued rates and fatal overdose largely related to opioids and specifically fentanyl. Just to kind of put this into context. Over the last three years we've seen rates and opioid fatalities increase dramatically in 2019 we had 114 fatal overdoses and in 2020 that jumped up about 25% to 157 fatalities and now in 2021 we're looking at 181 fatalities. So that's almost another 2530% jump just over, you know, each year for two years really concerning the median median age for a fatal overdose is 40 in 2020. So we know that, you know, half not more than half of these deaths are young, young people. So this is a really concerning public health issue and just want to thank you all for your consideration. Of the proposals in here as well, recognizing that this isn't the whole picture that you've also looked at our recommendations within our budget memo and everything along those lines. So I would just like to say that essentially while the budget memo look to sort of fill gaps and strengthen a lot of our existing systems. This bill really sets the stage for more innovative initiatives so that we can adapt to sort of the current day nature of the opioid and specifically the fentanyl crisis that we're experiencing. I'll just go through a large walkthrough of the bill. And sort of the way that I think of it is that there's three main policy initiatives and then three sorts of pilot appropriations. So the policy initiatives are related to expanding who can be designated as a syringe service provider. The current health department language is pretty prescriptive about that and that it needs to be a service organization or a health care provider and we're just looking to open that up so that if there are opportunities to designate other organizations that come into contact with people who are injection drug users that we have that flexibility. The sort of section second section of the bill is related to prior authorization for medication assisted treatment. I think we will return to this component as we've kind of received some new information about the potential fiscal impact of this. So I think we'll sort of save that for last if that's OK. But the sort of third policy committee I'll turn it over to representative small as she's been involved in the overdose prevention site working group component. Good afternoon everyone representative Taylor small for the record overdose prevention sites also known as safe injection sites are a program that we've seen internationally and now growing recognition here in the United States. We've done similar research into overdose prevention sites but the difference now as compared to the past is that there are actually two areas within the state of Vermont and Burlington and then in Brattleboro who have significant interest in upstanding an overdose prevention site within their communities but need better guidance from the state to recognize whether there is legislative barriers to implementing these sites or whether it is putting that on us back on the municipalities of localities to be able to to understand such a service. What I will highlight as we just covered the immense increase in overdose deaths here in the state of Vermont is that the prevention sites is that internationally you've seen zero deaths within overdose prevention sites which is the goal I believe here is reducing our death rate for folks who are using drugs. And so I know that working groups are not your favorite option when looking at options for investing funding but it seems integral as a next step in the direction of being able to to understand those prevention sites here in the state to put this working group into action. So moving on the sorts of three pilot programs that we have included are related to a mobile distribution of medication assisted treatment. And as well as recovery and treatment for justice involved individuals and the third being kind of facilitating warm handoffs and greater coordination within our treatment and recovery system. So to go into mobile MIT. A lot of this comes to need for greater access to specifically methadone which is one of the medications provided within our hub and spoke system. Currently it's being limited to the hubs that we have around the state which mostly requires in person visit during a very narrow window of time that doesn't necessarily work for everybody based on geography based on work schedule things along those lines. Fortunately the federal rules around methadone distribution have changed recently to allow for mobile distribution of methadone. So this is looking to sort of pilot within one district you know van if you will that will with the purpose of expanding that access to previously underserved regions of a district for a hub. We do know an example of the Howard Center has an existing van that's limited to group or northing prescription so we're able to see a lot of their costs associated with that which is how we've sort of based this number here for 450,000. I'll move on. The second point of this is supports for justice involved for monitors. We have seen over the past several years some really tragic gaps and the continuum of services for both for monitors within our criminal justice system within prisons and especially upon reentry or leaving prisons. We have had a few tragic incidents I think specifically with the chin and women's correctional facility