 Good morning and welcome to House Human Services Committee today is Thursday, March 10. And this morning we're starting out our conversation on continuing work on a committee bill relating to opioid overdose response services. And we have sort of a working draft and we have asked the Department of Health and the Deputy Commissioner Kelly Daugherty to come talk to us and maybe share impressions or comments on the bill and any suggestions they might have. On some level this is a conversation but we'll start Deputy Commissioner with you. Thank you very much. Good morning Madam Chair and members of the committee. My name is Kelly Daugherty and I am Deputy Commissioner at the Department of Health. I'd like to start just by thanking the committee for pulling this together because as you know, our overdoses have increased with the overdose deaths have increased with the COVID pandemic and we are certainly open to discussing anything that might help turn the curve on opioid overdoses or overdoses in general. So would you like me to just sort of give you my initial thoughts and then go from there. Okay. So there are a number of things in here that we would certainly support. There are also a couple of things in here that we have some reservations about. So, you know, maybe I'll start with the items for which we have some reservations. The first one being the peer run syringe service programs. This is actually something that the Department of Health really did examine over the last couple of years. And we feel that the requirements that are in place now that syringe service programs, either be an aid service organization, substance use treatment provider or a licensed health care provider sort of ensures that there's the infrastructure and capacity to do the work of the program. We also, we don't believe that there is a shortage of availability of syringe syringes and other associated supplies. And we already have mobile mobile syringe service units that travel to the more underserved areas of the state. So, you know, we don't see this as a priority and do have some concerns about sort of opening that door wider for other providers. The other thing that certainly we are not opposed to but just have had some experience with was the mobile medication assisted treatment. This is something that was tried before my time. And so I don't have a lot of the specific details but I know that there were challenges with actually patients being receptive to accessing mobile medication assisted treatment. Granted that may have changed since I believe it was in around 2005 or so that this was tried. And there were just certainly a lot of logistical challenges with that. So again, we could look back at sort of more specifics around what those challenges were, and maybe see if the landscape has changed. But I know that it was tried and was ultimately unsuccessful in the past. I'll pause there and see if anybody has any questions about those two items. I do. One, as it relates to operation of syringe service programs, not saying this is a route that we would go down. We heard and agreed with you that peer that coming back with a report on peer syringe exchange got, you know, was not the way to go, or that rather than guidelines, it was a report. Would you be okay with just section one, which of the bill, which does not identify that does not limit. In other words, there would mean it's still. It would need the programs would still need to be approved by you under section 4478 and, you know, all the other things and rather than identify a new program, but just leave it open. Would you be concerned about that. I'm not sure I completely understand the distinction between the what we did not do section two. Or section, but we just did section one. Would you be okay with that. Yeah, I think that we would be okay with that. Okay, thank you. Next question around the. I was just going to say it does it does give the potential for opening that door, a little, you know, which was part of my concern. You have the responsibility of approving approving them. Yes. So I mean it opens the, it gives you more flexibility. Right to do that. Okay. Hi, question about the mobile. Services is deputy commissioner you are you aware that there is about to start a mobile. Mobile service a mobile methadone. And so, I mean, part of that might, you know, include. Who knows what I mean, you know, so, um, I guess I'm a little surprised that we are basing our concern around information that is 15 years old. Um, and like I said, we don't oppose mobile. MAT services. I just wanted to make the committee aware that it was something that had been tried and I know that there were challenges so certainly understand that the landscape may have changed over the last 15 years and are open to seeing if it can be successful this time around. And then federal government is supporting this. Yeah, with grants. So, so clearly there is some landscape change or some interest in continuing to do that. Okay. Those are, well, I guess, um, what are the department's ideas for reaching rural Vermont. Yeah, so I mean one thing that we've, you know, that has come out of some of the flexibilities that the federal government has allowed because of the cobit emergency is the induction on buprenorphine via telemedicine. So that has helped and there is a significant amount of advocacy at the federal level to keep some of those flexibilities in place. So that certainly helps at least for those folks who are starting on buprenorphine. They don't need an in person visit necessarily. But with methadone you still do have to have your initial visit in person so this is something that could help with that. But some of the other flexibilities are around sort of take home methadone has a little bit more flexibility around it because of the cobit emergency. And that is something that would certainly help folks who are, of course, stabilized on their methadone but would allow them to not need to travel to a hub site as frequently as before and we're hoping that these flexibilities will remain even after the public health has been lifted and you know President Biden actually did mention that in his State of the Union address so like I said we're hopeful that at the federal level those will continue which will certainly help access particularly in rural areas. And I apologize members of my committee may know this more than I do. Are we are we totally tied to and limited by federal rules as it relates to methadone. Are there things that we can do as a state. As it relates to whether it's take home