 I'd like to get started by first going around and having us all very quickly introduce ourselves because we don't have a lot of time, but I really think it's important for us to each other, each of us to know who's in the room with us. Welcome, Jill. You can have a seat while we're doing quick introductions, but I'd like to welcome those who are from the Albany School of Pharmacy. Downstairs, you'll see many white coats downstairs today is Pharmacy Day. It just happened that we were having to be looking at some of our agenda that touches on these issues. But let's go around and if you're here representing an organization or engaged somehow to follow these issues, please identify that. And let's just do a quick redamon. Go around. Oh, I'm sorry. Thank you. Good morning. Hi, I'm Cali Fort and I'm a fourth year Pharmacy student and I'm on rotation with D. August and Kennedy Walker. Thank you. Welcome. Margaret Lagas, a contract lobbyist with logistics representing America's health insurance plans. Jamie Fee with Perman Piper, also a lobbyist representing CVS Health this morning. Wayne Fisher with Orca Media. I'm executive lead and I'm a public affairs representative. I'm Jen Lindman. I'm with Vermont Department of Health in Burlington. Welcome. James Warmer. I'm a Wayne Woodstock Pharmacy and also the executive director of the Vermont Pharmacy Association. You said we're a lot of hurt though for the pharmacists this week. Susie Grotowski, everything health care. Hi, I'm Samantha Mattel. I'm a fourth year Pharmacy student on rotation with Lisa at Diva. Jen Kennedy, I'm a lobbyist and the representative is just saying that. Jessica Barnard, the executive director of the Vermont Medical Society representing Physicians. Devin Green from the Vermont Association of Hospitals and Health Systems. Laura Pelosi at MMR Government Relations, care for pharma. Sarah Teensha with Blue Cross and Blue Shield of Vermont. Nancy Hobe, a pharmacy director for Vermont Medicaid, Lisa. Brian Murphy, the director of Pharmacy and Vendor Management at the Cross Division of Vermont. Heather Scholdeis, William Scholdeis and associates here today on behalf of the Vermont Association of Change Directors. Jim Dandenell, also a pharmacist at Cramer. Becky Ladaski with DRM for Pfizer. Maureen Thiel Kennedy with Otis and Kennedy, the representative of the Vermont Pharmacists Association with Vermont Retail Justice. Christina Watson, Cramer, care for you. Meredith Roberts, executive director of the American Nursing Association of Vermont. Eric Siebert with Morris Government Affairs representing the Association of Accessible Medicine. Welcome. I'm going to skip over our committee members introducing ourselves. Although we are publicly listed everywhere. It's up to date now. It's up to date now. Yeah, it's been updated. Yeah, that's updated. But because of time, we'll have us introduce ourselves at a later time. So yesterday we started to get updates on the work that this committee and the legislature has done around issues having to do with prescription drugs in particular. And we heard both an update about the initiative around possible importation of prescription drugs from Canada. We heard from NASHV, which is an organization which is working with multiple states doing that. And we heard from Blue Cross Blue Shield about some of the pressures that they're experiencing as one of the major insurers for Vermonters. And heard several bills that have been introduced in this biennium that touch on prescription drug issues as well. This morning I would like to welcome Jill Abrams from the Attorney General's Office who has been working to implement an initiative on price transparency that this body actually did several iterations of. I'm hoping that maybe, we have a brief time, but if you could briefly remind us and those who are gathered here what the legislation laid out and directed the Attorney General's Office to implement for us. And then maybe update us on where we are in the process. I know you've been working on it again this past year, so given the time. And we do need to be on the floor, unfortunately, so we'll go right up to the 9.30 hour and I'm guessing there may be other questions and we'll have to return to this a little later time. Thank you for the record, Jill Abrams, Assistant Attorney General. I brought copies of the report that I submitted. You may all already have them, but I've got copies. Well, there's electronic ones that are posted, but if you would distribute those for those who would like a hard copy, I'm still in that world. And there are many others who have gathered around who would like a hard copy. Could I ask you to just ask? There are enough for the committee and then some additional. Can I check and see, Demis, while we're talking, can you check to see where we can access it online and post it on our website? If you need some assistance with that, we'll maybe help you. And it's also accessible on the Attorney General's website. Okay, so just to sort of, I'll do a brief overview and then I thought if it's okay with you, Chairman Lippert, I would sort of talk about some takeaways and some challenges. Yes, absolutely. Okay, so big picture. The law, the original law I believe was enacted in 2016, so we've had a little bit of