where there is a really devastating loss of life following the release of several women and the goal here is to build those supports for both substance use disorder counseling and recovery while people are incarcerated, as well as to create that continuum that upon read entry that they are again I'll use this term warm hand off that they are immediately connected to the regional existing resource that is available via a recovery center via a hub and spoke provider but that somebody is not that somebody is fully aware and connected to the to the resources available and the third component of this is looking at kind of opportunity to facilitate a peer network. You know recovery centers have their role as far as peer support peer meetings and this is maybe looking at an opportunity to create that network among justice involved people in recovery or seeking treatment. You'll notice that we have given the department a great amount of flexibility within this to award one or more grants. You may be aware that there was a previous request for a specific recovery center dedicated to justice involved for monitors and that is sort of within the purview but we also wanted to recognize the work that's happening around the state existing where this need may also need to be met. So that's why we sort of didn't choose to spell out to a specific organization or recovery center within this language as is going on to the final bit, which is the warm hand off component. This is actually something that has been implemented in a few parts of the state. I can speak for Bennington County having an example of this through their overdose outreach project and essentially what this involves to put the language here clearly is that emergency medical responders first responders are constantly doing now to respond to overdose and resuscitating individuals sometimes multiple times and a single tonight. And we're really trying to see upon that point of contact with an individual how do we make the most of that moment, especially when it may be a point in time where an individual is open to engaging in treatment or recovery after having that life threatening experience. So, again, I think this creates flexibility of how an organization could propose facilitating these warm handoffs but the example that we have in Bennington is for an on call recovery coach to be able to accompany a first responder. So that when that person is resuscitated the recovery coach is there to have a follow up with the individual, if possible, even make a direct referral to a treatment provider. And so that is essentially what this is seeking to accomplish. For some context there, the grant awarded in Bennington was $45,000 to make this possible and so the $180,000 that you see here is essentially looking at expanding this to four districts as a start. I think within all of this we want to see these as sort of pilots right within within a limited capacity, but that may provide information about the opportunities available, safer when the opioid abasement advisory group is looking at what are the options for investing resources in the future. So that is that and then going back to what we've sort of tabled the fire authorization component. So basically to provide all over the context and this front, there's currently about 9000 Vermonters receiving medication assisted treatment. And we have reason to believe that that's only about half of the Vermonters with opioid use disorder that would benefit from receiving treatment. So we're interested in seeing what sort of barriers to treatment may exist and how can those be alleviated so that people are more comfortable engaging in treatment. One of the interests that really brought my attention to prior authorization was first hearing from a provider within our committee that they saw this as something that could hold it off their prescription plan and their treatment plans for hours. Well, while an insurance company needs to sort of sign off on whatever medication they prescribed and also a pretty significant study of almost a million people within Medicare. Medicare removed prior authorization for MAT and for this group saw that people engaged in treatment. More so, there's an uptake and people engage with treatment and a decrease in costs. Other healthcare costs such as emergency room visits inpatient treatment. So seeing that this policy as a whole is sort of we're spending the money where we want to be spending it right as opposed to on the other end. But to give a little bit more context here. In 2019, we passed law that basically created for non Medicaid insurers that as long as it was within the FDA's recommended dosage that there was no prior authorization. We've looked at applying that to Medicaid now after receiving reports over the past three years that show that about 95% of the prior authorizations that take place the vast majority get approved. So each one of these is taking 30 minutes up to 12 hours, but the vast majority are getting the green light eventually and we're wondering part of these additional wait times, deterring people from engaging in treatment. We've also learned that Medicaid really prefers a treatment plan that is focused on their preferred medication, which in this case would be. They have a few with on the list but predominantly we'll see is Suboxone, which is a buprenorphine and naloxone