or that. The take home is really clinically determined so once someone, you know the clinician, the physician who's prescribing the methadone, ultimately can make that decision around, you know whether someone is stable enough to be able to start taking their methadone home. So, but there are a lot of federal regulations around sort of how methadone facilities operate. But the decision on take home is a clinical one. I don't know if there are a limit federal limits on how much can be taken home at a time that's something I would have to dig into a little bit. Yeah, just have a question about, is there a possibility of opening more locations for people to more homes I guess you would call them, especially with gas, so expensive right now and people having to travel from a month down to, you know, in the Moio County down to Berlin. So, is there a possibility is interested in, you know, looking into opening more access points. Yeah, I mean that's certainly something that is possible we may need, you know, additional funding to help support those sites but but certainly that's something that is possible. Is anyone else besides me have questions. Okay, Deputy Commissioner please continue. Okay, so I would say that the other thing that that we have some reservations about is the eliminating the prior authorization for MAT. And this is something that both the Department of Vermont Health Access and the Department of Health have reservations about. We feel that the prior authorization put some protections in place, you know, for patients and we would not like to see that prior authorization be waived. And then Kelly, we, I'm sorry Deputy Commissioner we have a question. Good morning. Can you provide us with information or do you know information about, you know, like what percent of prior authorizations result in a denial. I don't have that data off the top of my head but I can certainly find that information out at least for our Medicaid population from diva and provide that to you. I would anticipate that it's very low but I don't want to, you know, say that without actually seeing the data. And when, could you elaborate a little bit more when you said that you feel like it serves as a protection for people receiving that service. Well I think just like any service for which prior authorization is required it's just to determine the appropriateness of the care for the patient. Before the, you know, the payer agrees to reimburse for it so I think it just provides sort of a little bit of oversight, I guess I would say that ultimately is there to protect the patient. So, I guess what I'm trying to figure out is whether it's really about monitoring the cost. Or if it's really about patient access. I think that having that data around, you know, how many are actually denied versus approved will help to sort of illuminate that. Yes, if I may. Good morning everybody. I have the data right here from 2021. And there is a total of 3,130 prior authorizations were approved and 182 were denied. So like 94.5% are approved, and it's the average wait time is half hour but the longest wait time is just shy of 12 hours. So I guess my question would be, you know, the potential protections that could be in place. What's the benefit to be having these, you know, over 3000 cases in which people are waiting a half hour to receive their treatment. You know, it sounds to me that, you know, waiting a half an hour is not would not present and a huge barrier to accessing treatment. And we, you know, we talk with diva regularly about these issues so I could certainly talk with our partners over at the Department of Vermont health access and, and, you know, get back to you on that. Okay, I just wanted to add into what Dean just said and also our conversations over the break about that half hour, and it was really that these folks have come in and need to work up first. And sometimes that can take an hour to two hours and that's incredibly important. We all know because we have to know what the right dosage is and all of those sort of things and that they're ready and, you know, all of those things. But then to leave the patient and say, Okay, we're going to go get the prior approval now and give them, and it, remember it ranges anywhere between a half hour and 11 hours. That's where we are losing folks to just walking out. And if you figure 94% is it worth even losing one person who might go out and end up dead the next day. I just don't think it is. That's it. That's a good point. And like I said, we'll certainly look more closely at this with our diva partners. And thank you, Deputy Commissioner just so that you know, we are hearing from them after lunch today. Oh great. But we have a, and we have a question from Representative McFawn. Thanks Madam Chair. Deputy Commissioner, could you tell me what happens with that patient or prospective patient during that time when the prior approval is being sought. Is there any, any discussion that goes on with them. So any counseling anything like that. I think that a lot of that happens when they're doing the initial work up identifying sort of the patient's needs and ideally they would be connecting them to recovery services and other services in the community but I think depending upon the length of that wait for the prior authorization, you know, they could wait in the office but I imagine that a lot of people leave and end up then, you know, being contacted by the provider once the authorization has gone through and they can get their medication. So I think it probably varies depending on what that length of time is, but ideally all of our providers would be connecting them with other sort of services to support them in the meantime. Okay. So, essentially, they're kind of a limbo for whatever time that wait period takes place. Correct. Correct. Correct. Okay, good. Thank you. Thank you deputy commissioner. As I, as I look at the proposal here in section four we really have two strategies that we're putting forward. One is not eliminating the prior authorization but delaying the prior authorization 60 days to allow folks to get inducted into treatment as fast as possible, find the right dosage and then be able to get that approval later on. And the other strategy being having medications themselves having one medication needs class, remove the prior authorization, as long as it's in line with the FDA. So does the department have a, it sounds like you don't have a preference for either of these, but just wondering what the thought presses up is around delaying the prior