experience. There have been some changes and I would like to talk about the changes a little bit in the takeaway challenge part. But essentially, what the law does is it directs DIVA, the Department of Vermont Health Access, and any insurer that insures over 5,000 lives in the state of Vermont, which currently are Blue Cross, Blue Shield, Vermont, and MVP, to do some research into their own data and each come up with a different list. So DIVA is to come up with a list of 10 drugs to include at least one generic that has the price of which has increased either over 15% in one year period or over 50% in five year period. And DIVA is to submit that information both based on the wholesale acquisition cost or WAC or its net price, meaning net of rebates and other price concessions. So DIVA submits two separate lists. The insurers also submit a similar kind of list but based only on their net prices. And the statute gives some explanation about what sort of inquiry they should make and the inquiries based on drugs that have a substantial impact on cost in Vermont and which Vermonters would want to know more about. So without going into the details because I'm sure I can't describe how they actually do the data polls, but appended to my report as exhibits A and B are the DIVA WAC and net lists. Exhibit C is a really helpful memo that was done by DIVA that explained the process that DIVA used to create the two lists. And then exhibits C and D are the Blue Cross Blue Shield and MVP respectively lists of drugs that they selected. So I think the takeaway at least from my perspective in creating the report is that the prices for generics for brands and for specialty drugs are going up. So unfortunately not a big secret. There is no overlap between the drugs on the DIVA lists and the insurer lists. There's one overlap on the two insurer lists but none with DIVA are either WAC or net. The one drug that's common to MVP and Blue Cross Blue Shield is a drug called Polozyme and it's a cystic fibrosis specialty drug. Blue Cross reported an increase of 57.9% in that drug price over five years MVP reported 67% over one year. Each of the two insurers listed a generic per their statutory responsibility on their drug list. And just to pause for a second and this is sort of a takeaway and a challenge. The law tried to I think be as forward thinking as possible and so allowed the entity making the list to either choose one year or five year as its yardstick. So that's both helpful and a challenge because the two insurance companies each chose a different time period. So MVP is reporting for one year Blue Cross Blue Shield for five years well within the statutory right but just different. And DIVA has a combination. In some instances they reported both one and five years for the same drug sometimes five sometimes one. So there's a little bit of a challenge in trying to compare all the information. So with respect to the generics that Blue Cross Blue Shield and MVP listed Blue Cross Blue Shield reported a 98% increase over five years for that particular generic MVP of 44.6% over one year. So again sizable increases. Blue Cross Blue Shield's list was all specialty drugs except for the one statutorily required generic drug. And it reported a range increase over five years of 57.9% to 103%. MVP listed two specialty drugs again used a one year period. Its range of increase was 21.467% on the one year basis. So that sort of big picture prices are increasing. Some challenges that we faced is that as I understand it and the insurers are far better at explaining this than I am. But as I understand it based on conversations we've had over the last year and the conversation I had with the two insurers yesterday. There are a lot of different ways as I understand that you could pull the data. And again I think that the statute tried to give some leeway. I think in giving leeway may have created some potential difficulties as well. But again I'm not the right person to speak to that. But it took several tries before the insurers and they worked really hard and really long over a lot of months. But it took a while before they were both satisfied with their lists and were satisfied that they were pulling the data in essentially the same way. And you know Brian Murphy is here and maybe he can speak better to it than I. But when we talked yesterday my understanding of what the insurers were saying is that they think they may be able to come up with something that would give us even better data. And so obviously that's the committee's decision to make. But that is part of what we're wanting both the results of the report and also to hear any recommendations around to strengthen what we put in place or streamline it if it's appropriate. So I don't know what that mechanism is. I don't know that they do either but it was clear from the conversation that there may be some ways that they could provide us with information that would be helpful to the committee. And you know maybe the committee would give them some direction about what the committee would like to see. So another challenge that was faced is that Diva's actual net cost for its drugs under federal statute can't be disclosed. Even to the AG's office under our confidentiality provision as it is in the statute. So