kind of combination. What we have found is that there are other treatment options that may work better for some patients. But this prior authorization process is a bit of a way that. Medicaid or the or the treatment providers I'm not exactly sure who the noun is acting in this case, but patients are being directed into a certain lane, right. They want to be prescribed Suboxone as opposed to other treatments that may work better with their physiology. Right. So we saw an interest in relieving a lot of these restrictions. We tried to curtail to the best of our ability, things that we thought would make it sort of a negotiation between the two. But just yesterday, we received further information that really the amount of dedicating towards their preferred medications. And there are a couple of different things that go into this. I don't want to get too technical, but really, you wouldn't think that a brand name medication is going to be the most financially beneficial for the medication spend. But in this case, it is. And looking at people having say the choice to pick something such as an innovative medication such as sublocate, which is much more expensive. The projections from diva for the changes as included within this bill were anywhere from 17 to $35 million if I'm getting that correct. So we are definitely willing to acknowledge the many demands for resources that the Appropriations Committee is receiving right now. We believe that this work is still important and we're gathering more information from providers and we're happy to say that this has expressed willingness to sort of meet again to find something that may work to bring these costs down while still eliminating some of the barriers but as it stands right now, this prior authorization piece as presented to you would be even just for sort of moving outside of the current terms of their negotiation with distributors and providers that alone would be a $4 million hit to our sort of rebate agreement is my understanding. So I hope that I can only imagine how much information you are all taking in at this time. I hope that enough of that got across and really would be happy to hear any questions unless a representative small has anything to add. The only other piece that I will add to it is really recognizing how fundamental has changed the landscape of the treatments that are needed here in the state of Vermont, which is why we're looking into the prior authorizations piece and hearing from spoke providers that the preferred medication is actually causing really intense withdrawal symptoms for folks that is help not having them maintain on MIT and instead going back to using instead. So really encourage that we're going to continue this conversation and understand that there might be a whining of the eyes when you look at the estimated fiscal impact as currently presented. Is your recommendation here that we strike the prior authorization from the bill. There is one component that includes them to continue reporting on their prior authorization. We would hope that that stays within the bill. You're going to have to tell us exactly what that is. Oh, those reports. Yeah, you said the reporting aspect. So I'm actually looking at the and I just just to finish this conversation briefly I'm actually looking at the the Divas report for pharmacy claims and prior authorizations for calendar year 2021 on the sublocate that you mentioned. They had 584 claims that they paid for prior authorizations approved was 254 number denied was 24 so that was a 91 points 4% approval rate so I don't know what's good what's bad there but you know, 91% seems to be a good number. I don't know. But anyway, and hence the reason why you're going to want to continue to explore and again just to reiterate as you said, wait time for authorizations 30 minutes up to 11.95 hours. So, that's have a day at any rate. So you're going to let us know which of these sections exactly would need to be struck in order to have to have done what you have said you want to do, which is continue to look at this number one. Number two, can you prioritize your entire request for us please. These are the things that we want to this is absolutely must all the way down to you know something they're all need to do they really are just in a prioritize for us please what. What our committee would like to see done because you have no money you have no money. And I hope that is understood. We are underwater with the budget requests that we have. We are cutting very significantly into. Important programs. I'm really excited and wish that I had more time to understand this because I can see there's huge potential here. And a bit of what I'm wondering about also is, are there opportunities within existing programs within the office so can be moving somebody around, et cetera. And you know, if we have another week, right bacon has has your portion of this portion of the budget. And you could put you had, you could think about it, but we don't have another week. It's frustrating because I can see the great value and what you're trying to do here. And then I have one follow up. I like the idea of the mobile hub. It's mobile hub and spoke essential mobile hub rather. So, the only the only issue of course with that is that it needs to make the same ground I presume, every day, right. It just so that everyone understands