authorization, knowing that the induction period is so important for medically assisted treatment. So, you know, I think that part of the prior authorization process is just looking at the appropriateness of the treatment for the patient, and I guess I would have to think through the clinical implications of let's say I get inducted on MAT and, you know, then, you know, there's a delay in the prior authorization and for some reason the prior authorization is denied. And then what would that do to sort of my course of treatment. So, you know I think I would just have to think through what the potential implications of that would be. And I would also highlight a prior authorizations are only taking a half hour. It really shouldn't be much of an issue if it's 60 days down the line versus right up front. Right. Another piece I heard from community is this move towards mono buprenorphine treatment, especially in addressing the fentanyl crisis and knowing that with the naloxone addition it pushes folks into a media withdrawal and can actually push people off of maintaining on MAT. And in my understanding, because of the preferred drug realm, any prescription of buprenorphine is a prior authorization regardless of dosage even if it falls within FDA guidelines. So I'm wondering, how do we alleviate that barrier for seeing providers move closer towards prescribing buprenorphine and getting folks on treatment. It seems like we're immediately putting up a wall for them to be able to get access to that treatment up front. Right. Like I said, I think that this is something that we can have further conversation about and I just want to reiterate that, you know, we certainly don't want to stand in the way of people getting access to treatment. You know, we just want to make sure that the appropriate safeguards are in place so I'd like to be able to go back and have a conversation with our eight up clinical team, as well as with our diva partners. Thank you. If you have any other questions, please continue with areas that you either have concerns with or those areas that you don't. So, I want to highlight the services for justice involved individuals we certainly support, you know, developing tailored interventions for that vulnerable population and we actually already do work closely with corrections. In terms of when people are transitioning out of incarceration and into the community are 12 recovery centers across the state already serve justice involved individuals. So I would be curious if the committee is thinking about sort of a standalone service for these folks or whether it's something that could be, you know, directed to, you know, additional resources directed to our existing recovery centers to help sort of maybe enhance that work that is happening. So, you know, certainly support the concept, but just curious how much flexibility there is in implementing that. I'm going to turn to the team represent Whitman. Yeah, thank you and correct me if I'm wrong, but Commissioner already are an intention in drafting this language was to be flexible about how these could be awarded we know that there are both existing organizations throughout the state interested in doing this work. Some are recovery centers, some of them are not recovery centers but doing different capacities we know that there is a need for a well at the same time it's not across the board. There are some capacities in some parts of the state that are not happening across the board, like, for example, direct services to people while they are incarcerated so bringing those recovery services to people while they're there. So, I think that this could be the way that we've drafted it it could be one organization. It could be multiple organizations if it bolster one existing organization already has. And but it's not necessarily a recovery center it's not necessarily, you know, we've just kept it flexible as written. Deputy Commissioner if I might add to that. It was at this point in the drafting. It has been our committee's proposal to leave that decision to you to the department as to where it is best directed. There is some. There is some concern from an organization or from an individual that wants to start a a program a particular program. And I want to say we thank that individual or I do for bringing the idea and the need to at least me and of course, would like it to be specific to them and to not have an RFP process. And because they have experience and all of that. And as you may know, or if not you, David Englander may know, while I do like to tell the health department what to do. We do like to acknowledge your expertise and this was something where we would we would like to give you the authority. Thank you and we would certainly look as broadly as possible. Thank you for talking about this. I think the only other comment that I have is, you know, we are open to the overdose prevention site working group proposal. Certainly something that I know is a hot topic of conversation right now, particularly in Burlington area. And, you know, we would not oppose that group and looking at it further building upon the work that was done by the opioid coordination council. It was about four years ago at this point, when they did have sort of a study group on that and, you know, again looking at what, you know what has changed in the landscape since then potentially. And like I said at the, at the start, you know, we certainly want to look at all opportunities to help address our overdose crisis so I don't think that there's anything else that was really that really stood out. But happy to answer any other questions. Thank you. Thank you Deputy Commissioner and we are working on the, the language of the of that study. And what we discussed it yesterday and decided we perhaps needed to massage it a little bit. And would love to have your feedback on it. Of course yesterday, just to let you in case anyone is unaware today is Thursday and we will be making decisions about our actions on this bill. By end of the day tomorrow. I think that one of the takeaways from the study group that convened a few years ago, was that there was a perceived challenge with an overdose prevention site in a rural state like Vermont. They've seemed to have worked or where they've, you know, operated have been really in like inner cities where there's a critical mass of people. And I know that folks are looking at this for the for Burlington. We are largest city in Vermont. But just wondering how that would work with people traveling from other places to utilize an overdose