again trying to select a list of drugs and trying to compare apples to apples was made more complicated as a result of that. And I know Nancy Hogue is here and she is the expert on this stuff, not I, but she explained to me that in addition to that fact the drugs and the population served by the insurers and Diva may be somewhat different and that may be another reason that there's not the sort of overlap that we might have expected to see. But again better left to Nancy than to me. So as a result the AG's office was really challenged with trying to find a list of 15 drugs under the statute in the way that the committee had envisioned. And so I think we're actually looking for some guidance too and hoping for, probably not today, but some more thinking about the statute. We feel like the report as it's gone out has certainly generated questions and inquiries from colleagues across the country. Vermont was the first one to put a law like this into place. Other states have followed from the statutes that I've reviewed. They're all different. And so I think as I understand what Nashville is trying to do is to sort of come up with some sort of a model legislation for people to use, incorporate whatever a particular state wants. But trying to have reporting where you can sort of compare on an apples to apples basis. So and some of the statutes that have been enacted in other states have been met with legal challenges. I think we did a really good job in Vermont at identifying potential legal challenges and avoiding them. We built in the public, non-public versions of the report and that sort of thing. So those are the kinds of challenges that have been faced elsewhere. I'm happy to answer any questions you have. So the really, as I've been remembering, there were two parts of which was establishing a list to look at the increases. I mean the context of this of course is that there's been significant increases, which again we had lots of anecdotes, but we said we want to see what the data shows. And so that's what you've been describing. And also we're asking manufacturers to provide information that explained or justified the increases because our testimony in past years has, well shall we say it's not been clear, what really to attribute the drug increases and that. So is there anything that you have, I mean in your past you said much of that information cannot be shared because of proprietary issues. Is there anything that, is there anything new on that front? No, I don't think so. And just to be clear, this year's report doesn't include a list of manufacturers and their information because of the challenges we've faced with this iteration of the law. And in the conversation I was contacted by folks on the senate side in the fall asking about sort of what was happening. And I explained some of the challenges and their suggestion for this year was to raise the challenges to submit the report in a broader way to identify those challenges. And I hope that for the next iteration of the report we could address some of those and incorporate them so that we could do the kind of presentation that might be a little more granular. So I, this committee is very interested in these issues still. And there is a challenge with being the first to put something forward. We've tried to revise it somewhat. And I would like to appreciate our lips of counsel. I'm proud of you being here. My personal hope is that we can work with Nash B, who we heard from yesterday, but we can hear from again, specific to this. To see, to understand how we might strengthen what we're doing in Vermont in coordination with other states who have followed in some of the past, because I understand enhanced laws that go beyond what we've done in Vermont, but we'll not put down the spot at this point to ask her to explain those differences for us right now. But that is certainly one of my hopes as the chair to both get feedback from you, to hear from the insurers who, and Diva, who we have scheduled later this morning. And then to, well, to visit the question though, is this, is what we intended here, reducing information that's of value. I don't, as a chair, want us to go through an exercise that simply puts us through an exercise but doesn't provide value, because I know it's valuable time on your part and everyone's part. On the other hand, my experience over time with this and other issues is that sometimes the initial work, it takes some time to sort out what it is that we need to most appropriately try to achieve and how to achieve it. So I'm not, because I'm not signaling at this point that we're going to leave the field of trying to gather further information around this. But let me open it up to questions from committee members at this point and see if there's any other questions. Just a question of clarification. You were, I didn't quite get the full sense of what you were saying about the confidentiality and publicly sharing. Is that the proprietary information you said that you can? Or Diva, you also mentioned Diva. Diva, okay, so there were two. I'm sorry, I was talking like the FedEx man, I think, trying to get it all in. Yeah, so confidentiality comes up in a couple of different ways, a few different ways. So I think the first thing I was talking