that they need to go see all the same patients on a daily basis because typically the patients go to the hub every day. I just wanted to make sure, you know, yeah. And to put that into context, I think the current method is that there are times Medicaid funded transportation have an individual and then bringing them back. So, I think that the efficiency of the transportation is something to. I can also see the real worthiness of doing it this way, because there are probably people that would prefer not to either camp or don't want to be seen doing it. And this way, or are very uncomfortable doing it. So this way, we can get them on the free plan. There's a lot of reasons to do it. They were a bunch of Jim and my problem, I haven't had lunch. This is scary for everybody. Yeah. Jim Robin day. And then we have to get them. Yeah, I just want to make sure I understand at the $880,000. That's one time. That's not going right. So all of these are considered. Okay, so just one time. Okay. Secondly, what was the vote in your committee 11. Thank you. Thank you. And so there's 880 and then I figured around 10,000 for per diem, but 890,000. Because you have of the 11 people on your working group and I'm thinking that that nine people need to get paid. So I could be wrong about that. I'll go fine. So anyway, I was just guessing. And when you're talking about some of these other things, has the health care committee seen this. We're planning on a drive by. Okay, is it in our committee now we have it. Okay, so also need to do a drive by with corrections and institutions. If you're talking that justice involved. Yeah, we have connected actually sorry, I don't want to speak. I can't confirm whether or not we're doing a drive by health care. I was speaking off the cuff. We have, we have communicated with the chair and vice chair of corrections institutions and they have no issues. And similarly, we have had conversations with the house health care committee, specifically looking at the diva section, the prior authorization that support and they were pending the fiscal note, which we have now received. Okay, so they're aware of this bill. And we will continue the conversations as our amendment. Okay, okay. Did you have any testimony as to whether the general fund could match Medicaid and any of these instances. No, we were really hoping to leave that to your expertise as far as whether some of this could be applied to a global commitment. Okay, so we did not receive testimony. And then just to clarify, so if we did this divas as any increased costs of 12 to 30 million in the Prior authorization that's what the cost would be that my understanding 17 to 35 million. Correct the 35 million. And that's rather significant. And they're saying, without the prior authorization. It would increase the amount of unnecessary, not necessarily the best choices. I think maybe the specific term would be preferred versus not preferred. And that that's sort of a free utilization of non preferred medications. And that's we don't want that. So the technical current about preferred versus non preferred has to do with their negotiations, as it relates to cost. I think that has more to do with that. Yeah, thank you. One more question from red. Thank you. And then let's turn to Mr. Mike Wilde. Okay, then I have one question with two parts on the substance use support for justice involved for monitors. The turning point style concept up there in the county area. And of course, you're aware, I believe that under the 1115 negotiation, they are negotiating to get that day into the 1115 waiver, the turning point concepts into the 1115 waiver. So it's not currently eligible, but it could be eligible under the assuming we get a new 1115 waiver under the one correct for magic. And then on the on the overdose emergency response support. Isn't that expert. Isn't that expert expert expert expert. It's a referral treatment screen brief, a brief intervention referral treatment. And I believe that that most health and human services offices have been trained. But some staff people have been trained and expert and I believe I know our hospital has a expert clinician or had an expert clinicians as committee funded one in the emergency room. So I'm wondering, you know, where's the where's the linkage without that concept. Yeah, well, I will say that one of the main. Let me answer your first question, whether or not these will be recovery coaches. Again, there's flexibility and I would say it could be either a certified recovery coach, which would fall under the 1115 waiver doesn't necessarily need to be within Chippin County, obviously. But that it could be either that or say licensed alcohol and drug abuse counselor. Let me ask it another way. Did you take any testimony that refers this screening brief intervention referral treatment concept that the state was using four years ago and I don't know the current status of so I'm asking you with the current statuses of that. Yeah, we did not receive testimony on that and I think that's your, your second question as it relates to the sort of 180,000 for warm handoffs. Yes. Yeah, so my understanding is that one component of this is. Sort of developing the memorandums of understanding between various stakeholders. Typically, if an emergency first responder is going to go to the site. That medical information can't really