prevention site and then, you know, leaving there and traveling so whether there'd be a critical massive people to sustain such a facility in Burlington. So, you know, any potential legal challenges of course would have to be would have to be worked out. And so I mean, maybe if we were identifying what that committee needed to look at one of the questions would be, is there a critical mass, or however one, however one frames that could be raised a question. And I will also just highlight that Burlington is not the only area in the state of Vermont that is exploring and has done significant research into overdose prevention sites there's also the consortium in southern Vermont that partnered with northeastern law school to do a very extensive report on the barriers on the legislative and levels. Yep. Thank you representative small for pointing that out. Representative McFawn. Yes, thanks madam chair. Deputy Commissioner could you just. I don't think I got everything that he's just said about there's something going on in Burlington. There is a group that is that has formed to really look at the possibility of an overdose prevention site in Burlington. It grew out of the Burlington calm stat group which is a group that formed several years ago to look at the opioid crisis in the county area and kind of developed solutions so there's a subcommittee that has come out of that group that is looking at the potential for that in Burlington. Okay, thank you, Deputy Commissioner. Are there any other areas of the state that are doing something similar that you know of. Well the one like representative small said in the in the southern part of the state. I'm sorry you didn't know about that until just now. Yeah, I didn't know the specifics about that about that group but I know that there are other places that at least have mentioned it I don't know if anyone has gone as far as convening a group. Anywhere else in the state. Thank you. Representative Rosenquist. Thank you. I was just wondering if you could quickly review there's six initiatives that looks like to me in this bill. And I know you covered several of them but could we go through each one of them. I'm not sure you were. Opposed or have questions about it. The first one, expand the locations in which organized community based able to change programs and operate. So to that one in the beginning around, we would have some concerns about sort of opening the door to broaden the types of sites and we feel that there is sufficient access to syringe supplies across the state and there's also mobile exchange programs so. So that was something that I had highlighted that we had concerns about. Certainly open to like chair Pew mentioned doing, you know, looking into that and, you know, doing a report on that but that's something that we have looked at closely within the health department over the last couple of years. And the second one requires the department helps develop guidelines for peer delivered syringe exchange. My recollection is you weren't supportive of this is that correct. Correct. All right. In short sentence, can you say why you're not supportive. I think that the requirements that are in place now that the organization be an aid service organization a substance use treatment provider or a licensed medical provider, sort of ensures that they have. It's kind of a proxy for organizational capacity and infrastructure. And that coupled with, you know, that we don't feel that there's a need to broaden that scope that there are adequate services in place I think those two things combined, sort of, you know, make us feel that the, the opening that door is not necessary and maybe not wise. Thank you, Chair, Commissioner Dardy. If I may just few questions one is to just, you said that you've looked into peer delivered syringe exchange and I was wondering if you could talk a little bit more about what you found in a little bit of our research we saw that you know these could be sorts of like programs embedded in AIDS service organization, you know just an additional facet or capacity for outreach so could you just talk a little bit more about your reservations on this. Yeah, well they are already embedded in AIDS service organizations and. And so we are actually doing a pilot right now to add outreach workers to the current syringe service programs which could help sort of reach more people. And we that's certainly that we something we could look at expanding statewide. But, you know, it was within ADAP and our HIV STD have C program that those program folks really looked at whether there was a need to expand beyond those entities. And the conclusion was that that it was not a need and we felt that that having those parameters in place. Ensured that the services were provided in an adequate way. Um, so it kind of feels like we're talking about two separate things one is, you know whether or not the existing organizations are adequate, and the other is sorts of this additional capacity for peer delivered syringe exchange you to said that there's outreach workers, I kind of think of those as potentially synonymous based on who you hire to be the outreach worker and I just wanted to ask. Do you have you develop the guidelines for these outreach workers or is it just something that you're working with the service providers on something that we're piloting right now I don't know the extent to which there are written guidelines at this point but certainly they could be peer outreach workers the distinction is that it would that the organization is not a peer run organization. It's just limited in existing SSPs. And again it's just a pilot at this point but depending on how that goes we could certainly look to expand that to other existing SSPs in the state. I've been a legislator for a long time and I think one of the first bills that I reported on the floor of the house was the bill to allow needle exchange. And so it is something near and dear to my heart. I've been confronted this year with looking and relooking at legislation that I was involved in writing, and how perhaps it needs to change with the times, and many, many years, you know, and so. I know and understand the immense and incredible role that the AIDS service organizations have had in syringe exchange programs. I also know that the largest syringe exchange program is not an AIDS service organization. And, and we heard testimony yesterday that that while it is based in Burlington. It has individuals coming to Burlington, because the other places are not and things like that and I get. I'm