about was under federal law, a Medicaid agency isn't permitted to disclose on a per product basis their net cost. So Diva can't tell us that it pays X dollars per pill for a given drug. They can tell us the WAC cost, the wholesale acquisition cost. That's another question. Which is sort of like, I think of it as a parallel to the MSRP for a car, you know, sort of what you see on the sticker, but after some conversation usually you don't pay that price. And with drugs, particularly if you're a large purchaser, you get rebates and other kinds of price concessions which will bring your price down. So our Medicaid agency receives rebates and concessions as a result of being a Medicaid agency and may also be able to negotiate some supplemental rebates. So if the wholesale price is, you know, 40 dollars, Diva might be paying 20 dollars, but they're not allowed to disclose that under federal law, the 20 dollars. They can disclose the WAC, but not the real. And then I think the other confidential mention I made was the way the statute is written, there are certain public information that we can provide. So the price list, excuse me, the drug list that are created by Diva and the insurers are posted both on our website and on the Green Mountain Care Board website. With respect to the insurers, there is a non-public version because that version does show the net prices paid by the insurers. And again, that's a way of not disclosing what they're negotiating with the manufacturers. The manufacturers consider that sort of information to be treated secret. And so that information isn't disclosed. I think those are the two names mentioned. Thank you. Sure. I was just confirming with legislative counsel because what I'm remembering is that in fact, Diva, I believe, and Nancy's here with me more later. But I think Diva has in the past been able to share with us what their aggregate savings are. I believe in terms of the negotiated savings, but not the gradient or individual drug savings that are negotiated and they're substantial. So it's important for us to have a sense of that. Other committee member questions? Let me, is there anything, any final comment that you'd like to make? Well, let me emphasize again that this, the issues of prescription drug pricing increases. And from testimony that we've taken in the past, both around issues, it's around, there have been some egregious, from our point of view, egregious increases, both in the generic field, as well as in the brand names, as well as now in specialty drugs which are increasingly based on the data we're seeing, where the incredible increases in prices and the incredible prices, coupled sometimes with incredible outcomes as well. So acknowledging that, but nevertheless increases which really have made our driving a large portion or a significant portion of our healthcare costs, not just in Vermont, obviously, but clearly for Vermonters. So I guess I'll just say for myself as the chair of this committee, and I think it's shared by many of our committee members, we intend to continue to press forward with trying to find every avenue that we can at a state level to be aggressive about trying to reduce unjustified or maybe unjustified to make prescription drugs as affordable to Vermonters as possible. And to understand and intervene where we can to influence that. There are limits to what we can do as a state, but we also heard, as we heard from Nashmi, that much of the activity is happening at the state level. The initiatives are happening at states, not just Vermont, but other states as well. I think we, along with our colleagues in the Senate, who have different initiatives that come from the House and the Senate, intend to continue to press forward with this very important issue, and it's not a partisan issue. I dare to say this is an issue in this committee that has had strong support from every political part of the spectrum. In fact, when we passed out a number of our bills, they came out with very strong support across the entirety of the political views, often fully represented in our committee. So this is not an issue of arts and politics. This is an issue of working on behalf of Vermonters on prescription drugs. And while I'm doing an editorial, I'll just say that those of you who are working in the field of pharmacy, we're also struggling to understand how you are in the midst of this chain of price increases, availability, and trying to understand all the complexity of this system, and how much of it, and where there are black boxes that we can't get inside of in order to understand, or how to help both understand, explain, and then possibly intervene, very frustrating times. But again, I think there's a strong consensus that we will do our best to try to continue to move forward. I appreciate your joining us this morning, and we will take some of the concerns that you laid out here along with other testimony, and perhaps bringing a revised set of recommendations to make it more possible. I just, one thing I did want to say is that in doing this work, and in connection with other pharma work that I do, the Vermont legislature is often commented on or complimented for being the first one out of the box. So I just wanted you to know that because I work with people