be readily spread to all the other available stakeholders. So that's one role of these on call recovery coach is to walk through that process. I, the expert is new information to me. So I'd be happy to look into that. Let me know. Thank you. I'm sorry, big important. We should talk for an hour about this, but we can't. So I'm not seeing more questions from us and I'd like to get your line while down here to talk to us about the system. So, if perhaps you'll wait and see if there's more conversation, but it's my understanding that you're going to come to us with a proposal of amendment. We're going to need to see where we're comfortable. Thank you for the question about prioritizing a question that I have is also can this be fit into existing budgets. Is there something in ADAPS that we're not doing when the mention was made with regard to the mobile that, you know, not as many people are going to have to be transported up to the hub. You know, is there a bit of savings there that we could book legitimately? I mean, so let's do some really creative thinking. And I'm sorry, I keep looking at here because this is his and we don't have any time. But let's let's try to see if there are opportunities there. So no one come on down. Thank you very much for the record. No line while joint fiscal office. Let me just touch upon quickly some of the questions that were asked for deals. I started with that. Six thousand dollars estimate. That's the high end. That's not low. I just say can be absorbed within existing budgets. I don't think it needs an appropriation is so small. So I wouldn't worry about an appropriation for that. I wouldn't recommend that one's needed. The question about one time Harrison. I wish I thank you for that clarification. I will put that in my next version of this will know to make it clear. And then to represent the questions about F map Medicaid match. Great question. I'm going to follow up with the department on that. That said, I suspect it would be have to go under investments. And we all know what the problem with investments are. So I'll follow up, but I suspect that would be an investment issue and given the current state of unknownness and local equipment. That would be a consideration. Now I'll guide you to page three, the fiscal summary. Discussed there regardless of what what happens with the prior authorization conversation. There's still, you know, $880,000 in grants. So there is still an appropriation of 880 in the current version. As to the prior authorization stuff, you know, we did hear testimony earlier from D of explaining it and the pieces I will highlight are one that prior authorization is to represent the act of owns point is a tool used to control utilization. And so the sense is without prior authorization they will have control over utilization to push to guide people to the therapeutic equivalent that's a preferred drug that would their theory do the same thing. That said, most of that this is the thing I found most compelling. Most of that money that the 1230 was for one drug. Supplicated, which costs over $20,000 per year per patient. So that's that's where a lot of that estimate came from. In terms of the impact the other piece we've heard that would affect about 4 million would be supplemental rebates and that's because when they negotiate with them pharmacy manufacturers. They're required to have a prior authorization policy and they don't have a prior authorization policy. As I understand it, they're not eligible for rebates. That's why there's the loss of rebates. So that's the two big pieces of where what their estimate. So that's my answer I want to because when I first heard that my job at the ground to I was represented Fagan at the time. And we could both of our job tables so hard. Everyone love. So, so I just want to just sort of explain sort of like my understanding of from conversations from the testimony we heard why that number is so big. I don't have anything further to. Let's see a question. Peter, thank you clarify question. If I may, the prior authorization regarding the rebates, as you said, a prior that needs to be in place in order for the rebates to exist. Does a removal of it one prior off effect all rebates or is it just limited to the specific drugs. I don't know the answer to that. The great question that that's a question I have to defer to the Medicaid. Robin. Yeah, so who pays if there's a 17 to $35 million. So that would basically mean that the Medicaid costs would increase. That's what I wanted to know. That's the effect of what happened. Yeah, so, and so we would have to cover that expected increase in utilization in the budget. Even budget would go up by that by that amount of money. By the way, I should have clarified to you that's gross. Okay, that's gross. So we don't know what the number is that would be. Well, I mean, we would if we were going to do this policy, we would put a number in. Yeah. And then I have the gross and that it's 40, you know, on the state shares 44.2%. So basically half almost. Even 44% of $17 million. Very much never. Any more questions for. Not seeing any. So work is being done. At some point we have to say all our income free on all of the bills. If this needs to get done. Tomorrow, tomorrow being Thursday, because we are running out of time. So. Work harder work faster. That's what she said. Thank you.