getting nervous. I'll say that we are looking at let's continue what we're doing. We're not looking at other. And I have to say, and I like what we're doing. You know, I have some, but I, you know, it's like it's time. I think it's time for us to, to not hold on and go let's keep doing exactly what we're doing and let's keep funding, exactly who we're funding. And yes, let's perhaps keep doing that. And what else can we do. Because as you began your presentation your testimony today, you said we have a problem. We have a huge problem in Vermont that is, despite the fact that that we have been on the cutting edge of response, our opiate deaths are increasing and we've seen more than we have in years and so I am looking at how we can do things differently, or how we can expand and not. And I'm, I guess, I'll be honest, Deputy Commissioner I'm hearing from you some concerns about even exploring that. I think that we could certainly continue to explore it. I definitely don't want to be a person who says we're going to do it this way because this is the way we've always done it and that's generally not how I operate or the Department of Health operates. So, we could certainly go back and look at the capacity and utilization and the existing system and identify where there might be gaps in the capacity for syringe service programs and how best to fill those gaps. So I don't, I certainly don't want to give the impression that I'm not open to exploring that. Thank you madam chair, and yeah just to provide a little bit more context to this as well. This is an issue that I thought was pretty, you know important, knowing that clients from Bennington were going up to say for recovery and Burlington to receive services so the idea that you know that they're readily available is something that I question and I do think that the existing definition that limits to a service organization substance use treatment centers and licensed health care providers in Bennington. The one designated spot was our free clinic. And, you know, because it was a licensed health care provider was able to have the standards etc etc. But something about the culture or the points of contact that they had with individuals they were receiving, you know one client per quarter. You know it wasn't having that interface so I think a lot of our reasoning is where are the organizations that are having current interface and current points of contact with injection drug users and how can we think creatively about helping them meet the standards of the Department of Health. I understand that that's a concern but if it's within our, you know, within this legislation that remains the same. It needs to be approved by the commissioner and meet those standards that are set for everybody else and Yeah, and one other thing that I wanted to clarify about the peer delivered syringe exchanges that all of the cases that we've seen is not that it's necessarily operated or an organization run by peers, necessarily, but that it would be an existing organization that sets up this program to train and, you know, essentially recruit staff that have lived experience. Yeah, just to clarify that and if there's anything we can do in the language to clarify that. Actually, I know safe recovery employees people with lived experience and that's been a real benefit for the people that they serve that, you know, they really can understand and meet people where they are. Oh, go ahead. You look like you want to say something. Yeah, yeah, so I guess I would just want to understanding that you want to hear reservations about opening the door is that you want to make sure that people meet the standards of the Department of Health but that remains within this language that just makes it less protective about who can, who can strive to meet those standards. Yeah, understood. And, you know, we certainly obviously support having oversight over those standards. Thank you. And Carl was at number three. And I understand about the working group. Number five requires the Department of Health to adapt emergency rules authorize its rent service providers to facilitate and support peer delivered syringe exchange or just goes along with a prior one here about the group so you probably have already responded to that. And Carl, I think that may be something that the committee needs to talk about in terms of how, in terms of how far we go, or whether we start with one piece which is to widen the definition and ask them to come back with a report or something like that. Thank you. I think six was grant programs. Again, there. It was mainly about mobile medication assisted treatment and didn't seem supportive of mobile units. You know, we're certainly not opposed to it and I think we just want to look at what those specific barriers were that were encountered and see if there's a way that it could be that we could sort of plan to address those from the start. So definitely not opposed to mobile medication assess assisted treatment in concept, but we just want to be mindful of what barriers there might be, you know, heading into that. You know, heading into that. And Carl, if I can think of, I mean, if it is possible. I am aware that they're that the Howard Center is about to embark. They have a federal grant to do it and if I can get that person get someone from Howard Center to to testify this afternoon. As to what research they have how, how, you know, we might, that might help us as well. Okay, just to close out what I was talking about here I'm just concerned that it seems that there are a lot of areas of this bill at the moment that the department would like to do more research. Okay. And yet we have like 24 hours. I don't know if it's premature. I'm just concerned that we don't have more support from the department at this point in our decision making process. So I just like to make that comment. If there is a way that it can be, we get more buy in from the department. I feel a lot more supportive. Absolutely. I appreciate that. What I hear that we have some submit list at this point with this draft what I hear we have some potential support. Or shall we say not whatever is to remove the quote unquote limitation of the definition of syringe exchange program. And maybe a report back, not to not to do a peer thing but maybe a report back. I understand that there is concern. And there is a support. There is a lot of money, but they're supported the concept of looking at justice involved the monitors and and having grants in terms of that. There is concern or question about pre authorization