all over the country. And what we do is the subject of a lot of discussion everywhere. Okay, pressing forward. Thank you. So we'll go to the floor at this point. We are scheduled to hear from both Brian Murphy from the Trust for Steel and Nancy Hogue after the floor. Okay, let me start with apologies. But it is the nature of this building that one never knows what's happening on the floor and for how long. And I and a number of chairs were completely wrong in our sense of what the debate would be and the amount of time it would take. But it is also an essential part of our work. So I have spoken with Brian Murphy from Blue Cross Blue Shield and Nancy Hogue and Diva who were our first, to be our first witnesses. They have agreed to come back at another time. It is generally our practice when there are folks, witnesses who have come a distance and who are not regularly available in the building to hear from them prior. So I'm going to ask us, because there are so few seats, Brian, who was going to stay and listen said I'll have to come back. But I'd like to start, and I'd like to hear from Lauren from Sondra Rosa and from Jeff Hockberg. And we have really just between now and noon. So if you could be thinking about how to portion your time so that we can hear from each of you, we'll probably have minimal time for questions from committee. But we do want to hear your testimony and welcome you. So let's start by having Lauren join us at the witness chair and our practice in the legislative recorded testimony. So we ask for witnesses to identify themselves by name and affiliation and we look forward to hearing from you. Thank you so much. So I said my name is Dr. Lauren Bodie. I am an assistant professor at Albany College of Pharmacy here in Colchester. I have a couple other roles that I think are germane today. I am also a pharmacist clinician with the University of Vermont Department of Family Medicine practicing at one of the clinics in Milton Vermont. And I'm also here with the Vermont Pharmacists Association. And I can't tell you yet first off I want to say how much I appreciate the time to be able to address you in particular being pharmacist day here in Montpelier. But this is what we're talking about today is very important to me on a couple different levels. So I am coming into this with a, what I think is a somewhat unique or rare perspective of someone who is a pharmacist who has practiced in community pharmacy. But I currently work in a primary care clinic. Both pharmacy and primary care are things that I hold in the, of the highest importance. And what I really like about this initiative of that of granting some limited prescriptive authority to pharmacists is that I think it can be good for both. Good for pharmacy in Vermont, good for primary care in Vermont, but most importantly good for volunteers. So this is, so to start off, you know, this is a initiative that other jurisdictions, states and both their neighbors to the North and Canada have been pursuing for many years. That of granting some appropriately limited prescribing authority to pharmacists. And what they're, what they're seeing is some positive results. I think this is understandable because we've seen in many venues that when pharmacists are getting more closely involved with the health care team more centrally located in the continuum of the patient's care. You see three major things happen. One is that the quality of care improves. So whether this is by assessing patients needing their blood pressure targets, more A1Cs coming into goal, a marker of diabetes control, or just overall adherence to medications, pharmacists support these initiatives. The other is that care tends to cost less. This is almost a corollary of that first point because healthier people cost the system less. And then the second and the third is that patients are more satisfied with their care. And so for these reasons, I would anticipate that in Vermont, we would see these same sort of results that we have seen in these other states on the territories of Canada in during what in those times that they have expanded pharmacists ability to provide care that's within this group of their education and training. So there are a few aspects that I think would be particularly helpful for Vermont to kind of create some examples for how this may play out in the state as it hasn't other places. So one of them is for pharmacists to be able to prescribe medications for tobacco cessation. So nearly one in five for monitors currently smokes today. This is a huge public health burden with its attendant costs of heart disease, lung disease and cancer that comes with. We also know that patients who have healthcare provider support of pharmacists included. We have the studies that show that pharmacists are highly effective in helping patients stop smoking or using tobacco can be really important for helping patients be successful in their efforts. But what we also know that there are currently barriers to access to these prescription medications because there are barriers to access to care in our state. And what was particularly interesting is that just last week in a major report that came out from the Surgeon General, the Surgeon General specifically called out pharmacists ability to