and just and I will share with the committee later or whatever blue cross blue shield is actually in support of the language. The cross blue shield is in support of the pre authorization language they have a little tweaking about where a sentence is total pre authorization or for the second day period they are. I sent them the language that was in the our draft bill. Actually they said they, they expressed support that they were made some comments and I'm a little slow so I emailed back and I said does that mean that you support the language as written. And I will share those emails. I'm sorry. And then and the I believe the department is okay with the study. The evaluation. More information on the. What are we calling them now over. What are we calling them? The overdose prevention sites. And there. So there's that and we have, when we discussed it yesterday. It was a, maybe we needed to work on that language and I want to share that language with folks. Did I give, have I covered all the pieces and Kelly deputy commissioner. It's my summary somewhat. Yes, it's correct. And also I would just add that we also support and concept the medication, the mobile medication assisted treatment. Sorry to that again. They support in concept. Mobile medication. Okay. Absolutely. It sounded like the commissioner had a concern about this in pre authorization issue that if, let's say we went to that 60 days and at the end of that was thought that the person shouldn't have been pre authorized. Okay. What would be the outcome of that. In other words, would the person be taken out medically assisted medication at that point or not. I'm just curious what the outcome of that would be. I'm just curious what the commissioner would say about that. I don't think this person should be on that drive. But they have. So what would be the consequence. I guess that's what I was curious what the commissioner would say about that. Right, right. And, you know, I'm not a clinician. So I, you know, I think that the clinical considerations would have to be taken into account of, you know, what that person's, you know, what each person on a case by case basis, their experience was on the medication. I think that if it was deemed to be a successful treatment for that person, I can't imagine that the, the payer would deny authorization for it. So I think that that's an open question and it might also be something if you have your, if diva is going to be with you this afternoon that maybe you would ask them that question as well. Thank you. And just a reminder that for prior authorizations it's not on the prescribers and or the doctor. It's the, the payer as the deputy commissioner was saying so either Medicaid or Blue Cross Blue Shield. Yes. Representative McFawn. Thank you madam chair. As we, as we've been discussing this bill. It appears that, at least to me, that there's information that was gathered by a group of our committee. Am I correct in that. Yes, over the part of the army. Yes, that was part of the direction just as a group over break worked on reach up. Okay, a group. I'm talking about this one now. It was Dane, and it was Taylor, and it was Jessica, and it was Kelly. Okay. So, whatever information like that piece that you just came out with the Blue Cross Blue Shield. It's in a way that we can, the rest of the committee can have that information. But whatever else is there, I think it would make a big difference in terms of the questions we ask or how we feel about the, the bill itself. To me anyway. Important. So if there is other information, it comes out in bits and pieces, as, as when the, when the agency said well we're not in favor of this, and then all of a sudden there's information about it. People have and that's the kind of stuff I think that the committee as a whole, if we had that information. It would be much easier for me to make up my mind on what I'm going to do. Thank you. President McFawn, absolutely and in terms of the email traffic. As it related to the Blue Cross Blue Shield. I will forward that to Julie, who can figure out how to send it to the committee. The smaller group did meet over Zoom with Blue Cross, Blue Shield over the break. And it was just Monday. Thank you so much. And Tupper, Representative McFawn, it was just on Monday. And so we just heard back from them last night and a follow-up this morning. So it hasn't been that long. 7.59 this morning. Yeah. Well, yeah, I mean, I'm finding out information when different members of the committee start talking about stuff. And I'm saying, well, I wish I knew that before. That's all I'm saying. Yeah. Good turn. Yeah, we're not having a lot of committee discussion like I'm used to having. And that's when that stuff comes up. And that's, and one of the things that we talked about sort of process-wise before was an understanding that there were, this week, we needed to do things a little differently because of how we spent the beginning part of the session and on very important work. And now we needed to, and that's why folks gave up their town meeting recess, just as you gave up your summer to work on something else. But I told you about all that stuff. Yeah. So one of the things based on conversations that we had yesterday about the study language, the report language on the, I believe that Dane and Taylor worked on some new language. And I believe they sent it to Katie, but I don't know if it is in a form that we can screen share so people can see it or whether we need to read it. Hi, let's cancel. Hi, I'm happy to, oops, I'm happy to share it. Just give me a minute to pull it up and I'll put it on the screen. This is from the email, correct? I believe so. Okay, great, let me pull it up. And I want to do this so that the deputy, I mean, I haven't read it, sorry to say. And so that we all can see deputy commissioner, because you expressed some interest in that study. And so I wanted you to see where the language may be morphing to or not. I need screen share capability. You just got it. I think you're about to get screen share. Katie, if you are talking to us, we can't hear you. I'm not talking. Would you like me to walk through the changes? I wasn't sure if you wanted me to do them. I can walk through them and maybe have the members who are working on this sort of discuss the rationale. Absolutely, that sounds like a perfect because some of us can't see the... Oh, I'm sorry. Okay. No, no. So this is the section five overdose prevention site working group. And this is first we have subsection A is the creation language. And so there's language and recognition of the, and then the new language rapid increase in overdose deaths across the state. With a record amount of opioid related deaths in 2021, there is the working group to identify the feasibility and the new language and liability of implementing overdose prevention sites in Vermont. And then in subsection, should I pause there? I think right now to, unless there is, I will leave it to Dane and Taylor to jump in if they think or for a committee member or for that matter, deputy commissioner to jump in if there is a question. Well, I can say, Carl, the liability piece was for you. Yeah, I understand. Yeah, I'm listening, I'm listening. The next section is the membership section. There have been some changes here instead of, let's see, the addition is a representative appointed by the state's attorneys. And then in subdivision six, three representatives appointed by the league of cities and towns or the regional planning commissions. And then in subdivision seven, two individuals with lived experience of opioid use disorder, including at least one of whom is in the recovery. One member appointed by safe recovery and one member appointed by the Vermont Association of Mental Health and Addiction Recovery. So that tracks the language in H711 from yesterday. And those are the changes in the membership section. And then in subdivision, excuse me, subsection C powers and duties. This is sort of the responsibilities of this group. So there have been some changes here. First, research the current implementation of overdose prevention sites nationally. Second, identify the feasibility and liability of publicly funding overdose prevention sites. Three, identify the feasibility and liability of privately funding overdose prevention sites. Four, make recommendations on municipal and local actions necessary to implement overdose prevention sites. And then lastly, same as the draft previously slot, make recommendations on executive and legislative actions necessary to implement overdose prevention sites, if any. Thank you, Katie. Would you like this document pulled down? Yeah, so that is hot off the draft press. So Deputy Commissioner, you've seen this at the same time I have, but we would love, we would appreciate your feedback as to what makes sense, et cetera. Yeah, I think that the updated language we could support, it's, I appreciate adding that language about exploring the, not only the feasibility but the liability and then also sort of the experience across the country because things have changed since the OCC looked at this four or so years ago. So I have no concerns about the revised language. Thank you. And one thing I will add about the membership are just a couple of clarifying points. As I believe I mentioned in committee yesterday, had a conversation with the Attorney General's office. They recommended moving it towards a more local approach and having the state's attorney appoint someone to the group rather than having someone from the Attorney General's office. We also felt that there was a need for more local perspective, whether that's looking into zoning, which is why the suggestion of the Regional Planning Commission or just municipal level. So looking out League of Cities and Towns did not make a choice on either one of those yet. One, because we have not talked to those groups yet and one is the housing. It looks like such an appointment where they might direct us. And two would love the committee's feedback on that. Of course, in the two individuals of lived experience, just want to match the language that we put in 7-Eleven and we'll show that the providers for medically assisted treatment is consistent with the language in 7-Eleven as well. Yes, and heard the peace and committee about liability and really wanna make that clear, especially when we're looking at funding streams and specifically pulling out publicly funded and privately funded because in my narrow research so far on overdose prevention sites across the nation, majority of not all are privately funded. And what I'm hearing from communities is that there may be a need for public funding. Which raises that question of liability on the state level as well. So we're seeing where the opportunities are there. And later in the bill when I talked about funding, I think I'd suggest that we put because there's so much money coming out of the general fund. Allocated for this. And I suggested with something that would indicate or other sources of income. Thank you Madam 7-Eleven. 7-Eleven. Yeah. Yes. So I don't know if Katie picked that up or not. Yeah, I'll just say yesterday I had a conversation with representative Fagan on appropriations and she recommended that since this is going to appropriations committee that we keep it general fund for now and they will make those decisions as far as whether or not they're designated to a different fund. I'd be happy to get that in writing or something if that would be comfortable for the committee but open to other ideas. Well, and perhaps Ray and I can Ray and I will be going to the appropriations at 10-15 to share about 7-Eleven. And I think we did the same thing in 7-Eleven and for the study committee or whatever it is. Advisory. The advisory committee and where are that like, you know. So, but would you like it in writing, Carl? No, I just thought it would be useful that, you know maybe there would be even a different source than 7-Eleven right now. That's what I'm thinking that 7-Eleven could be. Yeah, exactly. Whether you wouldn't want to necessarily mention it because it's not been approved yet or not the funds. But at least it would be in there that if other funds are available, it wouldn't come from the general fund. Exactly, exactly. Maybe some of this would be eligible for a global commitment or something like that. Sorry, sorry. Global commitment is now a fantasy. That's what I'll have to say that. There you go. If I could ask one more question, Commissioner Doherty I was just wondering the final sort of pilot about the warm handoff in responding, you know coordination with emergency response. You just haven't commented on that. And I was wondering if you had any thoughts? Yes. Yeah, no, I actually I'm glad that you mentioned this because I just wanted if you could provide just a little bit more detail about sort of what the vision is here. It was hard to sort of understand with the way that it's worded now what the vision is for this piece. Certainly I have no concerns about it the way that it's written. But so actually that's a good question. And I will