prescribe tobacco cessation medications as a potential avenue for closing this like public health gap that we see. So that's one area that I think could be particularly helpful to the state. Another would be giving pharmacists the ability to prescribe hormonal contraception. So nearly half of pregnancies are unplanned. So again another public health issue because when you have unplanned pregnancies that's a lack of access to care and potentially compromising both health and economic outcomes for mother and baby in the early years. What we know is that hormonal contraception is a preferred method of contraception by many women. But we also know from the national survey that nearly 30% of women who wish to go on hormonal contraception encounter problems getting it. 20% for in the most common being lack of access to a clinic or primary care provider or other prescribing provider who can provide that either initial or refill prescription for the hormonal contraception. This is something that has been rolled out in many places to a significant degree. For example in Oregon 10% of hormonal contraception is prescribed by a pharmacist at this point. The other thing that I think is notable about this is that to be American College of Obstetrics and Gynecology who is very active on this issue. They too have promoted the expanded role of pharmacists to be able to provide hormonal contraception. But even they say even maybe that's not far enough it should be over the counter potentially. So while that would be a bit of a paradigm shift for us something that can be a very actionable middle ground would be giving pharmacists the ability to assess the patient and then prescribe that hormonal contraception when appropriate. And the last thing are sort of a bundle of issues about access to timely care and streamlining what can be a really convoluted healthcare process for many patients. And these are things like giving pharmacists the ability to prescribe pen needles when an injectable medication is prescribed. You can't use the injectable medication without the pen needle. And if a prescribed or another provider forgets to send in that prescription that very often results in the delay of care for that patient that may prove a potentially insurmountable barrier depending on what else is going on with that patient. The same could be said for testing for diabetes or testing supplies for diabetes. Nebulization supplies a spacer for inhalers. Things where there was already been a therapeutic decision on the part of another provider to use this therapy in this patient. But haven't as been they have forgotten in the overburdened primary care system to prescribe some of these like ancillary items that are necessary to get the full benefit of those medications. In our current system the pharmacist has to call back to the provider's office say hey we need this. This is burden in the pharmacy more importantly burden in the healthcare provider's office that to my mind could very reasonably be done by the pharmacist at the point of dispensing to ensure that the patient has timely access to care. That we're not cluttering up the physician's voicemail and inbasket with something that is fully within our capability of addressing for ourselves. We just need the ability like the legal ability to actually do so. So this is kind of a general overview of the ways that we believe that this initiative could benefit the health of our doctors. I would love at this point to turn it over to my colleague Sandy Rosa to talk about the ways in which the contemporary pharmacy education is preparing pharmacists of today to fill this role and meet this challenge. This is a hard act to follow. Hello my name is Sandy Rosa. I'm a licensed pharmacist in the state of Vermont. I am the president of the Vermont Pharmacist Association. I am also the director of pharmacy practice experience at the College of Pharmacy and Coal Justice. I want to discuss with you how we are preparing our students to meet these challenges to be able to practice at the top of their practice, scope of their practice. Since 2006 the Doctor of Pharmacy degree has been the terminal degree for the profession and the education has risen to the doctoral level incorporating the clinical training seen in the education of other health professionals. The basic core courses teach the systems of the body and what can go wrong in such as immunology, pathology, biochemistry, and that. From there the students progress to glasses on how medications are formulated, their mechanism of action, side effects, interaction to each other and how genetic variations can influence drug action. And this is something called pharmacogenomics. Then putting this all together, there's an awful lot going on. There are given courses on the various body systems and how drugs affect each one in respiratory and cardiology and every body system that there is available. In addition students are trained in over-the-counter medications and how their indications are and when to refer patients to other providers but not out there to sell the ibuprofen when we feel that the pain is more than we can be handled. Throughout the entire curriculum students are educated in problem solving using case studies to illustrate the proper medication