turn and ask you if you could what is the problem we're trying to solve in this? Absolutely. Yeah, so I think that the idea is that we want the points of contact that we have with people that are at risk of fatal overdose to make the most of those moments where we have points of contact with people. So whenever somebody is resuscitated following an overdose by emergency medical responders who may be carrying Narcan to resuscitate them that can also be an opportunity to connect them with services such as recovery services, treatment services, et cetera. So the vision this is really based off of one of the community action grants that was received in Bennington. Actually I think it was called the overdose outreach group or something along those lines. And it was pairing up a recovery coach to accompany EMS to be on call to respond to overdose calls. And basically an understanding that is probably a moment where an individual may be more open to receiving care or open to learning more about services after they've had that experience. So looking to pair up a recovery coach to connect them with services. And in some cases actually make a direct referral to the local spoke treatment provider. And there are some technical things involved in that such as memorandums of understanding to be able for an individual to share their medical history with the other stakeholders. But a majority of the funding would go to the personnel, the on call recovery coach or maybe it could be a treatment provider here. So does that kind of clarify? It does. And like you said, there is some work already happening in the state sort of along these lines but certainly we would be supportive of expanding it statewide. We already do have emergency responders are leaving behind sort of information and about accessing treatment, connecting with Vermont HealthLink whenever they do respond to an overdose. But certainly we would be supportive of expanding those handoffs as much as we can. So no concerns there. Deputy commissioner, excuse me, I'm wondering if you could work with representative Whitman around, I don't know, descriptive language because I think you raised a good point. It's like, really? I don't quite understand what this is. And committee, where are we right now? Is this a good time to take? We'll be taking this up again this afternoon and we're gonna be hearing from Diva this afternoon. Let's look at our schedule. Well, I may need to have a conversation with Ledge Council or whatever because if we're sort of on a roll with this and we have at two o'clock a possible markup and vote of reach up, but I'm also looked on the floor and we don't have a lot on the floor. So we might be able to come back and I wanna talk with Ledge Council because there's been a question around the mobile and so I wanna see if we can get someone from Safe Recovery to talk about what they're doing. And despite the fact that I spent most of the evening with a email back and forth from Vermont Cares who wanted to testify and I said, please put it in writing and give it to me. I've yet to receive anything in writing and given the fact that we've had this conversation, I will be giving them an opportunity to share their concerns because and which may in fact have been addressed by the Deputy Commissioner right now in terms of moving in a different direction. But since I have not received, I asked for it in writing but we were spending way too much time back and forth last night saying, please let me testify rather than knowing in case they have other issues. So I will be asking them to, if they can testify this afternoon as well. So we can close that loop. I've also received an amendment suggestion from the AIDS Project of Southern Vermont who would also like to be included in the Overdose Prevention Site Working Group. So something for us to consider forward. Okay, I'm thinking that even though it's not, we don't have a break scheduled until 10, 15. Oh, except for we need that break because at 10, 15 is when two of us are leaving for that. I mean, I think that, well, let me, Topper and others, do we, what other kinds of conversation around this bill right now? We're gonna come back to it at one, but before, what other conversations do we wanna have? Yeah. Madam Chair, what I would like to see is, we've loaded up people, the Deputy Commissioner and others with what appears to me is tasks. And I'd like to just let us take a break and let these people start down that road. Because we don't have much time to get this thing done. And, you know, just having Katie go over what we did yesterday, you know, it's coming together, but there's still some things that we need to sort out. And I'd like to give those people time to do that. Okay. I've appreciated the discussion this morning. I will say that there was sort of one thing that I felt when we heard, well, we looked at that 15 years ago or that was tried 15 years ago. I'm like, a lot has changed in the world in 15 years. And I think that there are, you know, things that even if we did look at them 15 years ago, how they might be implemented, you know, a decade and a half later would be substantially different than maybe how it was done at that time. And so I hope that we're open as a committee, especially since we're in this bill, as Madam Chair has pointed out, really are maintaining the authority of the department to really be in the driver's seat about how some of these ideas are pursued, or even honestly, if they get pursued, I hope that we are open to keeping them in the bill. I'm just gonna be honest about it in some form because I feel like honestly, I feel like it is that what we are doing here are small steps to reduce the barriers, to try to reduce the barriers, because I'm not sure we're actually doing it yet, but to try to continue to reduce the barriers for people who might be at that moment. And I just, you know, echoing what Representative Drumstead earlier said that, you know, if 15 people get by on, you know, medication assisted treatment that, you know, maybe shouldn't have, but we saved one person because we reduced that time, that's a good trade-off for me. Bye. Okay. I think this is then, I'm hearing that this is a good time to take a break, and we will actually take a bit longer break to give people some time to group, to connect by email or by, you know, Zoom or whatever. And we will be back at 1030. And at 1030, we will be taking a different topic and we will be getting testimony around the reach-up bill. So with that, we will take a break. Thank you, Paul. Thank you. Thank you.