management in various conditions. Using a template called the pharmacist patient care process for patient assessment and treatment allows the students to gather information, assess areas for gaps in treatment, develop a medication plan, implement the plan in collaboration with the other health care providers and provide follow-up by measuring adherence and outcomes. Interpreting scientific literature and updated guidelines is also taught so that the students know where to find evidence-based therapy for treatment of patients. Skills such as compounding, sterile and non-terror technique, reading patient charts and assessment skills such as taking blood pressures, doing diabetes testing and clear wavering are taught throughout the entire curriculum. There are soft skills involved such as patient counseling and education and they're taught using simulated patients usually from the University of Vermont and thank you for that. Courses in ethics, HIPAA, law, health care systems and administration provide the student the understanding of the pharmacy working world and the importance of the high ethical standards that both the profession and the public hold us to. Professionalism is taught from the very beginning at orientation and continues throughout the entire curriculum. In addition to the scientific and clinical courses, all students are nationally immunized and certified by the American Pharmacist Association and our CPR and basic life support is certified. We also provide other certifications in medication therapy management and tobacco cessation. Finally, all the coursework comes together in their final year where they complete seven six-week rotations in hospitals, clinics, community pharmacies and other pharmacy-related situations such as Blue Cross Blue Shield of Vermont, Department of Health and things like that, long-term care, mail or pharmacy to develop further their clinical reasoning under the direction of experienced practitioners. Admission to pharmacy school is not only resting on good grades but with an interview process to assess their empathy and problem-solving skills. Throughout the years in schools, students extend themselves into the community in various outreach endeavors. In senior centers, schools, the Ronald McDonald House, Hope Lodge, the Lung Walk, Relay for Life and things like that. I am fully confident that students graduating from the Doctor of Pharmacy program are fully qualified to address the unmet medical needs of the Medi Vermont citizenry. Thank you. Thank you very much. Can I say briefly that I find some of what's been presented here compelling and we'll have no time to have committee discussion right now. I'm not aware that all of what's been described in terms of prescribing authority for pharmacists is in front of us in a proposal in a bill form, but we have the ability to create legislation as a committee bill or incorporate this into other proposals which may be in front of us. So I would invite, I'm sorry our legislative counsel isn't able to be in the room to have heard this testimony, but I would invite you to continue to be in touch as we look at the possibility of moving some of your proposals or all of your proposals forward. Thank you. You appreciate the opportunity. Thank you. Now let me check in with Mr. Hartford and his side. I welcome you to briefly share or I also welcome the possibility or include the possibility of having you return at a later time. I know that this is not the presentation that you probably anticipated. There is absolutely no way we can even begin to discuss pharmacist pricing in 10 minutes. Right, that's what I mean. Yeah, absolutely. I'd love to come back and maybe the same time Nancy Hogan for us to be available. Sure. And I realize you've traveled a distance, but I think that might just be better. I mean having heard your testimony we just heard and then realizing that we can't really begin to touch on what you want to share. Yeah, I'll just, and I do have some copies if anyone needs the slides, but they are online too. I think they speak to themselves. You can do it by yourself for the record and be able to say a few words and then we'll have you back again. Hello, my name is Jeff Hartford. I'm the acting president of the Ramon Retail Drugist. And what I'm here today to talk about prescription pricing is first I want to applaud this committee for really taking this up. This is a very complex, very dynamic. It changes from minute to minute to what's going on. And it takes a long time to really grasp the quality and the working of pharmacy pricing. And I know you were read age 785 from Representative Sir Colin Hanses yesterday, I believe. Yes, we did. And it's a great, great opportunity. I can mention I'm also on the National Committee for the National Community Pharmacy Association of the State Legislation Council. Rate setting is something that is being talked at a national level. And it is one key component. And what I really wanted to share is that with that, with importation, I know there's a 340D bill out there. Actually a 340, I'm not aware of a 340D bill. Maybe it's on the Senate side. Maybe it's on the Senate side. Maybe it's on the Senate side. Well, we should make sure we see that. Wholesale importation from Canada. Expanding the scope of our licensed professionals so that they can better determine and improve access. These are all key components to this. And what, and even Blue Cross Blue Shield's notion of investing in a manufacturer or a non-profit manufacturer would have heard such a thing. It's great. These are all great initiatives. And they all need support. But I think what we need to do is we need to consider our perspective. And if you go... Hour by hour. Hour in the state. Any regulatory body, legislature. This is one model that I have about the flow of drug pricing and how it's interrelated with some of the major players. But it's so much more complex than this. And I know Brian's slide has one with just a sweater. And that's the problem. No matter what initiative we go down, I'm not sure that we could ever fully evaluate it or be able to fully predict what might happen. And I think there's an opportunity with a combination of what's in part of you on H785 with a rate review establishment body, coupled with some kind of perspective. And I'm here to tell you that there is one player in the entire chain that sees absolutely everything. And that is the whole thing. I can literally log in on this computer right here and on a dashboard see everything that's going on in my pharmacy from my acquisition costs, my third-party reimbursements, projected DIR fees from Medicare, which I won't even get into. I have access to 340B pricing. I have various wholesaler pricing. I see everything there is. And that wholesaler captures it all. They can capture every bit of data that I have, every claim that I transmit, they capture it. They know how much I'm being reimbursed and they certainly know how much it costs me. What if the state had eyes like that? We could then position ourselves to fully evaluate and dive into every one of the great ideas that's been put in front of this committee and others. It allows for the importation process to happen because you need a wholesaler anyway. It gives eyes into 340B as to whether or not the supplemental rebates, which are entirely proprietary, are of greater benefit than the 340B price. All of those things are inter-regional to that. If you, with rate setting and with potential switching to something a great model like our Medicaid system has as a fee-per-service model, we could streamline the pathway and eliminate the pharmacist's burden of pay-for-product. They could be paid for service they provide and it could be allowed in the opportunity to expand to greater spits and prescriptive authority or other things that are allowed under their licensure. You could fully access our healthcare professionals and improve access because that's the number one thing. Prices are going up and access is going down. And we don't necessarily know how to evaluate the prices that are in there. Our perspective is getting more and more cloud and that's what we need. We need perspective. I'd love to dive in more, but I really don't want to take any more time. You have successfully peaked our interest. Can you, sorry, can you just going back to the very beginning, clarify who you're representing and what kind of perspective within this? I'm the president of the Vermont Retail Drugists. So we're a body of pharmacy ownership. And this, sorry, the second part of your question earlier. That was pretty much my question. Just what piece of the web of... Yeah, so I personally, I also operate as a director and owner of several pharmacies in Southern Vermont. And I also serve on the National Community Pharmacy Association State Legislative Council. Thank you so much. Thank you. And we will work to bring you as well as the other witnesses who we have Nancy Hoke and Brian Murphy back at another time. I'm not sure it'll be next week because we've already had to anticipate that and do some scheduling. But we'll work together and with Jemez Martin, our committee assistant to find the time to hear from you again before long. We're here to come back anytime. Like I said, it's complex. Okay. Let me also just say again thank you to those who are here from Albany College of Pharmacy who are fortunate in Vermont to have you in Vermont as a new educational resource and a resource to the state generally. And so I'm pleased that you're here today and welcome you to continue to develop a relationship at the policy level with those Vermont Legislature and the House Health Care Committee. And also with us are my colleagues from University of Vermont Medical Center. Excellent. Thank you. I'm sorry if you were to introduce on the floor, but I guess I just emphasize that we're going to be hearing from residents from the OBGYN program who are residents with Dr. Tillon. It's very, it becomes very powerful to actually weave training and experience, practical experience and training settings with us as policy makers. We can cite numerous examples where, and this may be one today, where there's a proposal to forward based on some very practical experience and it leads to policy change at the state level. So I welcome each of you to continue to not just do your professional training but to think about how to interspace with us as policy makers along the way. This is actually very important to us and ultimately to Vermont or something. Thank you. Let's stop. Thank you.